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Hospital Sepsis Program
13 Plays2 years ago
In this episode of the podcast, we will discuss Hospital Sepsis Programs with the recently released CDC Hospital Sepsis Program Core Elements document as an anchor. Our guest is Dr. Hallie Prescott, an Associate Professor in Pulmonary & Critical Care Medicine at the University of Michigan, and a staff physician at the Ann Arbor Veterans Affairs Healthcare System. Dr. Prescott’s primary focus of research has been on sepsis care and outcomes. She serves as co-chair of the international Surviving Sepsis Campaign Guidelines and as lead for the Michigan Hospital Medicine Safety Consortium’s Sepsis Initiative.
Additional Resources:
CDC Hospital Program Sepsis Program Core Elements: https://www.cdc.gov/sepsis/pdfs/sepsis-core-elements-H.pdf
CDC Additional Sepsis Clinical Resources: https://www.cdc.gov/sepsis/core-elements/resources.html
SCCM Surviving Sepsis Guidelines: https://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=2021&issue=11000&article=00021&type=Fulltext
Characterising an implementation intervention in terms of behaviour change techniques and theory: the ‘Sepsis Six’ clinical care bundle. Steinmo S, et al. Implementation Science 2015: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0300-7
Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial. Crit Care Medicine 2022: https://escholarship.org/content/qt4j222757/qt4j222757_noSplash_ad94a5b7db24a75b6176198a51129f5a.pdf
Books mentioned in this episode:
The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care. By Hannah Wunsch: https://www.amazon.com/Autumn-Ghost-Against-Epidemic-Revolutionized/dp/1771649453/ref=sr_1_1?crid=K1OFKS5NTQM4&keywords=the+autumn+ghost+hannah+wunsch&qid=1694808152&sprefix=autumn+ghosts%2Caps%2C108&sr=8-1
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Transcript
Introduction to Critical Matters Podcast
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Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
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Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
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And now, your host, Dr. Sergio Zanotti.
Significance of Sepsis Awareness Month
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September is Sepsis Awareness Month, a perfect time to reflect on our role as intensivists in increasing sepsis awareness among the public and in our role in making sepsis care in the hospital better.
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Sepsis is a major cause of morbidity and mortality in hospitalized patients, and there is ample opportunity to improve recognition and delivery of time-sensitive treatments for our patients.
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In today's episode of the podcast, we will discuss hospital sepsis programs with the recently released CDC Hospital Sepsis Program Core Elements document as an anchor.
Introduction to Dr. Hallie Prescott
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Our guest is Dr. Hallie Prescott, an Associate Professor in Pulmonary and Critical Care Medicine at the University of Michigan and a staff physician at the Ann Arbor Veterans Affairs Healthcare System.
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Dr. Prescott is a recognized clinician, educator, and researcher.
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The primary focus of her research has been on sepsis care and outcomes.
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She serves as co-chair of the International Surviving Sepsis Campaign Guidelines and as lead for the Michigan Hospital Medicine Safety Consortium's Sepsis Initiative.
00:01:31
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Hallie, welcome to Critical Matters.
00:01:35
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Hi there.
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Thanks so much for having me.
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Well, like I said, it's a very important topic, I think timely in terms of September being Sepsis Awareness Month.
Importance of Sepsis Care
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And obviously, you have not only dedicated a lot of your education and research time, but I'm sure like all of our colleagues take care of a lot of patients with sepsis.
00:01:54
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So today, we really wanted to focus on making care better through sepsis hospital programs.
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And maybe we can start as a more of introduction and just reminding us why we should care as clinicians about sepsis.
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Yeah, such a great question.
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So, you know, as you mentioned, sepsis is common.
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It's costly.
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It's deadly.
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It causes a lot of morbidity.
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Our current estimates are that about 1.7 million adults are hospitalized in the U.S. each year with sepsis and about 350,000 die.
Challenges of Early Sepsis Detection
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That accounts for about a third to a half of all hospital deaths in the U.S.,
00:02:34
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And even among our patients who survive hospitalization, we know that many of them face new morbidity, high rates of health deterioration, rehospitalization, death in the months after sepsis.
00:02:45
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So just a really important problem for us to be focusing on.
00:02:53
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Perfect.
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And one of the things that often comes up when we talk about sepsis is everybody thinks they know what they're supposed to do.
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Everybody thinks they know better than everybody else.
Complexity of Sepsis Treatment
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Yet over time, it seems that over and over again, there's opportunity for better treatment.
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And the question is, why is it so hard to get it right at the bedside?
00:03:13
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Yeah, that's a great question.
00:03:14
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So I think that there's a couple things.
00:03:17
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The first is I think that the very early sort of signs and symptoms of sepsis can be pretty nonspecific.
00:03:25
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And sort of over time, as things progress, it becomes sort of glaringly obvious, right, that a patient has sepsis, multi-organ failure, septic shock.
00:03:34
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But at that point, of course, it's much harder to treat and less responsive to treatment.
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So I think the trick is really trying to get it early, um,
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And I was at the National Forum for Sepsis in Washington, D.C.
Barriers to Early Sepsis Care
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earlier this week, and there was a number of patients and family members who were there.
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you know, sharing their stories and kind of over and over again, the thing that sort of came through in these stories was that patients would sort of tell their doctors, you know, something's not right.
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Like, I don't feel right.
00:04:07
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But it was early on.
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And, you know, maybe the vital signs or the labs, like things weren't sort of so obviously wrong from those assessments that,
00:04:15
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And so they were kind of reassured and brushed off and sent home.
00:04:19
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And I mean, again, like three or four different patient stories really all telling similar stories.
00:04:24
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And then, of course, like they've been told nothing to worry about.
00:04:27
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Everything's great.
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You know, this is no big deal.
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This was nothing, you know, whatever explained away.
00:04:32
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And then, you know, a couple of days go by, patients are getting sicker and sicker.
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They're reluctant to go back because, again, they've just been told everything's fine.
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And then when they do go back, you know, they're much, much sicker.
00:04:43
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So I think one thing is that it's just really important to be humble.
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It's important to kind of listen to our patients and validate their symptoms.
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And even if sort of we, you know, don't find anything in that moment, I think it's important to validate, you know, oh, yes, like that's a concerning symptom, you know,
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Right now, we don't see anything on labs.
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We don't see anything on vitals.
00:05:01
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But certainly, if things get worse or they don't improve, come
Communication Failures in Sepsis Treatment
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back.
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So I think we want to make sure that we're not sort of brushing our patients off.
00:05:09
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I think the second thing is that the actual delivery of what might seem like a simple set of treatments, you know, fluids, blood culture, antibiotics, is
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is actually kind of more complex than it might seem, requires coordination of multiple different people, and really can be broken down into kind of hundreds of hundreds of steps, and there's sort of opportunities for failure.
00:05:33
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So there was a...
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I think an ethnographic study where they did just hundreds of hours of observations.
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This was done in the UK a number of years ago where they're trying to understand, you know, barriers to delivering good early sepsis care.
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I'm just going to read a quote from this because it sort of resonated with me.
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It says, our emergent theory suggested that rather than being an apparently simple sequence of six steps,
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The sepsis six was actually involved a complex trajectory comprising multiple interdependent tasks that required prioritization and scheduling and which was prone to problems of coordination and operational failures.
00:06:13
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And I'll share just one kind of experience that I had that sort of really resonated with me about how these things can break down.
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I had a patient who...
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I was admitting to the ICU.
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This was about a decade ago.
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Patient was really sick, multi-organ failure, blood pressure low.
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You know, we immediately recognized this as sepsis and put in a whole bunch of stat orders, right?
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Blood cultures, other cultures, laboratories, x-rays, you know, additional IV access, antibiotics, kind of all of these things.
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And then, you know, I circled back to check on my patient about an hour later and it's like,
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Basal presser dose is rising.
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This patient is getting sicker, not better.
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And I said, goodness, you know, I think that we might need to give broader antibiotics because this patient is getting sicker, not better.
Role of Implementation Science in Sepsis Care
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And the nurse said to me, oh, like I haven't had time to hang the antibiotics yet.
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You know, you guys put in 100 stat orders and I'm just kind of working my way through them.
00:07:09
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And that sort of really resonated with me about how it's sort of not enough to make the plan in your head and put in the orders, but it's so important to communicate with the other people that you're working with so that you're all on the same page.
00:07:20
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So those are just kind of a few anecdotes about where I think sometimes we go wrong in recognition very, very early on and where we can, you know, sometimes have breakdown of communication and sort of failure to deliver the early sepsis treatments as quickly as we could.
