IHI.org asked Mitchell Levy about the recent work in the area of sepsis, and for his thoughts on what he’d like to see the website accomplish.  Here is his reply.

Q:  What is the scope of the problem with regard to sepsis?

A:  There are 750,000 cases of severe sepsis every year in North America. More people die in one year in North America from severe sepsis than from breast cancer, lung cancer, and colon cancer combined. The incidence of sepsis is strikingly high and significantly underestimated by many physicians — and certainly by the public. In addition, data in the literature suggest that the incidence of severe sepsis, given the graying of North America, is going to double over the next 25 or 30 years; so the implications for resource allocation and utilization in North America are enormous.

Q: What is the gap between current practice (and current results) for sepsis and what we know to be best practice?

A: There are two aspects to this:

First of all, for many years clinicians didn’t bother to categorize patients into sepsis, severe sepsis, and septic shock, because for the most part all we really had to offer our patients were antibiotics, glucose control, and supportive care. The drive to categorize the stage of the inflammatory response clearly was not very strong because it had limited impact on clinical practice. But now that we have interventions targeted at specific stages, there is a need to think in more depth about what stage of sepsis the patient is in.

Second, we now have enough data in the literature to inform a standard of care for the management of these patients. The sepsis guidelines that were recently published, and that are the basis for the Surviving Sepsis Campaign, are founded on data that suggest that the era of individual practice variations really needs to come to an end. There is some very good data that point at a survival benefit with specific inventions.

Q: What is the Surviving Sepsis Campaign?

A: The Surviving Sepsis Campaign started as a response to these new interventions for sepsis on the part of several global critical care societies: the European Society of Intensive Care Medicine, the Society of Critical Care Medicine, and the International Sepsis Forum. These three responded to the data in the literature by coming together and forming a campaign to improve the standard of care offered to patients with sepsis across the globe. In many ways, I think this is a role model for the future. Because physicians are busy — they are seeing more patients, their incomes are being slashed, their time constraints are getting even tighter — their ability to read and integrate literature and good research into practice is tougher than ever.  So in many ways it falls to critical care societies to advocate for change, adapting research and facilitating that process for members and clinicians.  That is what the Surviving Sepsis Campaign is: an attempt on the part of these societies to make it easier for physicians to adopt research. As some have put it, it is an attempt “to make the right thing to do the easy thing to do.”

Q: How were the sepsis guidelines developed?

A: The Surviving Sepsis Campaign comprises three phases. The first phase was the introduction of the campaign at the Barcelona meeting of the European Society of Intensive Care Medicine in 2002, where the sepsis campaign was announced and a target of a 25 percent reduction in mortality from severe sepsis over the next five years was announced.

The second step in pursuing an improved survival for patients was to produce a set of guidelines. Under the auspices of the Surviving Sepsis Campaign, about 50 experts were brought together in June 2002 at a conference that addressed two separate issues: the diagnosis and management of infection in critically ill patients with sepsis, and the general management of sepsis. That led to the third phase: the landmark publication of the guidelines in March 2003 in Critical Care Medicine and Intensive Care Medicine.

I call it “landmark” for two reasons: first and most important, 11 international critical care and infectious disease societies were signed on the manuscript in support of these guidelines. That is quite historic; traditionally, these societies have difficulty coming to a consensus. The fact that they were able to come to a consensus on a single set of guidelines speaks to the strength of the literature that informs them. Second, there are enough data in sepsis for the first time to create a single consensus set of guidelines. The fact that the data are strong enough to create the guidelines, and strong enough to draw consensus from so many critical care societies, make this a landmark event.

Q:  What are the major barriers in closing the gap between current practice and best practice?

A: All of us, researchers and clinicians alike, have struggled with how a clinician decides when to incorporate research from the literature into bedside practice.  There are a lot of obstacles: first, especially in critical care, clinicians are conservative by nature — which is both good news and bad news. The good news is that it means that strategies that have only been partially tested do not regularly get to the bedside and therefore needless harm is prevented for patients. The bad news is that it takes clinicians a long time incorporate proven strategies to the bedside.

The second obstacle is that clinicians are very busy and our ability to critically appraise the literature to separate out the mediocre data from the robust randomized control data with good methodology is limited. So there is a lag time between the publication of good data and the implementation of that data.

Q: What are the barriers to actually implementing the changes you’re recommending?

A: There are practical barriers. The first is cost: sometimes these changes incur either direct costs or labor costs. Second, some of these new strategies require a cultural change. For example, early goal-directed therapy and aggressive resuscitation in emergency departments requires a good collaboration across departments, between the urgent care areas and the critical care areas in many institutions. The obstacle to change here is not so much cost it is creating a different culture.

Q: How do you envision IHI.org accelerating improvement in this area?

A: There are several important things that will be on the website that will facilitate change:

• First, we’ll provide a good description of the “bundles”, which is the process of taking the guidelines and making them into operationalizable bundles of changes, so that they can be brought to the bedside more easily.
• Second, we hope to teach clinicians through the website how to create change teams.  A team approach is one of the keys to success; there will be pieces on the website that will guide clinicians through that process of creating change teams.
• Third, we’ll provide stories and frequently asked questions.  There’s lots to be learned when you first implement some of these new interventions, and being able to share the obstacles and solutions from one institution to another will be a really important piece in facilitating the change process.

Those of us who have been working in the Surviving Sepsis Campaign feel like we have done our job and now it’s up to the clinicians to help us.  We believe that we have created the right tools and the right education materials to make this process happen — to improve the care that every patient with sepsis, severe sepsis, and septic shock receives.  The next step is for clinicians to take these bundles into their institutions, use the tools on the website for data collection and measurement, and report their data to us and to the campaign. This campaign is only going to be successful if we can get clinicians to measure their outcomes and report them to us. So this is the time for clinicians to step up, measure their outcomes, and report them. Together we can reduce mortality in sepsis and save thousands of lives.