Core elements of sepsis quality. This is going to be interesting. You know, I've been giving day-long seminars on this topic for the last two decades, so to condense it down to 25 minutes, I'm going to have to start talking really, really fast, like one of those auctioneers, you know what I'm saying. You know, I thought, I just read this morning, this is totally not pertinent to the talk. I just read this morning, today is the 50th anniversary of Roe versus Wade, and I just thought, that's an interesting thing to be happening during the critical care congress, and you all know what the implications of the reversal of that may be for us, so we'll just move on. I have no conflicts of interest. You will find that the description in the program, which I didn't get to see until I got here to the meeting is a little bit different from what I'm talking about. But hopefully, hopefully this will be okay. We're going to talk about the evidence base for quality sepsis care, talk about some of the care elements that are key to quality sepsis care, discuss the composition of a sepsis team, and discuss the important functions of a sepsis team. So we're going to start with the evidence, and this is an obvious place to start. It's an obvious place for very good reasons, though. Having participated in two editions of the surviving sepsis campaign panel for the guidelines, I can tell you that these guidelines are comprehensively evidence-based. All of the literature that's come out since the last edition is reviewed carefully. It is graded rigorously by the grade methodology. We use librarians to find everything, methodologists to help us out, and topic experts, which I guess that's the category I fall into. We do our own meta-analyses when there are not high-quality meta-analyses available. You have representation on these guidelines from a variety of specialties and societies and a variety of viewpoints from the specialists, and they are updated every four years, which is some people have said, well, that's a real detriment. They ought to be continually upgraded, and that's probably not humanly possible, but by the time you have adopted what just came out in the last version, we'll get around to putting in what's new. So what are the core elements? I look at this, and these are what I think you would consider, along with me, probably the absolute core elements of the guidelines. Effective screening and diagnosis, as in we want to diagnose sepsis early, but we don't want a high false positive rate, obviously, so diagnosis is important. Treatment boils down to probably the most important things we do, are appropriate and timely antibiotics with appropriate amounts of fluids, and then vasopressors when they are necessary, and then what I was really proud of us in putting into the most recent version, and this was led by Hallie Prescott, led this part of the team, is involving the family in the care that we do and providing close, early, and often follow-up for patients who have survived sepsis. Okay. So what is the very first thing, though, the number one recommendation in the surviving sepsis campaign guidelines is using a performance improvement program. We're going to come back to that. That includes in your performance improvement program specific methods for diagnosing and screening and standard operating procedures, and I'll come back to that point in a bit. Obviously, antibiotics, I'm not going to preempt anything if I say we still do believe that early antibiotics are important. If you think an infection is probable or definite, you should give the antibiotics immediately within an hour. If you're not sure, if infection is on your list of items, but there are other things that also need ruling out, at least if it's still on the list, by three hours you need antibiotics in. That's fairly simple. All of this is to say we pay careful attention to source control. Antibiotics are one of our key means of source control, but if abscess drainage or other procedures are necessary, these should also be achieved in a timely fashion. Fluids, nothing has changed about the fluid recommendation. It remains at 30 mLs per kilogram, and I think Dr. Douglas is going to talk to you in more detail, but these are the guidelines. Now, the key thing about the guidelines, oh, no, I'm sorry, Stephanie, what I think is one of the most important things here is that we have put in assessing goals of care for patients, providing palliative care when appropriate. There's a long list here that our other speakers are going to address, so I'm not going to do that, but I think this is a key component that I hope you will pay attention to in the new surviving sepsis guidelines. The data is emerging. One of your top data-producing experts is going to talk to you momentarily, but nevertheless, this is a key component of quality sepsis care. I would go so far as to say that your program is lacking in quality if you don't have aggressive follow-up of patients who have survived sepsis. So these are guidelines that can't fit every individual patient, but the breadth of care that's put into them, the literature, the review, and the grading requires that if you're going to not do what these guidelines say that you have to have a very good and specific reason for not doing that, and this is how I approach guidelines of all sorts, especially in conditions where I'm not an expert of caring for the patient. I listen carefully because I know that the same care is taken in those guidelines. Again, number one, standard operating procedures and performance improvement. So we're going to turn to performance improvement for a moment. This is a great illustration for me of why I think performance improvement is of high degree of importance. So you guys all know that in May of 2000, the ARDSnet published in the New England Journal their study of 6 mLs per kilogram tidal volume versus 12, and they demonstrated that 6 mLs per kilogram reduced the relative risk of dying by 22.5% from 40 to 31% in so doing. So a number of years later, some of the ARDSnet investigators came back to all of the ARDSnet facilities and said, hey, since we