Hello, and welcome to today's webcast, Engaging Healthcare Leaders in Sepsis Prevention. This webcast is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies. Be sure to check out the companion podcast, which offers 0.25 hours of accredited continuing education credit free of charge. The podcast will be available today, immediately following this webcast at 2 p.m. Central Time. Registration information is available on your control panel. My name is Susan Lacey. I'm the Associate Director of Quality and Research at the Society for Critical Care Medicine in Mount Prospect, Illinois. I will be moderating today's webcast. A recording of the webcast will be available within five to seven business days. To access the recording, log in to mysccm.org, navigate to My Learning tab, and click on Engaging Healthcare Leaders in Sepsis Prevention course. You will find the handout, evaluation, and recording in the course section. This is a free webcast and offers one hour of accredited continuing education. Thanks for joining us. Here's a few housekeeping items before we get started. There's a Q&A at the end of the presentation. To submit questions through the presentation, type into the question box located on your control panel. Please note the disclaimers stating that the content to follow is for educational purposes only. And now I'd like to introduce you to your speakers for today. Craig Cooper-Smith is the Director of Emory Critical Care Center at Emory University Hospital in Atlanta, Georgia. Krista Shore is a Clinical Nurse Specialist at Cooper Hospital University Medical Center in Camden, New Jersey. And Judy Jacoby is a Senior Consultant and former Critical Care Pharmacist at Indiana University in Health in Lebanon, Indiana. And now I'll turn things over to our first presenter. Hi, thank you so much. I'm incredibly honored to be here. Thanks to SCCM for the invitation. And I'm tremendously honored to be sharing the metaphorical podium, I guess, with Judy and Krista. So I was asked to speak about how does morbidity from sepsis impact the financial health of an organization? And another way of saying this is really how do we convince people that sepsis matters? So my disclosures are here. The ones that are really relevant are I am the current co-chair of the steering committee of the Surviving Sepsis Campaign. At least for a few more months, I'm co-chairing the research arm of the Surviving Sepsis Campaign. And I was co-chair of Conflict of Interest and an author in the most recent Surviving Sepsis Guidelines, none of which I'll be talking about today. So let's start when we're trying to convince people that sepsis is important, the financial burden. Facts and figures, 1.7 million people in the United States get sepsis annually. If every single person who's discharged to hospice lives, 270,000 people die of sepsis each year in the United States. Obviously we know that most people who are discharged to hospice with sepsis do not live. And in fact, if everybody who's discharged to hospice with sepsis dies, 380,000 people die of sepsis each year in the United States, which actually makes it the third most common cause of death in the United States. And this does not include COVID-19 and the controversial question of whether COVID-19, which appears different clinically than sort of stereotypical sepsis, but clearly meets the intellectual definition, is sepsis. That's a US-centric world. How about in the world? Well, let's talk about the global burden of sepsis. Before COVID-19, there were about 50 million cases of sepsis worldwide, accounting for 11 million deaths, approximately 20% of all global deaths, making sepsis the number one or number two most common cause of death in the world. So everything I'm going to talk about from here on in is really United States data. And this doesn't suggest that sepsis is more important or less important than the United States, but the financial data we have is probably a little bit more robust than the US. So that's what I'll be talking about. So as we're talking about making the financial case, the first question we would ask is, how much does sepsis cost compared to other hospital conditions? And the best data from this comes from the HCUP, the Healthcare Cost and Utilization Project, which is a family of healthcare databases and related software tools and products developed through a federal-state industry partnership sponsored by AHRQ. And again, in this publication which recently came out, national inpatient hospital costs, the most expensive conditions by payer, here are the bottom lines. In 2017, aggregate hospital costs for about 36 million hospital stays totaled about $430 billion. And the five most expensive inpatient conditions in order were septicemia, osteoarthritis, live-born newborn infants, acute MI, and heart failure. I'm going to be talking about insurance type a little bit further, so it's probably helpful to understand different types of insurance. So what you see here is that approximately half the costs are Medicare patients, about 40% of hospital stays. There's some similarities between Medicaid and private insurance, a little bit more private insurance than Medicaid, and everything else is relatively a rounding error. So in the following data that I'm going to present, I'm going to ask you to ignore the fact that the term septicemia is used. So septicemia is a term that we've actually not used in the sepsis field since sepsis one was published in 1992, which explicitly says not to use it because it implies that sepsis has to be in the bloodstream, which is not correct. You do not need a bloodstream infection in order to be septic. You need an infection and a dysregulated host response to the infection, but in fact, most patients with sepsis are not bacteremia. So every time you see the word septicemia in the next couple of slides, please perform a sort of find and replace in your own mind and change the word to sepsis. So here's the 20 most expensive conditions treated in US hospitals, all payers in 2017. You can see them in order, but I'm going to highlight a couple of things. First, looking at aggregate hospital costs, sepsis is nearly double any other conditions. And when looking at either the number of hospital stays or the percent of hospital stays, sepsis is nearly double any other condition except for giving birth, which accounts for more stays but is obviously significantly cheaper than sepsis. That's all comers. The most expensive population is the Medicare population, elderly patients. And when we look specifically at sepsis in elderly patients in Medicare, people over the age of 65, we see that in fact, sepsis accounts for more than double the costs for Medicare than any other condition, more than double MI, more than double COPD, more than double heart failure, diabetes, et cetera. You see there, a huge amount of financial burden. Or you might say that's Medicare patients, how about other patients? I told you the two really most common things, that's about half the patients that come out are both Medicaid and private insurance. And you see that in terms of cost and in terms of hospital stay, sepsis is number two for the cost in Medicaid, pretty close to Liveborn, even though it's actually only about one-sixth of the number of patients. And for private insurance, it's about equal to osteoarthritis and Liveborn while taking up a lower percentage of stays, less