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Patients need Sep-1: Why don’t some doctors like it?
Since its inception, the CMS Sep-1 Core Quality Measure has been unpopular in some circles. It is now under official attack by the American College of Emergency Physicians (ACEP) and the Infectious Diseases Society of America (IDSA), along with a handful of smaller professional societies. These societies appealed the National Quality Forum’s (NQF) 2021 recommendation that the measure be renewed. The NQF is the multidisciplinary and broadly representative group of evaluators who evaluate proposals for CMS-sponsored quality improvement on behalf of the American people and of the Centers for Medicare & Medicaid Services (CMS). Readers of CHEST Physician are likely familiar with core measures, in general, and with Sep-1, in particular. CMS requires hospitals to publicly report their compliance with several Core Quality Measures, and the failure to do so results in across the board reductions in Medicare payments. As of now, no penalties are levied for the degree of compliance but only for failure to report the degree of compliance.
The measure asks, in the main, for hospitals to perform what most physicians can agree should be standard care for patients with sepsis. Depending on whether shock is present, the measure requires:
1. Blood cultures before antibiotics
2. Antibiotics within 3 hours of recognition of sepsis
3. Serum lactate measurement in the first 3 hours and, if increased, a repeat measurement by 6 hours
4. If the patient is hypotensive, 30 mL/kg IV crystalloid within 3 hours, or documentation of why that is not appropriate for the patient
5. If hypotension persists, vasopressors within 6 hours
6. Repeat cardiovascular assessment within 6 hours for patients with shock
If I evaluate these criteria as a patient who has been hospitalized for a serious infection, which I am, they do not seem particularly stringent. In fact, as a patient, I would want my doctors and nurses to act substantially faster than this if I had sepsis or septic shock. If my doctor did not come back in less than 6 hours to check on my shock status, I would be disappointed, to say the least. Nevertheless, some physicians and professional societies see no reason why these should be standards and state that the data underlying them are of low quality. Meanwhile, according to CMS’ own careful evaluation, national compliance with the measures is less than 50%, while being compliant with the measures reduces absolute overall mortality by approximately 4%, from 26.3% to 22.2% (Townsend SR et al. Chest. 2022;161[2]:392-406). This would translate to between 14,000 and 15,000 fewer patients dying from sepsis per year, if all patients received bundled, measure-compliant care. These are patients I don’t care to ignore.
ACEP and IDSA point specifically to the new Surviving Sepsis Campaign Guidelines (SSC) recommendations as evidence that the antibiotic measure is based on low quality evidence (Evans L et al. Crit Care Med. 2021;49[11]:1974-82). In this regard, they are technically correct; the system of evidence review that the SSC panel uses, Grading of Assessment, Recommendations, and Evaluation (GRADE), considers that retrospective analyses, which nearly all of these studies are, can be graded no higher than low quality. Clearly, retrospective studies will never achieve the level of certainty that we achieve with randomized controlled trials, but the NQF, itself, typically views that when a number of well-performed retrospective studies point in the same direction, the level of evidence is at least moderate. After all, just as it would be inappropriate to randomize participants to decades of smoking vs nonsmoking in order prove that smoking causes lung cancer, it is not appropriate to randomize patients with sepsis to receive delayed antibiotics before we accept that such delays are harmful to them.
ACEP and IDSA also assert that the association of early antibiotics with survival is “stronger” for septic shock than for sepsis. In fact, the association is quite strong for both severities of illness. Until it progresses to septic shock, the expected mortality of sepsis is lower, and the percent reduction in mortality is less than for septic shock. However, the opportunity for lives preserved is quite large, because the number of patients with sepsis at presentation is approximately 10 times higher than the number with septic shock at presentation. Antibiotic delays are also associated with progression from infection or sepsis to septic shock (Whiles BB et al. Crit Care Med. 2017;45[4]:623-29; Bisarya R et al. Chest. 2022;161[1]:112-20). Importantly, SSC gave a strong recommendation for all patients with suspected sepsis to receive antibiotics within 3 hours of suspecting sepsis and within 1 hour of suspecting septic shock, a recommendation even stronger than that of Sep-1.
Critics opine that CMS should stop looking at the process measures and focus only on the outcomes of sepsis care. There is a certain attractiveness to this proposition. One could say that it does not matter so much how a hospital achieves lower mortality as long as they do achieve it. However, the question would then become – how low should the mortality rate be? I have a notion that whatever the number, the Sep-1 critics would find it unbearable.
There is a core principle embedded in the Sep-1 process measures, in SSC guidelines, and in the concept of early goal-directed therapy that preceded them: success is not dependent only on what we do but on when we do it. All of you have experienced this. Each of you has attended a professional school, whether medical, nursing, respiratory therapy, etc. None of you showed up unannounced on opening day of the semester and was admitted to that school. All of you garnered the grades, solicited the letters of recommendation, took the entrance exams, and submitted an application. Some of you went to an interview. All of these things were done in a timely fashion; professional schools do not accept incomplete applications or late applications. Doing the right things at the wrong time would have left us all pursuing different careers.
