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![CCaarree BBuunnddllee:: DDeeffiinniittiioonn
AA ssmmaallll sseett [[nnoo mmoorree tthhaann 55]] ooff
eevviiddeennccee--bbaasseedd iinntteerrvveennttiioonnss ffoorr aa
ddeeffiinneedd ppaattiieenntt sseeggmmeenntt//ppooppuullaattiioonn aanndd
ccaarree sseettttiinngg tthhaatt,, wwhheenn iimmpplleemmeenntteedd
ttooggeetthheerr,, wwiillll rreessuulltt iinn ssiiggnniiffiiccaannttllyy bbeetttteerr
oouuttccoommeess tthhaann wwhheenn iimmpplleemmeenntteedd
iinnddiivviidduuaallllyy
RReessaarr eett aall.. IIHHII IInnnnoovvaattiioonn SSeerriieess 22001122..](https://image.slidesharecdn.com/salon113kasim14-141209110423-conversion-gate02/75/Salon-1-13-kasim-14-00-15-00-paul-fulbrook-4-2048.jpg)
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Salon 1 13 kasim 14.00 15.00 paul fulbrook
- 1. UUssee ooff CCaarreeBBuunnddlleess iinn CCrriittiiccaall CCaarree PPaauull FFuullbbrrooookk,, AAuussttrraalliiaa PPrrooffeessssoorr ooff NNuurrssiinngg,, AAuussttrraalliiaann CCaatthhoolliicc UUnniivveerrssiittyy NNuurrssiinngg DDiirreeccttoorr RReesseeaarrcchh,, TThhee PPrriinnccee CChhaarrlleess HHoossppiittaall,, BBrriissbbaannee AAddjjuunncctt PPrrooffeessssoorr,, UUnniivveerrssiittyy ooff TTaassmmaanniiaa NNaattiioonnaall VViiccee PPrreessiiddeenntt AACCCCCCNN
- 2. Outline Backgroundand definition The ventilator bundle Measures – Compliance and reliability The sepsis bundles – Compliance – Outcomes – Current trials
- 3. Background: EBP •It is imperative that those working in critical care environments examine their practice to ensure that it is evidence-based and of a high quality. • The importance of knowledge-based practice is constantly emphasised, with the expectation that evidence-based decision-making and practice is at the heart of all healthcare (Bonell, 1999). • Evidence-based practice emphasises the use of existing research.
- 4. CCaarree BBuunnddllee:: DDeeffiinniittiioonn AA ssmmaallll sseett [[nnoo mmoorree tthhaann 55]] ooff eevviiddeennccee--bbaasseedd iinntteerrvveennttiioonnss ffoorr aa ddeeffiinneedd ppaattiieenntt sseeggmmeenntt//ppooppuullaattiioonn aanndd ccaarree sseettttiinngg tthhaatt,, wwhheenn iimmpplleemmeenntteedd ttooggeetthheerr,, wwiillll rreessuulltt iinn ssiiggnniiffiiccaannttllyy bbeetttteerr oouuttccoommeess tthhaann wwhheenn iimmpplleemmeenntteedd iinnddiivviidduuaallllyy RReessaarr eett aall.. IIHHII IInnnnoovvaattiioonn SSeerriieess 22001122..
- 5. CCaarree bbuunnddlleess ·The ‘bundle’ concept was developed originally in 2001 by IHI · First described in nursing literature (Fulbrook Mooney, 2003) · Goal: to improve critical care processes · Each element relatively independent · Used within a defined population in one location
- 6. Evidence-based practice Care bundles provide a method for establishing best clinical practice, which is evidence-based. Individual components of each care bundle should be well defined and based on strong science; usually level one or two research. By grouping evidence-based practices together, within a single clinical protocol that guides patient management (or process), the overall quality of care given to critically ill patients will improve.
