Last, the macrolide antibiotic telithromycin (Ketek), specified in Table 5.1 for SEP-1, has been discontinued due to business reasons [22]. The initial antibiotic should be broad-spectrum, based on local sensitivity patterns, with daily assessment of appropriate antibiotic de-escalation and cessation. Clinician reviewers underwent one hour of training on SEP-1 abstraction by the lead investigator (C.R.) , All rights reserved. , H Inadequate source control may lead to worsening organ function and hemodynamic instability despite appropriate resuscitative measures.17 A thorough examination and appropriate imaging studies should be performed to determine the optimal way to control the source and assess the risks associ ated with each intervention. Respondents were also asked to provide suggestions for monotherapy antibiotics not listed in Table 5.0. They pulled together the best of the newest science into a set of evidence-based guidelines for the management of severe sepsis and septic shock. After cultures . These recommendations are based on our understanding of autoregulation of blood flow in the vascular beds of central organs (brain, heart, kidneys). and has the potential to be used for financial incentives centered on SEP-1 measure compliance performance.86. A pragmatic strategy may involve starting with broad-spectrum antimicrobials, particularly in the setting of hypotension, and then rapidly de-escalating to an antimicrobial with the narrowest spectrum based on local sensitivity patterns. , sec. Tools such as the Systemic Inflammatory Response Syndrome criteria and the quick version of the Sequential Organ Failure Assessment can help with early diagnosis and triage. K C. M. C. was president of the Society of Critical Care Medicine in 2015 and a payment was made from this organization to Emory University for time spent in this role. In 2001, definitions were updated with clinical and laboratory variables.5, In 2004, the Surviving Sepsis Campaign guidelines adopted those definitions, which led to the development of a protocol-driven model for sepsis care used worldwide.6 The US Centers for Medicare and Medicaid Services (CMS) followed suit, defining sepsis as the presence of at least 2 SIRS criteria plus infection; severe sepsis as sepsis with organ dysfunction (including serum lactate > 2 mmol/L); and septic shock as fluid-resistant hypotension requiring vasopressors, or a lactate level of at least 4 mmol/L.7. SC Leito , What's Next? , . Abbreviations: IV, intravenous; MATS WG, Modification of Antibiotic Tables for SEP-1 Workgroup; SEP-1, Severe Sepsis and Septic Shock: Management Bundle. All Rights Reserved. Reason*: JS et al. , 4/12/2017 10:36:07 AM, is there an evaluation or assessment model or tool, Certified Professional in Patient Safety (CPPS). Vail et al59 found increased mortality associated with phenylephrine use in septic shock in a multicenter cohort study conducted during a norepinephrine shortage. Whether it affects outcomes is unclear. consistent with antibiotic selection guidelines detailed in the Notes for Abstraction?" Are you saying this is no longer true? But recognizing sepsis can be a challenge, and best management practices continue to evolve. Some have cautioned against giving too much fluid, especially in patients who have limited cardiorespiratory reserve.26 Overzealous fluid administration can result in pulmonary edema, hypoxemic respiratory failure, organ edema, intra-abdominal hypertension, prolonged ICU stay and time on mechanical ventilation, and even increased risk of death.26,27. Nachamkin are strictly confidential. The initiative is also timely. Clinical data related to its use are limited to a recent trial that showed that the addition of angiotensin II improved blood pressure in patients with refractory vasodilatory shock receiving high-dose vasopressors.60 The data are still sparse on its safety, and its precise role in refractory shock treatment algorithms has yet to be defined. , , Wilson Randomized controlled trials of vasopressors and inotropes in septic shock. data element, an IV or IO antibiotic must be administered Biomarkers facilitate early diagnosis, identify patients at high risk, and monitor disease progression to guide resuscitation goals and tailor management. We are all at potential risk of sepsis, but certain populations much more so: people with a weakened immune system because of underlying disease or certain treatments they are receiving including chemotherapy. In January 2013, the State of New York mandated that all state hospitals initiate processes for early detection and treatment of sepsis. In parallel with the introduction of the SSCs Severe Sepsis Bundles, several other US groups have reported notable results from complementary sepsis improvement campaigns. Edward J Septimus and others, Sepsis National