A Brief Conversation with...David Shimabukuroby Kevin W. Hatton, MD, FCCM Volume 28 | Issue 2 | Summer 2017 Dr. David Shimabukuro, M.D. is a Clinical Professor of Anesthesia and Perioperative Care at the University of California San Francisco (UCSF). In addition, he is an Associate Medical Director for several of the intensive care units at the UCSF Moffitt-Long Medical Center. His research interests and clinical expertise center around sepsis detection and treatment and the development of healthcare system measures to improve organ system dysfunction in critical illness. Can you briefly describe your recent research article for our readers? In this article, we describe the results from our retrospective cohort study of approximately 1000 patients admitted to the UCSF Moffitt-Long Medical Center with severe sepsis or septic shock over a three-year period (January 2012 – December 2014). During this period, we implemented a sepsis intervention bundle, based on work funded through the California Delivery System Reform Incentive Program, throughout our hospital that consisted of five main components:
In addition to the development of the sepsis bundle, we developed a process to leverage our EMR, in real-time, to monitor patients for the development of sepsis and created a hospital-wide education program, that included attendings, fellows, residents and many other healthcare workers to identify sepsis and to implement the sepsis bundle whenever the possibility of sepsis existed. We measured our internal compliance with the defined sepsis bundle and provided targeted education to clinicians or clinical areas that needed additional help with bundle compliance. Very cool…so what were your article’s most important conclusions? Overall, we had very good sepsis bundle compliance over the 3-year study period (just over 72%). This was a very good sign that our education plan about sepsis and the sepsis bundle were effective. More importantly, though, we found that the use of the sepsis bundle was associated with a 31% lower risk of in-hospital mortality, when adjusting for important contributors to mortality in our patient cohort. From this data, we calculated that the number needed to treat (NNT) to prevent death with this sepsis bundle alone was 15. Wow! Those results are fantastic…what drove you to look at this topic? I’ve been interested in sepsis and sepsis care for a number of years. Earlier in my career, a close friend and colleague developed severe septic shock. We had not worked together in a few years, but still, I flew across the country to see her and be with her while she was in the Intensive Care Unit. And even though she was receiving the very best care based on the most current evidence and guidelines, she still had a very complicated course. Fortunately, she recovered and is back to her surgical practice—but, even now, the events had a real and profound effect on my view of sepsis and how we can improve the care we provide to our patients. A personal connection to a disease or its treatment can be a strong motivator to improve our clinical practice or research. What do you plan to do next with this work? From our data, we noticed that patients who developed “nosocomial sepsis” had a much worse outcome than those who developed “community-acquired sepsis”. This is an interesting finding because I had assumed that patients that arrived from the community have probably been septic for a longer period of time and have a longer delay in first-dose of antibiotics and fluid resuscitation than those patients who are in the hospital. Yet, somehow these patients, despite the likely delays in care, seemed to have a better survival than those patients who should not have had significant delays in care delivery. I really want to investigate the underlying reasons for the differences in outcomes among these patient groups to see if there are actions that should be taken for one group or the other to further improve mortality in our patients. That’s a great way to further evaluate an unexpected result from your study. What advice do you have for junior faculty or fellows that want to improve the care in their own hospitals? Be patient. In the beginning, you may feel that new or important things are not happening in your hospital or in your career…especially not at the pace that you want. Creating new protocols, adopting newly published findings, developing research programs, getting published…these all take time. But just be patient. Focus on your current responsibilities and learn and do everything you can. One day, you will get your chance to make a big difference and when you do…you should be ready to take it, run with it, and make the absolute most of your opportunity. |