- 7. Levels of evidence Level of evidence Criteria 1 Strong evidence from at least one systematic review of multiple well designed randomised controlled trials 2 Strong evidence from at least one properly designed randomised controlled trial of appropriate size 3 Evidence from well designed trials without randomisation, single group pre-post, cohort, time series or matched case control studies 4 Evidence from well designed experimental studies from more than one centre or research group 5 Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees (after Moore et al., 1995)
- 8. There should besufficient evidence to support each element of the bundle Each element should be applied to most, if not all, patients
- 9. TThhee vveennttiillaattoorr ccaarreebbuunnddllee · DDeeeepp vveeiinn tthhrroommbboossiiss ((DDVVTT)) pprroopphhyyllaaxxiiss · GGaassttrriicc uullcceerraattiioonn pprroopphhyyllaaxxiiss · HHeeaadd ooff bbeedd eelleevvaattiioonn ((3300oo)) · SSeeddaattiioonn hhoolldd ((sseeddaattiioonn vvaaccaattiioonn)) aanndd aasssseessssmmeenntt ooff rreeaaddiinneessss ttoo wweeaann IInn 22001100,, aa 55tthh eelleemmeenntt wwaass aaddddeedd:: – DDaaiillyy oorraall ccaarree wwiitthh cchhlloorrhheexxiiddiinnee GGoooodd eevviiddeennccee ooff aassssoocciiaattiioonn bbeettwweeeenn VVCCBB iimmpplleemmeennttaattiioonn aanndd VVAAPP rreedduuccttiioonn ((LLaawwrreennccee FFuullbbrrooookk,, 22001111)) FFeeeeddbbaacckk iimmpprroovveess ccoommpplliiaannccee bbuutt HHOOBBEE ccoommpplliiaannccee rreellaattiivveellyy ppoooorr ((LLaawwrreennccee FFuullbbrrooookk,, 22001122))
- 10. PPrroocceessss aanndd oouuttccoommee Process measures are easier to measure than outcome measures, and can be used to provide immediate feedback to clinicians However, it is important to link process measures with their counterpart outcome measures “Outcome measures . . . are ultimately what patients care about” (Berenholtz et al., 2002)
- 11. OOuuttccoommeess Whilst theindividual components of a care bundle each has a strong evidence base, there is, as yet, limited evidence that demonstrates that clustering components in this way improves patient outcome (Fulbrook Mooney, 2003)
- 12. AAllll oorr nnootthhiinnggmmeeaassuurreemmeenntt PPaarrttiiaall ccoommpplliiaannccee nnoott mmeeaassuurreedd AAllll eelleemmeennttss mmuusstt bbee ccoommpplliieedd wwiitthh uunnlleessss mmeeddiiccaallllyy ccoonnttrraa--iinnddiiccaatteedd Management of early severe sepsis • USA, UK, New Zealand Australia (n = 2,461) • Scenario-based questionnaire (MC) given to ED, acute medicine, and critical care doctors • Based on 6-hour resuscitation bundle • Only 2 respondents complied with all SSC guideline recommendations • 81% identified reasons they could not implement at least one of the recommendations Reade et al. Emerg Med J 2010; 27: 110-115.