Hospital Inpatient Quality Measure (SEP-1): Multistakeholder Work Group Recommendations for Appropriate Antibiotics for the Treatment of Sepsis, Clinical Infectious Diseases, Volume 65, Issue 9, 1 November 2017, Pages 15651569, https://doi.org/10.1093/cid/cix603. A prospective, randomized pilot study, Association between US norepinephrine shortage and mortality among patients with septic shock, Angiotensin II for the treatment of vasodilatory shock, Early Goal-Directed Therapy Collaborative Group, Early goal-directed therapy in the treatment of severe sepsis and septic shock, Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial, Effect of levosimendan on mortality in severe sepsis and septic shock: a meta-analysis of randomised trials, Hemodynamic effects of i.v. Singer et al8 compared SOFA and SIRS and identified 3 independent predictors of organ dysfunction associated with poor outcomes in sepsis to create the simplified qSOFA: Respiratory rate at least 22 breaths/minute, Systolic blood pressure 100 mm Hg or lower. Altered mental status (Glasgow Coma Scale score < 15). medicare.gov/hospitalcompare/search.html? RN Clinicians should move away from using static measures to assess volume status. Sepsis Care Enters New Era. Atlanta, GA: CDC, 2013, Early Goal-Directed Therapy Collaborative Group, Early goal-directed therapy in the treatment of severe sepsis and septic shock. The data analyzed is the de-identified data the institution reported to CMS. Nonetheless, clinicians should practice extreme caution with etomidate use in septic shock (Table 3).73, Randomized controlled trials of corticosteroids in septic shock. 2021;4 (12):e2138596. Failing to meet this initial resuscitation guideline delays resolution of hypotension and increases intensive care duration and mortality. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Vasopressors should be started peripherally rather than waiting for central venous access. Cadena SEP-1 overall hospital performance is publicly available on the CMS website (medicare.gov/hospitalcompare/search.html?) qSOFA has the advantage of its elements being easy to obtain in clinical practice. Information Management Association (AHIMA), CMS, and NCHS. The CMS definition continues to recommend SIRS for sepsis identification, while Sepsis-3 uses sequential organ failure assessment (SOFA) or the quick version (qSOFA) to define sepsis (described below). Yayan DK Mendona Central venous pressure, the static measure most often used to guide resuscitation, has been found to be accurate in only half of cases, compared with thermodilution using pulmonary artery catheters to assess change in cardiac output with volume administration.29 A 2017 meta-analysis30 showed that the use of dynamic assessment in goal-directed therapy is associated with lower mortality risk, shorter ICU stay, and shorter duration of mechanical ventilation. Fact sheets, brochures, and posters for patients, Fact sheets, infographics, and brochures for healthcare professionals, Sample social media messages, news releases, drop-in articles, and more, Brochures and fact sheets for Spanish speakers. These hemodynamic effects lead to impaired tissue perfusion and organ dysfunction. Your comment will be reviewed and published at the journal's discretion. Rivers S The limited sensitivity and specificity of single biomarkers may be overcome by using a combination of biomarkers, which is a current focus of research.80 For now, the decision to initiate, escalate, and de-escalate therapy should be based on clinical assessment, with procalcitonin or other biomarkers used as an adjunct to other clinical factors.17, In 2001, Rivers et al61 compared usual care for severe sepsis or septic shock with a protocolized targeting of physiologic end points as goals of resuscitation for the 6 hours before admission to the ICU in a single center. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Arterial blood pressure monitoring is essential and carries low risks of limb ischemia and bleeding. An early lactate level is recommended if sepsis is suspected because an elevated level correlates with mortality. In sepsis without shock, the evidence is less clear, and antimicrobials are recommended within three hours of recognition. Huh Centers for Medicare & Medicaid Services (CMS) IMPAQ International, LLC Page 1 Summary of Sepsis TEP Evaluation of Measures 5/25/2021 The materials presented in this document do not represent final measure specifications for the Sepsis outcome measure . The joint SSC/IHI website package also includes 11 quality indicators to gauge whether the changes clinicians are making are actually leading to improvement. Potential conflicts of interest. With the trend in management moving away from protocolized care in favor of appropriate usual care, an understanding of sepsis physiology and best