Very early in my career as an attending physician in the ICU, I found myself exasperated by the circumstances of many patients who we received in the ICU with sepsis. I would peruse their medical records and find that they had been septic, ie, had met criteria for severe sepsis, 1 to 2 days before their deterioration to septic shock, yet they had not been diagnosed with sepsis until shock developed. In the ICU, we began resuscitative fluids, ensured appropriate antibiotics, and started vasopressors, but it was often to no avail. The treatments we gave made no difference for many patients, because they were given too late. For me, this was career altering; much of my career since that time has focused on teaching medical personnel how to recognize sepsis, how to give timely and appropriate treatments, and how to keep the data to show when they have done that and when they have not.
Before Sep-1 many, if not most, of the hospitals in the United States had no particular strategy in place to recognize and treat patients with sepsis, even though it was and is the most common cause of death and the costliest condition in American hospitals. Now, most hospitals do have such strategies. Assertions by professional societies that it is difficult to collect the data for Sep-1 reporting are likely true. However, keeping patients safe and alive is a hospital’s primary reason for existing. As long as hospitals are tracking each antibiotic and every liter of fluid so that they can bill for them, my own ears are deaf to hearing that it is too difficult to make sure that we are doing our job. Modifying or eliminating Sep-1 for any reason except data that show we can clearly further improve the outcome for all patients with sepsis is the wrong move to make. So far, other professional societies want to remove elements of Sep-1 without evidence that it would improve our care for patients with sepsis or their outcomes. Thankfully, from the time we proposed the first criteria for diagnosing sepsis, CHEST has promoted what is best for patients, whether it is difficult or not.
Dr. Simpson is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement, including by serving as a senior adviser to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the U.S. Department of Health and Human Services and an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. Dr. Simpson is the senior medical adviser for Sepsis Alliance, a nationwide patient information and advocacy organization. He is the immediate past president of CHEST.
Since its inception, the CMS Sep-1 Core Quality Measure has been unpopular in some circles. It is now under official attack by the American College of Emergency Physicians (ACEP) and the Infectious Diseases Society of America (IDSA), along with a handful of smaller professional societies. These societies appealed the National Quality Forum’s (NQF) 2021 recommendation that the measure be renewed. The NQF is the multidisciplinary and broadly representative group of evaluators who evaluate proposals for CMS-sponsored quality improvement on behalf of the American people and of the Centers for Medicare & Medicaid Services (CMS). Readers of CHEST Physician are likely familiar with core measures, in general, and with Sep-1, in particular. CMS requires hospitals to publicly report their compliance with several Core Quality Measures, and the failure to do so results in across the board reductions in Medicare payments. As of now, no penalties are levied for the degree of compliance but only for failure to report the degree of compliance.
The measure asks, in the main, for hospitals to perform what most physicians can agree should be standard care for patients with sepsis. Depending on whether shock is present, the measure requires:
1. Blood cultures before antibiotics
2. Antibiotics within 3 hours of recognition of sepsis
3. Serum lactate measurement in the first 3 hours and, if increased, a repeat measurement by 6 hours
4. If the patient is hypotensive, 30 mL/kg IV crystalloid within 3 hours, or documentation of why that is not appropriate for the patient
5. If hypotension persists, vasopressors within 6 hours
6. Repeat cardiovascular assessment within 6 hours for patients with shock
If I evaluate these criteria as a patient who has been hospitalized for a serious infection, which I am, they do not seem particularly stringent. In fact, as a patient, I would want my doctors and nurses to act substantially faster than this if I had sepsis or septic shock. If my doctor did not come back in less than 6 hours to check on my shock status, I would be disappointed, to say the least. Nevertheless, some physicians and professional societies see no reason why these should be standards and state that the data underlying them are of low quality. Meanwhile, according to CMS’ own careful evaluation, national compliance with the measures is less than 50%, while being compliant with the measures reduces absolute overall mortality by approximately 4%, from 26.3% to 22.2% (Townsend SR et al. Chest. 2022;161[2]:392-406). This would translate to between 14,000 and 15,000 fewer patients dying from sepsis per year, if all patients received bundled, measure-compliant care. These are patients I don’t care to ignore.
ACEP and IDSA point specifically to the new Surviving Sepsis Campaign Guidelines (SSC) recommendations as evidence that the antibiotic measure is based on low quality evidence (Evans L et al. Crit Care Med. 2021;49[11]:1974-82). In this regard, they are technically correct; the system of evidence review that the SSC panel uses, Grading of Assessment, Recommendations, and Evaluation (GRADE), considers that retrospective analyses, which nearly all of these studies are, can be graded no higher than low quality. Clearly, retrospective studies will never achieve the level of certainty that we achieve with randomized controlled trials, but the NQF, itself, typically views that when a number of well-performed retrospective studies point in the same direction, the level of evidence is at least moderate. After all, just as it would be inappropriate to randomize participants to decades of smoking vs nonsmoking in order prove that smoking causes lung cancer, it is not appropriate to randomize patients with sepsis to receive delayed antibiotics before we accept that such delays are harmful to them.