people, more expensive. And in the small number of people who are self-pay or no charge, sepsis is again, the number one most expensive hospital condition. So this study came out in our own journal just a year or two ago. Sepsis Among Medicare Beneficiaries, Pre-COVID Disease 2019 Update, looking at sepsis amongst Medicare beneficiaries from 2012 to 2020. So recent data. The design of the study was an analysis of paid Medicare claims via the CMS Data Link Project, looking at literally all United States acute care hospitals, except for the VA and the Defense Health Agency. Looked at all Medicare beneficiaries over this eight year with an explicit sepsis diagnostic code assigned during an inpatient admission. And what did they find? First, the count of Medicare patients fee for service plus Medicare Advantage inpatient sepsis admissions arose from 980,000 to 1.7 million, literally doubling. The six-month mortality rates were incredibly high, 60% for septic shock, 35.5% for severe sepsis on the sepsis one definition, 30.8% for sepsis attributed to a specific organism, 26.5% for unspecified sepsis. And then finally, an estimation that the aggregate cost of sepsis hospital care for the entire US population, just Medicare, was at least $57.5 billion in 2019. This is some data from the paper, showing this is the rate of inpatient sepsis stays of all acute inpatient stays. And you'll see from 2012 to 2019, it went from 7% to 12.5% or 13%. You'll see the incredibly high mortality and also understanding that if somebody survives a week, that does not mean that they survive. So at the bottom of this, we see one week mortality and one week mortality for inpatients with sepsis is approximately 25%. That's horrifying and that's terrible. And then look at the six-month mortality. The six-month mortality goes nearly twice as high, while it is decreasing slightly over time, just because you survive a week, an extra nearly twofold number of patients who survive a week will actually succumb to sepsis over the subsequent six months. And the average cost of sepsis for inpatient cares in a fee-for-service patient has been steadily increasing, although it decreased in 2014 and 15. So you see it's approximately $20,000 per patient. So they concluded that sepsis among Medicare beneficiaries pre-COVID imposed immense burdens on patients, their families, and taxpayers, and also say vis-a-vis the topic of my talk, also immense burden upon healthcare organizations. Sepsis does not stop the day that somebody leaves hospital. This is a nice study from JAMA looking at the proportion and cost of unplanned 30-day readmissions after sepsis compared to other medical conditions. A bit of a complicated slide, but look up top. Of all index readmitted within 30 patients, the percentage who are readmitted with sepsis from sepsis are so much higher than everything else. And in fact, the estimated mean length of stay is higher than any other disease, and the cost is higher than any other disease. So if one is admitted for sepsis and myocardial infarction, heart failure, pneumonia, COPD, much more likely to be readmitted if you're admitted with sepsis, much more likely if you're readmitted to stay longer and for it to cost more. And here's a companion paper, if you will, the epidemiology and predictors of 30-day readmission in patients with sepsis. This is looking at nearly a million patients, of which 17.5% had a 30-day readmission with a median time to readmission of only 11 days. The most common reason that patients were readmitted was infection, almost half the patients, followed by a number of different types of organ dysfunction. So put a different way, nearly one in five patients with sepsis is readmitted to the hospital within 30 days. About half of them are readmitted with infection, about a quarter with sepsis, and about half readmitted with something else. But your journey with sepsis does not end the day of discharge. A huge number of patients gets readmitted. And this is from the lay press, but I think it's a really useful quote. In assessing readmission costs, the study found that the mean cost per readmission was found to be $16,852, which amounts to $3.5 billion of annual costs in the United States. And putting that into context, a group that looks at readmissions is close to $7 billion. But importantly, sepsis readmissions account for literally half that amount on an annual basis, which is a significant cost of the health care system, adding that several approaches could be explored as potential solutions to this problem, which both Krista and Judy will be talking about after I finish this talk in a few minutes. So a big question is, are patients dying from sepsis or are patients dying with sepsis? Well, we see the prevalence of underlying causes and preventability of sepsis-induced associated mortality in U.S. acute care hospitals. This study got a lot of press. It's a small study, only looking at 568 randomly selected patients admitted to six U.S. academic and community hospitals back in 2015. The long results, so what I'm going to have you do is just focus on the end, which is here. Only 3.7% of sepsis deaths were judged to be definitely or moderately likely preventable, with another 8.3% considered to be possibly preventable. So if generalizable, understanding small study, less than 600 patients, the range of preventable deaths from sepsis, not the number of people who get septic, but the range of preventable deaths is about 4% to 12%. So true, is the glass half empty or glass half full? So if it's true, we can prevent only 7,000 to 32,000 deaths in the United States, 400,000 to 1.3 million deaths in the world, not taking into account the horrific finances that I just talked to you about and human suffering of preventing secondary sepsis, something you could prevent by potentially rapidly treating and diagnosing sepsis on admission. So my last couple of minutes, do simple interventions matter? And of course, I hope you know that I'm going to say yes. So this is a landmark paper that came out last year. I believe Chris is an author on this. Effects of Compliance with the Early Management Bundle, SEP-1 on Mortality, Changes Among Medicare Beneficiaries with Sepsis, a Propensity Score Matched Cohort. Long title, what are we actually seeing? We're seeing patient-level data reported to Medicare by 3,200 hospitals looking at the surviving sepsis bundle, antibiotics, 30 cc's per kilo, blood cultures, pressors, lactate, reassessing patients. And they completed two matches to evaluate possible level treatments, looking at 123,000 patients, so those who were matched who were not compliant. And what did they find as their take-home point? Their take-home point in the post-doc analysis of data submitted to the U.S. for Medicare, compliance with SEP-1 was associated with a significant reduction in 30% mortality, a 5.7% absolute risk reduction, and even using the most stringent literature-based matching criteria, a 4% absolute risk reduction in mortality, suggesting that if the relationship between SEP-1 compliance and 30-day mortality is causal, rendering SEP-1 compliant care likely reduces the incidence of avoidable deaths. The final study I'm going to show is one that I think most of you are likely familiar with, which is time-to-treatment immortality during mandated emergency care for sepsis. So I'm going to 50,000 patients, 150 hospitals in New York State, where