published this, what's happened? What are you doing in your non-study patients or your pre-study patients? And as it turns out, only 31% of the patients in the centers that actually proved that this was useful, this was now four years after they proved that it was useful, only 31% of those centers were actually using what they had demonstrated to be effective and life-saving. So I've always found this to be poignant and go, okay, if the places that showed that it's true aren't even doing what they showed, how are the rest of us doing? And you all know that. And this applies to sepsis as well. So there are three principles that I'd like to adhere to for a high-quality sepsis program. Very first absolutely always has to be that we are patient-centric. We care about what patients care about. Number two would be that we are evidence-based, and we've touched on that for a moment. Number three is that our outcomes and processes are measured. What do we mean by that? So I want you to look at this. This is the right season for this slide. I don't always get to give this in playoff season, but you guys can look at these and you see some familiar logos on here from the NFL. Now, I want you to raise your hand here if you know who won last year's Super Bowl, okay? And now I want you to think about how do you know who won last year's Super Bowl? And a lot of you will go, well, I watched it. That's how I know. I would posit to you that that actually is not how you know who won. How you know is that every time the Rams or the Bengals carried the ball across the gold line, six points were toted up on a board. Every time they kicked the football over the bar, one or three points were added, okay? So why do you know who won? Because they were keeping score, okay? Now, these football teams, this week even, will be doing some things during the week. They'll be running. They'll be throwing the football. They will be tackling each other and blocking each other, and they won't be keeping score. And I want to remind you, what do we call that? Call that practice, right? They call that practice. If you're not, whoa, that's on the next slide. I'll get to it. I just want to say, by the way, how important is it to keep score in sepsis outcomes compared with how important is it to keep score of NFL football games? In your mind, in your heart and mind. In mine, it's much more important. The NFL has a record of the score of every single game that's ever been played. You can go find those. You can find all kinds of things that keep score about. But what I want to remind you is this. If you are not keeping score of your sepsis outcomes, you're just practicing. And I've always found this to be a particular irony because what we call what doctors, nurses, pharmacists, RTs do, we call it practice. Historically, it's always been practice. Well, isn't that interesting? It's time for us to quit practicing and keep score. So to keep score, we have to measure outcomes. And what outcomes do we want to measure for a high-quality sepsis team? So first off, they are outcomes that are of importance to patients, such as what? The ultimate outcome of am I going to get out of this place alive? Okay, that's what they care about the most, initially anyway. Intermediate outcomes that are important, and I can tell you this as an ICU patient myself, that the time you spend in an ICU is important. And the faster you can get out of there, and furthermore, the faster you can get out of the hospital, that's the number one thing on your mind when you are in this position. Secondly, process outcomes. These are important, and you know that a lot of what we talk about in surviving sepsis in the SEP1 measure are process outcomes. The only reason to measure process outcomes is if they contribute to the ultimate outcomes that are of major importance to patients. But that is why we do it. And examples of process outcomes are these. Did we get blood cultures before the antibiotics? Did we give antibiotics within an hour or within three? Did we give the right amount of fluid? So, I'm going to turn for just a moment to what I think, though, is the core of sepsis quality. And Dr. Glaucum-Flecken and Lady Glaucum-Flecken sort of preempted me this morning in their thing because the core of sepsis quality is humanity. We are human beings. These things aren't happening on an automated assembly line by robots. They are happening because we are people, people who need to have empathy and people who need to think long and hard about the decisions we make. And it's best if we do that as a team. I cannot produce sepsis quality at the University of Kansas Hospital by myself. I have to do it in concert with others. So, what are the key components of quality in sepsis as far as the team goes? First, it has to be interprofessional and interdisciplinary. We need more than one variety of person, meaning this is not a team of doctors. However, who has to be on the team because this is the way hospitals work. You do need a doctor. You need a champion, it's called, a physician champion who can relate the information, interpret the technical information and make it relatable to the rest of the team. You need at least a nurse who provides day-to-day leadership and has the knowledge of what actually happens at the bedside after the doctor writes his or her order and walks away. And you need a hospital executive. Now, this is, it feels like anathema sometimes, hospital executives and us don't always get along, but the truth of it is the lights remain on in your hospital because you have hospital executives and administration to do it. Nothing moves in your hospital unless an executive is there to help it move down the line. And so, that's why we need that person on the team. Now, who would you like on the team? That's who must be on the team. Those three, depending on the size of your hospital, in our hospital, we have multiple varieties of doctor, anesthesia, surgery, pulmonary critical care, hospitalist. We have pharmacists, we have respiratory therapists, we have people from our information technology team because, boy, can they make screening easier for