I apologies for the delay in my response. This issue is not is the current protocol the best possible, I will guarantee it is not and that it will change, nor is it about is clinician judgment better or worse than a protocol. The issue is, are our patients reliably receiving what we feel is the best care every time it is indicated. It is really about our unreliability to do what we think or know to be correct, every time, for every patient 24/7. In order to do this we must employ level 2 reliability methods of check lists, reminders, redundancy, defaults, scheduling and protocols that are carefully established and agreed upon by the clinicians. We still do not recognize severe sepsis early, we still forget to get the blood cultures and lactate, we fail to give the antibiotics early, we are not aggressive enough with the fluid, fail to reduce the VT control the glucose and an array of other processes are faulty.
I am a protocol person, our protocol is not exactly like the SSC guidelines because guidelines are insufficient because they lack explicitness needed to create reliability. Give antibiotics must be specified as to what antibiotic depending on the patients diagnosis (pneumonia, soft tissue, meningitis etc) and then the clinician may modify it (this happens about 5% of the time) according to his judgment for other patient factors. I agree no protocol meets every patients needs, but on the other hand they are very good at improving our reliability. They also afford the opportunity to allow us to learn when they do not work or have to be over ridden. This learning cannot be accomplished when chaos prevails with every clinician doing their own thing. My advice for what it is worth: 1. In your local environment drive consensus around what you believe to be best practice and can live with and feel is doable and acceptable. 2. Make the practice as explicit as possible, one that a nurse could carry out as a standing order. 3. Establish level 2 reliability processes around the agreed upon process 4. Monitor if the process is being followed and keep refining it until compliance is very high (>85-90%) for each individual element. 5. Non-compliance is a chance to learn, there are some good reasons why a clinician does not want to follow the protocol but more commonly non-compliance is a systems problem that needs to be corrected 6. Monitor outcomes 7. Don't be afraid to improve the process and even change to protocol as you learn PS: the new benchmark mortality rate for severe sepsis/septic shock is going to be < 10% by achieving high reliability. Terry P. Clemmer, MD Director of Critical Care Medicine LDS Hospital 8th Ave and 'C' Street Salt Lake City, Utah 84143 Phone 801-408-3661 E-mail: [email protected]<mailto:[email protected]> "Confidential Report for Improvement of Hospital, Facility and Patient Care--Not Part of Medical Record and Not to be Used in Litigation--Prepared Pursuant to Utah Code Ann. § 26-25-1 et seq., or Idaho Code Ann. § 39-1392 et seq." From: [email protected] [mailto:[email protected]] On Behalf Of Dr.Sunil T Pandya Sent: Tuesday, December 20, 2011 5:29 PM To: Ron Daniels Cc: [email protected] Subject: Re: [Sepsis Groups] SSC guidelines Dear all, Many of you have pointed out the right things during your discussions..but somewhere during the discussion...the debate is taking a unhealthy trend..subtle ego clashes are overtly palpable...! We are of the firm opinion that both protocols and professional (with right experience) help improving the patient outcome. Protocols are in place and audited 24 x 7....right professional with good competence may not be available 24 x 7.....if you have a right person to put in a central line and integrate resuscitation with lactate / ScVO2 / IVC US / Echo...nothing like it....but if somebody less experienced is there...do not attempt IJV / SCV....but do not delay measuring peripheral lactate levels, wide bore peripheral vein insertion and resus. and improving tissue oxygenation! Central line improves patient comfort levels....may not be mandatory during initial resuscitation if competent person is unavailable...but eventually they need it, if not for monitoring..for several other reasons. Let the healthy debate continue... Thanks, Sunil ------------ Dr.Sunil T Pandya Hon. Secretary, AOA India (www.aoaindia.com<http://www.aoaindia.com>) Hon. Secretary, Society of Obstetric Medicine, India Head, Dept. of Anaesthesia, Pain and Critical Care, Fernandez Hospital (Health care for Women and the Newborn), www.fernandezhospital.com<http://www.fernandezhospital.com> Director, Prerna Anaesthesia and Critical Care Services Pvt Ltd (www.prernaanaesthesia.com<http://www.prernaanaesthesia.com>) Hyderabad, India. On Tue, Dec 20, 2011 at 11:15 PM, Ron Daniels <[email protected]<mailto:[email protected]>> wrote: Jeffrey, I'm not bickering! I agree that the Rivers protocol and SSC Resusc Bundle have saved countless lives: I'm an SSC zealot! I also agree strongly that extensive academic debate is sometimes the enemy of rapid progress (infuriates me on a daily basis) and that this can bring about harm by omission. I was simply saying that there is room for pragmatism in application of both the Bundle and Rivers' protocol (as intimated by the two-tiered grading of EGDT elements in the 2008 update). I think if we're going to bring everyone with us we need to embrace this and accept that folks will want to adopt local variations in implementation. My message, which I might