hospitals got to do whatever problem they wanted as long as it complied with the three-hour, six-hour surviving sepsis bundle. And under the rubric of pictures worth 1,000 words, here you go. For every hour delayed treatment, mortality goes higher. What we do changes death and changes financial implications in our patients. So in conclusion, sepsis is the third most common cause of death in the U.S. and likely the most common cause of death worldwide. It's the single most expensive condition treated in the hospital, nearly twice as expensive as any other condition, more than twice as expensive for Medicare recipients. The cost does not end with discharge. Nearly one in five patients with sepsis are readmitted within 30 days, and they have a longer length of stay and are more expensive than any other condition. I just said that. And while many deaths from sepsis are from a primary disease, a significant number are preventable, important, expensive, and deadly. And with that, thank you very much, and I'm going to hand this over to Krista now. Thank you, Craig. That was an excellent presentation, and it's certainly a good lead-in to what I'm going to discuss with you all today. And again, I'm also very pleased to be able to present this information to you and certainly near and dear to my heart. As far as disclosures, I am a member of the Surviving Sepsis Campaign Steering Committee. I'm a paid consultant for a current study that's underway with the NIH. It's the AIM study comparing the three-hour bundle to the hour one bundle. So when I think about sepsis management, I think initially the goal here was to talk about hospitals, hospital health care management. But just as Craig said, there are a significant number of readmissions. Patients come to the hospital, present from all different sources. So my opinion is that I think we need to think about sepsis on the continuum of care, meaning from the time the patient's initially admitted to the hospital to the time they get home. And there's a lot of places the patient could go in between, including the emergency department, various units within the hospital. If the patient requires some assistance after the discharge from the hospital, they may be discharged to a rehab facility, short-term care, long-term care, and again, how they interact even with the outpatient health care facilities. I think we need to think about engaging leadership on a bigger scale than just the hospital itself. And when we think about hospital leaders, it could be anyone who has a stake in sepsis care. So it's your CNOs in the hospitals, your CMOs, the CIOs, there's many different types of leaders. It could be the board of your institution where they have a significant interest in quality of care that's delivered to a patient. So again, when we think about leaders, it's a variety of stakeholders. When we think about sepsis management, again, there are many, many health care providers, not only within the hospital, but outside the hospital that care for these patients. So my objective today is just to talk to you briefly about how to engage health care leaders in sepsis care across the continuum. I'm going to talk about how you can present information that's of value to the institution, kind of spin it a little bit differently than Craig presented some really great information about the burden of sepsis. And I'm going to talk about how we can use that to engage our health care leaders. And then also talk to you about the importance of engaging health care leaders and how that's important to patients and families. And in the end, I'm just going to close and maybe give you some ideas on how you can propose a business plan to your health care leadership if you need something to help improve sepsis care in your institution. So why and what? So when you're trying to engage your health care leadership, you may only have a short period of time, which is the significance of the hourglass. Just as an example, I had the opportunity to present to the board and I was told that I was going to be able to talk about sepsis and what we were doing and what our numbers were. And I had five minutes to do it. So for anyone who's presented anything, it's easy to give an hour's talk. It's very difficult to prepare something in five minutes and get your point across. But the reason I'm mentioning this is if you have the opportunity to present to any one of those stakeholders that I mentioned about how you can improve sepsis care in your institution, you may want to prepare a presentation that's 10 minutes that you can decrease to five or increase to 15. You want to make sure that you're sharing why sepsis is important to this health care facility. You know, it may be different for each individual institution. So if you're in a hospital, why it's important to your hospital system may be different than why it's important to a short term rehab facility. And when you're presenting that information, you also want to provide data, data and rationale. So data, not only from what Craig had presented, but also data that's unique to your institution that helps to support the why, why this is important to our facility. I'm just going to pretend like I'm working for your facility right now. So when we get into the value of the institution, there is a lot of low hanging fruit here. You know, hospitals are, you know, concerned about their reputation, and Craig mentioned about the SEP-1 measures that we're reporting to CMS. Some of that data is publicly reported, and the public is very savvy now, especially with social media being able to capture this information and knowing which hospital has a higher mortality for sepsis in your area. So protecting the hospital or the rehab facility or the nursing home, your reputation as far as caring for patients and having a lower mortality is important. And also patient satisfaction, you know, we want patients to share their positive experience, and that helps the institution maintain their reputation. When we think about resource utilization, Craig mentioned that, you know, patients that have a longer hospitalization potentially have higher mortality. We also need to think about what does an ICU, a long ICU length of stay and a long hospital stay do to that institution as well. So that actually impacts throughput. So if a patient with sepsis is in that hospital bed for a long period of time, that means that no one else can be admitted to that particular bed. So we want to think about what can we do to potentially decrease complications in patients, decrease organ function so that patients aren't requiring a hospital stay for long periods in time, and potentially can be discharged home as opposed to a long-term or a short-term rehab facility. And then again, Craig also mentioned the significance about readmissions. So it's not only that patients are more likely to die on their readmission, it's also very costly to the facility. And there's some financial implications about this. So you may have payers that are looking at readmissions and maybe going to pay you for the first sepsis admission, but may not pay for the readmission to that particular patient if, and indeed, it's related to their initial hospitalization for sepsis. So there are some financial implications, and insurance companies are kind of talking about this now, asking to ensure that, you know, the facilities are following protocols and the