- 13. CCoommpplliiaannccee Component Overallelement compliance DVT 29/32 = 90.6% SH 9/32 = 28.1% GUP 25/32 = 78.1% HOBE 27/32 = 84.4% Patient 1 on day 1 = non-compliant = 0% Patient 1 on day 8 = compliant = 100% 1 e.g. DVT prophylaxis 2 e.g. sedation hold 3 e.g. GU prophylaxis 4 e.g. head of bed Patient 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Day 1 Y Y Y Y N N N N N N Y Y Y N Y Y Day 2 Y Y Y Y N N N N N N Y Y Y N Y Y Day 3 Y N Y Y N N N N Y Y Y Y Y Y Y Y Day 4 Y Y Y Y Y Y N N Y N Y Y Y Y N N Day 5 Y N Y Y Y Y N N Y Y Y Y Y Y Y Y Day 6 Y Y Y N Y N N N N N Y Y Y Y Y Y Day 7 Y Y Y Y Y N Y N Y Y Y Y Y Y Y N Day 8 Y Y Y Y Y N Y N Y Y Y Y Y Y Y Y Care Bundle Compliance. Y = compliance, N = non compliance Overall Compliance 9/16 = 56.3% 14/16 = 87.5% Total = 90/128 = 70.3% ICU compliance day 1 = 0% ICU compliance day 8 = 50% All or Nothing Compliance
- 14. Run charts CareBundle Component Compliance 150 100 50 0 1 2 3 4 5 6 7 8 Audit Days Compliance (%) DVT prophylaxis Sedation hold GU prophylaxis Bed head elevation
- 15. Run chart: dailycompliance Care Bundle Compliance 120 100 (%) Compliance 80 60 40 20 0 Audit Days Overall compliance Target compliance All or nothing compliance Cumulative T reliability 1 2 3 4 5 6 7 8
- 16. Compliance and outcome • Assessing compliance provides limited information in itself. • Run charts can also be used to demonstrate the impact of interventions on outcome measures. • Assessing compliance against a local outcome measure is more likely to demonstrate the impact of a new intervention. • To demonstrate effective change data would need to be collected for at least six months, and preferably a year. Audit feedback Run chart demonstrating effect of compliance on an outcome measure
- 17. Bundle Reliability Measures of reliability inform teams about the extent of error-free operation of their clinical processes. This measure tells teams how often every element included in the relevant bundle was completed in each patient during the review period. Not following every indicated bundle element in each patient constitutes an error. Defined as the % of cases for whom all applicable bundle elements are completed. The suggested reliability goal for compliance is 95% – Numerator: The number of relevant cases that completed all elements of the bundle – Denominator: The total number of relevant cases
- 18. RReelliiaabbiilliittyy Component 1 e.g. DVT prophylaxis 2 e.g. sedation hold 3 e.g. GU prophylaxis 4 e.g. head of bed Patient 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Day 1 Y Y Y Y N N N N N N Y Y Y N Y Y Day 2 Y Y Y Y N N N N N N Y Y Y N Y Y Day 3 Y N Y Y N N N N Y Y Y Y Y Y Y Y Day 4 Y Y Y Y Y Y N N Y N Y Y Y Y N N Day 5 Y N Y Y Y Y N N Y Y Y Y Y Y Y Y Day 6 Y Y Y N Y N N N N N Y Y Y Y Y Y Day 7 Y Y Y Y Y N Y N Y Y Y Y Y Y Y N Day 8 Y Y Y Y Y N Y N Y Y Y Y Y Y Y Y Care Bundle Compliance. Y = compliance, N = non compliance On days 4 5, only patient 1 was compliant with all 4 elements On days 7 8, patients 1 and 3 were compliant with all 4 elements Overall bundle reliability = 6/32 = 18..88%% If reliability 95% in any month, teams should identify which specific bundle elements are not being reliably executed.
- 19. SSuurrvviivviinngg SSeeppssiiss AAgglloobbaall pprrooggrraamm ttoo:: RReedduuccee mmoorrttaalliittyy rraatteess iinn sseevveerree sseeppssiiss • Sepsis Resuscitation Bundle: Tasks that should begin immediately, but must be done within 6 hours for patients with severe sepsis or septic shock. • Sepsis Management Bundle: Tasks that should begin immediately, but must be done within 24 hours for patients with severe sepsis or septic shock.