00:07:39
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And I think it just brings a great example of why it's so important to really invest in implementation science research, because we might know what to do, but to deliver that consistently at a large scale, and we're talking about big numbers with sepsis, is a lot more difficult
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than we think it is.
00:07:57
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And I think it just speaks also, Hallie, to what you were saying about communication.
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If I put an order for staff but don't communicate that to somebody verbally in terms of what's most important first, they might just be doing what they thought they were supposed to be doing, going down the list as it appears, right, and crossing out each one of those orders.
00:08:18
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And maybe the antibiotics are the 24th order, and we wanted that first.
00:08:24
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Yeah, exactly right.
00:08:27
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Any other thoughts on factors that can impact successful implementation of a sepsis guidelines at the bedside from implementation science perspective?
00:08:37
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Yeah, I mean, one of the things, I mean, I think we'll get into it with the hospital sepsis program core elements, but one of the things that I think is just so important is kind of continually reevaluating where things stand and pushing to do them better, right?
00:08:51
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I know that a lot of hospitals have invested in
00:08:54
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you know, initiating processes or kind of like risk scores to help identify sepsis.
00:09:00
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But you also hear that a lot of times, you know, these things are firing on every other patient.
00:09:04
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And so they're not as helpful as they could be.
00:09:06
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And so I think part of it is, you know, doing something right, like implementing this risk score.
00:09:11
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But then it's also evaluating how that's working in practice and continually refining it to make sure that it's actually helping the bedside clinician, right?
00:09:19
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Like it's not helpful to make an order set and then have three people use it.
00:09:23
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It's not helpful to have a risk score that alarms on, you know, hundreds of thousands of patients and is snoozed 99% of the time or ignored 99% of the time.
00:09:32
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So I think that it's that sort of continual evaluation of, is this helping the bedside clinician?
CDC's Hospital Sepsis Program Initiative
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Is this helping to improve the management and outcomes and, you know, striving to tinker, refine, sort of make it better?
00:09:46
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I think that's an important point that we probably have opportunity for improvement because many healthcare systems have invested, like you said, in maybe tools to early recognition, but we've never invested in fine-tuning them and making sure that they're actually useful.
00:10:02
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And it feels often as a clinician at the bedside that we give antibiotics to those who don't need it, and then those who need it desperately, we miss it, right?
00:10:10
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And it just feels like we're not doing what we should be doing.
00:10:15
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Yeah, exactly.
00:10:15
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So it's like you got to launch the programs and then you got to reevaluate them.
00:10:19
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Yeah.
00:10:19
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Yeah.
00:10:20
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So let's dive into the topic that we wanted to focus on, which is the CDC Hospital Sepsis Program Initiative.
00:10:28
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And this is a recent document that I understand you have helped the CDC create as an expert, as a content expert.
00:10:38
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And before we go into talking about what this CDC document is, is there evidence to support quality improvement programs in sepsis?
Success of New York's Sepsis Regulation
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Yeah, I think yes is the short answer to that question.
00:10:54
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I mean, I think that, you know, a lot of the data that we have, you know, comes from sort of single hospitals or sort of, you know, coalitions of the willing, like hospitals that have participated in the
00:11:09
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surviving sepsis campaign, quality improvement initiatives.
00:11:12
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But I think that we have really robust evidence, for example, coming out of the New York State's ROIS regulation, where they had, you know, mandated that hospitals, you know,
00:11:25
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essentially develop sepsis guidelines and protocols for each of the hospitals and submit their data to the New York State Department of Health.
00:11:33
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And there was an analysis that looked at, you know, what are the trends in New York over time and how do those trends compare to what's happening in the surrounding hospitals?
00:11:43
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And they found that, you know, there was about a 3.5% absolute mortality reduction over the course of the first few years of rolling out that population.
00:11:53
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you know, those regulations that really forced hospitals to put together a committee to develop a process and a protocol for screening and identifying sepsis and, you know, completing those early aspects
Evidence for Bundled Sepsis Initiatives
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of management.
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So I think absolutely, that's probably the strongest piece of evidence we have that, you know, it is possible to do better.
00:12:13
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And I bring it up because I find that a lot of clinicians cherry-pick elements of sepsis guidelines and argue, we don't have evidence for this.
00:12:22
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Why are they recommending this or that?
00:12:24
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And at the end of the day, if we want to be true scientists, we have to recognize that we operate on the best available evidence with the idea that we continuously have to criticize it and find better explanations for
00:12:36
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or better answers to how we should do things.
00:12:39
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Yet, when this has been studied, like you said, initiatives that maybe sometimes have a bundle of individual elements that perhaps by themselves don't have the most robust evidence, but are based on sound scientific principles, have over and over again demonstrated to benefit patients.
00:12:56
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And that is, I think, an important point that often is missed in the discussion of minutiae about specific items of treatment.
Evolving Nature of Sepsis Definitions
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Yeah, I think you're exactly right.
00:13:08
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I mean, we hear the kind of same thing about the sepsis definition, right?
00:13:11
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I mean, this term sepsis has been around in the literature for thousands of years.
00:13:15
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This is a term that's been used, right?
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It comes from this Greek word to rot.
00:13:19
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And, you know, sometimes you'll hear like, well, we don't even know what sepsis is.
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You know, we don't have this appropriate definition.
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We need to get a better definition.
00:13:25
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And, you know, I totally agree.
00:13:27
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Like our definition is a work in progress.
00:13:28
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You know, we will have better definitions.
00:13:30
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you know, information in the future.
00:13:32
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And at some point we'll be able to sort of refine and improve.
00:13:34
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But I think it's unrealistic to think that we're ever going to get to perfect knowledge.
00:13:39
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And I think it's the wrong decision to say, because we don't have perfect knowledge in this moment about, you know, diagnosis or sort of, you know, every piece of data we could ever want to inform treatment that like we can't do better than what we're doing right now.
00:13:51
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Right.
00:13:51
Speaker
This like medicine is in this
00:13:53
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you know, constant stage of evolution.
00:13:55
Speaker
You know, we take the best available data that we have and we use that to inform the care that we deliver.
00:14:02
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And again, just like how I talked about how, you know, hospitals are always, you know, should be always working to improve the delivery of the care.
00:14:09
Speaker
Same thing, like for the Surviving Sepsis Campaign Guidelines, every four years we go back, we look at the literature, and we update the recommendations based on what's been learned in that time.
00:14:19
Speaker
But, you know, I think it's really, you know, it's an error or, you know, it's sort of a missed opportunity if we just kind of throw up our hands and say, oh, goodness, we don't
Critique of Sepsis Programs by Clinicians
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know anything.
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We can't, you know, we can't move things forward right now.
00:14:31
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We do the best we have with the data we have right now.
00:14:34
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You talked about being humble.
00:14:36
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One of the things that I find often clinicians lack is that humbleness.
00:14:42
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And when we talk about sepsis programs, the first response I will get is, oh, we already do that.
00:14:48
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Yet the CDC did a recent survey, and I understand the data suggests that there's plenty of room for opportunity.
00:14:55
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Any comments on that?
00:14:57
Speaker
Yeah, absolutely.
00:14:58
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Right.
00:14:58
Speaker
So that was questions that were added to the NHSN annual survey.
00:15:03
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So this goes out to essentially, you know, all 5000 hospitals in the US.
00:15:07
Speaker
And those questions were added this past year as we were preparing and sort of in the process of developing these questions.
00:15:15
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hospital sepsis program core elements to really get kind of an understanding of what's the baseline state of affairs.
00:15:21
Speaker
And you're exactly right.
00:15:23
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It was the majority of hospitals have a program that is sort of tasked with evaluating and improving management and outcomes of sepsis.
00:15:31
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And that, you know, in some hospitals, maybe a specific dedicated committee for sepsis and other
00:15:36
Speaker
hospitals that may be sort of a broader patient safety and quality committee where, you know, sepsis is one of the topics, but 73% of hospitals responded that, yes, we have such a committee.
00:15:46
Speaker
So that's great.
00:15:47
Speaker
I mean, that's the majority of hospitals.
00:15:50
Speaker
There's certainly still an improvement, right?
00:15:52
Speaker
That means a quarter of hospitals don't have a committee.
00:15:55
Speaker
So that's kind of like at the top level.
00:15:56
Speaker
Then you start digging deeper to sort of understand, well, like what's going on with this committee.