SEP-1 measures and looking at compliance. And last but not least is staff satisfaction. So we know that we need significant staff support to care for these patients. They can be on various spectrums. So some patients with sepsis are pretty easy to take care of, and they do well. They're in and out of the hospital in three or four days. And then we have other patients that are very complicated, maybe in the hospital for weeks to months with multiple organ dysfunction. And we need to ensure that we have the staff that can care for those individuals. So again, I'm trying to make a point here that there may be items that we need to engage our leadership in that are helpful to us to ensure we're giving the best care to these patients at the appropriate time. And again, there's value to the institution in having staff support and staff satisfaction to help care for these individual patients with sepsis. We know that there's a lot of moving parts in caring for a patient with sepsis, from identifying sepsis to the initiation of treatment. We do not have a specific test, as you all know, to tell us that the patient has sepsis, but we're also expected to give the appropriate care as soon as we recognize the patient has sepsis. Craig presented some significant information about the burden of sepsis, not only within the United States, but globally. But if you're trying to engage your institution, your institutional leaders, if you need something to help improve the care for these patients with sepsis, we need to share what the burden is within our own institution, within our own community. So presenting cases per month and cases per year, what is your compliance at your institution with the SEP-1 measures? Are you above the national average, below the national average, or are you having difficulty with one element or two elements? And what about your mortality? Is your mortality higher than the hospital that's 10 miles away? Do you have a different patient population? Understanding what's happening in your institution and the burden of sepsis within your own facility is very important if you're trying to engage your leaders, especially if you need something that's going to make a difference in potentially improving care for those individuals. And again, presenting what the financial cost is to your institution. So if you're a leader within your hospital, a sepsis advocate, a sepsis champion, for instance, and you're trying to make a case that maybe you're engaging leadership because you need IT support. Maybe you don't have protocols that are in place and you need some protocols built or you need to build order sets. Another reason why we may want to engage leadership is maybe we need a research coordinator. Maybe we need a sepsis coordinator, and we'll get into how we can actually design something like that. But I also mentioned very early in the talk that it's not just a hospital issue, sepsis. It occurs across the continuum of care. So maybe you want to align yourselves with the community. So where do you discharge your patients to? Which rehab facilities? Which long-term care and short-term care? Maybe you want to align yourselves so that the burden of sepsis is not on one particular institution, but you're sharing it, trying to figure out ways to actually decrease the burden, the financial costs, and decrease mortality, but engaging multiple institutions to make that happen. So we realize that the patient is in the center of what we all do in health care. You know, we're focusing on the burden. We're focusing on financial implications. But in the end, we're really trying to take care of patients and their families. And what's important to patients and families is their hospital experience. You know, for instance, patients want to know that if they come in through the emergency department through discharge, are they going to receive the same care, the same level of care as they transfer from one unit to another? Are they going to receive the three-hour bundle and the six-hour bundle, whether they're in the emergency department or the ICU? So again, it's pretty much about the experience that they have. Are we educating patients on potential complications after their discharge about post-sepsis syndrome? Are we letting patients know that they're at risk for readmission so they can be aware and their families, are they aware of the signs and symptoms of sepsis, and do they even know what sepsis is so that if they can reach out to a health care provider to help decrease the readmission, are we providing that information? And then we think about, is it enough that we discharge patients to a facility or home? Are we thinking about the quality of life that patients experience after sepsis? Some patients experience sequelae. It could be that they're on a long-term or short-term ventilator after hospital discharge or dialysis, or maybe they're not able to take care of themselves, complete their ADLs. In the end, I think the most important thing to patients and families is they return to what they consider a normal life, and that really is our goal, to provide quality of care to our patients in the best way we can. And the reason I'm talking to you about patients and families is because I think that's a way potentially to engage leadership. So if you're thinking about, you know, maybe you need that order set, maybe you want to have an order set building or trying to engage leadership into providing that support for your department. So maybe you need to develop a business plan to engage hospital leadership. And again, we need leadership commitment in order to make change and improve outcomes for our patients with sepsis. So you need to reach out to the C-suite leaders. In our experience, whenever we were involved with a performance improvement program, even a statewide program or something that was more national, we always had to have leadership commitment because we knew we were going to make changes and we didn't want to hit barriers. We wanted to be able to go to the leadership who supported us and say, you know, we're moving on. We need help. We need IT support. So again, we reached out to our CMO, but you may have other leaders that may be more appropriate for what your needs are. You want to make sure that you have sepsis champions. So there may be one sepsis champion for your institution, but it's important to have unit-based champions as well because, again, reminding ourselves that sepsis is not an ICU issue, it's not an emergency department issue, it is across the continuum of care. And then thinking about the importance of a multidisciplinary team to actually drive the program forward. So when you're creating a business plan, you need to have a community of people that are giving information and providing information and supporting this concern and quality improvement initiative. So you want members of various departments. So for instance, in a hospital, you want the emergency department, the ICU, hospitalists, medical, surgical, even surgeons, because sepsis happens with surgical patients as well. And then try to figure out how that multidisciplinary team can actually provide information to you to actually create this business plan and, again, present that to the leadership of your institution. When I talk about the patient stories, that is another important way to actually help you with your potential plan. You know, if you're presenting