Surviving Sepsis Campaign Declarations

 
Barcelona, Spain, 2nd October 2002: Intensive care professionals from around the globe called today for concerted action to reduce the number of deaths from one of the world’s oldest and most virulent killers – sepsis.  It is estimated that worldwide, 1,400 people die each day from sepsis (1), with up to 30% dying within one month of diagnosis (2-6). Comparatively, more people die from sepsis than from breast or colon cancer (7).
 
The ‘Barcelona Declaration’ is the debut initiative of the newly formed ‘Surviving Sepsis Campaign’ which brings together, for the first time, three leading professional organizations in the field of sepsis (the European Society of Intensive Care Medicine, the Society of Critical Care Medicine, and the International Sepsis Forum).  Professionals meeting at the 15th Annual Congress of the European Society of Intensive Care Medicine agreed that improvements in the recognition and treatment of sepsis are essential to reduce the high mortality rate associated with the condition by 25% over the next 5 years.
 
Formerly known as ‘blood poisoning’, sepsis is a syndrome characterized by an overwhelming systemic response by the body to infection, which can rapidly lead to organ failure and, ultimately, death. Sepsis may cause multiple organs in the body to fail and trigger the onset of both abnormal clotting and bleeding. It can strike anyone but is most likely to develop from infection associated with pneumonia, trauma, surgery, burns, or conditions such as cancer and AIDS. In fact, 80% of patients who die from major injuries are actually killed by sepsis. 
 
“We have the technology and resources today to treat most conditions and injuries yet infection, which has been killing people since history began, still defeats us,” said Prof. Graham Ramsay, ESICM President. “Physicians have tried their best to tackle the scourge of sepsis but without greater resources, education, and awareness, their efforts can only have limited success.”
 
Endorsed by intensive care professionals around the world, the ‘Barcelona Declaration’ urges governments and healthcare providers to recognize the growing burden of sepsis and to commit to providing adequate resources to combat it. For healthcare professionals, a five-point action plan aims to improve the management of sepsis and save lives by addressing the following:
 

• Diagnosis - Facilitate early and accurate diagnosis through the adoption of one, single, clear definition of sepsis.
• Treatment - Ensure appropriate and timely use of treatments and interventions via consistent clinical protocols.
• Referral - Recognize universally acceptable referral guidelines in all countries of the world.
• Education - Provide leadership, support, and information to clinicians about sepsis management.
• Counseling - Post-ICU care and counseling for sepsis patients to ensure continuous quality care by providing a framework for improving and accelerating access to post-ICU care and counseling for patients.

 
“Advances in critical care have been among some of the most dramatic in medicine,” commented Prof. Mitchell Levy, governing council, of the SCCM, “but we are well aware that a comprehensive program of education and action by policy makers and the medical community could significantly reduce the number of deaths caused by sepsis each year.”  
 
References
 
1. Bone RC, et al. Chest. 1992;101:1644–1655.
2. Rivers E, et al. N Engl J Med. 2001;345:1368–1377. 
3. Natanson C, et al. Crit Care Med. 1998;26:1927–1931. 
4. Briegel J, et al. Clin Invest. 1994;72:782–787. 
5. Bollaert PE, et al. Crit Care Med. 1998; 26: 645–50.
6. Bernard GR, et al. N Engl J Med. 2001;344:699–709.
7. OECD Health Report. 2001.  
 

As the Surviving Sepsis Campaign marks 10 years of progress with the publication of the third edition of its “International Guidelines for Management of Severe Sepsis and Septic Shock,” we are gratified to reflect on what has been achieved through committed participation in the Campaign by clinicians worldwide.  Nevertheless, sepsis remains a disorder of epidemic incidence and severe consequences with an unacceptably high death rate and devastating long-term effects (1, 2). Application of sepsis care bundles has reduced mortality in hospitals that joined the Surviving Sepsis Campaign, but the number of hospitals involved and the compliance in those hospitals remains low. We are, therefore, compelled to delineate new steps that will save many more lives. 
 

The Campaign’s History:  Accomplishments to Date
The original goal of the Campaign was to reduce mortality from severe sepsis and septic shock by 25%.  Activities toward this goal included:

• Developing evidence-based guidelines for appropriate care
• Improving diagnosis
• Educating healthcare professionals
• Increasing the use of appropriate treatment
• Building awareness of sepsis

 
The Campaign proceeded in three phases: 

Phase I:  Introduction of the Campaign--Following the announcement of the target in 2002, awareness of the incidence and prevalence of the condition became heightened.  Although clinicians were more attuned to the signs of sepsis, a need to enhance the recognition among patients and their families was identified (3).