- 20. NNuurrssiinngg ccoonnssiiddeerraattiioonnss AAiittkkeenneett aall 22001111 DDeellpphhii ssttuuddyy bbaasseedd oonn SSuurrvviivviinngg SSeeppssiiss CCaammppaaiiggnn gguuiiddeelliinneess GGRRAADDEE uusseedd ttoo rraattee qquuaalliittyy ooff eevviiddeennccee 6633 rreeccoommmmeennddaattiioonnss ddeessiiggnneedd ttoo ccoommpplleemmeenntt SSSSCC gguuiiddeelliinneess RReesseeaarrcchh nneeeeddeedd uurrggeennttllyy – RReeccooggnniittiioonn ooff ddeetteerriioorraattiioonn//ddiiaaggnnoossiiss ooff sseeppssiiss//eeffffeecctt ooff eeaarrllyy rreessuusscc mmeeaassuurreess – MMeetthhooddss ooff hhaaeemmooddyynnaammiicc ssuuppppoorrtt//aasssseessssmmeenntt – TTyyppee aanndd eeffffeecctt ooff ssuuppppoorrttiivvee ccaarree ee..gg.. pprreessssuurree iinnjjuurryy pprreevveennttiioonn – AApppplliiccaattiioonn ttoo ppaaeeddiiaattrriiccss
- 21. Sepsis bbuunnddlleess:: mmeettaaaannaallyyssiiss CChhaammbbeerrllaaiinn eett aall 22001111 22000044-1111 2211 sseeppssiiss bbuunnddllee ssttuuddiieess:: ttoottaall nn 2233,,443388 SSuurrvviivvaall bbeenneeffiitt:: – 66hhrr rreessuusscc bbuunnddllee == hhiigghheesstt bbeenneeffiitt:: OORR 22..1122 ((1111 ssttuuddiieess;; nn == 11,,881199)) – 2244hhrr bbuunnddllee == lloowweesstt bbeenneeffiitt:: OORR 11..6655 ((55 ssttuuddiieess;; nn == 1166,,552211)) – CCoommbbiinneedd bbuunnddllee bbeenneeffiitt:: OORR 11..7744 ((1122 ssttuuddiieess;; nn == 55,,009988)) – SSccvvOO22 7700%% bbeenneeffiitt:: OORR 22..0055 ((55 ssttuuddiieess;; nn == 1111,,553300))
- 22. CCoommpplliiaannccee MMoorrttaalliittyy22001133 Autho rs Setting Design n Measures Reported compliance Mortality Almeida et al., 2013 Portugal 1 ICU Prospective cohort 300 · 6h compliance · Compliance of each element · Day vs night compliance · All or nothing compliance 2% · Element compliance range 4-100%. · Element compliance better at night Hospital mortality · day 40% · night 34% Chou et al., 2013 Taiwan 1 ICU Before and after study: 4 phase (modified bundle) 55, 30, 26, 53 · 6- and 24h compliance · All or nothing for both bundles · Before 20% (phase 1) · After 79.2% (phase 4) Hospital mortality · Before 43.6% · After 10.0% · (lactate mortality OR 2.2) Miller et al., 2013 USA 11 hospitals 18 ICUs Prospective cohort (3 phase) 4329 · Combined 6h- and 24h bundle · “All-or-none compliance…non-compliance with any single element interpreted as non-compliance with bundle” · Baseline compliance 4.9% · Post-implementation compliance 73.4% Hospital mortality i) Bundle Compliant · Baseline 21.2% · Post-implementation 8.7% ii) Bundle non-compliant · Baseline 21.7% · Post-implementation 9.7% Zhi-qiang et al., 2013 China 11 hospitals Prospective cohort 218 · 6- and 24h compliance · Overall compliance: “when patients met all relevant targets” · 6h 5.5% (n = 12) · 24h 17.4% (n = 38) · 28 day mortality 33.0% · 6h comp 25.0%; non-comp 33.5% · 24h comp 26.3%; non-comp 34.4%
- 23. 22001122 SSeeppssiiss GGuuiiddeelliinneess DDeelllliinnggeerr RRPP,, LLeevvyy MMMM,, RRhhooddeess AA,, eett aall.. SSuurrvviivviinngg SSeeppssiiss CCaammppaaiiggnn:: IInntteerrnnaattiioonnaall gguuiiddeelliinneess ffoorr mmaannaaggeemmeenntt ooff sseevveerree sseeppssiiss aanndd sseeppttiicc sshhoocckk:: 22001122.. CCrriittiiccaall CCaarree MMeeddiicciinnee.. 22001133 FFeebb;;4411((22))::558800- 663377..
