Sepsis Surveillance Definition Work Update

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1 Sepsis Surveillance Definition Work Update Anthony Fiore, MD, MPH Chief, Epidemiology Research and Innovations Branch Division of Healthcare Quality Promotion Centers for Disease Control and Prevention HICPAC Meeting November 6, 2015 The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

2 Objectives Provide overview of recent CDC and partner activities aimed at sepsis prevention and increasing awareness of early interventions Review limitations of current approaches to estimating sepsis burden Discuss CDC s current and planned work with partners to estimate burden, improve sepsis surveillance and increase sepsis awareness

3 Recent Changes, Increasing Focus Initial care for patients with sepsis increasingly focused on intervention bundles October 2015: Implementation of CMS process measure: Severe Sepsis and Sept ic Shock Management Bundle (NQF #0500) SEP-1 in the Hospital Inpatient Quality Reporting Program (HIQR) Sepsis clinical definitions and interventions are in flux Anticipated in 2016: Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) will present new approach for early recognition of patients at risk for severe outcomes

4 Haemophilus influenzae Streptococcus pneumoniae Group B Streptococcus Escherichia coli Group A Streptococcus Urinary tract infections Meningitis and other Central nervous system infections Neisseria meningitidis Staphylococcus aureus Pneumonia Skin and soft tissue infections Bloodstream infections Intra-abdominal infections Sepsis is a final common pathway for many different infections Sepsis Sepsis-related adverse outcomes or death Slide courtesy of J Jernigan, DHQP

5 Streptococcus pneumoniae Haemophilus influenzae Group B Streptococcus Escherichia coli Group A Streptococcus Neisseria meningitidis Staphylococcus aureus Three possible points of intervention to prevent adverse outcomes and death #1: Primary Prevention Urinary Tract Infection Meningitis and other Central nervous system infections Pneumonia Skin and Soft Tissue Infections Bloodstream Infections Intra-abdominal lnfections #2: Early Recognition and Diagnosis Sepsis Sepsis-related Adverse Outcomes and Death #3: Optimal Clinical Management and Treatment Slide courtesy of J Jernigan

6 Successful Implementation Will Require Engagement of Multiple Stakeholders Primary Prevention Early Recognition and Diagnosis Optimal Clinical Management and Treatment Major role for CDC Epidemiologic studies and surveillance to inform prevention strategies Outbreak response Prevention guidance and education Epidemiologic support for vaccine development and deployment Slide courtesy of J Jernigan

7 CDC Work on Primary Prevention of Infections Commonly Presenting as Sepsis: Selected Examples Preventing healthcare associated infections Estimated 151,000 CLABSI prevented and up to 27,000 lives saved Reductions in CAUTI, invasive MRSA and C. difficile infections in healthcare settings attributable to infection control improvements and antibiotic stewardship Developing and leading antimicrobial stewardship initiatives Support for vaccine development and programs Haemophilus influenzae type b, Streptococcus pneumoniae, Neisseria meningitidis, influenza virus (many 100s of thousands of infections prevented) Peri- or post- exposure prophylaxis for invasive pathogens Group A Streptococcus, Group B Streptococcus, N. meningitidis Preventing or reducing situations that put people at risk for infection Slide adapted from J Jernigan

8 New Sepsis Patient Materials

9 CDC Sepsis Awareness Month Efforts Collaboration with numerous clinical partners and patient advocacy orgs Print materials Video from CDC director, Dr. Frieden 9-part Blog Series on CDC s Safe Healthcare Blog Twitter chat with SCCM and numerous other partners with more than 12.9M impressions Over 70k views to CDC s sepsis website in September alone

10 Challenges: Sepsis Identification and Tracking Difficult syndromic definition based on clinician suspecting infection No gold standard diagnostic test Cultures are often negative Biomarkers not adequate Most patients with sepsis become ill in community, and have initial encounter in outpatient settings or the ED Concerns that o 2001 sepsis definition* does not capture some cases, and is inconsistently applied by clinicians o SIRS criteria not specific enough and inadequate to distinguish severe sepsis o Optimal bundled interventions are not defined *Levy MM, Fink MP, Marshall JC, et al. SCCM/ESICM/ACCP/ATS/SIS SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31: Slide adapted from L Epstein, CDC

11 Challenge: Tracking Sepsis Incidence and Mortality Death certificate data dependent on clinician assigning sepsis as underlying or contributing cause of death Administrative claims data have been the primary means of estimating sepsis burden. However, Analyses using administrative codes are demonstrating an increasing incidence of sepsis accompanied by decreasing mortality o No change or decreases in incidence of typical underlying infections (pneumonia, intraabdominal infections, bacteremia, etc.)

12 Hospitalizations for Which Certain Infection Codes Were Listed as a Primary Diagnosis, C Rhee, et al. New Engl J Med 2014;370: Data are from weighted national estimates from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), Agency for Healthcare Research and Quality (AHRQ), based on data collected by individual states and provided to the AHRQ by the states

13 Challenges: Sepsis Identification and Tracking Several different sepsis definitions are needed to address different key issues o Early detection to aid clinical management (sensitive, elements easily captured during initial clinical encounter) o Research studies to evaluate effectiveness of interventions o National surveillance (specific, consistent over time, elements easily captured using electronic health records) CDC role: Lead development of surveillance definition that can establish baseline and metric to track intervention impact

14 Current CDC Activities in Surveillance Measure Development Working with Harvard Prevention Epicenter and partners to develop and test a surveillance definition based on electronic clinical data Will be tested across multiple healthcare systems and hundreds of hospitals Goals Year 1: o Develop estimates of national incidence and mortality burden for sepsis and septic shock o Characterize trends in sepsis incidence and mortality Working with critical care experts to establish groundwork for understanding relationship between clinical definitions in development and surveillance data using electronic health records

15 CDC Sepsis Prevention and Assessment Activity: Next Steps Conduct studies that will better define risk factors, microbiologic causes, preventable fraction Assess sepsis definition candidates based on electronic clinical data that could be adapted for national surveillance Continue engagement with critical care experts, clinicians and the public to increase awareness of sepsis prevention and early intervention measures Work with partners to identify opportunities to improve and assess early intervention impact, including antibiotic use Emphasize primary prevention programs that prevent infections that cause sepsis (e.g., vaccine preventable infections, device-associated HAIs, etc.)

16 THANK YOU ACKNOWLEDGMENTS: LAUREN EPSTEIN, SHELLEY MAGILL, JOHN JERNIGAN FOR SLIDES For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone: CDC-INFO ( )/TTY: Visit: Contact CDC at: CDC-INFO or The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

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