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Chair’s Letter - March 2016

Jeffrey J. Pothof, MD, FACEP

Jeff PothofI recently spent some time sitting on a committee at my health system that was looking to update an old sepsis definition and treatment guideline that would be used by providers across our entire enterprise. As you might suspect, initially, there were few points of agreement, wide variability in what providers believed was best evidence based practice, and difficulty in coming to an agreed upon approach despite the clear desire to do what was best for our patients.

The elephant in the room was the new CMS sepsis measures (SEP-1) and the deliberation of whether we would adopt the measure bundles in their entirety or pick and choose those things which had the best evidence. On one hand some providers felt it was their purview to assess the evidence and make treatment guideline determinations at the local level. Other providers felt the recommendations might improve patient care and feared not following the CMS recommendations would have us looking like an underperforming institution on hospitalcompare.org. It might erode the confidence patients have in our health system, and eventually set our organization up to take Medicare withholding penalties.

The hours dragged on as we debated the utility of a lactate cutoff of 2.0. Maybe this was okay for the emergency department and the ICU, but did it apply to the general care wards? Would antimicrobial stewardship fly out the window and C. dif rates skyrocket? Did we really have to perform a perfusion reassessment that was so scripted?

Then, two days before our final meeting, the meeting where we would summarize the outcome of this hard fought intellectual battle, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) were published in JAMA. 1,2. The debate once again ensued. Should we adopt the new definitions right now or wait? Do we need SOFA and qSOFA calculators built into our electronic medical record and order entry systems? Do our behind the scene electronic sepsis screening algorithms currently based off of SIRS criteria need to be re-thought? Will adopting new evidence hurt our performance on SEP-1? How fast will CMS respond to these new definitions? How fast can we respond?

Our collective minds prevailed and we completed the guideline. Reflecting back on the process there were moments that were difficult and challenging, but there was a silver lining. It somehow has become rare these days to have emergency medicine physicians, intensivists, hospitalists, pharmacists, quality analysts, and computer support all in the same room and all passionate about creating a guideline that provides the best care we know how to deliver to our patients. Was there conflict? Sure. Was it respectful? You bet. Was it necessary? Absolutely. Our committee, by virtue of having to respond to external forces, engaged in a robust discussion that left us all with a better understanding of the issue at hand and the unique value our disciplines bring to the table. Although we may not all agree on every point of any given guideline, it does provide an opportunity to discuss clinical practice that bridges the inter-departmental chiasms of our institutions for the betterment of patient care. I can’t help but believe that this sort of process is good for healthcare and healthcare providers and can only serve to improve the care our patients experience.

  1. Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
  2. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.

 

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