- 24. SSeeppssiiss bbuunnddllee mmooddiiffiiccaattiioonnss TThhee ‘‘oolldd’’ SSeeppssiiss RReessuusscciittaattiioonn Buunnddllee wwaass mmooddiiffiieedd iinnttoo ttwwoo nneeww bbuunnddlleess:: – SSeevveerree SSeeppssiiss 33-HHoouurr RReessuusscciittaattiioonn Buunnddllee – 66-HHoouurr SSeeppttiicc SShhoocckk Buunnddllee TThhee ‘‘oolldd’’ SSeeppssiiss MMaannaaggeemmeenntt Buunnddllee hhaass bbeeeenn eelliimmiinnaatteedd – NNeeww:: OOtthheerr SSuuppppoorrttiivvee TThheerraappiieess
- 25. SSeevveerree SSeeppssiiss 33-hhoouurr RReessuusscciittaattiioonn Buunnddllee MMeeaassuurree llaaccttaattee lleevveell OObbttaaiinn bblloooodd ccuullttuurreess ((bbeeffoorree ggiivviinngg aannttiibbiioottiiccss)) AAddmmiinniisstteerr bbrrooaadd ssppeeccttrruumm aannttiibbiioottiiccss AAddmmiinniisstteerr 3300 mmLL//kkgg ccrryyssttaallllllooiidd ffoorr hhyyppootteennssiioonn oorr llaaccttaattee 44 mmmmooll//LL ((3366 mmgg//ddLL))
- 26. 66-hhoouurr SSeeppttiicc SShhoocckkBuunnddllee 11.. AAppppllyy vvaassoopprreessssoorrss iiff hhyyppootteennssiivvee ((wwhheenn nnoonn-rreessppoonnssiivvee ttoo iinniittiiaall fflluuiidd rreessuusscc)) ttoo mmaaiinnttaaiinn MMAAPP 6655 mmmm HHgg 22.. PPeerrssiisstteenntt hhyyppootteennssiioonn ddeessppiittee vvoolluummee rreessuusscc oorr iinniittiiaall llaaccttaattee 44 mmmmooll//LL – MMaaiinnttaaiinn CCVVPP ((ttaarrggeett 88 mmmm HHgg)) – MMaaiinnttaaiinn cceennttrraall vveennoouuss OO22 ssaattuurraattiioonn ((ttaarrggeett 7700%%)) 33.. RReemmeeaassuurree llaaccttaattee iiff iinniittiiaall llaaccttaattee eelleevvaatteedd ((ttaarrggeett == nnoorrmmaall;; aarrtteerriiaall 11..66 mmmmooll//LL,, vveennoouuss 22..22 mmmmooll//LL))
- 27. Severe SSeeppssiiss Buunnddlleess::OOtthheerr SSuuppppoorrttiivvee TThheerraappiieess 11.. Blloooodd pprroodduucctt aaddmmiinniissttrraattiioonn 22.. MMaaiinnttaaiinn aaddeeqquuaattee ggllyyccaaeemmiicc ccoonnttrrooll 33.. MMeecchhaanniiccaall vveennttiillaattiioonn ooff sseeppssiiss-iinndduucceedd AARRDDSS 44.. SSeeddaattiioonn,, aannaallggeessiiaa,, aanndd nneeuurroommuussccuullaarr bblloocckkaaddee 55.. DDVVTT aanndd ppeeppttiicc uullcceerr ddiisseeaassee pprroopphhyyllaaxxiiss 66.. NNuuttrriittiioonn 77.. SSeettttiinngg ggooaallss ooff ccaarree
- 28. 3 Major SepsisTrials ProCESS (Protocolized Care for Early Septic Shock) – USA – 3 arms ARISE (Australian Resuscitation In Sepsis Evaluation Randomised Controlled Trial) – Australia, commenced 2008 – 2 arms ProMISe (Protocolised Management in Sepsis Trial) – UK – 2 arms Adult ED patients Inclusion criteria based on Rivers et al (2001). Early goal-directed therapy in the treatment of sepsis and septic shock. New Eng J Med 345:1368-77.
