134 Annals of Thoracic Medicine - Vol 9, Issue 3, July-September 2014

Department of Intensive
Care, College of
Medicine,
1
College
of Public Health and
Health Informatics,
3
Departments of
Medical Services,
4
Quality Management,
King Saud bin
Abdulaziz University
for Health Sciences,
Riyadh, Kingdom
of Saudi Arabia,
2
Department of
Pulmonary and Critical
Care Medicine, Alpert
Medical School and
Rhode Island Hospital,
Providence, RI, USA
Improving the care of sepsis:
Between system redesign and
professional responsibility:
A roundtable discussion in the world
sepsis day, September 25, 2013,
Riyadh, Saudi Arabia
Yaseen Arabi, Ahmed Alamry
1
, Mitchell M. Levy
2
, Saadi Taher
3
,
Abdellatif M. Marini
4
Abstract:
This paper summarizes the roundtable discussion in September 25, 2013, Riyadh, Saudi Arabia as part of the
World Sepsis Day held in King Abdulaziz Medical City, Riyadh. The objectives of the roundtable discussion were
to (1) review the chasm between the current management of sepsis and best practice, (2) discuss system redesign
and role of the microsystem in sepsis management, (3) emphasize the multidisciplinary nature of the care of
sepsis and that improvement of the care of sepsis is the responsibility of all, (4) discuss the bundle concept in
sepsis management, and (5) refect on the individual responsibility of the health care team toward sepsis with a
focus on accountability and the moral agent.
Key words:
Accountability, moral responsibility, sepsis bundle, World Sepsis Day
M
ore than 2,400 healthcare institutions in
over 40 countries around the world held
the World Sepsis Day in September 2013 to draw
attention to this deadly disease, its impact on
human life, and share progress in therapies.
[1]

King Abdulaziz Medical City (KAMC), Riyadh,
Saudi Arabia has launched a sepsis improvement
project and as part of this initiative, the World
Sepsis Day was held on September 25, 2013 to
raise awareness of sepsis among its healthcare
professionals, to highlight the progress of the
improvement project and to sustain and spread
the improvement.
The objectives of the roundtable discussion
were to:
1. review the chasm between the current
management of sepsis and best practice,
2. discuss system redesign and role of the
microsystem in sepsis management,
3 emphasize the multidisciplinary nature of
care of sepsis and that improvement of the
care of sepsis is the responsibility of all,
4. discuss the bundle concept in sepsis
management, and
5. refect on the individual responsibility of the
health care team toward sepsis with a focus
on accountability and the moral agent.
The Scope of the Problem: The Chasm
in the Care of Sepsis
Severe sepsis is a major cause of human death
[2]

with increasing incidence.
[3-5]
Despite advances
in diagnostic and therapeutic modalities; the
number of sepsis cases continues to increase
dramatically - at a rate of 8-13% annually.
Hospitalizations for sepsis have more than
doubled over the last 10 years, and in many
countries, more people are hospitalized each
year for sepsis than for heart attack.
[6]
In fact,
studies have shown that sepsis may be the most
common cause of death in USA outnumbering
acute myocardial infraction, and is responsible
for 60-80% of death in the developing countries.
Studies have shown that early timely appropriate
therapy, especially with intravenous fluid
and antimicrobial therapy is associated with
reduction of the risk of deaths.
[7]
In addition,
early sepsis treatment is cost-effective, and
improves resource utilization by reducing the
number of hospital and critical care bed days.
As a result, clinical practice guidelines by the
Surviving Sepsis Campaign emphasized early
recognition and intervention through the timely
implementation of a bundle of interventions in
a time-bound fashion.
[8-10]
Unfortunately, studies
Address for
correspondence:
Dr. Yaseen M.
Arabi, Department of
Intensive Care, College of
Medicine, King Saud bin
Abdulaziz University for
Health Sciences, P.O. Box
22490, Mail Code 1425,
Riyadh 11426, Kingdom of
Saudi Arabia.