ACEP and IDSA also assert that the association of early antibiotics with survival is “stronger” for septic shock than for sepsis. In fact, the association is quite strong for both severities of illness. Until it progresses to septic shock, the expected mortality of sepsis is lower, and the percent reduction in mortality is less than for septic shock. However, the opportunity for lives preserved is quite large, because the number of patients with sepsis at presentation is approximately 10 times higher than the number with septic shock at presentation. Antibiotic delays are also associated with progression from infection or sepsis to septic shock (Whiles BB et al. Crit Care Med. 2017;45[4]:623-29; Bisarya R et al. Chest. 2022;161[1]:112-20). Importantly, SSC gave a strong recommendation for all patients with suspected sepsis to receive antibiotics within 3 hours of suspecting sepsis and within 1 hour of suspecting septic shock, a recommendation even stronger than that of Sep-1.
Critics opine that CMS should stop looking at the process measures and focus only on the outcomes of sepsis care. There is a certain attractiveness to this proposition. One could say that it does not matter so much how a hospital achieves lower mortality as long as they do achieve it. However, the question would then become – how low should the mortality rate be? I have a notion that whatever the number, the Sep-1 critics would find it unbearable.
There is a core principle embedded in the Sep-1 process measures, in SSC guidelines, and in the concept of early goal-directed therapy that preceded them: success is not dependent only on what we do but on when we do it. All of you have experienced this. Each of you has attended a professional school, whether medical, nursing, respiratory therapy, etc. None of you showed up unannounced on opening day of the semester and was admitted to that school. All of you garnered the grades, solicited the letters of recommendation, took the entrance exams, and submitted an application. Some of you went to an interview. All of these things were done in a timely fashion; professional schools do not accept incomplete applications or late applications. Doing the right things at the wrong time would have left us all pursuing different careers.
Very early in my career as an attending physician in the ICU, I found myself exasperated by the circumstances of many patients who we received in the ICU with sepsis. I would peruse their medical records and find that they had been septic, ie, had met criteria for severe sepsis, 1 to 2 days before their deterioration to septic shock, yet they had not been diagnosed with sepsis until shock developed. In the ICU, we began resuscitative fluids, ensured appropriate antibiotics, and started vasopressors, but it was often to no avail. The treatments we gave made no difference for many patients, because they were given too late. For me, this was career altering; much of my career since that time has focused on teaching medical personnel how to recognize sepsis, how to give timely and appropriate treatments, and how to keep the data to show when they have done that and when they have not.
Before Sep-1 many, if not most, of the hospitals in the United States had no particular strategy in place to recognize and treat patients with sepsis, even though it was and is the most common cause of death and the costliest condition in American hospitals. Now, most hospitals do have such strategies. Assertions by professional societies that it is difficult to collect the data for Sep-1 reporting are likely true. However, keeping patients safe and alive is a hospital’s primary reason for existing. As long as hospitals are tracking each antibiotic and every liter of fluid so that they can bill for them, my own ears are deaf to hearing that it is too difficult to make sure that we are doing our job. Modifying or eliminating Sep-1 for any reason except data that show we can clearly further improve the outcome for all patients with sepsis is the wrong move to make. So far, other professional societies want to remove elements of Sep-1 without evidence that it would improve our care for patients with sepsis or their outcomes. Thankfully, from the time we proposed the first criteria for diagnosing sepsis, CHEST has promoted what is best for patients, whether it is difficult or not.
Dr. Simpson is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement, including by serving as a senior adviser to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the U.S. Department of Health and Human Services and an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. Dr. Simpson is the senior medical adviser for Sepsis Alliance, a nationwide patient information and advocacy organization. He is the immediate past president of CHEST.
Since its inception, the CMS Sep-1 Core Quality Measure has been unpopular in some circles. It is now under official attack by the American College of Emergency Physicians (ACEP) and the Infectious Diseases Society of America (IDSA), along with a handful of smaller professional societies. These societies appealed the National Quality Forum’s (NQF) 2021 recommendation that the measure be renewed. The NQF is the multidisciplinary and broadly representative group of evaluators who evaluate proposals for CMS-sponsored quality improvement on behalf of the American people and of the Centers for Medicare & Medicaid Services (CMS). Readers of CHEST Physician are likely familiar with core measures, in general, and with Sep-1, in particular. CMS requires hospitals to publicly report their compliance with several Core Quality Measures, and the failure to do so results in across the board reductions in Medicare payments. As of now, no penalties are levied for the degree of compliance but only for failure to report the degree of compliance.