Phase II:  Publication of the Guidelines--In June 2003, representatives from 11 international societies convened to develop an evidence-based set of guidelines for the management of severe sepsis and septic shock.  Immediately following publication in 2004 (4), the Campaign initiated an educational effort to disseminate the knowledge and recommendations widely.  An updated set of guidelines, published in 2008, was sponsored by 26 professional societies (5).  The current, third edition, which reflects the latest evidence related to sepsis treatment and involves 30 organizations, appears in the February 2013 issues of Critical Care Medicine and Intensive Care Medicine (6). The Surviving Sepsis Campaign Guidelines have become the gold standard for sepsis care as they are incorporated into hospital protocols and regulatory mandates internationally. 

Phase III:  Guideline Implementation, Data Collection, and Behavior Change-- Drawing on the expertise in quality improvement gained through partnering with the Institute for Healthcare Improvement, we constructed the Surviving Sepsis Campaign Care Bundles from key guideline recommendations. Subsequent development and distribution of a data collection tool along with a website, online discussion forum, implementation manual, newsletter, and a series of educational meetings enabled local and regional networks of hospitals worldwide to document and improve performance. 

The Campaign Today:  Significant Results
A recent analysis of more than 25,000 patient charts from 186 hospitals over a 5-year period confirms that ongoing hospital participation in the Campaign is associated with continuous quality improvement and a sustained, linear decrease in mortality (7); however, despite the evidence demonstrating the value of using performance metrics for maintaining standards of care for the management of sepsis, marked differences remain between hospitals in the delivery of care for septic patients (8). Published data clearly show that delays in the recognition and treatment of sepsis are associated with worse outcomes while early treatment improves survival (9).  Reviewing the inconsistent application of measures identifies an important opportunity to reduce sepsis-induced mortality further.  In particular, earlier identification of patients who develop sepsis on the wards and improvements in the timely application of evidence-based, validated therapies represents a unique opportunity to save additional lives.  
 

The Campaign’s Future: An Invitation to Recommit 
As the European Society of Intensive Care Medicine and the Society of Critical Care Medicine jointly publish the third edition of the Surviving Sepsis Campaign Guidelines, we invite clinicians around the world to join us in renewing our commitment to the goals set in 2002: to further reduce mortality from sepsis worldwide and to provide the imperative for healthcare providers to improve the care and outcomes of septic patients.  
Specifically, in this next phase of the Campaign we challenge our colleagues as well as ourselves to:

 

• Increase the number of hospitals contributing data to the Surviving Sepsis Campaign to 10,000 worldwide
• Apply the guidelines to 100% of patients in whom the diagnosis is suspected
• Develop a strategy to improve the care of septic patients where healthcare resources are limited

The potential to save lives is enormous.  Assuming that the reduction in mortality seen to date can be sustained and 10,000 hospitals comply with the Campaign recommendations, we could save 400,000 lives if we treat only half of the eligible patients with the Surviving Sepsis Campaign Bundles.    Extension of the Surviving Sepsis Campaign to under-resourced populations may have an even greater impact.

With the introduction of new guidelines, revised bundles, and enhanced resources that include a new database and a new website, the Campaign invites each of you to make a personal commitment to join us in providing the care our patients around the world deserve. Log on to www.survivingsepis.org to show your commitment.

References
1. Angus DC, Linde-Zwirble WT, Lidicker J, et al: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29:1303–1310
2. Iwashyna TJ, Ely EW, Smith DM, et al: Long-term cognitive impairment and disability among survivors of severe sepsis. JAMA. 2010;304:1787-1794 
3. Rubulotta FM, Ramsay G, Parker MM, et al:  An international survey: Public awareness and perception of sepsis Crit Care Med. 2009 Jan;37:167-70
4. Dellinger RP, Carlet JM, Masur H, et al: Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004; 32:858–873 and Intensive Care Med 2004; 30:536–555
5.  Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008; 36:296–327. Erratum in: Crit Care Med. 2008; 36:1394–1396 and Intensive Care Med. 2008; 34:17–60
6.  Dellinger RP, Levy MM, Rhodes A, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013; 41: 580-637 and Intensive Care Med 2013; 39: 
7. Levy MM, Dellinger RP, Townsend SR, et al; Surviving Sepsis Campaign: The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010; 38:367–374
8. Levy MM, Artigas A, Phillips GS, et al:  Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe:  a prospective cohort study. Lancet Inf Dis 2012; 12:919-924
9. Rivers E, Nguyen B, Havstad S, et al: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368–1377