to the board, for instance, you have that five minutes, sometimes just presenting a patient story, talking about the challenges that you may have experienced with providing care for an individual versus what it looks like when you have successful, timely, effective care for patients with sepsis. So, for instance, if you don't have a protocol in place, maybe you're going to see fallouts in specific elements of the bundles that are actually going to impact care. Again, we want to deliver timely care and appropriate care as soon as feasibly possible when we recognize sepsis. So having a leadership understand this through a patient story may actually be helpful. You know, you can present a positive story and potentially one that has challenges just to show the difference. Again, there may be significant outcome differences, and maybe that will also help contribute to your business plan as well. When you develop your brief presentation, I think one of the important things is just to have three things that you're going to talk about. So what you know at the center, how you're going to engage the institution as you're talking about sepsis, that's what you're passionate about. We're going to use an example of, say, you want to hire a sepsis coordinator. You know, you don't have one in your institution, but you've heard from other people out in the sepsis world that they have sepsis coordinators, and that's very helpful. So say your goal is to hire a sepsis coordinator, and then you have some aims. What do you need to do, and what is the sepsis coordinator going to do? So some of the things that the sepsis coordinator can do is educate staff. We have a lot of staff turnover. Again, someone mentioned that, you know, we have a lot of nurses that are new. We have residents that turn over every year. There's constant education that needs to be done. This is a good opportunity to hire a sepsis coordinator. They can review cases and identify areas for improvement, organize compliance with national measures, and then you can say, okay, what do I need to hire this person? You know, what are the logistics around that? How can I collaborate with human resources to get this done? Maybe you're willing to accept a part-time person. Maybe they're willing to give you a full-time person, but again, trying to tie your presentation to what's important to your institution as far as a mission and vision is really important, but trying to keep it brief and three particular points I think is helpful in engaging leadership. So some of the hints I have for you is, you know, you really need to tie your business plan, so whatever it is that you need. Not everything has a financial piece to it, and maybe you want to collaborate with those community facilities outside, so where your hospital discharges patients to. Maybe you want to collaborate with them. It's not necessarily going to cost anything other than time, but again, you want to make sure that your business plan is within the organization's strategic objective. So you want to be in line with the hospital's mission and vision, and that helps because you can kind of pose to say, this is in line with what we want to do as far as decreasing mortality and improving outcomes for our patients. You also want to make sure that you address key stakeholders, so that multidisciplinary team that you have, you can kind of send them out as investigators to understand what individuals want clinically to improve care for patients with sepsis and what the business leadership is looking at. So understanding some of the financial implications, as Craig had mentioned, that, you know, there's a significant cost of caring for these individuals, so when you think about it on a national level of billions of dollars, it's also very high up there for institutions and caring for patients with sepsis. So trying to align all those different things when you're presenting to leadership is very helpful rather than just presenting a problem or something that you want. Just trying to tie it into their strategic objectives is also very helpful. Lastly I just want to mention that having leadership support is a cultural being. So when we think about, you know, the Joint Commission, and this is from a paper talking about sentinel events and how hospital leaders, it's so important to have a culture of safety where the leadership is supporting a culture of safety and the employees are supporting a culture of safety. So what leaders do is what the staff will follow. So if our hospital leadership is supportive of improving outcomes for patients with sepsis, not only discharging them from the hospital, but improving their overall outcomes and quality of life, the organization that supports those leaders will follow their lead. And again, establishing a safety culture I think is key in engaging not only leaders, but the employees of that institution as well. So my take home messages are when you think about engaging leaders, think about sepsis across the continuum, ensure that you're showing that there's value to the institution by aligning with their strategic values and provide rationale as to why this is important to the institution. Again, pulling some of that information that Craig had mentioned about the burden of sepsis. So why is this important? And what data do we have, not only nationally and globally, but what information do we have within our own institution that will tell us that we need to do something different? We need to improve the care that we're delivering to these patients in our own institution. And I gave you some tips on how to propose a business plan. If you need support, you need resources, you need a pharmacist, you need sepsis coordinators, or you need to build order sets, just think about how you can get that. It does take a little bit of time, but I think engaging leadership and aligning with the mission and vision of your institution, I think is the way to go. So with that, I thank you so much for your time. There's some resources here, again, I don't have, didn't have a lot of literature, research literature on engaging hospital leadership, but these are some resources that you may be find useful. And with that, I'm going to pass it off to Judy Jacoby, talking about how technology can contribute to sepsis prevention. Judy? Yes. Thank you very much. I'm happy to wrap up this discussion with several new challenges. You know, you think you have your sepsis plan in place, but the world is evolving rapidly. So I'm just going to touch on some of the technology that may assist you in your patient identification as well as data collection. Now I'm not an IT specialist, but I, like many of you, struggled with maintaining a high quality sepsis care as part of a sepsis team. And while we felt like we put a lot of data into the electronic health record, it was often a daunting challenge to get anything back out. And so I'm excited about the potential of new technologies, but at the same time, a little bit terrified as well, because it's evolving so rapidly and really none of us are trained in these specialized areas, but anything we can do to decrease workload and the task burden while improving care is going to be beneficial. I have nothing to disclose other than the fact that I'm not an IT specialist. And so, you know, really what you need to look at is what kind of organizational strengths do you already have that you can