The measure asks, in the main, for hospitals to perform what most physicians can agree should be standard care for patients with sepsis. Depending on whether shock is present, the measure requires:
1. Blood cultures before antibiotics
2. Antibiotics within 3 hours of recognition of sepsis
3. Serum lactate measurement in the first 3 hours and, if increased, a repeat measurement by 6 hours
4. If the patient is hypotensive, 30 mL/kg IV crystalloid within 3 hours, or documentation of why that is not appropriate for the patient
5. If hypotension persists, vasopressors within 6 hours
6. Repeat cardiovascular assessment within 6 hours for patients with shock
If I evaluate these criteria as a patient who has been hospitalized for a serious infection, which I am, they do not seem particularly stringent. In fact, as a patient, I would want my doctors and nurses to act substantially faster than this if I had sepsis or septic shock. If my doctor did not come back in less than 6 hours to check on my shock status, I would be disappointed, to say the least. Nevertheless, some physicians and professional societies see no reason why these should be standards and state that the data underlying them are of low quality. Meanwhile, according to CMS’ own careful evaluation, national compliance with the measures is less than 50%, while being compliant with the measures reduces absolute overall mortality by approximately 4%, from 26.3% to 22.2% (Townsend SR et al. Chest. 2022;161[2]:392-406). This would translate to between 14,000 and 15,000 fewer patients dying from sepsis per year, if all patients received bundled, measure-compliant care. These are patients I don’t care to ignore.
ACEP and IDSA point specifically to the new Surviving Sepsis Campaign Guidelines (SSC) recommendations as evidence that the antibiotic measure is based on low quality evidence (Evans L et al. Crit Care Med. 2021;49[11]:1974-82). In this regard, they are technically correct; the system of evidence review that the SSC panel uses, Grading of Assessment, Recommendations, and Evaluation (GRADE), considers that retrospective analyses, which nearly all of these studies are, can be graded no higher than low quality. Clearly, retrospective studies will never achieve the level of certainty that we achieve with randomized controlled trials, but the NQF, itself, typically views that when a number of well-performed retrospective studies point in the same direction, the level of evidence is at least moderate. After all, just as it would be inappropriate to randomize participants to decades of smoking vs nonsmoking in order prove that smoking causes lung cancer, it is not appropriate to randomize patients with sepsis to receive delayed antibiotics before we accept that such delays are harmful to them.
ACEP and IDSA also assert that the association of early antibiotics with survival is “stronger” for septic shock than for sepsis. In fact, the association is quite strong for both severities of illness. Until it progresses to septic shock, the expected mortality of sepsis is lower, and the percent reduction in mortality is less than for septic shock. However, the opportunity for lives preserved is quite large, because the number of patients with sepsis at presentation is approximately 10 times higher than the number with septic shock at presentation. Antibiotic delays are also associated with progression from infection or sepsis to septic shock (Whiles BB et al. Crit Care Med. 2017;45[4]:623-29; Bisarya R et al. Chest. 2022;161[1]:112-20). Importantly, SSC gave a strong recommendation for all patients with suspected sepsis to receive antibiotics within 3 hours of suspecting sepsis and within 1 hour of suspecting septic shock, a recommendation even stronger than that of Sep-1.
Critics opine that CMS should stop looking at the process measures and focus only on the outcomes of sepsis care. There is a certain attractiveness to this proposition. One could say that it does not matter so much how a hospital achieves lower mortality as long as they do achieve it. However, the question would then become – how low should the mortality rate be? I have a notion that whatever the number, the Sep-1 critics would find it unbearable.
There is a core principle embedded in the Sep-1 process measures, in SSC guidelines, and in the concept of early goal-directed therapy that preceded them: success is not dependent only on what we do but on when we do it. All of you have experienced this. Each of you has attended a professional school, whether medical, nursing, respiratory therapy, etc. None of you showed up unannounced on opening day of the semester and was admitted to that school. All of you garnered the grades, solicited the letters of recommendation, took the entrance exams, and submitted an application. Some of you went to an interview. All of these things were done in a timely fashion; professional schools do not accept incomplete applications or late applications. Doing the right things at the wrong time would have left us all pursuing different careers.
Very early in my career as an attending physician in the ICU, I found myself exasperated by the circumstances of many patients who we received in the ICU with sepsis. I would peruse their medical records and find that they had been septic, ie, had met criteria for severe sepsis, 1 to 2 days before their deterioration to septic shock, yet they had not been diagnosed with sepsis until shock developed. In the ICU, we began resuscitative fluids, ensured appropriate antibiotics, and started vasopressors, but it was often to no avail. The treatments we gave made no difference for many patients, because they were given too late. For me, this was career altering; much of my career since that time has focused on teaching medical personnel how to recognize sepsis, how to give timely and appropriate treatments, and how to keep the data to show when they have done that and when they have not.
