Intervention:
Sepsis
Date:
Thursday, May 8, 2014
Sponsor:
•Canadian Patient Safety Institute
•Canadian ICU Collaborative
Speakers:
•John C. Marshall, MD FACS, St. Michael’s Hospital, University of Toronto
Purpose of the Call:
Provide update on the Surviving Sepsis Campaign
2. Your Hosts & Presenters
Vos hôtes et présentateurs
Bruce Harries, Moderator
Denny Laporta, MD, FRCPC, CSPQ
Ardis Eliason, Technical Host
John C. Marshall, MD, FRCSC, FACS
208/05/2014
3. Interacting in WebEx: Today’s Tools
Interagir dans Webex : outils à utiliser
3
Be prepared to use:
- Pointer
- Raise hand
- CHAT
- Text Tool
“writing on the slide”
- Shape Tools
Have you used WebEx before?
Avez-vous déjà utilisé WebEx?
YES / OUI NO / NON
Soyez prêts à
utiliser les outils :
- le pointeur
- lever la main
- clavardage
- Outil textuel
pour « écrire sur la
diapo »
- Outils de forme08/05/2014
Type your
message
& click
‘send’
Select
‘send to’
5. What professions are represented?
Quelles professions sont représentées?
Nurse MD
Educator / Quality
Improvement
Professional
Infection
Control
Administrator /
Senior Leader
Other
POINTER
Respiratory
Therapist
Nutritionist
508/05/2014
6. Dr. John C. Marshall
Surviving Sepsis: State of the Art
7. The Surviving Sepsis Campaign:
State of the Art
St. Michael’s Hospital University of Toronto
John C. Marshall MD FACS
Safer Healthcare Now
May 8, 2014
9. • Definitions
• Diagnosis of infection
• Antibiotics
• Hemodynamic support
• Source control
• ICU care
• Adjunctive therapies
• Novel therapies
10. Phase 1 Barcelona declaration
Phase 2 Evidence-based guidelines
Phase 3 Implementation and
evaluation
11. A global program to reduce
mortality rates in severe sepsis
ESICM, ISF and SCCM
Partially funded by unrestricted educational grants
from Baxter, Edwards, Philips and Lilly
12. Sponsoring Organizations
• American Association of Critical Care Nurses
• American College of Chest Physicians
• American College of Emergency Physicians
• American Thoracic Society
• Australian and New Zealand Intensive Care Society
• European Society of Clinical Microbiology and Infectious
Diseases
• European Society of Intensive Care Medicine
• European Respiratory Society
• International Sepsis Forum
• Society of Critical Care Medicine
• Surgical Infection Society
19. American Association of Critical-Care Nurses
American College of Chest Physicians
American College of Emergency Physicians
American Thoracic Society
Canadian Critical Care Society
European Society of Clinical Microbiology and Infectious Diseases
European Society of Intensive Care Medicine
European Respiratory Society
International Sepsis Forum
Society of Critical Care Medicine
Japanese Association for Acute Medicine
Japanese Society of Intensive Care Medicine
Surgical Infection Society
Participation and endorsement by the German Sepsis Society and
the Latin American Sepsis Institute.
Sponsors 2006
47. “Early versus late necrosectomy
in severe necrotizing pancreatitis”
Number Mortality
Early 25 58%
Late 11 27%
- Mier et al Am.J.Surg 173:71, 1997
48. Improving Sepsis Care
• Recognition
• Resuscitation
• Diagnosis and treatment of
infection
• Physiologic support
49. Ventilation with lower tidal volumes as compared
with traditional tidal volumes for acute lung injury
and the acute respiratory distress syndrome
Mortality
(%)Controls 39.8
Volume-limited 31.0*
ARDSNet; NEJM 342:1301, 2000
*P=0.007
50. Impact of Fluid Strategy in ARDS
Conservative Liberal p.