00:16:02
Speaker
And we find that only half of hospitals actually provide any specified effort to the leader of this committee.
00:16:09
Speaker
Right.
00:16:09
Speaker
So this is a really important topic.
00:16:10
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We said.
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Speaker
One third to one half of all hospital deaths are due to sepsis, right?
00:16:15
Speaker
350 million people in the U.S. die every year with sepsis.
00:16:18
Speaker
So this is a really important topic.
00:16:20
Speaker
And, you know, only half of hospitals even really have any sort of dedicated or sort of specified effort.
00:16:26
Speaker
This is like a volunteer activity that's happening in a lot of places.
00:16:30
Speaker
I think there is an opportunity to provide more dedicated effort to support those activities.
00:16:35
Speaker
And then again, you kind of go down the list and look at, well, who's involved in these committees?
00:16:39
Speaker
You know, does the sepsis committee sort of interact with antimicrobial stewardship or, you know, have representation from these different important stakeholders in the hospital, like emergency physicians, as well as critical care physicians, if you have an ICU, et cetera.
00:16:53
Speaker
So I think that, yeah, there are certainly opportunities for improvement in
00:16:57
Speaker
in terms of, you know, the resources for these committees, who's on these committees, and also, like we mentioned before, the sort of continual re-evaluation of the state of affairs and constantly trying to, like, push that needle forward to, you know, improve the screening, improve the delivery of care year on, you know, year upon year.
Hospital Focus on External Mandates vs. Patient Care
00:17:19
Speaker
And one of the important aspects as we dive further into what the hospital sepsis program core elements are is the feeling I get, and I want your comments on this, that a lot of hospitals are reacting to external mandates or requirements on reporting.
00:17:41
Speaker
And there seems to be more of a focus on what I call metrification, which is getting to that metric as opposed to understanding that
00:17:49
Speaker
that the goal here is to improve care and reduce morbidity and mortality on a very, very large number of patients, which is ultimately what I think we should be focusing on in healthcare.
00:18:00
Speaker
Yeah, you know, I think you're exactly right.
00:18:02
Speaker
You know, unfortunately, I do think that is kind of a natural response, right, to a lot of metrics, you know, especially patients.
00:18:09
Speaker
metrics that try to, you know, do risk adjustment and account for how sick people are.
00:18:13
Speaker
A lot of times the gut reaction, right, is, well, my patients are sicker and it's not really fully being captured or, you know, something like that.
00:18:21
Speaker
And yeah, I think it's really important to sort of do what's best for patients, right, and the rest will follow.
Overview of CDC's Hospital Sepsis Program Core Elements
00:18:29
Speaker
And the core elements really is trying to bring together
00:18:33
Speaker
what's available in the literature, what's available from a lot of feedback from frontline clinicians across dozens of hospitals, what's available from, you know, broad stakeholder input that we collected, you know, and incorporated prior to releasing these.
00:18:48
Speaker
It's really trying to bring together, you know,
00:18:51
Speaker
here's, you know, what you can do.
00:18:52
Speaker
Here's what we recommend to really develop a program to do the best that you can do.
00:19:00
Speaker
And there's, you know, a ton of recommendations in there.
00:19:02
Speaker
And we recognize that not that the programs are not going to look the same across all hospitals.
00:19:07
Speaker
And so we, you know, sort of do provide a lot of guidance and it can be tailored to specific hospitals.
00:19:13
Speaker
It can also be, you know,
00:19:15
Speaker
For hospitals that don't have a program, for hospitals that have had a program for a long time, how do you get better?
00:19:20
Speaker
It's really meant to be sort of a flexible guidance.
00:19:23
Speaker
But like you say, trying to, you know, really just do the best for the patients.
00:19:30
Speaker
I think that's, you know, just so important and not sort of just focus overly narrowly, like exactly on the metric and trying to improve, you know, just how you look on a metric, but really trying to do with specifications.
00:19:42
Speaker
And when you do that, the metric will follow.
00:19:44
Speaker
So before we dive into a little bit more detail, what is the CDC hospital sepsis program?
00:19:51
Speaker
Yes.
00:19:52
Speaker
So these...
00:19:53
Speaker
core elements of hospital sepsis programs is essentially a manager's guide, I'll say, to developing a program to evaluate and improve the management and outcomes of sepsis.
00:20:06
Speaker
And these can be at the hospital level.
00:20:08
Speaker
These can be at the health system level.
00:20:09
Speaker
They can be specific to sepsis.
00:20:11
Speaker
Again, sepsis can be part of a broader sort of committee.
00:20:14
Speaker
But some programs
00:20:18
Speaker
sort of program to do all of these things to improve outcomes from sepsis.
00:20:25
Speaker
And again, it goes through sort of a number of different, seven different core elements that are important to this program.
00:20:32
Speaker
Again, recognizing that there's flexibility across different types of hospitals in terms of exactly what that program looks like.
00:20:39
Speaker
Um,
00:20:40
Speaker
But again, meant to be sort of just like a broad manager's guideline, as opposed to something like surviving sepsis campaign or SEP1 bundles, which you could imagine is like a little bit more like a recipe for treating sepsis.
00:20:52
Speaker
CDC's core elements is like, okay, here's the manager's guide to how to like build the best kitchen you can build to then go make those recipes.
00:21:00
Speaker
And I think it's important because really what they're defining are the core principles that we should be focusing on.
00:21:07
Speaker
And what I like about, and we're going to talk about the core elements in a little bit, is that really you could adapt these to your reality, right?
00:21:18
Speaker
I mean, this is...
00:21:20
Speaker
useful for the highest performing sepsis program, maybe deployed in a large system to improving or moving the needle in a small community hospital.
00:21:31
Speaker
You can utilize these core elements and adapt them.
00:21:35
Speaker
And really, it can be a great guide for clinicians to improve care.
00:21:40
Speaker
But also, I think it's a great guide for clinicians to engage leadership and
00:21:45
Speaker
and that we're going to be serious about this, these are some of the things that we need to be focusing on, as opposed to we're just doing it because we have to do it, and everybody feels it's a tremendous waste of time.
00:21:56
Speaker
Yeah, thank you.
00:21:56
Speaker
I mean, that is something we spent so much time, you know, really trying to be mindful of, is to make sure that these were relevant to all different types of hospitals across the U.S. So let's start, maybe if you can just tell us, the way I understand the document is that you have a set of core elements.
00:22:13
Speaker
I think there's
00:22:16
Speaker
I have to count, but seven core elements, right?
00:22:18
Speaker
Or seven core elements.
00:22:21
Speaker
And that each core element has a set of what they call priority examples, which is, okay, these are the things that are most important for this core element for programs to focus on.
00:22:32
Speaker
And then it has additional examples, which I guess would be like the extra credit, right?
00:22:37
Speaker
You've really done all this and you want to move forward or why don't you try these?
00:22:40
Speaker
Okay.
00:22:42
Speaker
And maybe we can start by just telling us what are the core elements and what does each one in a nutshell represent and then maybe we can dive into some of these a little bit more in detail.
Seven Core Elements of Hospital Sepsis Programs
00:22:53
Speaker
Yeah.
00:22:53
Speaker
So yes, you're exactly right in terms of that's how things are organized.
00:22:57
Speaker
We have these seven core elements.
00:22:59
Speaker
We provide a bunch of examples within each core element of what are sort of very concrete things that would reflect sort of success or movement towards achieving this core element.
00:23:11
Speaker
And then we prioritize those examples into ones that we would say are these are top priorities and these are sort of additional examples.
00:23:19
Speaker
So
00:23:20
Speaker
The first core element is hospital leadership commitment.
00:23:24
Speaker
And this essentially means that you need to have people at the very top of your hospital or healthcare system committed to improving this problem.
00:23:33
Speaker
It's going to be hard to move the needle if you don't have buy-in from your hospital leadership.
00:23:39
Speaker
And then again, we provide examples of how that could be demonstrated or manifested.
00:23:45
Speaker
The second one is accountability.
00:23:47
Speaker
And there's kind of two components to accountability.
00:23:50
Speaker
The first one is that there needs to be defined leadership for the sepsis program.
00:23:55
Speaker
And we recommend having either one leader or two co-leaders.
00:23:59
Speaker
And the essential idea there is that, you know, there can be a committee, but if there's not someone in charge of that committee or someone leading the program, sometimes it ends up being kind of like no one's in charge and no one really kind of feels responsibility or ownership.
00:24:12
Speaker
So it's really about defining...
00:24:14
Speaker
Who's the leader?