have worded poorly, is to go deliver the Bundle, do it reliably and consistently and with core goals consistent with SSC recommendations, but do it in a way which best suits the needs of your local patients. Does this make more sense? I'm guessing even the great man himself wouldn't claim to argue that he knows that, eg, ScvO2 >70% is better than >71%.. Kind regards Ron On Tue, Dec 20, 2011 at 5:19 PM, Jeffrey R Hanlon RN <[email protected]<mailto:[email protected]>> wrote: And what did those healthcare professionals do before the protocol. They applied what they knew and what they thought was best for the patient with the information at hand. Once the protocol was developed it gave a consistent model to follow that saved lives. I have watched it work on many occassions. Each physician still has the ability to use his or her knowledge base and experience to treat the patient but having a tested model that can be initiated even by prehospital personnel will, in my humble opinion continue to save the patients from an ever increasing killer. The longer we continue to bicker and pick it apart the more people are going to succumb to sepsis. We need to all be on the same page. Jeffrey R Hanlon RN Stamp Out Sepsis -----Original Message----- From: [email protected]<mailto:[email protected]> To: Jeffrey R Hanlon RN ; sepsisteam ; Joan.Greene Cc: sepsisgroups Sent: Tue, Dec 20, 2011 6:22 am Subject: RE: [Sepsis Groups] SSC guidelines Ron, I agree with you. It is not any individual part of the protocol that makes the difference. It is early recognition, appropriate antibiotic and fluid management altogether. In addition, the end goal must be tailored to the individual patient. Jeffrey, protocols do not save lives, health care professionals do. Riad Cachecho,MD,MBA Director of Trauma Crozer Chester Medical Center One Medical Center Boulevard Vivaqua Pavillion, suite 440 Upland, PA 19013 610-447-6090<tel:610-447-6090> THIS EMAIL CONTAINS CONFIDENTIAL INFORMATION. ANY INFORMATION CONTAINED IS USED FOR PEER REVIEW PURPOSES ONLY. ________________________________ From: [email protected]<mailto:[email protected]> [mailto:[email protected]<mailto:[email protected]?>] On Behalf Of Jeffrey R Hanlon RN Sent: Monday, December 19, 2011 10:27 PM To: [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]> Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] SSC guidelines All I can say is the protocol has and continues to save lives! Jeffrey R Hanlon RN Stamp Out Sepsis -----Original Message----- From: [email protected]<mailto:[email protected]> To: Joan Greene Cc: sepsisgroups Sent: Thu, Dec 15, 2011 3:46 am Subject: Re: [Sepsis Groups] SSC guidelines Hi Joan, My views (for what they're worth): * Key issue is ScvO2 as sole indicator of O2 delivery. Agree other modalities of assessment of volume responsiveness and O2 delivery have equal or greater role, but I believe answer lies in a colleciton of clinical information: dangerous for anyone to run too fast with a single modality! * CVC is necessary for a majority of these patients for pressors/ tropes anyway. The authors don't argue against CVC but against over-reliance on CVP and ScvO2. Pragmatically, we need to build a larger picture: we assimilate informaiton from multiple sources to build our picture * Slight concerns with article. It confuses septic shock with severe sepsis which is not helpful or appropriate (see criteria fig 1). Referencing is somewhat author-centric Summary: Don't let this hold you back. EDs get excited about EGDT and forget the basics. Let's try not to get hung up on individual modalities (esp until we have ARISE/ ProCESS/ ProMISe) but recognise and intervene quickly using the monitoring strategies we have to hand and an assimilation of information. Rivers' protocol is good- and prob better than random care- but no-one ever suggested it was the ultimate answer! What do others think? kind regards Ron On Mon, Dec 12, 2011 at 4:37 AM, Joan Greene <[email protected]<mailto:[email protected]>> wrote: Has anyone else received push-back in their early goal-directed therapy protocols after the attached article was published? We recently implemented the SSC guidelines for EGDT in our hospital by using a screening algorithm to activate a sepsis response team. The response team follows the 6-hour bundle. Now, we have some physicians who want to revisit the need for a central line based on this article. The bundle cannot be followed without a central line to measure the CVP and/or ScvO2 monitoring. I would appreciate any comments. Thank you. Joan Greene San Diego -- Dr Ron Daniels Suspect Sepsis: save someone's life today. Sign our e-petition at http://epetitions.direct.gov.uk/petitions/19602 Fellow: NHS Improvement Faculty Chair: Surviving Sepsis Campaign United Kingdom Chair: United Kingdom Sepsis Group Member of Congress: Global Sepsis Alliance Survive Sepsis Programme Director First Trustee: U.K Sepsis Trust Twitter: @sepsisuk _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org -- Dr Ron Daniels Suspect Sepsis: save someone's life today. Sign our e-petition at http://epetitions.direct.gov.uk/petitions/19602 Fellow: NHS Improvement Faculty Chair: Surviving Sepsis Campaign United Kingdom Chair: United Kingdom Sepsis Group Member of Congress: Global Sepsis Alliance Survive Sepsis Programme Director First Trustee: U.K Sepsis Trust Twitter: @sepsisuk _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
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