Resources to Help Apply New Sepsis Definitions

2016 - 3 June- 45th Critical Care Congress Highlights
This article discusses the new sepsis definitions that were released during the 45th Critical Care Congress.


New definitions for sepsis and septic shock that were developed by a task force co-convened by the Society of Critical Care Medicine (SCCM) continue to generate widespread attention among SCCM members and the broader healthcare community.
 
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) published in the February 23, 2016 issue of the Journal of the American Medical Association (JAMA) generated nearly 820,000 page views during the first month following publication. The paper ranks in the top one percent (99th percentile) of all research outputs ever tracked by Altmetric, and ranks first compared to other research outputs of similar age from JAMA.

Medscape, MedPage Today and the Pittsburgh Post-Gazette were just three of several media outlets reporting on the new definitions.

“The attention has been stunningly successful,” said Craig M. Coopersmith, MD, FCCM, a task force member and immediate past president of SCCM. “There has been a high degree of intellectual debate, which is always a good thing. The comments have been largely supportive. The concerns expressed are often just seeking further clarification and additional prospective validation, which we strongly support.”

A Deeper Dive
The new recommendations define sepsis as life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities substantially increase mortality.

Absent from the new definitions is the term severe sepsis—a significant change from previous definitions. The task force deemed this term redundant, because sepsis has a mortality rate of 10 percent or higher, making the condition already severe.

Two of the most common clarifications sought in the wake of the new definitions involve the absence of systemic inflammatory response syndrome (SIRS) from the sepsis definition and the introduction of a new measure—the quick Sepsis-Related Organ Failure Assessment (qSOFA)—put forth in Sepsis-3 to help clinicians more quickly identify patients with, or at risk of developing, sepsis.

“SIRS is not included in the new definitions, but it doesn’t mean that it’s not still clinically important,” Dr. Coopersmith said. “SIRS can still be very helpful in identifying patients with infection; it just doesn’t have great utility in identifying patients with sepsis.”

The new qSOFA measure is aimed at bridging this gap. The qSOFA assessment directs physicians to assess three symptoms in patients with suspected sepsis: altered mental status, fast respiratory rate (greater than 22 breaths/min), and low blood pressure (less than 100 mm Hg). Blood tests are not required.

While qSOFA does not diagnose sepsis, data indicate that patients with two or more of these conditions are at a significantly greater risk of having a prolonged ICU stay (three or more days) or to die in the hospital. For these patients, Sepsis-3 recommends that clinicians investigate further for organ dysfunction, initiate or escalate therapy as appropriate, and consider referral to critical care or increase the frequency of monitoring.

Find Related Resources
The Society established www.sccm.org/sepsisredefined to educate physicians about the new definitions, the application of qSOFA and various clinical frameworks for using both. The page features various resources, including:
• The full presentation (video and PowerPoint) from the 45th Critical Care Congress announcing the new sepsis definitions
• A presentation (video and PowerPoint) from the 45th Critical Care Congress outlining how to use the new definitions
• Two Critical Care podcast interviews—one featuring Dr. Coopersmith and another with Clifford S. Deutschman, MS, MD, corresponding author for the JAMA article
• Webcasts exploring the rationale for the new definitions of sepsis and septic shock, the qSOFA and a discussion on how to apply this assessment with patients at bedside
• Critical Care Medicine articles by Seymour et al and Angus et al, which present conceptual frameworks to help patients, clinicians, researchers and hospitals apply the new definitions

These SCCM education efforts are ongoing. New resources will be added or updated as new information becomes available.

“It’s incredibly important that SCCM be a leader in these education efforts,” Dr. Coopersmith said. “SCCM has been a leader in all domains of sepsis for more than a decade—definitions, management, research, quality improvement and measurement. It will continue to be a resource for helping clinicians align these new definitions with their various work.”

Surviving Sepsis Campaign Response
Similarly, the Surviving Sepsis Campaign (SSC), a joint collaboration of SCCM and the European Society of Intensive Care Medicine committed to reducing mortality from severe sepsis and septic shock worldwide, is also working to educate hospitals and clinicians on the implications of the new definitions for current work. In March, members of the SSC Executive Committee issued a statement highlighting important considerations regarding the new definitions, including guidance for hospitals and clinicians in three important areas:
• Screening for, and management of, infection
• Screening for organ dysfunction and management of sepsis (formerly called severe sepsis)
• Identification and management of initial hypotension

The SSC statement, available at www.survivingsepsis.org, currently does not advise significant clinical changes. It notes, “For hospitals who have prepared for the transition, screening for early identification and treatment of patients with sepsis (formerly called severe sepsis) should continue essentially as has been previously recommended by SSC.” 

 “The Surviving Sepsis Campaign has always served the needs of practicing clinicians,” said Mitchell M. Levy, MD, a member of both the Sepsis-3 task force and the SSC executive committee.

“Right now, practicing clinicians, particularly here in the United States, should continue to use the bundles, which are best-practice models for the treatment of sepsis. The new definitions should not interfere with that.”

While the new definitions and the introduction of qSOFA offer potential improvements in how clinicians diagnose, treat and report patients with sepsis, widespread adoption will take time and require further testing, Dr. Levy said.

“The task force believes that it’s a newer and better system, but we need prospective testing to prove it, and there will need to be a transition,” Dr. Levy said. “My advice to clinicians in the field is not to force it.”

Federal, state and Centers for Disease Control and Prevention initiatives on sepsis that use different definitions, along with others required by the Centers for Medicare & Medicaid Services (CMS) for coding, add to the challenge of clinical integration.
 
“Although we’re changing the definitions, a lot of the other [sepsis] initiatives and coding are not going to change rapidly,” Dr. Levy said. “We need to help clinicians balance their appreciation of the new definitions with the need to continue reporting to CMS and others. It’s a real challenge, and one in which SCCM really wants to help.”

In addition to offering clinical guidance regarding Sepsis-3, the SSC statement advises hospitals on important considerations beyond the examination room.

“Hospitals should prepare for major changes that can alter fiscal considerations. Hospitals should develop detailed plans and educate their physician and nursing staff and their coding departments to ensure that their coders accurately capture the sense of the new definitions.”

The SSC statement concludes, “Sepsis team leaders should reinforce the message that the new definitions do not change the primary focus of early sepsis identification and initiation of timely treatment in the management of this vulnerable patient population.”