00:24:15
Speaker
Who's taking ownership?
00:24:15
Speaker
You know, who's running this program?
00:24:18
Speaker
The second piece to accountability is about setting concrete program goals and evaluating progress towards those goals, for example, annually and updating them over time.
00:24:31
Speaker
So, for example, sometimes people will say, you know, the goal of our sepsis program is to eliminate deaths from sepsis.
00:24:39
Speaker
And that's like pretty aspirational.
00:24:41
Speaker
And I think what we're trying to push here is, you know, what is the concrete goal that your program is working towards in the next year?
00:24:48
Speaker
And we want something that you're not already achieving today, meaning that this is actually representing a step forward, but it's not something that's so far off in the future that people really can't kind of rally around and work towards doing.
00:24:59
Speaker
So it's about setting annual goals and re-updating them.
00:25:03
Speaker
That's the second piece of accountability.
00:25:05
Speaker
Um,
00:25:06
Speaker
The third core element is multi-professional expertise.
00:25:10
Speaker
And this really just recognizes that, you know, it really takes a village to care for patients with sepsis and that you need to have engagement of, you know, multiple sort of specialties and disciplines across your hospital and healthcare system.
00:25:26
Speaker
And so we sort of, you know, list out important people to engage in sepsis.
00:25:32
Speaker
performance improvement work as well as kind of performance evaluation and education.
00:25:37
Speaker
The next core element is action, and this is really about implementing things into practice to improve the management of sepsis.
00:25:46
Speaker
So this is where we're talking about screening protocols and order sets and, you know, huddles at the bedside or code sepsis or all these different things that hospitals, you know, do to improve the delivery of, you know, recommended sepsis practices.
00:26:05
Speaker
Um, the next item is tracking, and this is where you collect data on things like the epidemiology of sepsis in your hospital, the management, so the delivery of key recommended practices and also outcomes.
00:26:20
Speaker
And I think another really key part of tracking is tracking the things that you've implemented in action, right?
00:26:25
Speaker
Like you made this great order set.
00:26:27
Speaker
It's awesome.
00:26:28
Speaker
Unfortunately, no one is aware of it and it's only been accessed four times, right?
00:26:32
Speaker
That's really important to track and
00:26:34
Speaker
what you're doing to improve sepsis care so that you can refine it, make sure it's being used, understand maybe why it's not being used and improve it so it can actually, you know, do what it's intended to do and improve the delivery of care in your hospital.
00:26:49
Speaker
The sixth item is reporting.
00:26:51
Speaker
So this basically means that, you know, you track this information on sepsis, but you report it back to the relevant people.
00:26:59
Speaker
So this is, you know, frontline providers, you know, unit directors, you know, the people who are going to take this data directly.
00:27:06
Speaker
and act on it.
00:27:07
Speaker
It's important.
00:27:08
Speaker
It's not just in some vault somewhere, you know, only a few people are looking at it, but this is, this is, you know, passed off to the relevant partners.
00:27:14
Speaker
And so people can use that data to, again, refine what they're doing and improve things going forward.
00:27:19
Speaker
Um, the final element is then education, um, and just recognizing really how important it is, um, to educate, um, really all, you know, healthcare providers, staff, patients, families, caregivers, um, on sepsis.
00:27:34
Speaker
You know, we see repeatedly that, um,
00:27:36
Speaker
you know, that sepsis is a term that the lay public is not necessarily aware of, despite being, you know, more common than, you know, heart attack and stroke.
00:27:46
Speaker
People do not know that term.
00:27:49
Speaker
And even if they've kind of vaguely heard of it, they don't know the, you know, the sort of warning symptoms.
00:27:54
Speaker
And that's true even among patients who have been diagnosed with sepsis, discharged, and, you know, are of course at risk for, you know, having recurrent episodes of sepsis.
00:28:02
Speaker
So,
00:28:03
Speaker
So those are the seven core elements.
00:28:06
Speaker
So really sort of comprehensive guidance about kind of all the different activities that hospitals are doing to reduce the burden of sepsis.
00:28:18
Speaker
Perfect.
00:28:19
Speaker
And I think that what I would like to do, Ali, is to just go into some of these in more detail and maybe ask you a couple more questions and dig a little bit deeper, and especially from the perspective of the clinicians at the bedside, which a lot of them obviously are taking care of their patients, but a lot of them also will be involved in sepsis committees.
Engagement of Hospital Leadership in Sepsis Programs
00:28:40
Speaker
So why don't we start with hospital leadership commitment?
00:28:43
Speaker
And I think this is a great document to
00:28:45
Speaker
to sit down with your CMO or CNO at your hospital and talk about, are we going to do this?
00:28:50
Speaker
Let's do it in the right way.
00:28:52
Speaker
These are some recommendations from the CDC.
00:28:55
Speaker
And I think that having an executive from the C-suite sponsor the sepsis committee or the sepsis improvement program is very important.
00:29:05
Speaker
Any other thoughts there from the hospital leadership commitment in terms of resources?
00:29:11
Speaker
Yeah, so I think, you know, that's so key is having an executive sponsor and ideally having, you know, regular monthly something like this meetings with that executive sponsor so they understand, you know, what you're working on and they're able to, you know, advocate for the resources that you need to run the program.
00:29:29
Speaker
You know, we think that in most circumstances, the program leader should have, you know, specified effort to run the program.
00:29:38
Speaker
And leadership is also going to be very helpful in terms of, you know, ensuring the engagement and buy-in from partners, you know, and other sort of departments, making sure that the emergency department is involved, you know, the hospital wards, the ICU, the pharmacy, kind of all the people that you need to bring together to run the program.
00:29:58
Speaker
So it's important for leadership to be engaged.
00:30:00
Speaker
You know, it's very helpful for them to have the executive sponsor meet with the committee or meet with the program leaders regularly and also to, you know, signal to the hospital, right, to send out communications to say sepsis is a priority of our hospital.
00:30:13
Speaker
You know, here's what we are doing to make sure that everybody sort of feels that this is really an important sort of core mission of the hospital.
00:30:25
Speaker
What about accountability?
00:30:26
Speaker
I know that you talked about that already in terms of the different aspects about it, but I have seen a lot of sepsis committees where nobody is a designated leader and maybe the sepsis coordinator just brings the last numbers, a couple of cases, there's discussion, and we move on to the next meeting.
00:30:46
Speaker
So how should we structure this to be more effective?
00:30:50
Speaker
Yeah, I think you're exactly right.
00:30:51
Speaker
So like sort of step one, there needs to be a committee.
00:30:54
Speaker
And as we mentioned, that's happening in 73% of hospitals.
00:30:59
Speaker
But like you've just mentioned, that doesn't always mean that it's sort of an effective committee.
00:31:05
Speaker
So we think it's absolutely key.
00:31:07
Speaker
We think probably ideally it should be co-led by a physician and a nurse or by a single person.
00:31:15
Speaker
So one to two leaders for whom
00:31:19
Speaker
you know, this is kind of like a core piece of their job.
00:31:22
Speaker
They have the sort of ownership and responsibility to run that program.
00:31:26
Speaker
Because like you say, if there's sort of a committee of 12 people, but no one's actually charged with running it, it can sort of feel that no one's actually in charge of it.
00:31:35
Speaker
Are there other aspects of accountability that you want to mention?
00:31:39
Speaker
Yeah, I think so.
00:31:40
Speaker
The other one, like I mentioned before, is that I think it's really important to set goals and to have those be based on, you know, what you know about your hospitals, um,
00:31:54
Speaker
management and outcomes.
00:31:55
Speaker
And that may be hard if you're sort of just brand new, starting up a committee, and maybe you don't have a lot of data, and you're kind of just getting going.
00:32:02
Speaker
But even, you know, sort of having some informal conversations with, you know, people throughout your hospital, just to kind of get, you know, the feeling of the
00:32:10
Speaker
Among the clinicians of, what do we think are our key areas for improvement?
00:32:13
Speaker
Where should we start focusing on?
00:32:16
Speaker
And then thinking about, what are the goals over the coming year?
00:32:21
Speaker
Re-evaluating progress towards those goals and moving the needle forward.
00:32:25
Speaker
So I think that's really important.
00:32:26
Speaker
Like I mentioned, sometimes people have these kind of pie-in-the-sky ideas.
00:32:30
Speaker
you know, goals.
00:32:31
Speaker
And then it's really hard to assess, like if you have an unrealistic goal or if you have no goal, how do you know if your program is really doing what it's intended to be doing?