(N=503) (N=497)
60 day mortality 25.5% 28.4% 0.30
Ventilator-free days 14.6±0.5 12.1±0.5 <0.001
ICU-free days 13.4±0.4 11.2±0.4 <0.001
CNS failure FD 18.8±0.5 17.2±0.5 0.03
- ARDSNet, N Engl J Med 354:2564, 2006
56. • Global process change initiative
based on “sepsis bundles”
• 15,022 patients enrolled
• 7% absolute, 5.4% relative mortality
reduction (p<0.001)
Surviving Sepsis
Campaign
57. Unadjusted
Risk-adjusted
Bundle target Population N
OR p-value
OR 95% CI p-value
Measure Lactate All 15,022
0.86 <0.0001
0.97 [0.90, 1.05] 0.48
Obtain blood cultures before
antibiotics
All 15,022
0.70 <0.0001
0.76 [0.70, 0.83] <0.0001
Commence broad-spectrum
antibiotics
All 15,022
0.78 <0.0001
0.86 [0.79, 0.93] <0.0001
Achieve tight glucose control All 15,022
0.65 <0.0001
0.67 [0.62, 0.71] <0.0001
Administer drotrecogin alfa Multi-organ failure 8,733
0.90 0.26
0.84 [0.69, 1.02] 0.07
Administer drotrecogin alfa Shock despite fluids 7,854
0.91 0.30
0.81 [0.68, 0.96] 0.02
Administer low-dose steroids Shock despite fluids 7,854
1.06 0.18
1.06 [0.96, 1.17] 0.24
Demonstrate CVP ≥ 8 mm Hg Shock despite fluids 7,854
1.08 0.10
1.00 [0.89, 1.12] 0.98
Demonstrate ScvO2 ≥ 70% Shock despite fluids 7,854
0.94 0.24
0.98 [0.86, 1.10] 0.69
Achieve low plateau pressure control Mechanical ventilation 7,860
0.67 <0.0001
0.70 [0.62, 0.78] <0.0001
58. - Kaukonen et al JAMA 2014
Survival in Sepsis is Improving
59. Conclusions
• The SSC has raised awareness regarding
sepsis management and defined
optimal approaches to care
• This has been associated with improved
survival
• But the elements responsible for that
improvement need further study
63. 63
aC3KTion Net
• Network of ICUs (Networks) from across
Canada
• Academic
• Community
• Primary activity will be Knowledge Translation
and development of Critical Care Knowledge
Synthesis products
• Not KT Research
• Measurement of uptake/outcomes
64. 64
Network Activities
• Measurement of current practice
• Knowledge Synthesis: Development of clinical practice guidelines,
evidence syntheses and scoping reviews.
• Testing of Knowledge Products: Reviewed and tested before
implementation, to ensure acceptability, ability to achieve intended
purpose and ascertain possible barriers
• Knowledge Implementation: Local teams will use strategies/tools
tailored to knowledge product.
– Education, protocols, checklists, order sets, organizational changes and
reminder systems
– PDSA cycles to track implementation activities
65. 65
Even when motivated to change our behavior, we
cannot manage what we do not measure.
Measurement can identify gaps in best practice.
Measurement can illuminate the results of our
efforts at implementing best practice.
Measurement can inform future research direction.
Measurement- Why?
66. Model for Participation
• Main benefits of participation
– Access to KT activities/initiatives
– Access to KS products
– Access to educational events/webinars
– Access to a repository of knowledge products, protocols etc.
– Opportunity to participate in incubator units
– Ability to influence network activities
– Benchmarked reports of performance with national peers
– A vehicle to drive critical care quality improvement
• ICUs provide periodic data in return
66
67. Current Status
• Baseline Data Collection
– Started and ongoing. Site recruitment ongoing.
• Development of barriers/enablers
Questionnaires
– Completed
• Repository of KT tools/Products
– Being populated
• KT activities
– Slated for 2014
67
69. Canadian ICU Collaborative
Faculty
Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital
(McGill University), Montreal
Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary
Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre
Leanne Couves, Improvement Advisor, Improvement Associates Ltd.
Maryanne D’Arpino, Patient Safety Improvement Lead, CPSI
Bruce Harries, Collaborative Director, Improvement Associates Ltd.
Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University
Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology,
University of Western Ontario; Chair/Chief of Critical Care Western
Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre;
John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital
Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium
Guidelines, Society of Critical Care Medline (SCCM)
6908/05/2014
70. Reminders
Rappels
Call is recorded
Slides and links to
recordings will be
available on Safer
Healthcare Now!
Communities of Practice
Additional resources are
available on the SHN
Website and
Communities of Practice
L'appel est enregistré
Les diapositives et liens
vers les enregistrements
seront disponibles sur Des
soins de santé plus
sécuritaires maintenant!
Communautés de pratique
Des ressources
supplémentaires sont
disponibles sur le site Web
SSPSM et Communautés
de Pratique
7008/05/2014