E-mail: yaseenarabi@
yahoo.com
Submission: 20-01-2014
Accepted: 10-03-2014
Position Paper
Access this article online
Quick Response Code:
Website:
www.thoracicmedicine.org
DOI:
10.4103/1817-1737.134066
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Arabi, et al.: Improving the care of sepsis
Annals of Thoracic Medicine - Vol 9, Issue 3, July-September 2014 135
have shown that compliance with clinical practice guidelines
for severe sepsis and septic shock is poor. This fnding has
been consistent in studies from around the world, including
the United States, Europe, and Asia.
[11-18]
This fnding for severe
sepsis and septic shock illustrates what was described by the
Institute of Medicine as a chasm
[19]
between knowledge and
practice. As such, improving sepsis management has become
the target for several international campaigns.
[10]
Appreciation of Systems
W. Edwards Deming was the frst to highlight the importance
of understanding of systems in moving the prevailing
management style to quality. The 1999 report of the Institute
of Medicine, To Err is Human, was a landmark in appreciation
of systems in health care.
[20]
The report highlighted that faulty
systems, processes, and conditions lead people to make
mistakes or fail to prevent them. A system is an interdependent
group of items, people, or processes working together toward a
common purpose.
[21]
As such, understanding how systems work
and interact has become at the heart of improvement science.
Two issues face health systems when they try to improve the
quality of care. First, there is the issue of the weak link in the
chain of processes. The value of care in a health system is as
good as the services generated by the small clinical units or
microsystems of which it is composed;
[22]
an example of a
microsystem is the intensive care unit (ICU). Therefore, when
some of its microsystems are weak links, essential services of
the health system will break down, or result in ineffective and
costly workarounds.
The second issue is the need to get many processes and
communications right in order to get the whole process right.
For example, lets take a process that has six attributes and lets
assume that the health system can reliably produce each of
those six attributes 90% of the time. Using simple probability,
the odds of all six attributes being present at the same time
would be 90% to the 6
th
power, which is 53%. This means that,
from the perspective of a patient, the odds is approximately
50% that one of the sex attributes will not be applied to his or
her care.
[23]
Sepsis management is an example of the increasing complexity
with interlinking processes in the clinical management
environment, where system failures are likely to occur. And,
thus for us to improve care of septic patients, we have to
understand the system and apply improvement methodology
to redesign the care process to achieve reliability. Recognizing
the system theory, the Surviving Sepsis Campaign guidelines
call for performance improvement efforts in addressing severe
sepsis to improve patient outcomes.
[8]
The sepsis improvement
project at KAMC - Riyadh focused on system redesign to
achieve early recognition and timely response to severe sepsis
and septic shock. The project had implemented multiple
changes in the process of care including electronic alert system
and sepsis response team.
All or None Bundle Concept
The concept of bundle has been introduced by the Institute for
Healthcare Improvement to help health care providers more
reliably deliver the best possible care for patients undergoing
particular treatments with inherent risks.
[24]
A bundle is a small
set of evidence-based practices generally three to fve, that,
when performed collectively and reliably, have been proven
to improve patient outcomes.
[25]
The bundle resembles a list,
but has certain characteristics.
[24]
First, all bundle elements
are all necessary and all suffcient, that must all be completed
to succeed. Second, all the elements are evidence-based.
Third, the bundle includes the all-or-nothing measurement.
Fourth, the bundle components occur in the same time and
space continuum.
[24]
The bundle is a tool for implementation
and measurement. The sepsis resuscitation bundle is a good
example; as it consists of several evidence-based practice
interventions that are time-bound. By measuring compliance
of the sepsis resuscitation bundle, the improvement can be
guided objectively.
The Care of Sepsis is Multidisciplinary:
Improvement is the Responsibility of All
The nature of the care of sepsis is multidisciplinary. Patients
with sepsis are often frst seen in the emergency department
and are usually admitted to different medical and surgical
specialties with the severe cases admitted to the ICUs. Further,
the process of care of sepsis requires a multidisciplinary team
to be carried out effectively in a timely fashion; that involves
physicians, nurses, pharmacists, and others. By performing
timely assessment and recording vital signs, the nurses play a
key role in early recognition of sepsis. In addition, the nurses
role in timely administration of fuids and antibiotics as well as
obtaining the necessary lab work is central to the success of any
improvement project for sepsis. The physician role starts with
early and accurate assessment followed by early intervention
of the septic patients (resuscitation and referral) that may
save lives. In addition, identifying the source of infection and
achieving source control are critical in management of the septic
patient. The pharmacists have an essential role in ensuring
the correct selection and timely delivery of antibiotics to the
nursing unit. Diagnostic services, including the laboratory
and radiology play a pivotal role in early diagnosis and in
identifcation of the source of sepsis.