Before Sep-1 many, if not most, of the hospitals in the United States had no particular strategy in place to recognize and treat patients with sepsis, even though it was and is the most common cause of death and the costliest condition in American hospitals. Now, most hospitals do have such strategies. Assertions by professional societies that it is difficult to collect the data for Sep-1 reporting are likely true. However, keeping patients safe and alive is a hospital’s primary reason for existing. As long as hospitals are tracking each antibiotic and every liter of fluid so that they can bill for them, my own ears are deaf to hearing that it is too difficult to make sure that we are doing our job. Modifying or eliminating Sep-1 for any reason except data that show we can clearly further improve the outcome for all patients with sepsis is the wrong move to make. So far, other professional societies want to remove elements of Sep-1 without evidence that it would improve our care for patients with sepsis or their outcomes. Thankfully, from the time we proposed the first criteria for diagnosing sepsis, CHEST has promoted what is best for patients, whether it is difficult or not.
Dr. Simpson is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement, including by serving as a senior adviser to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the U.S. Department of Health and Human Services and an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. Dr. Simpson is the senior medical adviser for Sepsis Alliance, a nationwide patient information and advocacy organization. He is the immediate past president of CHEST.
Past President’s perspective
It’s January 1, 2022, as I write, and my CHEST presidency came to an end last night as the fireworks lit up the sky. With COVID-19 waxing and waning across the United States and around the world, I have been a wartime president. CHEST has not been able to do a number of the things that we would normally have done in person, including that there has not been an in-person CHEST annual meeting during my entire presidency. We have, nonetheless, achieved some important things that I will share with you.
If you’re a typical CHEST member, you probably don’t spend a lot of time wondering about CHEST’s finances, nor should you. Nevertheless, CHEST – your organization – does have to be fiscally responsible if we desire to continue our educational and research missions, and that is the job of your Board of Regents, your presidents, and your professional staff at the CHEST headquarters. I’m happy to tell you that your organization is in healthy financial condition, in spite of a challenging economic environment and, being forced into remote, online annual meetings and board reviews for 2 years. What that means to us and to you is that we get to maintain and improve our full array of educational activities, including our annual meeting, our journal, our board reviews, our hands-on courses at the CHEST headquarters, and our web content. And, we get to accelerate our advocacy activities for our patients and for the clinical folks who care for them (us!). CHEST is primed for emerging from this pandemic stronger, because we have had to make the most of every dollar we have, and more innovative, because that’s how we have done it. We are ready for new ways of interacting and for innovative new ways of delivering education, sponsoring research, fostering networking, and leading in the clinical arena of chest medicine.
During my time as CHEST President, many of us have become progressively more aware of the blatant inequities that continue in society – and, yes, even in medicine. Perhaps more than anything, it both saddens and angers me when anyone values or devalues someone else’s life because of the color of their skin, who they feel attracted to or love, the sex they were born with or their knowledge that nature gave them the wrong physical characteristics for their gender, what physical impairments they have, where they were born, where they were educated - or not, what language is their first language, or what opportunities they were presented with in their lives. Everyone deserves the opportunity to be who and what they are and to be respected for who they are, and everyone deserves the opportunity to excel. The strongest collaborations have diverse constituents with unified goals, and I want for CHEST to be among the strongest of professional collaborations. It has been deeply important to me during my presidency to champion these values, and we have worked hard to make CHEST an inclusive and diverse organization. Much remains to be done, but we did make some good progress this year.
We established a spirometry working group to look at the science around race-based adjustments for normal values, to call out if there are mistakes or omissions in that approach, and to propose the work that needs to be done to correct them. We invited the American Thoracic Society and the Canadian Thoracic Society to join us in this effort. Race is a social construct, not a physiologic principle, and some data suggest that apparent differences in physiology could actually reflect differences in socioeconomic status of study participants. In similar work, our nephrology colleagues demonstrated that apparent differences in normal glomerular filtration rate (GFR) are related to socio-economic and health care access issues; they called for labs to no longer report race-based norms for creatinine and GFR values. Our colleagues believe that race-based GFR norms have harmed patients by promoting delay in treatments aimed at preventing dialysis or by causing delays in the initiation of dialysis. In our world, asbestos companies have argued that African American and other populations of color should receive lower asbestosis settlements on the basis that they began with lower predicted lung function and, therefore, had been less damaged by exposure to asbestos. I am very interested to see our working group’s output. I think it could result in landmark changes in our evaluation and treatment of patients with lung diseases.
A very important undertaking for us this year was a top to bottom analysis of our own practices around diversity, equity, and inclusion. We started by taking lessons from the CHEST Foundation-sponsored listening tour across the nation. Many of our patients of color lack adequate access to the care they need, which informs our efforts in advocacy and health policy. We also learned that, as a profession, we have not earned the trust of our patients of color, and we must take steps to remedy that. CHEST began this effort by developing the First 5 Minutes program, which teaches all of us how to take the first moments of our interactions with patients to enhance our empathy and to establish trusting relationships with them. You will hear more about this program in the months to come.
