Congratulations on your excellent achievement. Pat Posa Sent from my iPhone
On Mar 8, 2012, at 5:41 PM, "Martie Mattson" <[email protected]> wrote: > As one of the consultants with the Integrated Nurse Leadership Program, I > recently completed work with a cohort of nine hospitals in the San Francisco > Bay Area. The improvement project with a goal to reduce sepsis mortality by > 15% was funded by a grant from the Gordon and Betty Moore Foundation and went > from 2008 to 2010. The hospitals implemented RN screening for early sepsis > on every adult inpatient every shift and every adult patient at triage in the > ED. The nurses assessed for signs of SIRS and/or signs of new organ > dysfunction (hypotension, altered mental status, new or increasing need for > O2) and a suspected or confirmed infection. A positive screen triggered a > lactate, and if severe sepsis was confirmed, a blood culture, antibiotic, and > fluid bolus within an hour. Sepsis mortality was reduced in the nine > hospitals by an average of 40% from baseline at the end of the 2 years and > the improvement still continues. They are now at an average 44% mortality > reduction. All-or-none compliance with all project-measured resuscitation > bundle elements (lactate, blood culture, antibiotic and fluid bolus) improved > to a median of 36% and compliance with nurse screening went from essentially > none to a median of 91%. So I absolutely share the bias that early > recognition is a large part of the “magic bullet” to reduce sepsis mortality. > > > > Martie > Martie Mattson, RN, MSN, CNS > Sepsis Consultant > Integrated Nurse Leadership Program > Center for Health Professions, University of California Medical Center > (415) 412-2364 > [email protected] > > > > > From: [email protected] > [mailto:[email protected]] On Behalf Of Steven > Simpson > Sent: Wednesday, March 07, 2012 6:59 AM > To: Ron Elkin; Robert A Balk > Cc: [email protected] > Subject: Re: [Sepsis Groups] SIRS temperature criteria > > > Thanks for your reply, Bob. I'm sorry that you and I are old enough to give > "historical" perspective on these issues! I think you underscored Ron's > point, which is that missing people with severe sepsis is potentially deadly > and being more sensitive is a wise approach. I have to agree with you that > some lack of specificity may be the reason that none of our tested > pharmaceutical agents has been the magic bullet. But I will again reveal my > bias when I say that early recognition and aggressive treatment is the best > magic bullet of all. From the standpoint of quality improvement, it does > indeed seem that getting everyone to recognize severe sepsis early would be > magic! > > SQS > > > Steven Q. Simpson, MD > Professor of Medicine > Director, Fellowship Training > Division of Pulmonary Diseases and Critical Care Medicine > University of Kansas > 3901 Rainbow Blvd. > Kansas City, KS 66160-7381 > Phone: (913) 588-6045 > Fax: (913) 588-4098 > > > >>> Robert A Balk <[email protected]> 3/7/2012 7:18 AM >>> > Good Morning Steve and Group > I have not been on this list serve discussion, but will be happy to provide > some background on the 1991 Sepsis Definition Consensus Conference and the > rationale for the 2/4 SIRS criteria. The 4 SIRS criteria as they were came > from the entry criteria for the Upjohn sponsored High Dose Methylprednisolone > in Severe Sepsis and Septic Shock study which seemed to identify a population > of patients with presumed sepsis that had a significantly high risk for > morbidity and mortality from the septic process. The truth of where the > criteria actually came from is that a group of investigators sat is a room > and came to agreement on workable, plausible criteria that would allow for > rapid and early identification of potential patients with sepsis that could > be enrolled into an early intervention study. As the subsequent article > entitled “Sepsis Syndrome: A valid clinical entity” the concept of a > systemic inflammatory response whether from documented infection, documented > bacteremia, or presumed infection seems to yield a similar clinical picture. > This background and the desire to come to a more uniform and acceptable > definition for sepsis that would facilitate early identification of patients > for enrollment in clinical intervention trials was the impetus for the 1991 > Consensus Conference. The definition that was put forward has been > criticized for being too sensitive and not specific, but that was the > intention. Bill Knaus actually had data to guide the conference from the > large APACHE and APACHE II data base that demonstrated the best combination > of sensitivity and specificity came from having 2 of the 4 criteria. > Obviously, the more criteria the better the specificity, but with the goal of > having a clinical definition to allow for early identification of potential > patients the 2/4 criteria won. > The changes in temperature based on methods of measurement were not addressed > with the definition and I do agree that axillary and tympanic temperature > determinations do not seem to be reliable indicators of core temperature in > our institution. The