Professional Responsibility: Accountability
and the Moral Agent
Accountability
The Institute of Medicines Report To Err Is Human
[20]
triggered
a paradigm shift in quality and safety from the traditional focus
on identifying who is at fault to focus on improving systems.
As a result, quality improvement projects have utilized
interventions such as computerized systems and checklists and
a few institutions even brought in human-factors engineers to
improve processes of care.
However, in the last few years, several prominent healthcare
leaders began to question the singular focus on systems. It has
been suggested that of similar importance to system thinking
is having a more aggressive approach to poorly performing
physicians and creating accountability.
[26]
It is evident that adhering to the sepsis bundle saves lives.
However, we know that compliance with the standards
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Arabi, et al.: Improving the care of sepsis
136 Annals of Thoracic Medicine - Vol 9, Issue 3, July-September 2014
remains suboptimal even after system improvement. In
medicine, it is estimated by research that we only practice
50% of the known evidence. It has been suggested that in
order to move forward and address the chasm in quality and
safety; the focus should be on three points: First, practice
standards, i.e., making sure that our care follow the standard
guidelines the sepsis resuscitation bundle is one example.
Second, measurement of process and outcomes and third,
transparent communication and feedback these results to the
system to improve it and keep our care customer-oriented,
helping the patients have better health and safer recovery.
However, having standards, measurements and transparent
communication do not guarantee full compliance. What would
be the attitude toward all people who dont comply with the
bundle interventions? How to deal with noncompliance? Is
education or advising enough or more aggressive steps like
penalty are needed?
Health care professionals have a busy nature of work. They
do not take care of one patient population (like sepsis); they
have other complex sick patients like postoperative patients,
congestive heart failure to name a few. Most often than not, the
noncompliance with standards is not deliberate, i.e., healthcare
professionals either forget or underestimate the importance
of the standards. In such case, checklists and protocols are
likely to help.
However, sometimes healthcare professionals resist the change.
For example, many academic physicians are highly infuenced
by pro and con debates like the role of central venous pressure
measurement, or even the whole concept of early goal directed
therapy. Most of the time, the con side does not have alternative
or factual evidence. May authorities now call for nonaccepting
such unfounded resistance. Although, the best approach to
address the accountability question is still unclear, several
approaches have been suggested such as public reporting and
individual practitioner compliance measurement.
The Moral Agent
Accountability focuses on the external monitoring. Of similar
importance, or perhaps of greater importance, is the internal
monitoring, the moral agent. Medicine is a moral profession
and physicians are agents of commitment to do what is
in the best interest of their patients. Although medicine
requires scientifc and technological knowledge, it is frst
and foremost oriented toward a healing relationship with
patients that demands moral accountability. Batalden and
Leach suggested that we should have a daily conversation
with ourselves discerning the truth and putting what is good
for the patient ahead of what is good for us.
[27]
For patients
with severe sepsis, we know that the provision of evidence-
based practice, the sepsis bundle, is in the best interest of the
patient, therefore, we need to make all efforts in providing
that level of care.
Summary and Recommendations
1. There is a chasm between the care we have for severe sepsis
and septic shock and the care we could have. Therefore,
hospitals should undertake performance improvement
efforts for severe sepsis and septic shock.
2. Improving the care of sepsis requires the appreciation
of systems. System redesign is required to achieve
breakthrough results.
3. The care of sepsis is multidisciplinary, and therefore,
improvement is the responsibility of all.
4. In addition to focus on system redesign, serious consideration
should be given to measurement and accountability.
5. Healthcare professionals need to maintain their commitment
to do what is best for patients consistent with their moral agent
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How to cite this article: Arabi Y, Alamry A, Levy MM, Taher S,
Marini AM. Improving the care of sepsis: Between system redesign
and professional responsibility: A roundtable discussion in the world
sepsis day, September 25, 2013, Riyadh, Saudi Arabia. Ann Thorac
Med 2014;9:134-7.
Source of Support: Nil, Confict of Interest: None declared.
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