build on, or what are your weaknesses that new technology can help augment? Now in the whole area of sepsis care, it's not a surprise to anyone that this is really a process, a quality improvement project. And it goes back to the Right Care, Right Now philosophy of the Society of Critical Care Medicine in terms of finding ways to promptly deliver care that's effective, get a consistent response and measure what you accomplish so that you can improve. And as you can see, inserting in some of the new technologies, such as the general umbrella of artificial intelligence or, you know, machines that can think and process more like humans to subsets like machine learning that can look at a specific data set or groups of data sets and follow a process to help answer a question. With all of the factors that Krista so elegantly described in terms of what we need to accomplish with our healthcare teams, patient inclusion, who we're studying, so that we can really make it, you know, as easy for our caregivers to get the best results. Now as I said, everything's always evolving and so it's not just sepsis, it's healthcare in general. And we're using the 2021 Surviving Sepsis Guidelines. They kind of focused on a one-hour bundle for the most critically ill patients. And so putting a highlight on being able to identify those patients as rapidly as possible and then mobilize your response team. But, you know, there were some concerns about that being likely to lead to excessive antimicrobial prescribing and so clearly less ill patients have a little bit more buffer in terms of time. But you really have to evaluate some data to really know where you stand. And Craig presented the Townsend data and the New York data about SEP1, the sepsis measure. And it's important to note that the measure that we've been using is now proposed to become part of our value-based purchasing program by the Centers for Medicare and Medicaid Services in 2026. And so if you didn't have motivation to start to really measure your data or at least evaluate what's currently being proposed, this is certainly some extra incentive. And knowing your data, again, as Krista discussed, makes this program very valuable to your institution financially and all the other reasons that she explained. And so as she said, you really need that functioning sepsis team, ideally with a champion. And as we'll talk about, the most brilliant technology in the world isn't necessarily taking care of patients. You still need that action-packed group that's going to make sure that what you want to accomplish still happens in a timely basis and get that urgency to make it happen on a consistent basis. So, you know, we all started with things like order sets, and they're incredibly helpful. If you haven't looked at yours in a while, it's a good time to look at it because you want to make sure that at the very least you have the proper elements for SEP1 that you are currently measuring, knowing that it's just going to become more important in the future. Dale and his group looked at patients with sepsis, and they found in a large health system of many hospitals in the Pacific Northwest from 2020 to 2022 that they only used it about half the time. So here's a huge opportunity, and perhaps your compliance is lower than what you would like. They did find, though, that the patients who were treated with that order set, looking at some very specific measures, there were a variety of benefits associated in terms of patient outcome, hospital durations, and importantly on multivariate analysis, a lower mortality. And so one of the important triggers that you can think of beyond the fact that you've used the order set is that it then gets the proper team people involved, gets the proper components taken care of, and ideally then leads to better outcomes in the long run. Now obviously we have to be able to identify these patients in a timely fashion and this is where some of the new technology has really just begun to show some important benefits. It's just a little daunting because there are now a variety, and the list grows every day, of scoring systems for severity of illness. And I've listed some of them here, a variety of early warning scores. Of course we know about the first phase systemic inflammatory response system and we all did checklists and SOFA scoring then to assess severity of illness. These tools are going to be very beneficial but not universally, right? And it really depends upon what kind of data you are able to present to your informatic system in order to get the best response. Now the surviving sepsis guidelines didn't recommend a specific scoring system in 2021. Perhaps that will be on their agenda for their 2025 update. But other than to say that the QSOFA was one that they did not suggest as a screening tool. So just to quickly look at some of those electronic warning scores. Once you set it up, one way you can test it is to put it to an existing database and there are a variety of databases available to test that on. And this was a retrospective assessment of patients from the general ward, right? So these are patients who weren't otherwise recognized as sick enough to be in the ICU. They excluded surgical patients and looked at a big body of data and compared it to how those patients were evaluated clinically real-time. And what they found is that the NEWS and the NEWS2 score systems worked pretty well and similarly and perhaps better than the other scores for sepsis identification and similar to the SOFA score in mortality prediction. So do these always work? Well it depends again on your patient population and what data is there in your database. The EPIC sepsis model got negatives and positives in some of the literature. A retrospective very large evaluation at Michigan Medicine suggested that the EPIC sepsis model did not do a good job at identifying patients with sepsis. In fact it missed 67% of the patients that they were ultimately coded as sepsis. Where a much smaller study in Cleveland found that indeed they did see some benefits with the EPIC sepsis warning early warning system related to timing of the alert to initiating antimicrobials. Unfortunately all this retrospective data is you know going to have a lot of noise in it potentially and depending upon exactly what kind of sepsis program was in place for the patient population that's being evaluated it may influence it. So the TRUES study with prospective data so the targeted real-time early warning system a huge number of patients were evaluated prospectively and again a big health system and they felt like they had a relatively low severity of illness of these patients and but they did see that seven percent of this large number of patients triggered an alert but again on comparison to how they were actually coded and they did not all have sepsis. So one of the considerations is false alerts and then timing of the alert. Did the alert come before you already ordered antibiotics in which case it's going to be helpful to help move the system along faster or did it come later when you've already figured it out on your own. And similar to the data presented previously by Craig they did find that if they were able to shorten the time to antimicrobials it appeared to be beneficial they similarly had an increased risk of mortality for every hour delay to antimicrobial prescribing. So it's challenging for a clinician to say