CHEST is dedicated to ensuring that all of our members have equitable opportunities to take part in our learning activities, both as participants and as developers. Likewise, we want any member who desires to advance in our organization to have wide open opportunity to develop and use their skills. We hired a consulting firm who specializes in aiding nonprofits with their diversity, equity, and inclusion goals to help us find our weaknesses in that area. They spent several months interviewing members at all stages of their careers and in a variety of job types, with the goal of determining what it is like to be a CHEST member of color, a woman, a member of the LGBTQIA community, or a member of any group that has been made to feel “other.” We are currently working to turn their findings into concrete steps to make CHEST the most diverse and inclusive medical society possible. Finally, our consultants are helping us to ensure that the people we hire to work for our organization full time have equitable opportunities in their workplace, and that CHEST headquarters feels inclusive and is diverse for them.
COVID-19 rages on. In fact, daily case numbers at this writing are skyrocketing, higher than at any time during the pandemic, and hospitalization rates, while lower than with some of the previous waves, are following. Many of us are stressed, and in many of our ICUs, we have fewer nurses than we did at the outset of the pandemic. The CHEST COVID-19 task force continues on the job, though, with fresh content to match the current circumstances. These dedicated individuals, who I recognized with a Presidential Citation for 2021, have worked since the early days of the pandemic to scour the literature and the landscape to find the right data and the right experts to inform the topical infographics, reviews, webinars, and podcasts that are freely available to all and are posted on the CHEST website. I hope that you have availed yourself of the material there, and, if not, you have missed some valuable learning opportunities. Missed them in real time, that is; they are all on the site for you to use at will. We are optimistic that someday soon, there will be less of a need for the COVID-19 task force, but the members are all ready to continue their work until that time comes..
I’ve highlighted just a few of the higher profile things that CHEST achieved in 2021. It would be impossible for me to cover all that CHEST has accomplished this past year. My sources tell me that during my presidency, we generated, signed on, or declined to join nearly 100 advocacy statements on topics ranging from recall of home CPAP machines to access to appropriate supplemental oxygen for patients with interstitial lung disease, to the acquisition of a nebulizer company by a tobacco company. We held successful board review sessions and repeated our all online, yet interactive, version of the CHEST annual meeting, with more than 4,000 total attendees– not as large as an in-person meeting, but not terribly far off, either. I will add that our program chairs and their committee pivoted from a meeting in Vancouver to a meeting in Orlando to, with only 6 weeks’ notice, a meeting in the ether. We are fortunate to have worked with such talented and dedicated individuals, and all of us owe them a lot for their efforts.
If, as I say, I have been a wartime president, then the worldwide viral pandemic that directly affects those of us in chest medicine has been the war. In spite of the current tsunami of cases, I am optimistic that the war ends relatively soon. CHEST will not simply return to normalcy, though. Dr. David Schulman, a brilliant and innovative educator, has taken the leadership reins of the organization, and I foresee exhilarating times ahead.
We are making it through a challenging environment, and CHEST is stronger for it. I will look forward to seeing all of you in Nashville, when we, at long last, can look one another in the eye, shake one another’s hand, and enjoy the experience of the CHEST annual meeting together. And if you don’t mind me asking, when you see me in Nashville, will you please do exactly that?
It’s January 1, 2022, as I write, and my CHEST presidency came to an end last night as the fireworks lit up the sky. With COVID-19 waxing and waning across the United States and around the world, I have been a wartime president. CHEST has not been able to do a number of the things that we would normally have done in person, including that there has not been an in-person CHEST annual meeting during my entire presidency. We have, nonetheless, achieved some important things that I will share with you.
If you’re a typical CHEST member, you probably don’t spend a lot of time wondering about CHEST’s finances, nor should you. Nevertheless, CHEST – your organization – does have to be fiscally responsible if we desire to continue our educational and research missions, and that is the job of your Board of Regents, your presidents, and your professional staff at the CHEST headquarters. I’m happy to tell you that your organization is in healthy financial condition, in spite of a challenging economic environment and, being forced into remote, online annual meetings and board reviews for 2 years. What that means to us and to you is that we get to maintain and improve our full array of educational activities, including our annual meeting, our journal, our board reviews, our hands-on courses at the CHEST headquarters, and our web content. And, we get to accelerate our advocacy activities for our patients and for the clinical folks who care for them (us!). CHEST is primed for emerging from this pandemic stronger, because we have had to make the most of every dollar we have, and more innovative, because that’s how we have done it. We are ready for new ways of interacting and for innovative new ways of delivering education, sponsoring research, fostering networking, and leading in the clinical arena of chest medicine.