00:32:39
Speaker
So I think it's really important to try to, you know, use the resources you have to get a handle on, you know, where are gaps that we should be focusing our energies on and set, you know, realistic but ambitious goals and track progress to those and reset those goals on an approximately annual basis.
Collaboration Across Hospital Departments
00:32:58
Speaker
Perfect.
00:32:59
Speaker
Then multi-professional expertise, the third core element, which obviously I think is at the core of what we try to do in the ICU, but it is an area where I think there's a little more opportunity to improve.
00:33:13
Speaker
Can you talk about that?
00:33:15
Speaker
Yeah, absolutely.
00:33:16
Speaker
So, you know, again, sepsis is just something that spans so many different areas of the hospital, emergency department, the wards, the ICU, you know, pediatric units, you know, maternal units.
00:33:29
Speaker
You know, we need help from pharmacists, you know, infectious disease, antimicrobial stewardship providers.
00:33:35
Speaker
And so I think it's important that, again, like having this signal from high up leadership that this is important, I think, can help improve engagement.
00:33:44
Speaker
And, you know, I do think sort of we need to be pragmatic.
00:33:49
Speaker
And, you know, it's unrealistic to have meetings of 40 people with regularity or anything like that.
00:33:54
Speaker
But trying to bring together sort of the key people that you need, you know, for your regular meetings and then have other people that you engage on kind of an ad hoc basis.
00:34:02
Speaker
But there's no way that these committees can just be run by, you know, ICU physicians or ER physicians alone.
00:34:09
Speaker
These have to be really multidisciplinary.
00:34:12
Speaker
They have to involve, you know, different areas of the hospital to be effective.
00:34:17
Speaker
And I think another important aspect is that we tend to see that there's still a lot of silo mentality within hospitals, right?
00:34:24
Speaker
Like people look at SEP1 and say, oh, that all those fallouts are in the ED, right?
00:34:30
Speaker
It's not our problem.
00:34:31
Speaker
Yet.
00:34:32
Speaker
I do believe that, and I would like to hear your comments, that sepsis being defined as presumed or documented infection with organ failure falls right in the lap of the intensivist.
00:34:44
Speaker
That's what we do, right?
00:34:45
Speaker
We manage multi-organ failure, and I think we should be leading these efforts.
00:34:51
Speaker
Yeah, no, absolutely.
00:34:53
Speaker
I mean, you know, it's important in the ER, it's important in the wards, it's absolutely important in the ICU.
00:34:57
Speaker
And, you know, certainly I think that, you know, we may see things a little bit different, like, of course, you know, community onset sepsis largely goes through the emergency department.
00:35:06
Speaker
but we see a ton of hospital onset sepsis in the hospital wards and in the ICU.
00:35:12
Speaker
And those cases account for a smaller proportion, right?
00:35:15
Speaker
But they are much more deadly, very important.
00:35:20
Speaker
And so, yeah, no, all of these different locations in the hospital, it's very important to have them involved.
00:35:27
Speaker
I do agree, you know, there's kind of like
00:35:30
Speaker
silos and this kind of like tribal nature of medicine.
00:35:33
Speaker
And it's really important to work together.
00:35:35
Speaker
You know, we're all here to, you know, do the best for our patients.
00:35:39
Speaker
And it's important to work together in that goal.
00:35:42
Speaker
And I do believe that the ICU can be a great leader in terms of improving care outside of the ICU.
00:35:47
Speaker
And this being a topic that is so, so dear to what we do every day, I think is a great opportunity for our ICU clinicians to really become engaged and take the lead.
00:36:00
Speaker
Oh, yeah.
00:36:01
Speaker
No, I agree.
00:36:01
Speaker
Absolutely.
00:36:02
Speaker
I mean, sepsis is something that I think is, you know, near and dear to the heart of all intensivists because it's something that we see so commonly in the ICU.
00:36:09
Speaker
And I think intensivists absolutely can and should take a lead in these programs and, you know, take a lead in terms of, you know, education of, you know, hospital staff, patients and families.
00:36:22
Speaker
Yeah, I totally agree.
00:36:25
Speaker
Now, one of my favorite quotes, I think is from Herb Spencer, is that the goal of education and research is not knowledge, but action.
Action Initiatives in Sepsis Care
00:36:34
Speaker
So the next core element is action.
00:36:37
Speaker
And what are your thoughts on what's most important here?
00:36:41
Speaker
Oh, goodness.
00:36:41
Speaker
Yeah.
00:36:42
Speaker
So action is a massive core element, right?
00:36:44
Speaker
We could have probably broken it down into a whole bunch of them.
00:36:46
Speaker
But, you know, we put them all here in one thing.
00:36:49
Speaker
I mean, action is, I don't know, it's where the action is.
00:36:51
Speaker
So this is just really sort of
00:36:56
Speaker
all the initiatives that your hospital is doing to improve the management of sepsis, right?
00:37:01
Speaker
This is screening processes, you know, refinement of those processes, identifying it when patients are admitted with sepsis, identifying the development of sepsis in patients, right, who are post-operative or, you know, admitted to the hospital for other causes.
00:37:14
Speaker
This is having like a guideline or a
00:37:17
Speaker
standardized clinical practice, order sets, all these different things that we do to make it easy to do the best care for patients, right?
00:37:26
Speaker
Like generally, the easier it is to do the right thing, the more likely we are to do it.
00:37:30
Speaker
So this is really about trying to, you know, align the structures and processes in your hospital to make it easy to provide recommended, you know, sort of evidence-based management.
00:37:43
Speaker
And I believe that one of the most important aspects is something that you mentioned earlier in our conversation, which is related to if you develop order sets, if you develop protocols, how are you following the utilization and usefulness of those, right?
00:37:58
Speaker
And I think it's very, very common for people to come up with a sepsis pink sheet, a sepsis order set, and everybody thinks, okay, we're done.
00:38:08
Speaker
And there's a lot more to that.
00:38:11
Speaker
Yes, I think you're exactly right.
00:38:13
Speaker
So that is like a message that I hope really comes clear through this document is just how important it is to evaluate what you're doing and refine it over time.
00:38:21
Speaker
And I'm really hoping that, you know, the Coromelts will bring increased attention to the importance of having hospital sepsis programs.
00:38:29
Speaker
And that by doing that, that we'll also have sort of greater sharing of resources across hospitals.
00:38:34
Speaker
Because I do worry a little bit that we've got 5,000 hospitals in the U.S. that are all to some extent kind of reinventing the wheel, right?
00:38:40
Speaker
Like we have these,
00:38:42
Speaker
international guidelines for sepsis, the surviving sepsis campaign guidelines, but ultimately those need to be translated into sort of a local treatment pathway and sort of local order sets.
00:38:53
Speaker
And, you know, I don't think that those necessarily should be exactly the same across hospitals, but it's probably a lot easier to take something off the shelf and tweak it or adapt it to your hospital than
00:39:04
Speaker
than really having everybody kind of start from scratch.
00:39:07
Speaker
So I do hope that this really kind of catalyzes sharing of stuff across hospitals and really investing into the science of what is the best way to screen, you know, when people come in the door to the ER, what is the best way to screen on the hospital wards?
00:39:21
Speaker
What is the best way to roll out the order set?
00:39:24
Speaker
You know, what is the best way to make that order set so like intuitive and user friendly that, you know, of course, people are always going to use this order set.
00:39:33
Speaker
It makes their lives easier.
00:39:34
Speaker
So I'm really hoping that it kind of like injects a lot of kind of energy into those things.
00:39:41
Speaker
Perfect.
00:39:41
Speaker
There's two more things I wanted to ask you about on action.
00:39:45
Speaker
The first one is code sepsis protocols.
00:39:49
Speaker
Any thoughts on that?
00:39:53
Speaker
Yeah, so I think that these are used in some hospitals, and I think that they're sort of slightly different in terms of how they are implemented.
00:40:05
Speaker
So I think the idea generally is that, you know, we have these rapid response teams, which is like, you know, bring people to the bedside when the patient is acutely ill to sort of rapidly stabilize patients.
00:40:16
Speaker
And so...
00:40:18
Speaker
Hospitals have kind of taken that general idea and applied it to sepsis.
00:40:22
Speaker
And sometimes that means that you have a rapid response team and you make sure that your rapid response team really has kind of like dedicated, you know, training, education, expertise in sepsis management.
00:40:33
Speaker
And I think that's great.
00:40:35
Speaker
And I think that some hospitals have also taken a slightly different approach where they have, you know, made kind of dedicated teams that are just responding to sepsis.