second consensus conference in 2001 attempted to open > up the definition by adding further clinical criteria that suggests the > presence of infection, but I do not know of any comparative trial that has > demonstrated that one definition improves our ability to identify a severe > sepsis population better than another. The original definition of severe > sepsis and/or septic shock has actually been used with or without minor > modification, in just about every sepsis trial conducted. (maybe that is why > we are still struggling to find the “magic bullet” to reverse the process). > Bob Balk > > Robert A. Balk, MD > Director - Pulmonary and Critical Care Medicine > Rush University Medical Center > 1653 W. Congress Parkway > Chicago, IL 60612 > T- 312-942-6744 > F- 312-942-8187 > > This message and any attachments contain information intended for the > exclusive use of the individual, or entity, to whom it is addressed and may > contain information that is privileged, confidential and/or exempt from > disclosure under applicable law. If the reader of this message is not the > intended recipient, or their employee or agent you are hereby notified that > any distribution or copying of this communication is strictly prohibited. If > you received this message in error, please phone me immediately at > 312-942-6744. > > From: Steven Simpson [mailto:[email protected]] > Sent: Tuesday, March 06, 2012 1:45 PM > To: Ron Elkin > Cc: Andy Bourgeois; [email protected]; Robert A Balk; > Roberta Johnston > Subject: Re: [Sepsis Groups] SIRS temperature criteria > > Hi Ron, > I agree completely that a patient with infection and organ dysfunction who > can't mount a "complete" SIRS response (2 or more criteria), should be > treated aggressively. I was simply pointing out that the original definition > for fever that was proposed by Bone, et al was more stringent than what we > now use. I don't know if Bob Balk is on this list serve or not, but I think > I'll copy him to get his insight. He was clearly involved from the first and > was there at the initial ACCP-SCCM consensus conference in 1991. Perhaps he > knows why the fever criterion was loosened at the consensus conference and > won't mind sharing with us. I was a fellow under Roger Bone and Bob Balk at > the time of the aforementioned publication describing the clinical importance > of what they referred to at the time as sepsis syndrome. It is an important > historical point to remember that previous to the 1991 consensus conference > there was NO commonly accepted set of criteria for diagnosing sepsis. We owe > a great debt to these men for moving us beyond the diagnostic free for all > that existed previously. The definitions give us the means to educate many > different types of provider and to improve our performance at caring for > septic patients in a systematic way. They, of course, do not remove the > obligation for any of us - doctors, nurses, mid-levels, or anyone else - to > think and to err on the side of safe and effective patient care, if we are to > err at all. Your points are very well taken and very germane. What they > indicate is what I already know to be true, that you and your team have moved > beyond the point of consistently recognizing the clear-cut cases of severe > sepsis and on to making sure that no septic patient is left behind. Your > efforts to get everyone on this list serve to that level are both laudable > and appreciated. > > SQS > > > Steven Q. Simpson, MD > Professor of Medicine > Director, Fellowship Training > Division of Pulmonary Diseases and Critical Care Medicine > University of Kansas > 3901 Rainbow Blvd. > Kansas City, KS 66160-7381 > Phone: (913) 588-6045 > Fax: (913) 588-4098 > > > >>> Ron Elkin <[email protected]> 3/6/2012 12:47 PM >>> > Hi, > > At the risk of repetition: > > In some respects the strict definition of sepsis, 2 signs of SIRS + > infection, can be an obstacle to diagnosis. Signs of SIRS lack sensitivity, > specificity, and accuracy for the diagnosis of severe sepsis and septic shock. > > 10-15% of our patients with infection and organ failure - ie severe sepsis or > septic shock - have FEWER than 2 signs of SIRS. These are mainly the elderly, > the immunosuppressed, or patients on drugs or with other conditions that > preclude tachycardia or fever, or even tachypnea (beta blockers, calcium > channel blockers, NSAIDS, ASA, sedatives, narcotics, pacemakers, heart block, > bradyarrhythmias, hypothyroidism, etc). > > Fever is a particularly fickle indicator of infection. I daresay we are all > aware of debilitated elderly people who never exceed 36 degrees C in health > and present with obtundation as the only manifestation of severe sepsis, ie > no SIRS. Many of these patients have positive cultures and get better with > fluid and antibiotics. If we don't call this severe sepsis because signs of > SIRS are absent, what do we call it? In this context stipulating a > temperature threshold for SIRS as 38 or 38.3 seems irrelevant. > > Signs of SIRS are undeniably useful for screening and often lead one to > suspect infection as the probable cause of acute organ failure. One of the > purposes of initial screening, however, is to avoid missing cases. The > sensitivity of the initial screen should therefore be high, with the > knowledge that there will indeed be false positives. It is an error to > terminate screening because there are 0-1 sign of SIRS. > > Our screening methods have accordingly moved towards the following 3 > questions which we regard as completely independent of one another: > 1) Are there 1 or more new signs of SIRS? > 2) Is there suspicion of infection? > 3) Is there evidence of new organ dysfunction? > > "Yes" to any of these 3 questions is intended to trigger a call to the MD > with further investigation to follow. > > References are attached. > > Thanks > > Ron Elkin, MD > California Pacific Medical Center > San Francisco, California > > On Tue, Feb 28, 2012 at 9:45 AM, Steven Simpson <[email protected]> wrote: > It should be pointed out that the original validation of the sepsis syndrome > (now called severe sepsis) was in the following landmark paper: Bone RC, et > al. Sepsis Syndrome: A Valid Clinical Entity. Critical Care Medicine > 17:389-393. The inclusion criterion for temperature was rectal T > 101 > degrees F or < 96 degrees F. That would be 38.3 degrees C and 35.5 degrees C. > I'm not sure how, exactly, we got to the numbers 38 and 36 in our "standard" > criteria, nor how we wandered away from rectal temperatures, unless it was > deemed more useful, i.e. more sensitive or more inclusive to allow different > methods of obtaining temperature. Interestingly, TM probes and continuous > bladder temps were not even available at the time of the original study! > Nevertheless, the SSC has demonstrated very much improved survival of > patients fitting the more standard criteria, and we should probably be > circumspect about tossing them out at this juncture. > > SQS > > > >>> Andy Bourgeois <[email protected]> 2/27/2012 11:48 AM >>> > > SIRS criteria have been defined differently in various studies. > > The temperature was 38 degrees C in a few early articles: > > One of the early definitions of sepsis: > Definitions for sepsis and organ failure and guidelines for the use of > innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. > American College of Chest Physicians/Society of Critical Care Medicine. > Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, > Sibbald WJ. > Chest. 1992 Jun;101(6):1644-55. Review > > The original Early Goal Directed Therapy article from 2001 > Early goal-directed therapy in the treatment of severe sepsis and septic > shock. > Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, > Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. > N Engl J Med. 2001 Nov 8;345(19):1368-77. > > Most of the more recent studies and reviews use 38.3 degrees C: > > International Sepsis Definitions Conference in 2001 > 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. > Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, > Vincent JL, Ramsay G; SCCM/ESICM/ACCP/ATS/SIS. > Crit Care Med. 2003 Apr;31(4):1250-6. Review. > > In this 2006 review article from some of the original Early Goal Directed > Therapy investigators: > Severe sepsis and septic shock: review of the literature and emergency > department management guidelines. > Nguyen HB, Rivers EP, Abrahamian FM, et al. > Ann Emerg Med. 2006 Jul;48(1):28-54. Epub 2006 May 2. Review. > > The Surviving Sepsis Campaign - 2008 > Surviving Sepsis Campaign: international guidelines for management of severe > sepsis and septic shock: 2008. > Dellinger RP, Levy MM, Carlet JM, et al. > Crit Care Med. 2008 Jan;36(1):296-327. Erratum in: Crit Care Med. 2008 > Apr;36(4):1394-6. > > I'd recommend 38.3 degrees C to match the more recent definitions so that > your sepsis statistics can be easily compared to published studies. > > Here's an article on comparison of methods of measuring temperature. Bottom > line is that IR ear probes are somewhat variable and axillary reads too low. > Go with oral, rectal or bladder. > > Erickson RS, Kirklin SK. Comparison of ear-based, bladder, oral, and axillary > methods for core temperature measurement. Crit Care Med. 1993 > Oct;21(10):1528-34. > PubMed PMID: 8403963. > > > Andy Bourgeois, MD, FAAEM, FACEP > Emergency Medicine > Simi Valley Hospital > > > > > > On Thu, Feb 23, 2012 at 11:47 AM, Johnston, Roberta > <[email protected]> wrote: > Hi everyone- Our Sepsis committee would like to know if the temp criteria is > 38.3 or 38, and is the method of obtaining the temperature? Thanks in > advance, Roberta > > Roberta Johnston, RN,BS,CMC. > Cardiopulmonary Case Manager > 700 High St. > Williamsport, Pa. 17701 > Phone:570-321-2112, Fax:570-321-2822;Cell: 570-560-8993 > [email protected] > > Confidentiality Notice: This message and any attachments originate by > electronic mail from Susquehanna Health System and their > subsidiaries/affiliates (“SHS”). 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Thank you for your cooperation. > > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > > <SF Chronicle Article on Sepsis Project.docx> > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
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