During my time as CHEST President, many of us have become progressively more aware of the blatant inequities that continue in society – and, yes, even in medicine. Perhaps more than anything, it both saddens and angers me when anyone values or devalues someone else’s life because of the color of their skin, who they feel attracted to or love, the sex they were born with or their knowledge that nature gave them the wrong physical characteristics for their gender, what physical impairments they have, where they were born, where they were educated - or not, what language is their first language, or what opportunities they were presented with in their lives. Everyone deserves the opportunity to be who and what they are and to be respected for who they are, and everyone deserves the opportunity to excel. The strongest collaborations have diverse constituents with unified goals, and I want for CHEST to be among the strongest of professional collaborations. It has been deeply important to me during my presidency to champion these values, and we have worked hard to make CHEST an inclusive and diverse organization. Much remains to be done, but we did make some good progress this year.
We established a spirometry working group to look at the science around race-based adjustments for normal values, to call out if there are mistakes or omissions in that approach, and to propose the work that needs to be done to correct them. We invited the American Thoracic Society and the Canadian Thoracic Society to join us in this effort. Race is a social construct, not a physiologic principle, and some data suggest that apparent differences in physiology could actually reflect differences in socioeconomic status of study participants. In similar work, our nephrology colleagues demonstrated that apparent differences in normal glomerular filtration rate (GFR) are related to socio-economic and health care access issues; they called for labs to no longer report race-based norms for creatinine and GFR values. Our colleagues believe that race-based GFR norms have harmed patients by promoting delay in treatments aimed at preventing dialysis or by causing delays in the initiation of dialysis. In our world, asbestos companies have argued that African American and other populations of color should receive lower asbestosis settlements on the basis that they began with lower predicted lung function and, therefore, had been less damaged by exposure to asbestos. I am very interested to see our working group’s output. I think it could result in landmark changes in our evaluation and treatment of patients with lung diseases.
A very important undertaking for us this year was a top to bottom analysis of our own practices around diversity, equity, and inclusion. We started by taking lessons from the CHEST Foundation-sponsored listening tour across the nation. Many of our patients of color lack adequate access to the care they need, which informs our efforts in advocacy and health policy. We also learned that, as a profession, we have not earned the trust of our patients of color, and we must take steps to remedy that. CHEST began this effort by developing the First 5 Minutes program, which teaches all of us how to take the first moments of our interactions with patients to enhance our empathy and to establish trusting relationships with them. You will hear more about this program in the months to come.
CHEST is dedicated to ensuring that all of our members have equitable opportunities to take part in our learning activities, both as participants and as developers. Likewise, we want any member who desires to advance in our organization to have wide open opportunity to develop and use their skills. We hired a consulting firm who specializes in aiding nonprofits with their diversity, equity, and inclusion goals to help us find our weaknesses in that area. They spent several months interviewing members at all stages of their careers and in a variety of job types, with the goal of determining what it is like to be a CHEST member of color, a woman, a member of the LGBTQIA community, or a member of any group that has been made to feel “other.” We are currently working to turn their findings into concrete steps to make CHEST the most diverse and inclusive medical society possible. Finally, our consultants are helping us to ensure that the people we hire to work for our organization full time have equitable opportunities in their workplace, and that CHEST headquarters feels inclusive and is diverse for them.
COVID-19 rages on. In fact, daily case numbers at this writing are skyrocketing, higher than at any time during the pandemic, and hospitalization rates, while lower than with some of the previous waves, are following. Many of us are stressed, and in many of our ICUs, we have fewer nurses than we did at the outset of the pandemic. The CHEST COVID-19 task force continues on the job, though, with fresh content to match the current circumstances. These dedicated individuals, who I recognized with a Presidential Citation for 2021, have worked since the early days of the pandemic to scour the literature and the landscape to find the right data and the right experts to inform the topical infographics, reviews, webinars, and podcasts that are freely available to all and are posted on the CHEST website. I hope that you have availed yourself of the material there, and, if not, you have missed some valuable learning opportunities. Missed them in real time, that is; they are all on the site for you to use at will. We are optimistic that someday soon, there will be less of a need for the COVID-19 task force, but the members are all ready to continue their work until that time comes..
I’ve highlighted just a few of the higher profile things that CHEST achieved in 2021. It would be impossible for me to cover all that CHEST has accomplished this past year. My sources tell me that during my presidency, we generated, signed on, or declined to join nearly 100 advocacy statements on topics ranging from recall of home CPAP machines to access to appropriate supplemental oxygen for patients with interstitial lung disease, to the acquisition of a nebulizer company by a tobacco company. We held successful board review sessions and repeated our all online, yet interactive, version of the CHEST annual meeting, with more than 4,000 total attendees– not as large as an in-person meeting, but not terribly far off, either. I will add that our program chairs and their committee pivoted from a meeting in Vancouver to a meeting in Orlando to, with only 6 weeks’ notice, a meeting in the ether. We are fortunate to have worked with such talented and dedicated individuals, and all of us owe them a lot for their efforts.