00:40:46
Speaker
So if someone comes in through the emergency department and
00:40:48
Speaker
you know, they get some sort of triage, you know, evaluation, it flags likely for sepsis, it essentially activates this dedicated team to come to bedside, and, you know, rapidly kind of complete the evaluations in terms of, you know, blood cultures, you know, fluids, antibiotics, and these types of things.
00:41:08
Speaker
And again, I think that
00:41:10
Speaker
It's really going to be different.
00:41:12
Speaker
I can't say that every single hospital in the country is going to, like, that makes sense for every hospital to have a dedicated code sepsis team because I think it's really going to depend on the size of the hospital.
00:41:23
Speaker
But I think most hospitals do have, you know, many, many or most hospitals do have sort of general rapid response teams.
00:41:30
Speaker
And I think sort of excellence in the evaluation and management of sepsis should be a core competency for those teams.
00:41:38
Speaker
I think, you know, when we were preparing this guidance, we did, you mentioned, like, the lead for this statewide sepsis quality improvement initiative in the state of Michigan called Hospital Medicine Safety Sepsis Initiative.
00:41:52
Speaker
It's funded by Blue Cross Blue Shield of Michigan.
00:41:56
Speaker
We have 69 hospitals that participate.
00:41:59
Speaker
So these are, you know, hugely diverse set of hospitals that range from, you know, large medical centers and, you know, the Detroit, Southeastern Michigan area up to very smaller hospitals in our very rural upper peninsula of Michigan.
00:42:13
Speaker
So really like a whole range of hospitals.
00:42:15
Speaker
And we are always inviting our hospitals to share their challenges and share their successes and
00:42:22
Speaker
And the code sepsis approach has been something that has been implemented in a number of our hospitals.
00:42:28
Speaker
And as they have sort of tracked the management and outcomes of sepsis, I will say that we've had a number of hospitals that have, you know, really seen success in this approach.
00:42:39
Speaker
Excellent.
00:42:40
Speaker
The other question I had was related to discharge of patients.
00:42:45
Speaker
And I did notice that alongside many other areas in critical care, the recognition of this document of the challenges and dangers that patients who were in the hospital with sepsis or septic shock have if they survive once they leave.
00:43:02
Speaker
Any comments on that?
00:43:04
Speaker
Yeah.
Challenges in Post-Discharge Sepsis Care
00:43:05
Speaker
So this is, I think, a really important area.
00:43:07
Speaker
And I think also an area where, you know, there's very clear difference between these kind of core elements and some other prior sepsis initiatives, which have largely focused on the very early management.
00:43:17
Speaker
So this, you know, guidance is really meant to be sort of about comprehensive sepsis activities, but also the management of sepsis really from hospital admission all the way to discharge and beyond.
00:43:27
Speaker
And so we know just from the past 15 of 20 years, I mean, there's just been so many studies coming out, you know, that have shown the,
00:43:34
Speaker
you know, sort of detrimental longer term impacts that sepsis has on patients in terms of new morbidity, you know, not being able to go back to work or the activities that people were doing beforehand.
00:43:45
Speaker
And it's just so important to, um,
00:43:50
Speaker
like provide, I think, anticipatory guidance to patients to, you know, ensure that they have timely outpatient follow-up, to ensure that they have a, you know, a way to get their questions answered if they go home from the hospital and have a question three hours later about, wait, what's this antibiotic?
00:44:05
Speaker
Why am I supposed to be taking it, right?
00:44:07
Speaker
All of those things.
00:44:08
Speaker
And that certainly, I think, has not been a...
00:44:13
Speaker
A key focus in a lot of the sepsis work, but there have been, you know, smaller studies.
00:44:17
Speaker
There's a trial called the IMPACS trial that was done at Atrium Health, which is a healthcare system in North Carolina, where they, it was like a pragmatic trial with 700 patients hospitalized with sepsis.
00:44:30
Speaker
They specifically enrolled patients who sort of flagged as higher risk for potential readmission or mortality, and they randomized them to just, you know, routine care versus this sepsis transition and recovery program that essentially consisted of this kind of remote nurse navigator who was looking at the chart, making sure that essentially recommended sepsis care was being provided in hospital.
00:44:54
Speaker
Pinging the team if there was sort of suggestions for improvement, ensuring that the patient had timely outpatient follow-up, providing anticipatory guidance, including things like who to call if you have a question about this or who do you call if you have a question about that.
00:45:09
Speaker
And then they did a number of follow-up calls to patients, I think at like...
00:45:13
Speaker
two to three days, maybe five days, just asking if they had questions, issues with their medications, sort of new worries of symptoms.
00:45:22
Speaker
And this intervention was associated with a reduction in hospital readmission and mortality.
00:45:29
Speaker
And the intervention went to like 30 days post-discharge, but they actually followed patients all the way up to a year.
00:45:36
Speaker
And this effect of this kind of more support during this transitional phase was
00:45:41
Speaker
was associated with a durable outcome even out to one year on these outcomes that are traditionally very hard to move the needle on.
00:45:48
Speaker
So I think it shows the, you know, again, potential to improve outcomes even for really a very sort of challenging problem that sometimes, you know, people throw their hands up and say, oh goodness, I'm not sure that we can fix this or make it better.
00:46:03
Speaker
I think that we do have data that we can do better at discharge and that it can really make a difference for our patients.
00:46:09
Speaker
So
00:46:09
Speaker
So this is something that we have included in these core elements.
00:46:13
Speaker
And I would submit to our audience that this is an area of opportunity for intensivists, right?
00:46:19
Speaker
We're not really thinking all the time of educating families and patients on discharge and what to expect, what to look out to.
00:46:29
Speaker
But not only is it a very challenging issue, but as I think the data suggests, it's a massive problem.
00:46:35
Speaker
I guess up to 40% of patients discharged from hospital with sepsis might have a readmission in 30 days.
00:46:40
Speaker
So that is a real issue, right?
00:46:43
Speaker
Yeah, no, I think you're exactly right.
00:46:44
Speaker
And I do think you're right about sort of, you know, the importance of intensivists, even in this problem or sort of being part of the solution.
00:46:51
Speaker
Even if we only very rarely are the ones to actually discharge the patient from the hospital, often they'll go to the floor before they go out the door of the hospital.
00:47:00
Speaker
But in some work that I was involved in before, we looked at essentially...
00:47:04
Speaker
potentially inappropriate sort of discharge medication.
00:47:07
Speaker
So they got started on something that they probably shouldn't have, or they had a medication that was held, you know, appropriately because they were in septic shock.
00:47:15
Speaker
But then there was this kind of missed opportunity to reinitiate the medication prior to discharge.
00:47:21
Speaker
And it was interesting because we found that a lot of times it was sort of whatever the medications were on at the time of ICU to ward transfer, that's kind of what they went home on.
00:47:31
Speaker
And oftentimes, you know, it sort of wasn't picked back up.
00:47:34
Speaker
So I think it's so important when the patient goes from the ICU to the ward to do this medication reconciliation and sort of call out, yeah, you know, this patient was on a beta blocker, like probably they should be back on it.
00:47:45
Speaker
It's not yet time because their blood pressure is still not quite, you know, as robust as it normally is.
00:47:49
Speaker
But like, don't forget about it.
00:47:50
Speaker
Right.
00:47:52
Speaker
I do think there is an opportunity to improve that transition from ICU to ward that then can ultimately translate into improvements in the ultimate hospital discharge.
00:48:04
Speaker
And I think it just speaks to that voltage drop in any transition of care, right, whether it's from ICU to floor or floor to home, there's opportunity for us to do a better job and to recognize that that's a dangerous period or timeframe for our patients.
00:48:21
Speaker
Absolutely, yeah.
00:48:22
Speaker
Anytime there's a transition of care, I think from like ER to the ICU or ER to the ward, there's data about how often the second dose of antibiotics is given sort of very delayed because the patient got their first stuff, but then they're just kind of boarding in the ER for a long time, or they're physically in the ER, but someone in the hospital is managing them remotely.
00:48:41
Speaker
So these transitions are just so prone to kind of breakdown in the systems.
00:48:49
Speaker
So really important, I think, areas to focus on, you know, as we sort of develop tools to improve the delivery of care and as we work to sort of track and report back to really focus on those transitions between care locations and then the sort of ultimate discharge from the hospital, really important.
Tracking and Reporting Sepsis Data
00:49:07
Speaker
Perfect.