us if we know what it is we want to screen. A bunch of docs, we have a multitude of nurses on our team. In fact, our team is actually led by a nurse. But these are who you would like to have on your team. So, what's that team going to do? The things they need to understand, first off, is what are we trying to accomplish? And that, I think, remains in being patient-centered and understanding what things are important to patients. How will we know if we have achieved it? That's the measurement component here. And we need to constantly be thinking about this. What is it we're shooting for? How will we know if we get there or if we're making progress toward it? How will we know that a change is an improvement or that the change actually set us back? Again, measurement is key here. And what can we change that will result in improvement? Now, there are many things. You can look, if you're making the measurements, you can look at the things where you don't think you're living up to your own self-expectations, and you can make a change to them. I don't have a ton of time. In fact, I don't have enough time to go into this in detail. I just want you to know, this has been used in a whole lot of places. You may remember that Toyota was a builder of tin can automobiles in the 1950s and is now the leading automotive manufacturer in the world because they use this technique. It's called a Schuhart-Deming cycle, officially. We refer to it as a PDSA or Plan, Do, Study, Act cycle, or it can be referred to as small tests of change. Implement a test, see what happens, think about it, decide whether you need to stick with what you did or change something else. Do it on a small scale. That's the most that I have time to say about that. Now, the Surviving Sepsis Campaign, Surviving Sepsis Campaign doesn't just talk the talk, they walk the walk, and this is a Surviving Sepsis Campaign initiative that I was privileged to participate in. It was a collaboration between the Society of Critical Care Medicine and the Society of Hospital Medicine. We recognized that we were having difficulties, and still across America, we have difficulties identifying septic patients on the wards, on the hospital floor. Things happen like anchoring on the initial diagnosis and assuming that any signs or symptoms that are coming are because of the initial diagnosis rather than the sepsis that they are at high risk of developing. This was funded by the Gordon and Betty Moore Foundation and we had 60 centers across the US and I was privileged to lead the Midwest component of this. Our motto, our mantra for the people here who were working on the hospital floors was that we are going to screen every patient, every shift, every day. This was manual screening. As you all know, there are more automated screenings that are available, but this was a manual screening. Is that good enough? Hard telling. Every shift may be 12 hours or it may be eight hours and it may be that we need more screening than this, but at a minimum, we were going to do this. We implemented with teams using PDSA cycles, screening tools, bundles, checklists, et cetera. So what were the results of doing that over 2014 and 2015? What we found was that the odds of compliance with a three-hour bundle went up 9% per month over that two years on average amongst the 60 facilities. At the same time, the odds of mortality decreased by 4% per month across those facilities and the odds of being admitted to an intensive care unit with sepsis decreased by 3% per month. In essence, we were intervening, we were finding people early, intervening early and preventing both ICU admissions and death. And by using the same kind of tools that I just have sort of had to race through, as I said, I do this for day-long seminars myself. So let's talk just for a moment before we close about bundled care. Why do we bundle these care? Why is it we've got these five elements that, as you know, are components of both the Surviving Sepsis Campaign and the SEP1 bundle that we all have to report on, and why do we bundle them? Basically, we do that because if you make a checklist of these five things and tick them all off, it ensures that you don't miss key elements that have clearly been demonstrated to affect survival from sepsis. That simple. Now, in some cases, bundles, and I have seen no proof that this is true in sepsis, but I rather still suspect it, that in some instances, when you use all five things, you turn out to have synergy and not just additive effects. This seems to be observationally true in places who go from no sepsis performance improvement to using these tools and completing the bundles. As an example, and this is not bragging on me because it's not me that's achieving this in our emergency department, but I can tell you that since 2004, our sepsis mortalities using these tools at my own hospital have gone from 45% pre-institution for sepsis overall and 70% for septic shock down to under 5% and 20% for septic shock, and that's simply by using what seems to be simple tools. It's not always as simple as I make that sound, but it is definitely true. So just to kind of summarize here, I wanna say that the important, I think the key most important things about sepsis quality are, you'll notice, I keep coming back to this, that they are patient-centered, that we care about what our patients care about, and I think that is absolute number one, and it's what gives you your north star or your true north to shoot for. Your sepsis quality efforts need to be centered in the evidence, and that evidence needs to be graded and interpreted by the people who have capability to do that. There are some core care elements, and I think I've listed them, and I think that's probably why those were the elements that were chosen for this session that you're going to hear more about. You need to do this with a team, measure the important data, and implement small tests of change, and then last but not least, go Chiefs. Thank you.

sepsis quality care

evidence-based guidelines

screening and diagnosis

timely administration

patient's family involvement

performance improvement program