practice guidelines is . This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. According to Sean Townsend, MD, IHI faculty member and Fellow in Pulmonary and Critical Care Medicine at Massachusetts General Hospital (MGH) in Boston: I see the SSC as the sister campaign to IHIs 100,000 Lives Campaign. The cms sepsis bundle includes four main components: 1. Gasnik Dynamic measures are used to estimate the effects of additional volume on cardiac output. Source control is imperative in managing sepsis and septic shock. Although empiric combination antibiotics against gram-negative bacteria do not improve overall mortality, combination antibiotics are recommended for patients at high risk for multidrug-resistant organisms. The survey respondents cited a common concern of large amounts of antibiotic resistance as to why ampicillin-sulbactam, levofloxacin, and moxifloxacin were not approved. CDC: Cancer, Infection and Sepsis CDC: Life After Sepsis SCCM: Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis SCCM: New Recommendations Aim to Redefine Definition and Enhance Diagnosis of Sepsis, Septic Shock We do not capture any email address. Technical Resources & Guidelines; I Survived Sepsis. Ciprofloxacin has also seen an increase in clinical ineffectiveness, particularly in nosocomial gram-negative bacteremia [23]. Measure submission and evaluation worksheet 5.0. The Surviving Sepsis Campaign is challenging these dismal numbers. Empiric coverage for MRSA, gram-negative resistance, or fungal infection is recommended if these pathogens are considered likely. With sepsis-induced hypoperfusion or shock, resuscitation with 30 mL per kg of crystalloid fluids is recommended within the first three hours. With this in mind, fluid resuscitation should be managed as follows during consecutive phases28: Rescue: During the initial minutes to hours, fluid boluses (a 1- to 2-L fluid bolus of crystalloid solution) are required to reverse hypoperfusion and shock, Optimization: During the second phase, the benefits of giving additional fluid to improve cardiac output and tissue perfusion should be weighed against potential harms27, Stabilization: During the third phase, usually 24 to 48 hours after the onset of septic shock, an attempt should be made to achieve a net-neutral or a slightly negative fluid balance, De-escalation: The fourth phase, marked by shock resolution and organ recovery, should trigger aggressive fluid removal strategies.27. Hydroxyethyl starch solutions should be avoided because of increased mortality, and synthetic colloid gelatin should not be used because of lack of evidence. changes and updates to the SEP-1 measure and abstraction guidance in version 5.9 of the specifications manual, to discuss updates to the SEP-1 . The power of the bundles, explains Sean Townsend, comes from both the body of science behind them and method of execution: with absolute consistency. , Although SEP-1 has been adopted as a quality measure, some question its clinical relevance, as many of the core recommendations are not supported by strong evidence.86,87 Three major trials found that the mortality rate was no lower with bundled sepsis care than with usual care.8284 Seymour et al28 collected New York State Department of Health data for 49,331 patients with sepsis and septic shock and found that more rapid completion of the 3-hour bundleparticularly of antibiotic administration but not of fluidswas associated with decreased hospital mortality. , F . Kuo Risk factors for fungal infection in septic shock should trigger the addition of echinocandins or liposomal amphotericin B. Azoles are considered appropriate for hemodynamically stable patients.20, Antibiotics are not harmless: prolonged use of broad-spectrum antibiotics is associated with antimicrobial resistance, Clostridium difficile infection, and even death.21, A robust de-escalation strategy is needed to balance an initial broad-spectrum approach. Levy and his colleagues associated with the Societyof Critical Care Medicinesaw an opportunity. Sreeramoju / Improvement Stories / Texas A&M Health Science Center College of Medicine, Clinical Services Group, Hospital Corporation of America (HCA), Houston, Texas. Convene a multidisciplinary team that includes different professions and service lines. KS In particular, the SSC measure set is geared to both emergency department and critical care settings because, as IHIs Terry Clemmer explains: ED physicians see sepsis patients coming in from outside the hospital, but the ICU also sees another group: patients who develop sepsis in the hospital from an infection after surgery, for instance. V They assessed the factors behind the unacceptably high sepsis mortality rates in light of new research findings. . We know we have to work together, we have to cross domains. The SSC package also integrates