00:49:08
Speaker
So maybe we can do tracking and reporting together.
00:49:10
Speaker
And tracking obviously is a big challenge for a lot of hospital and hospital systems.
00:49:18
Speaker
It requires resources and nobody can track everything.
00:49:21
Speaker
But I do believe that often our biggest problem is that we're not clear on what the priority is and make sure that perfection is not the enemy of good and that we get data that we can actually use.
00:49:35
Speaker
Any comments on that?
00:49:37
Speaker
Yeah, so I totally agree.
00:49:38
Speaker
Nobody can measure everything and it probably wouldn't even be a better place if we did.
00:49:42
Speaker
So I think that it's really important to, again, I think like, you know, try to take the temperature of like what's happening on the, you know, front line to understand what do we think are potential problems and start measuring those things.
00:49:56
Speaker
And then I think that, you know, really sort of reiterating a little bit what's been said before, but it's so important to try to understand like the usability of
00:50:04
Speaker
um the use and the usability of the things that you have developed um and i think that's probably like sometimes a you know relatively neglected area of of measurement is trying to understand how well the order set how well the screening tool how well these things that have been implemented are actually being being used and trying to make those better um you know i think it's you know important to
00:50:27
Speaker
Yeah, just kind of going back with that accountability, setting these kind of concrete goals, you know, and then focusing measurement around trying to make sure that we have a way to actually assess whether we're making progress towards the thing that we sort of identified as a priority and recognizing that, like, you can change it again next year.
00:50:48
Speaker
Right.
00:50:48
Speaker
Like we should be changing it again next year.
00:50:51
Speaker
You know, we start focusing on some things if we discover, wait, no, that's actually not the problem.
00:50:55
Speaker
We think this is another big problem.
00:50:57
Speaker
You know, focusing on something else the next year.
00:51:00
Speaker
I think sort of it's always a work in progress.
00:51:04
Speaker
Absolutely.
00:51:05
Speaker
And I believe that one of the biggest problems that we have in healthcare is that when we talk about mortality, there's two issues that I see often.
00:51:16
Speaker
One is that it's very hard to have risk stratified mortality in a lot of places.
00:51:21
Speaker
So we're not comparing apples to apples.
00:51:23
Speaker
But also what I see is that often by increasing the denominator, you can improve your mortality.
00:51:28
Speaker
And that's really not what we're trying to do here.
00:51:30
Speaker
We're trying to improve the process of care and measure the same denominator definition for all our patients so that we know there's actually a change over time.
00:51:39
Speaker
Any comments on that, Hallie?
00:51:41
Speaker
Oh, yeah.
00:51:42
Speaker
So, yeah, these are sort of like these, you know, problems of performance measurement that you're exactly right are sort of big challenges.
00:51:48
Speaker
So I think that...
00:51:51
Speaker
One thing that we've seen kind of over and over again is that it's really not as helpful to identify patients with sepsis merely based on a diagnosis code of sepsis because the use of those diagnosis codes has really varied over time and varied across hospitals such that exactly like you're saying, the comparison is really biased by you're measuring potentially a different set of patients.
00:52:12
Speaker
So
00:52:13
Speaker
You know, the CDC has this sort of like electronic health record-based definition called the adult sepsis event criteria, and those are meant to be a more standardized definition that's like less prone to bias by these, you know, changes in labeling of patients.
00:52:31
Speaker
So I do think that can be really helpful.
00:52:34
Speaker
I think that, you know, the other option, if that's like maybe infeasible, would be to, you know, look at something like the combined...
00:52:43
Speaker
you know, sepsis plus some other, you know, infection codes to again, sort of avoid the biases resulting from like the increasing relabeling of sepsis or sorry, pneumonia to now being called sepsis.
00:52:57
Speaker
Um, uh, that, that, that's another potential way to sort of get around it.
00:53:01
Speaker
Um, but yeah, you're, you're, you're exactly right.
00:53:04
Speaker
Um, you know, a lot of times, um, there can be, uh, sort of apples to oranges comparisons.
00:53:11
Speaker
The, um,
00:53:13
Speaker
CMS, Center for Medicare and Medicaid Services, is working right now, you know, to develop a 30-day risk-adjusted mortality measure for community-onset sepsis.
00:53:27
Speaker
So...
00:53:28
Speaker
This will likely be using an approach similar to the CDC's adult sepsis event criteria that is essentially identifying sepsis based on electronic health record-based criteria for acute organ dysfunction, as well as evidence of infection to identify the cohort.
00:53:45
Speaker
And then using, again, data from the electronic health record to try to perform risk adjustments.
00:53:52
Speaker
And so the hope is that, you know, going forward, we will be able to have a little bit more clinical data, sort of nuance granularity built into these measures to get closer to trying to account for the differences in sepsis patients across hospitals and over time to, you know, get better at really trying to isolate differences or improvements in outcomes over time after accounting for differences in the types of patients.
00:54:21
Speaker
And reporting, obviously, is a critical
Effective Reporting for Sepsis Care
00:54:23
Speaker
step.
00:54:23
Speaker
If we're not socializing what we're measuring to the people who are involved with care, it's very difficult for people to be engaged and move the needle.
00:54:32
Speaker
Yeah, absolutely.
00:54:33
Speaker
Yeah.
00:54:36
Speaker
One of the things that is in here, it's not the priority example, but sort of a secondary example that we heard from a lot of our hospitals in Michigan is that they –
00:54:49
Speaker
provide feedback to individual clinicians about recent sepsis cases, and that that's been really helpful to driving individuals' engagement in, you know, quality improvement for sepsis.
00:55:01
Speaker
And they do this both providing sort of constructive suggestions of, oh, hey, you know, you know, this patient was treated, you know, like three days ago, and we know that there was this delay in getting antibiotics and, you know, sort of suggestions of how to make things better.
00:55:16
Speaker
But on the flip side,
00:55:18
Speaker
actually reaching out and say, oh, hey, you know, we know that you were involved in the team taking care of this patient in the emergency department on Wednesday.
00:55:25
Speaker
And, you know, we just wanted to say that, you know, great job, like antibiotics went in quickly, fluid went in as recommended, you know, patient did well, and like, good job.
00:55:33
Speaker
And some hospitals are even doing things like giving pins for like,
00:55:37
Speaker
you know, did a good job taking care of sepsis, and it's like a swag and a competition.
00:55:41
Speaker
And so I think that it's sort of a, I don't know, it's sort of a cool and creative way, I think, to give feedback, you know, kind of like at a smaller scale, right?
00:55:51
Speaker
A lot of times we focus on these big reports, you know, looking at mortality among hundreds of patients, but it might not resonate so much directly to the individual clinician because, you know, many of those patients you didn't take care of personally, someone else did, right?
00:56:03
Speaker
But this kind of individualized feedback that's timely, again, not on every single patient in the hospital, but on, you know, like some sample of patients in the hospital, you know, evaluating in real time and feeding back.
00:56:13
Speaker
I think that that's, I don't know, I thought that was a really cool idea.
00:56:17
Speaker
And we had a bunch of hospitals in Michigan that were doing kind of similar things like that.
00:56:21
Speaker
Agree.
00:56:22
Speaker
And finally, the last core element is education, which we're talking about today.
Education as a Critical Component of Sepsis Programs
00:56:27
Speaker
And I guess in honor of time, what I would say is that we'll put the links.
00:56:33
Speaker
There's a tremendous amount of resources available through the CDC and through the Surviving Cephas Campaign guidelines.
00:56:40
Speaker
But having a deliberate and intentional educational program for clinicians, for nurses, for pharmacists, for people in the hospital, I think is critical.
00:56:53
Speaker
Absolutely.
00:56:55
Speaker
So as we close, what would you say would be a good starting point if we want to move the needle for a hospital that maybe is not doing so much right now?
Starting a Sepsis Improvement Program
00:57:06
Speaker
How do we even start?
00:57:10
Speaker
Yes.
00:57:10
Speaker
I'm just looking through the core elements document here myself because we have a section on getting started.
00:57:23
Speaker
Getting started, I would say identify program leader or two co-leaders, engage your hospital or health system leadership.
00:57:32
Speaker
We talked about how important it is to have that high-level hospital input.
00:57:36
Speaker
And then I think, you know, again, sort of trying to conduct some kind of needs assessment, if that's like if there's data to support that or, again, if that's just, you know,
00:57:45
Speaker
conversations with a few different leaders in the emergency department and the hospital wards and the ICU and these different areas to say, you know, just kind of get input about what people think are like the biggest gap, right?
