Sepsis Management in the Emergency Department

1. Medical Staff Meeting Sepsis Management in the Emergency Department Bryon K. Frost, MD, FACEP September 13, 2010

2. We will discuss and define Cryptic Shock. Relevant literature review on Early Goal Directed Therapy in the Emergency Department. Lecture Agenda

3. Outcomes of Patients with a Baseline MAP > 100, Lactate >36CONTROL n = 25 and Treatment n = 23 MAP = SVR X CO Cryptic Shock: Inadequate tissue perfusion without hypotension. P<0.001

4. Sepsis A: Disease Continuum Cryptic Shock Infection/Trauma Sepsis Severe Sepsis SIRS Sepsis + > 1 system organ failure. Persistent hypotension SIRS with a presumed or confirmed infectious process • A clinical response arisingfrom a nonspecific insult, including 2 of the following: • Temperature 38oC or 36oC • HR 90 beats/min • WBC count 12,000/mm3or 4,000/mm3 ↓ SepticShock ↓ SIRS = systemic inflammatory response syndrome. The critical factor in saving lives of patients in shock is early recognition!!! Death

5. STAGE 1: Local Infection only (Anticipation) “You should already suspect that shock could appear if the underlying disease is left undiagnosed and untreated”.

6. STAGE 2: Systemic Infection (Pre-Shock) “The absence of shock is due to the fact that compensatory mechanisms are at play”( SVR gives rise to Cryptic Shock)

7. Stage 3: Compensated Shock-Normotensive, “Cryptic Shock” Many physicians fail to recognize this stage: “Pt does not look right"... and "I don't know what is going on, but the blood pressure is not too bad"...

8. Stage 4: Decompensated Shock-Reversible “B.P. can only be restored with intravenous fluid and vasopressors. If you have not diagnosed the cause of shock by now, it will be very difficult to treat pt.”

9. Stage 5: Decompensated Shock-Irreversible Death

10. Early Goal Directed Therapy (EGDT) Literature Review:

11. Early Goal Directed Therapy Dr. River’s Data: Rivers E. N Eng J Med. 2001; Nov8;345:1368-77 * P < 0.01

12. Resource Utilization of Survivors Dr. River’s Study : Health Care Resource Use - Days Decreased Resource Utilization - Days EGDT vs.. Control: Survivors * p < 0.02

13. Early Goal Directed Therapy Dr. Kumer’s Data: “Duration of hypotension before initiation of antimicrobial therapy is the critical determinant of survival in human septic shock” Kumer et al, Crit Care Med 2006

14. Literature Review of EGDT Effectiveness: Rivers E P Chest 2010;138:476-480

15. The “BAD”: “Community-acquired septic shock: early management and outcome in a nationwide study in Finland” -VARPULA “Failure to implement evidence-based guidelines for sepsis at the ED” -José The GOOD: “The Surviving Sepsis Campaign: Results of an International Guideline-based Performance Improvement Program targeting severe sepsis” -Levy, MD “Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis” -Thiel, MD “Effect of a Rapid Response System for patients in shock on time to treatment and mortality during 5 years” -Sebat,MD “Before–after study of a standardized hospital order set for the management of septic shock” -Micek, PharmD “Early Goal-Directed Therapy: Improving Mortality and Morbidity of Sepsis in the Emergency Department” –Anne Focht, RN “Impact of time to antibiotics on survival in patients with severe sepsis or sepsis shock in whom early goal-directed therapy was initiated in the emergency department” –Gaieski, MD Looking at the Literature: The UGLY: “Factors Associated with Nonadherence to Early Goal-Directed Therapy in the ED” –Mikkelsen, MD “We can’t do this here”, “The patient is not sick enough to have sepsis”

16. Septic Patients: 850 patients/yr Decreased Hospital Days: 3,800 patient days saved per year ! Lives Saved: 136 per year! Decreased Admit Costs: $31,011/admit $26,359,350/yr Decreased Hospital Costs: Henry Ford Hospital Data:

17. Potential Hospital Cost Savings Benefit at University of Virginia:

18. Dr. David Huang’s Data: “Exploring the advantages of effectively using EGDT at McLeod; pertaining to quality, cost and lives saved” C.E.A.=Cost Effective Analysis: a form of economic analysis that compares the relative costs and outcomes (effects) of two or more courses of action. QALY= Quality Adjusted Life Year: a measure of disease burden, including both the quality and the quantity of life lived. It is used in assessing the value, in money, of a medical intervention.

19. Societal perspective Cost-effective analysis: $50,000/QALY $20,000/QALY 30,000 More Cost More costlyMore effective More costlyLess effective 20,000 10,000 Difference in costs (US$) 0 Less Effective More Effective -10,000 Less costlyMore effective Less costlyLess effective Less Cost 1.0 -0.5 0.5 1.0 1.5 2.0 0 Difference in effectiveness (QALY per patient) QALY- Quality Adjusted Life Year

20. Societal perspective: $50,000/QALY $20,000/QALY 30,000 More costlyLess effective More costlyMore effective 20,000 Difference in costs (US$) 10,000 0 Cost per QALY = $7,800 -10,000 Less costlyMore effective Less costlyLess effective 1.0 -0.5 0.5 1.0 1.5 2.0 0 Difference in effectiveness (QALY per patient)

21. EGDT in perspective: E.G.D.T. EGDT Antihypertensive $105,000 $16,000 Cholesterol lowering drugs $143,000 $32,000 Newborn Hep B vaccine $49,000 $5,000 CABG for 2V disease $69,000 $8,000 Screening mammography $120,000 $40,000 Airbags $61,000 $24,000 Drotrecogin-alfa $140k $180k $60k $80k $160k $100k $40k $120k 0 20k League Table: modified from Schwartz, Leonard Davis Institute

22. Hospital perspective: 10,000 More costlyMore effective More costlyLess effective 0 -10,000 Difference in costs (US$) Cost Savings per survivor at 60 Days = $6,500 -20,000 Less costlyLess effective Less costlyMore effective -30,000 -0.25 0.25 0.5 0 Difference in survival (number of lives saved)