the early goal-directed therapy approach of the STOP Sepsis bundle with other clinical features in the VHAs bundle. Washington, DC: National Quality Forum. JS G It requires prompt recognition, appropriate antibiotics, careful hemodynamic support, and control of the source of infection. Sepsis represents life-threatening organ dysfunction caused by a dysregulated response to infection that kills up to one in three affected people. Resuscitation With sepsis-induced hypoperfusion or shock, resuscitation with 30 mL per kg of crystalloid fluids is recommended within the first three hours. Hospital Compare. Educational Information plus icon. . Turpin Departments across The Johns Hopkins Hospital have shown only 50 percent compliance since October. , . As for the antibiotics that resulted in a draw, the MATS WG was polled again to reach consensus on only ertapenem, as ticarcillin-clavulanate (Timentin) was discontinued due to safety issues [19]. M SE For hypoperfusion with adequate volume status and arterial blood pressure, adding dobutamine to norepinephrine or using epinephrine alone are options. Angiotensin II was recently approved as a vasopressor for use in septic shock. It requires prompt recognition, appropriate antibiotics, careful hemodynamic support, and control of the source of infection. Jorgensen , Early identification and appropriate management can improve these outcomes. The MATS WG recommendations are provided next to the SEP-1 antibiotic specifications detailed in the Specifications Manual for National Hospital Inpatient Quality Measures Discharges 1 July 2016 (3Q16) through 31 December 2016 (4Q16) version 5.1. Spotlight News Today, the Core Quality Measures Collaborative (CQMC) released four updated core measure sets covering specific clinical areas as part of its mission to provide useful quality metrics as the nation's health care system moves from one that pays based on volume of services to one that pays for value. Sepsis and septic shock complicating abortion, pregnancy, childbirth and the puerperium 69 k . According to Sean Townsend, both the STOP Sepsis and VHAinitiatives support the SSC strategy and potential for success. In 2016, the Sepsis-3 committee8 issued the following new definitions: SepsisA life-threatening condition caused by a dysregulated host response to infection, resulting in organ dysfunction. Available at: Centers for Medicare and Medicaid Services, Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates, The Joint Commission, Centers for Medicare and Medicaid Services, Specifications manual for national hospital inpatient quality measures v.5.1: alphabetical data dictionary: broad spectrum or other antibiotic selection, Infectious Diseases Society of America, American College of Emergency Physicians, Society of Critical Care Medicine, Re: National Hospital Inpatient Quality Measures: Sepsis Bundle Project (SEP) Performance Measure, The White House. KJ Mazuski CM Macrolide antibiotics, predominately administered as the first line of treatment for community-acquired respiratory tract infections caused by Mycoplasma pneumoniae, have been observed to have high rates of resistance in M. pneumoniae in Asia and moderate levels of resistance in Europe and the United States [20]. Public reporting of the measure will not begin until at least October 1, 2016. The compliance rate with the SEP-1 was determined by the institutional data extractor trained in data abstraction specific to CMS HQI metrics. Smith Med 2018; 71:10-15 e11. www.qualityforum.org/NQF_Revises_Sepsis_Measure.aspx, TOOLS FOR IDENTIFYING HIGH RISK: SOFA AND qSOFA, USUAL CARE VS PROTOCOLIZED INITIAL RESUSCITATION, Cleveland Clinic Center for Continuing Education. Description . Ann. J Rather, they can be added as adjunctive therapy for patients requiring higher doses of vasopressors.17,65, Adverse events in studies of corticosteroids were limited to hyperglycemia, hypernatremia, and hypertension, with no increase in superinfections.71 The limited adverse events, along with a uniform demonstration of shorter shock duration, ventilator duration, and ICU stay, suggest steroids may have a role in managing refractory septic shock.6669, If corticosteroids are used in septic shock, current guidelines recommend hydrocortisone 200 mg per day intravenously as a continuous drip or 50 mg bolus in 4 divided doses for at least 3 days, based on a systematic review showing a longer course of low-dose steroids is associated with a lower mortality rate.72 There is no clear consensus on whether steroids should be tapered or if abrupt cessation is appropriate, as larger randomized clinical trials did not use a tapering strategy and found no difference in shock recurrence.66,67 In most cases, steroids are stopped after cessation of vasopressors.65.
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