well gosh you know how do I go advocate for a specific program or how do I know if what we're using is effective and again you're just going to have to go back and look at your data and evaluate in the literature how some of these early warning systems are being tested and there's a large number of existing ICU databases that can be used to test these but potentially the way the future might be in silico trials that do a variety of different sensitivity alterations to change the variables in the testing model. What it really comes down to though is the importance of data scientists within your health system setting and if they aren't available in your own institution perhaps you're in a smaller facility finding ways to work with the whole electronic health record you know if it's a big company they ought to be able to help you with that process. So that's an important new group of not necessarily new but evolving technology that we think will be important. Now artificial intelligence I mentioned is you know something that honestly you know many of us use a component of every day if you've ever used Grammarly to fix the punctuation in something you've written that's a form of artificial intelligence. So there's subtle forms of it everywhere. What we're talking obviously is on a much grander scale and so a very important paper in a recent issue of the most recent issue of Critical Care Medicine gives a nice really elegant and clear overview of how you could potentially approach artificial intelligence implementation. So starting over on the right we've all got data start you know we've got layers and layers of data. The question is is any of that data integrated and do you have a process to go out and get more than what's in the electronic health record in terms of labs and vitals? Can you get a components of radiology? Can you get a variety of other inputs such as a sensor that a patient may be wearing or other new technologies? And you know can that data be effectively harmonized because it might not all agree. Can these devices as they interface go to the top later layer and generate data right? Can a specific group of signals automatically say hey draw this lab or order the lab for you? Now obviously you don't want a lot of extraneous labs but you know there are ways to streamline the process that a human doesn't need to be involved. And so again in between there's a variety of machine learning models that can again assess specific databases and help to answer specific questions. But you know again at the policy level you know who's going to carry out what needs to be done? Will it fit your workflow? What are your financial or legal constraints behind having all of this happen? And at the ultimate component though you still need that behavioral layer where clinicians are interacting evaluating patients. All the studies looking at things like order sets have suggested that if you get an alert and don't respond to it in a timely fashion it doesn't help patient care. And so you need that effector cell the rapid response to really carry this out. Now once you have or start to implement some of these new things over on the left side you know how do you know if it's helping you? And so you can do some real-time case reviews. You know you have a patient with sepsis. Let's go look at that individual patient and see how the system helped us. You can put something in place behind the scenes as a silent trial and evaluate larger groups of patients where you're not influencing clinical care. Or you can do some rapid cycle testing to put it in place and see you know how it compares historically. Maybe make some changes and continue to review and process. As I said data doesn't have an impact on its own and we learned this with the rapid pathogen or bacterial identification systems that you know if you if you don't have somebody to help you change antibiotics or motivation to change antibiotics the patient care is not going to change. And at the same time we know that extraneous alerts and alarms are only going to slow down the care our patients already need in a workload overload situation that many of our healthcare providers are in. So again it's setting up a process as Dale said make it ridiculously easy to do the right thing. So set up a system that works for people so that they're willing to use it. That your teams work together for this continuous improvement. Start to educate yourself on these new data systems. Work toward getting enough support in your institution for the data scientists, informatics specialists, and then finally implementation scientists that you need. And one of the handouts with this program is an implementation science for sepsis program. And so you'll see that as part of the materials that we have here. So thank you that concludes our formal comments and now hopefully we'll have a little bit of time for question and answer. I'll turn it back to Susan. Thanks so much. We have a couple of questions. We should be able to get to them. One of the questions is if we found an early indicator of sepsis could the outcomes be improved? Are there any promising biomarkers for early detection including digital biomarkers? What anyone in anyone can answer. So the early warning systems are going to be based on a growing number of measures. I think in some of the very preclinical data there are a variety of biologic markers that have been identified as potentially being helpful. And they're going to be need to tested need to be tested in larger populations prospectively to really demonstrate their benefit in larger populations. But there's active research going on in that. Craig is the research arm of surviving sepsis. Any thoughts on specific things you've seen? Yeah so there's about 10,000 different strategies right now. None of which are yet generalizable. None of which are yet ready for prime time. And they range from the incredibly complicated things like transcriptomics and genomics and epigenetics to much more straightforward things like just looking at 27 different things you can find in electronic medical record to the simplest vital signs trajectories. Just looking at vital signs over the first eight hours of somebody in somebody's in the hospital. They're likely looking at different patient populations. The goal is ultimately to get to a identifying people earlier and be precision medicine when you do. And it will be exciting probably 10 to 15 years from now as we can do what we do hopefully with the weather. Which is to say I've looked at the weather report four hours from now it's going to rain. And so if you're an umbrella carrier you'll get an umbrella. And you see that before the sky turns black. But we're not there yet. Lots of tremendously exciting stuff not just on mice it's pretty easy to cure mouse sepsis. But on people you know waveforms and the such. But none of them is ready for prime time yet. Thank you both of you. We have two comments and I will mention each one and then have some one of you respond. One challenge is the reimbursement and denials by private insurance payers without set three criteria being met. So does anyone have any response to that? So it's certainly not an easy question to answer. I know that there are payers that are looking at compliance with the SEP-1 measures. And there are a variety of reasons potentially why the measures aren't met. So it is quite complicated. I think the