- 29. ProCESS Protocolized Carefor Early Septic Shock 5-year RCT study 31 USA emergency departments (n = 1341) Three approaches to sepsis care – Early goal directed therapy Sepsis Resuscitation Bundle – Protocolized standard care Does not mandate central lines, inotropes or blood transfusion – Usual care
- 30. ProCESS Outcomes March2014 ProCESS set out to determine whether a specific protocol would increase survival in patients with septic shock. It showed that patient survival was essentially the same in all three treatment groups – 60-day mortalityEGDT (n = 439) 21% Protocol (n = 446) 18.2%Standard care (n = 456) 18.9% – 90-day and 1-year mortality ns indicating that sepsis patients in these clinical settings were receiving effective care N Eng J Med (May 2014) 370(18): 1683-93
- 31. Surviving Sepsis Campaign: Response to ProCESS The SSC will determine (any) appropriate revisions to the bundle elements when the ARISE and ProMISE study results are available. ProCESS does not address the protocolized management of patients with severe sepsis without septic shock The ProCESS results have no impact on the 3-hour bundle Regarding the SSC 6-hour bundle (2): – A companion paper appears to support a mean initial arterial pressure (MAP) target of 65 mm Hg, which is one of the indicators in this bundle. (5) – The ProCESS paper does not address repeating lactate measures in patients with elevated lactate while literature supports doing so. – When measured, the first ScvO2 was 71 ± 13%, which is another of the indication of the bundle. – The majority of the patients in the usual care (56.5%) and protocol-based standard care arms (57.9%) of ProCESS had central lines inserted as part of clinical care. – The 6-hour bundle currently asks only that CVP be measured and that a venous blood gas be sent from that line to obtain ScvO2. SSC recognizes that alternate means of obtaining results exist and will address specific ways of including those data in future iterations of the quality improvement database.
- 32. ARISE Outcomes 51centres in Australia NZ (n = 1600) – 90-day mortality EGDT 18.6% (n = 796 ) Usual care 18.8% (n = 804 ) – No significant differences in: Survival timeIn-hospital mortality Duration of organ support Hospital LOS – EGDT group More vasopressor infusion More blood transfusions More dobutamine Conclusion – EGDT in ED patients with early septic shock does not reduce all-cause 90- day mortality N Eng J Med (Oct 2014) 371(16): 1496-505.
- 33. ARISE 6h differences(p 0.001) EGDT Usual care CVC insertion 714 (90.0%) 494 (61.9%) Fluid volume 1.9 l 1.7l Vasopressor infusion 66.6% 57.8% Red cell transfusion 13.6% 7.0% Dobutamine 15.4% 2.6% MAP at 6h* 76.5 mm Hg 75.3 mm Hg ED LOS 1.4 h 2.0 h * p = 0.04 Also, between 6-72 hours, more EGDT patients received vasopressor infusion (58.8% vs 51.5% p = 0.004) and dobutamine (9.5% vs 5.0% p 0.001)
- 34. ProMISE ICNARC 56UK EDs, n = 1260 – 2 arms: EGDT usual care – Early signs of sepsis septic shock – Primary outcome 90-day mortality – Cost effectiveness Data collection Feb 2011 – July 2014 – Closed 24/7/14 – in follow-up Awaiting results….
