Case for Improvement

Mortality associated with severe sepsis remains unacceptably high: 30 to 50 percent. When shock is present, mortality is reported to be even higher: 50 to 60 percent.

There are approximately 750,000 new sepsis cases each year, with at least 210,000 fatalities. As medicine becomes more aggressive, with invasive procedures and immunosuppression, the incidence of sepsis is likely to increase even more.

Awareness of the seriousness of this condition remains low; severe sepsis is frequently under-diagnosed at an early stage when it is still potentially reversible. We still see many patients not receiving aggressive therapy early in their course who later are referred to the intensive care unit hours after their initial presentations.

Even though recent trials demonstrate mortality benefit with new interventions (see below), these interventions are still not being applied uniformly or in a timely fashion to the population of patients who need them. Reliability in the care of these patients is low; until standard processes are applied to this problem, best-known care will remain haphazard and unreliable and we will fail to achieve the target goal of significantly reducing mortality.

Severe sepsis and septic shock are areas of medicine and surgery where great strides can be made that can save thousands of lives. In addition, by finding better ways of working together, and new methods of reducing variability and increasing the reliability of our care processes, we will create new practice styles that will ensure that every patient receives the best-known care possible. This effort has the potential to transform the way medicine is practiced, as we learn to build into our routine practice methods of improvement that can be applied to other areas of medicine.

The Problem

1. Inconsistency in the early diagnosis of severe sepsis and septic shock
2. Frequent inadequate volume resuscitation without defined endpoints
3. Late or inadequate use of antibiotics
4. Frequent failure to support the cardiac output when depressed
5. Frequent failure to control hyperglycemia adequately
6. Frequent failure to use low tidal volumes and pressures in acute lung injury
7. Frequent failure to treat adrenal inadequacy in refractory shock