00:57:54
Speaker
Where to sort of start your focus and then thinking about, you know, what are your goals and the initial goals, maybe even to sort of like develop a system to do tracking and reporting of a few core things that you, you know, identified from those early interviews are important.
00:58:11
Speaker
And I think it's also important, again, to work simultaneously on developing, you know, tools, structures, processes to better support care.
00:58:20
Speaker
And from the get go, kind of building in a way to evaluate that whether those are, you know, having the intended effect and being used and improving care.
00:58:28
Speaker
So those would be the kind of high level starting points.
00:58:32
Speaker
There's also a.
00:58:33
Speaker
you know, a self-assessment at the very back of the core elements that goes through where you can sort of, you know, check, yes, no, this is happening and sort of provide, you know, it's like an area for notes.
00:58:43
Speaker
And that's really meant to be sort of helpful for hospitals to go through and help identify, you know, areas where they may first focus their energies.
00:58:54
Speaker
And I think that tool is also extremely useful for programs that might already be functioning at a high level, but it might be a great place to start to just to see, are we doing the right things or what are things that we could do a little bit better?
00:59:06
Speaker
Because at the end of the day, that really, that's the goal, right?
00:59:09
Speaker
To keep pushing the needle and keep improving the care we provide.
00:59:13
Speaker
Yes, absolutely.
00:59:14
Speaker
There's, I think, even in mature programs, I think there is, you know, essentially always an opportunity for further improvement.
00:59:22
Speaker
You're exactly right.
00:59:24
Speaker
So one of the things we like to do at the end of the podcast is to tap into the wisdom of our guests and ask a couple of questions that are unrelated to the clinical
Personal Stories and Motivational Messages
00:59:33
Speaker
topic.
00:59:33
Speaker
Would that be okay?
00:59:35
Speaker
Yep, sounds good.
00:59:36
Speaker
The first question is about books.
00:59:39
Speaker
Is there a book that has influenced you significantly or a book that you have often gifted to others?
00:59:45
Speaker
Yes.
00:59:46
Speaker
So I think the book that has...
00:59:51
Speaker
influenced me most over this past few months is called Autumn Ghost, How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care.
01:00:02
Speaker
And this book is by Hannah Wanch, who is a professor of anesthesia and critical care medicine.
01:00:08
Speaker
And, you know, she tells this story about doctors in Copenhagen during the
01:00:14
Speaker
You know, just onset of the polio epidemic and how they, you know, came up with this plan to do tracheostomies and positive pressure ventilation.
01:00:23
Speaker
And I thought I was just kind of really struck by the bravery of these doctors as she really sort of tells this story.
01:00:30
Speaker
uh, story in a very personable way.
01:00:32
Speaker
And you sort of get to know the key players in this hospital in Copenhagen.
01:00:35
Speaker
Um, and, and I was just really impressed with how they, you know, were so committed to kind of like pushing the envelope and, you know, developing this kind of new approach to care that, you know, really kind of like was a paradigm shift and changed the way that, you know, respiratory failure was treated.
01:00:51
Speaker
So I was really struck by that.
01:00:52
Speaker
I think many listeners, you know, this is kind of a topic near and dear to our hearts, uh,
01:00:56
Speaker
mechanical ventilation.
01:00:57
Speaker
So I would strongly encourage that book.
01:01:00
Speaker
It's very excellent.
01:01:02
Speaker
Perfect.
01:01:03
Speaker
The second question relates to something that you believe to be true in medicine or in life that most other people don't believe or don't act like they believe.
01:01:13
Speaker
Oh, yeah, this is a hard question, right?
01:01:16
Speaker
So...
01:01:17
Speaker
I don't know if other people don't believe it, but I'm a strong believer of the importance of like in person.
01:01:24
Speaker
I feel like in the past five years and right accelerated by the pandemic, everything's like Zoom or social media.
01:01:33
Speaker
And I just feel like human connection is just so important.
01:01:36
Speaker
And I don't know, I was sort of struck over the
01:01:41
Speaker
course of, you know, those early waves of the pandemic, just how terrible it was to have families missing from our ICUs, right?
01:01:49
Speaker
Like normally we have patients and we have their families on rounds.
01:01:52
Speaker
We invite them to come and participate in rounds.
01:01:54
Speaker
And then just one day they're all gone.
01:01:55
Speaker
And it was just so hard for our patients.
01:01:58
Speaker
And I had one patient in particular who'd been in the ICU for
01:02:05
Speaker
gosh, I don't know, like a month before COVID started and, you know, the family was there every single day and then all of a sudden, you know,
01:02:11
Speaker
rules changed as they did in basically every hospital that family is no longer allowed.
01:02:15
Speaker
Right.
01:02:16
Speaker
And so this patient just really struggled and, you know, we got an iPad and like doing FaceTime and stuff like that.
01:02:20
Speaker
But after a while, the novelty wore off and that was really frustrated.
01:02:23
Speaker
And then it was his birthday and, you know, we tried to call up, you know, can we make an exception?
01:02:28
Speaker
It's his birthday.
01:02:29
Speaker
Can family come?
01:02:30
Speaker
No, no, no, we can't make an exception.
01:02:31
Speaker
Right.
01:02:31
Speaker
Like we can't make an exception because then everybody would need an exception.
01:02:34
Speaker
So we sort of hatched this plan to, you
01:02:38
Speaker
take the patient outside.
01:02:40
Speaker
And so we got this, you know, like portable ventilator and enormous extension cord and portable suction machine.
01:02:46
Speaker
And we wheeled him outside under the pretense that like, you know, he hadn't been outside in months.
01:02:51
Speaker
We're just going to bring him outside.
01:02:52
Speaker
It was a beautiful day.
01:02:53
Speaker
We actually hadn't told him that we told his wife.
01:02:55
Speaker
And so then as she's like pulling up the driveway to this hospital,
01:02:59
Speaker
you can just sort of see him blinking like, Oh my gosh, is that what I think it is?
01:03:03
Speaker
And then she hops out of the car and starts singing happy birthday.
01:03:06
Speaker
And anyway, it was just like this amazing, uh, moment that I'll kind of never forget.
01:03:11
Speaker
Uh, and, uh,
01:03:14
Speaker
I think our whole ICU staff that was kind of like all involved in carrying out this plan was kind of like people were like walking on water at the end of the day.
01:03:20
Speaker
They kind of felt like it was like such an achievement to get this kind of in-person time for this patient.
01:03:27
Speaker
So anyway.
01:03:28
Speaker
Well, and I think it's a great story.
01:03:30
Speaker
And it's an important point, right, that we sometimes, it seems like the pendulum sometimes goes too far.
01:03:35
Speaker
We've got to bring it back a little bit.
01:03:37
Speaker
But clearly, for what's really meaningful and important, there is no substitution for human connection.
01:03:44
Speaker
and that requires us to see each other, to be present with each other, and I think it's a great point.
01:03:51
Speaker
The final question is, what would you want every intensivist or clinician listening to us to know?
01:03:56
Speaker
Could be a quote, a fact, or just a thought related to what we talked or something else.
01:04:00
Speaker
Yeah, I think the thought or phrase that I try to channel every time I'm on the ICU is, to whom much is given, much is expected.
01:04:11
Speaker
And the idea there is just that
01:04:13
Speaker
You know, I think we're very fortunate to be ICU physicians.
01:04:17
Speaker
You know, sometimes it's like we miss...
01:04:19
Speaker
you know, we miss dinner, we miss breakfast, we sort of miss time with our family when we're, you know, rounding in the ICU and it's hard, but it's so much harder for our patients and just trying to remember that it's just such a gift to be able to be intensivists and, you know, really trying to, you know, commit to give compassionate and sort of best possible evidence-based care to our patients every day.
01:04:41
Speaker
So that's the thought that I try to channel every time I go on to service.
01:04:46
Speaker
Perfect.
01:04:46
Speaker
I think this is a perfect place to stop.
01:04:48
Speaker
I want to thank you, Hallie, for sharing your time and your expertise on such an important topic.
01:04:53
Speaker
Hope to see you soon and in person and have you back on the podcast to discuss other important topics.
01:05:01
Speaker
Wonderful.
01:05:02
Speaker
Thanks so much for having me.
01:05:03
Speaker
I really enjoyed the conversation.
01:05:05
Speaker
Thank you.
01:05:09
Speaker
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01:05:12
Speaker
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01:05:18
Speaker
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01:05:23
Speaker
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