SEP-1 measures are guidelines on how we should be treating patients. But there are situations sometimes where we're not able to meet those certain measures by a specific time. And it's oftentimes very difficult to explain that in forms that are check boxes. Again and even the guidelines. I mean the guidelines are guidelines but they don't necessarily fit every single individual. So I think in the end I think our goal really as clinicians is to deliver the best care we can to these patients in the most appropriate time period. So as soon as the patient you know has signs and symptoms of sepsis the goal is to give the patient the appropriate treatment at that particular time. But also know that there are certain situations that are sometimes out of our control that you know are patient related or you know situationally related that unfortunately not we can't meet those goals 100% of the time. But again I think you really need to look at your institution specifically and see what your compliance is and see if there's areas for improvement. Because I think overall the compliance with the SEP-1 measure is you know about 60%. So we're not even close to 100% in the U.S. But again I think you just need to look at your specific institution and see if there's areas for improvement that potentially you're maybe you're consistently missing specific elements of the sepsis SEP-1 measures. And as those become part of value-based purchasing obviously that impact may become greater. But you know there's always going to be circumstances that for whatever reason the clinician didn't feel that the volume goal was appropriate for that patient. So what you need then is the appropriate documentation to say I've not done this because. Yeah I think you want to be able to pass the mirror test. Which is if you look at some like you look at the management can you look yourself in the mirror. And there are patients who you can look at retrospectively and say you know what we could have done better. We should have done better. And then the idea is not to get upset at a reimbursement. The idea is to get to everything that Judy and Krista were talking about. Which is how do we do better in my own institution? How do we change practice? And there's going to be the 10% or 20% it's not higher than 20% who just don't quite fit. Everybody will have the same discussion. How about if my patient is an EF of 10%? How about if my patient is an end-stage renal disease? And then you do exactly what Judy just said. You document why you're not going to do a specific element. You're still going to give. You're still going to drop cultures. You're still going to check a lactate and everything. Maybe you're not going to give 30 cc's per kilo for a specific reason. Document it. Either way you can look yourself in the mirror. Are we doing the best we can? And if the patient doesn't exactly fit, document why you're doing the best for the patient sitting in front of you. Yes, thank you. One last question. Any advice on how to pull clinicians out of the weeds in their resistance to following best practice recommendations or using order sets? For example, there is skepticism in their institution on the selected news tool or the second lactate. And this is justification for engaging in any protocol approach. So how might they override the skepticism of clinicians? Again, honestly, scorecards for individuals often are an effective way to communicate. Your colleague used the order set X number of times and their patients had Y result compared with yours. And not that this needs to be advertised that everyone can see it, but certainly the individual clinician. I think a lot of it comes to looking at financials associated with sepsis. If their hesitance is that I'm going to spend money on one extra lactate test when your hospital could be losing millions or billions of dollars with a poor result and the patient burden of that. That certainly is one potential mechanism. And peer pressure otherwise is often an important tool. Thank you. I definitely agree with Judy. I think data is valuable, especially if you're trying to make a specific point and you're trying to provide concrete information. This is the information I have on this specific patient population. And as far as drawing a second lactate, sometimes the patient actually gets worse before they get better. So drawing a second lactate is not only to see if the first lactate decreased, but it also could be an indication that your patient is actually getting worse. So there are a number of patients where the lactate increases. So missing that, I think, would be a detriment to that particular patient. But sharing data, I think, is the best way to educate clinicians. And again, not every person is going to be 100% on board, but the best thing you can do to engage leadership and staff is to provide the information as to why we're doing what we're doing. And this is the data that supports it. And again, Craig and Judy both gave a significant amount of information I think anyone could use in their institution to support why we need to do the things that we're doing currently. Yeah, culture change is hard. You know, Krista talked about that culture change is about the hardest thing there is to do. But also overcoming misconceptions is hard. If you ask most clinicians, are you a below-average clinician, the same number of people are going to say I'm a below-average clinician, or even less are going to say that I'm a below-average driver. If you ask people, are you above-average driver, 95% of people will tell you they're above-average, which means that 45% of people are misperceiving how well they drive. It's the same thing. Everybody believes they're fantastic. Everybody believes, no, I can do a masterpiece. The bundles, the guidelines, they're for somebody else. I really know what's best. And study after study after study shows the same thing, that if we actually follow simple, basic things, it changes outcomes. And no matter how smart you are, A, maybe you're not as smart as you think, but standardized approaches with the understanding that you can intermittently say this particular patient is not different, not a hundred out of a hundred are different. It's culture change. It's hard, but it's worth doing. Thank you very much. That concludes the question-and-answer session. I'd like to again thank Craig, Krista, and Judy for their contributions and passion about this topic, and thank the audience for attending. Again, the webcast has been recorded. The recording will be available to registered attendees within five to seven business days. Again, to access this recording, log in to mysccm.org, navigate to the My Learning tab, and click on Engaging Healthcare Leaders in Sepsis Prevention course. You will find the handout or the toolkit, evaluation, and recording of the course section. Remember to check out the companion podcast on the SCCM Diagnostic Excellence Program webpage, which will be available, well, it's available now at 2 p.m. Central Time. The podcast is available and will also provide 0.25 hours of accredited continuing education credits. Keep an eye out on other resources that will be available on the SCCM Diagnostic Excellence Program page. And that concludes our presentation for today. Thank you, everyone. Thank you. Thank you for the opportunity. Thank you. My pleasure.

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