Surviving the Sepsis Campaign

摘要

H ealth P olicy Surviving the Sepsis Campaign Alexis Lieser, MD CAL/ACEP Advocacy Fellow, Sacramento, CA Scenario: A 20-month-old male presents to your emergency department with a two day history of fever, nasal congestion and cough. Parents are concerned about the fever. He is well- appearing, fully immunized and is taking fluids in the emergency department (ED). The child screens positive for systemic inflammatory response syndrome (SIRS) on your hospital’s required sepsis screening forms in triage due to a fever of 38.5°C and tachycardia. The nurse requests you document the child does not need a lactate and blood cultures drawn as part of a sepsis protocol. This case is an increasing familiar situation for a lot of emergency physicians leading to frustration and wondering why you went to medical school in the first place. Words like “protocol” and “bundle” makes the average naturally independent thinking emergency physician want to make a bonfire out of all the sepsis screening documents in your hospital. We are strong clinicians who take ownership of our patients and feel the need to protect them from unnecessary testing. Sometimes it is time to take a step back and an objective look – what has led up to the scenario described above? What makes sense and how can we advocate for our patients? Protocols and/or bundles in medicine are not going away and will likely become even more prevalent with healthcare reform legislation undergoing implementation over the next several years. Physicians have a high level of medical training for a reason and need to be involved in when they should be used and what items they contain. Surviving Sepsis Campaign Background The “surviving sepsis” campaign started with an international survey of 1,050 physicians regarding sepsis, which was conducted by the European Society of Critical Care Medicine and the Society of Critical Care 1 . Generally, physicians were frustrated at the lack of a common medical definition of sepsis and eager for breakthroughs making it easier to differentiate sepsis from other conditions which may present in a similar manner. In the same year, the Rivers et al. 2 paper regarding early goal-directed therapy in the ED for sepsis was published further pushing sepsis into the spotlight 2 . The campaign founders acknowledged physicians were generally managing severe sepsis well but improvements could be made. A goal was set of reducing mortality from sepsis by 25% over a five year period. ACEP has been involved as a sponsor of the campaign helping to provide guidelines and appropriate implementation for the ED setting. 3-6 Since the Volume XII, no . 1 : February 2011 implementation of the campaign, there have been many articles assessing the clinical effectiveness of a more standardized approach to defining and treating the septic patient. 7-13 There have also been questions concerning costs, pharmaceutical involvement and a one size fits all approach. 14-17 As part of the campaign, guidelines were developed by evaluating this research with a GRADE approach, a structured system for rating quality of evidence that also takes into account an assessment of the balance between benefits versus risks, burden, and cost. 18 The Bundle Defined The campaign also advocates for sepsis bundles for patients with severe sepsis/septic shock. A bundle attempts to match our everyday practice with current research. 19-21 Bundles are defined as a “group of therapies for a given disease that, when implemented together, may result in better outcomes than if implemented individually” and “science supporting the individual treatment strategies in a bundle is sufficiently mature such that implementation of the approach should be considered either best practice or a reasonable and generally accepted practice” 22 . As an example, the recommended sepsis bundle elements are: ? Measure serum lactate ? Obtain blood cultures prior to antibiotic administration ? Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission ? Treat hypotension and/or elevated lactate with fluids, apply vasopressors for ongoing hypotension ? Maintain adequate central venous pressure and central venous oxygen saturation Arguments can be made about each specific item above for the case of sepsis but at the end of the day two principles are true which must be followed for success. First, placing items in protocols and/or bundles have potential to assist in patient care and we need to be open minded to this possibility. Second, standardized approaches must always allow room for clinical decisions and the art of medicine to be practiced. Clinical decision making is one of the issues many physicians feel are being lost in the rapidly changing healthcare environment and without this element patient care can be compromised by a robotic approach. Application of Protocols and Bundles in the ED Enormous amounts of time and research effort can be spent developing protocols