- 35. CCoonncclluussiioonnss SSoommee eevviiddeenncceetthhaatt iinnccrreeaasseedd ccoommpplliiaannccee rreedduucceess mmoorrbbiiddiittyy aanndd mmoorrttaalliittyy VVaarriioouuss bbuunnddllee mmooddiiffiiccaattiioonnss aanndd iinntteerrpprreettaattiioonn ooff wwhhaatt ccoonnssttiittuutteess ‘‘ccoommpplliiaannccee’’ BBuunnddllee rreelliiaabbiilliittyy nnoott rreeppoorrtteedd,, bbuutt ggeenneerraallllyy vveerryy llooww iiff ccaallccuullaatteedd difficult Inconsistent standards of reporting – makes comparison difficultEEaarrllyy ddaayyss:: nnoo ssttuuddiieess rreeppoorrtteedd uussiinngg ‘‘nneeww’’ sseeppssiiss bbuunnddlleess EEvviiddeennccee lleeaanniinngg ttoowwaarrddss nnoonn--eeffffeeccttiivveenneessss ooff 6hh EEGGDDTT 33hh sseeppssiiss bbuunnddllee nnoott eevvaalluuaatteedd
- 36. Dr Bronagh BlackwoodUK Prof Maureen Coombs NZ A/Prof Sharon Irving USA Prof Ruth Kleinpell USA Bronte Martin, Australia Prof Claire Rickard, Australia Kathleen Vollman USA Prof Ged Williams, UAE
Editor's Notes
- #2 Thank you etc
- #4 Evidence-based practice emphasises the use of existing research evidence rather than the generation of new research evidence. However, it is acknowledged that there is a dearth of traditional evidence available to inform critical care nursing practice (Fulbrook, 2003). There are many ways to introduce evidence into a practice setting, for example, through the development of evidence-based protocols and there has been considerable interest in developing clinical guidelines and care pathways as means to improve the quality of patient care (McQueen & Milloy, 2001). A tool that has been used extensively in the UK is the so-called ‘care bundle’.
- #6 Bundle concept approved by Australian Commission on Safety and Quality in Health Care in 2008.
- #10 The first 2 care bundles were the ventilator and central line bundles
- #11 By grouping evidence-based practices together, within a single clinical protocol that guides patient management (or process), the overall quality of care given to critically ill patients will improve. Berenholtz et al. (2002) argue that process measures are easier to measure than outcome measures and can be used to provide immediate feedback to clinicians. However, they also emphasise the importance of linking process measures with their counterpart outcome measures. “Outcome measures are ultimately what patients care about” (Berenholtz et al., 2002, p.8).
- #12 By grouping evidence-based practices together, within a single clinical protocol that guides patient management (or process), the overall quality of care given to critically ill patients will improve. Berenholtz et al. (2002) argue that process measures are easier to measure than outcome measures and can be used to provide immediate feedback to clinicians. However, they also emphasise the importance of linking process measures with their counterpart outcome measures. “Outcome measures are ultimately what patients care about” (Berenholtz et al., 2002, p.8).
- #13 2007 survey of mailing lists of specialist organisations (n = 11,795). Response rate 21% (N = 2,461). Less than half (47%) measured lactate level. Less than 1/3 (27%) gave initial recommended fluid challenge for hypotension. ScvO2 monitoring practices very varied. More than half (52%) did not give Packed RBC for ScvO2 <70% and anaemia. Time main concern of ED physicians ANZ physicians sceptical of the evidence.
- #14 Compliance Examples Patient 1 on: day 1, day 3, day 8 Non-compliant on days 1 and 3 Compliant on day 8 Unit compliance (n = 4 patients) on: day 1, day 3, day 7 Day 1 and day 3 none of the pts was compliant with all elements Day 8, 2 pts were compliant with all elements Reliability 5 elements at 90% compliance each = 0.9 x 0.9 x 0.9 x0.9 x 0.9 = 59% 3 elements @ 90% + 0.9 x 0.9 x 0.9 = 73%
- #19 Compliance Examples Patient 1 on: day 1, day 3, day 8 Non-compliant on days 1 and 3 Compliant on day 8 Unit compliance (n = 4 patients) on: day 1, day 3, day 7 Day 1 and day 3 none of the pts was compliant with all elements Day 8, 2 pts were compliant with all elements Reliability 5 elements at 90% compliance each = 0.9 x 0.9 x 0.9 x0.9 x 0.9 = 59% 3 elements @ 90% + 0.9 x 0.9 x 0.9 = 73%
- #20 The Surviving Sepsis Campaign was initiated in 2002 by the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine with the intent to reduce mortality rates in severe sepsis by 25% in 5 years. Guidelines were based on the first substantial review of evidence undertaken by Dellinger and colleagues (2004), were revised in 2008, and most recently in 2012. Although the Surviving Sepsis Campaign united many physicians in their approach to the management of severe sepsis, there have been many variations on what constitutes the sepsis bundles and this is an important cause of variability in compliance rates and benchmarking. Sepsis bundles have not been well supported in Australia. (Relatively low sepsis mortality – already doing it well) and scepticism about evidence)
- #21 GRADE = Grades of Recommendation , Assessment , Development, and Evaluation.
- #22 5 studies reported survival analysis of individual components of the 6 hour sepsis bundle. This outcome suggests that central venous oxygen saturation as an end-point – rather than any particular type of technology – may have contributed to increased survival benefit.
- #24 Consensus group of 68 international experts GRADE criteria used Grading of Recommendations Assessment, Development and Evaluation A = high to D = low
- #26 LACTATELactate: venous versus arterial – doesn’t matter – mortality risk very high – 30%. Even higher if hypotensive too - 46%.Hypotension alone mortality = 37%. Must have fast turnaround time for lactate ie. Mins CULTURES Before starting ABs. Two or more recommended. At least one from every line. Plus all body fluids. Same +ve culture from 2 sites = high likelihood of source of sepsis If vascular access device gives first +ve culture + high risk of being infection source ANTIBIOTICS Early administration reduces mortality. Full loading doses. Choice of Abs guided by what is known about community and hospital environment, patient factors.48-72 hour re-evaluation esp when causative agent identified and AB sensitivities FLUIDS Fluid challenge – ASAP – repeat as needed (rate 500-100/30 mins; to end-points BP >65 HR <100. NB pulmonary oedema Measure CVP and SVO2 – target CVP 8 and SVO2 > 70%
- #27 VASOPRESSORS Adequate fluid resusc is prerequisite. Aim MAP >65. start vasopressors when appropriate fluid challenge fails. DON’T WAIT to complete fluid challenge if hypotension severe. CHOICE: 1. norepinephrine (Dopamine an alternative if low risk of tachyarryhthmias or pt has bradycardia) 2. epinephrine may be added 3. vasopressin (ADH) may be added – anticipate same effect as NE. low doses may be effective when other vasopressors are not. Phenylephrine agent least likely to cause tachycardia – should increase SV. CVP Crystalloid but consider blood (packed cells) if anaemic and haematocrit <30% Central venous O2 saturation Give packed RBC if haematocrit <30% and hypovolaemic If CVP >8 give inotrope ie. Dobutamine. If Dob causes hypotension, give norepinephrine LACTATE Mortality high if hypoT and lactate high. End-points: SVO2 >70% and lactate normal
- #28 BLOOD PRODUCTS Once stabilised, maintain Hb 7-9 g/dL with red cells; transfuse if <7 BLOOD GLUCOSE Maintain glucose 4.5-6 mmol/L (60-180 mg/dL). Goal: 80% of measures in normal range, <2% hypo, < 20% hyper MV FOR SEPSIS INDUCED ARDS Avoid SIMV – either assist control or pressure control to prevent large VT. Targets: VT 6ml/kg; plateau pressure <30 cm H2O (permissive hypercapnia OK to keep pressures down). Add higher PEEP. Apply recruitment manoevres. Prone position if PaO2/FiO2 <100 mmHg. Elevate HOB 30-45. NIV if possibility if benefit greater than risk.. Regular breathing trials when rosable and stable. Conservative fluid management provided not hypo-perfused. SEDATION Minimise sedation. Avoid neuro-blockers (unless ARDS). If NMBs used, either intermittent of continuous with train-of-four testing. DVT and PUD DVT – grade 2 evidence – low molecular wt hep plus intermittent pneumatic compression devices PUD – no specific sepsis studies but Already established in ICU pts + logical NUTRITION Enteral - as tolerated. Avoid full caloric feeding in first week (500kcal/day). Use IV glucose plus insulin rather than TPN GOALS OF CARE Address goals early ie. Within 72 hours. Discuss with family. Incorporate goals into treatment inc EOL plans/palliative care.