If, as I say, I have been a wartime president, then the worldwide viral pandemic that directly affects those of us in chest medicine has been the war. In spite of the current tsunami of cases, I am optimistic that the war ends relatively soon. CHEST will not simply return to normalcy, though. Dr. David Schulman, a brilliant and innovative educator, has taken the leadership reins of the organization, and I foresee exhilarating times ahead.
We are making it through a challenging environment, and CHEST is stronger for it. I will look forward to seeing all of you in Nashville, when we, at long last, can look one another in the eye, shake one another’s hand, and enjoy the experience of the CHEST annual meeting together. And if you don’t mind me asking, when you see me in Nashville, will you please do exactly that?
It’s January 1, 2022, as I write, and my CHEST presidency came to an end last night as the fireworks lit up the sky. With COVID-19 waxing and waning across the United States and around the world, I have been a wartime president. CHEST has not been able to do a number of the things that we would normally have done in person, including that there has not been an in-person CHEST annual meeting during my entire presidency. We have, nonetheless, achieved some important things that I will share with you.
If you’re a typical CHEST member, you probably don’t spend a lot of time wondering about CHEST’s finances, nor should you. Nevertheless, CHEST – your organization – does have to be fiscally responsible if we desire to continue our educational and research missions, and that is the job of your Board of Regents, your presidents, and your professional staff at the CHEST headquarters. I’m happy to tell you that your organization is in healthy financial condition, in spite of a challenging economic environment and, being forced into remote, online annual meetings and board reviews for 2 years. What that means to us and to you is that we get to maintain and improve our full array of educational activities, including our annual meeting, our journal, our board reviews, our hands-on courses at the CHEST headquarters, and our web content. And, we get to accelerate our advocacy activities for our patients and for the clinical folks who care for them (us!). CHEST is primed for emerging from this pandemic stronger, because we have had to make the most of every dollar we have, and more innovative, because that’s how we have done it. We are ready for new ways of interacting and for innovative new ways of delivering education, sponsoring research, fostering networking, and leading in the clinical arena of chest medicine.
During my time as CHEST President, many of us have become progressively more aware of the blatant inequities that continue in society – and, yes, even in medicine. Perhaps more than anything, it both saddens and angers me when anyone values or devalues someone else’s life because of the color of their skin, who they feel attracted to or love, the sex they were born with or their knowledge that nature gave them the wrong physical characteristics for their gender, what physical impairments they have, where they were born, where they were educated - or not, what language is their first language, or what opportunities they were presented with in their lives. Everyone deserves the opportunity to be who and what they are and to be respected for who they are, and everyone deserves the opportunity to excel. The strongest collaborations have diverse constituents with unified goals, and I want for CHEST to be among the strongest of professional collaborations. It has been deeply important to me during my presidency to champion these values, and we have worked hard to make CHEST an inclusive and diverse organization. Much remains to be done, but we did make some good progress this year.
We established a spirometry working group to look at the science around race-based adjustments for normal values, to call out if there are mistakes or omissions in that approach, and to propose the work that needs to be done to correct them. We invited the American Thoracic Society and the Canadian Thoracic Society to join us in this effort. Race is a social construct, not a physiologic principle, and some data suggest that apparent differences in physiology could actually reflect differences in socioeconomic status of study participants. In similar work, our nephrology colleagues demonstrated that apparent differences in normal glomerular filtration rate (GFR) are related to socio-economic and health care access issues; they called for labs to no longer report race-based norms for creatinine and GFR values. Our colleagues believe that race-based GFR norms have harmed patients by promoting delay in treatments aimed at preventing dialysis or by causing delays in the initiation of dialysis. In our world, asbestos companies have argued that African American and other populations of color should receive lower asbestosis settlements on the basis that they began with lower predicted lung function and, therefore, had been less damaged by exposure to asbestos. I am very interested to see our working group’s output. I think it could result in landmark changes in our evaluation and treatment of patients with lung diseases.
A very important undertaking for us this year was a top to bottom analysis of our own practices around diversity, equity, and inclusion. We started by taking lessons from the CHEST Foundation-sponsored listening tour across the nation. Many of our patients of color lack adequate access to the care they need, which informs our efforts in advocacy and health policy. We also learned that, as a profession, we have not earned the trust of our patients of color, and we must take steps to remedy that. CHEST began this effort by developing the First 5 Minutes program, which teaches all of us how to take the first moments of our interactions with patients to enhance our empathy and to establish trusting relationships with them. You will hear more about this program in the months to come.
CHEST is dedicated to ensuring that all of our members have equitable opportunities to take part in our learning activities, both as participants and as developers. Likewise, we want any member who desires to advance in our organization to have wide open opportunity to develop and use their skills. We hired a consulting firm who specializes in aiding nonprofits with their diversity, equity, and inclusion goals to help us find our weaknesses in that area. They spent several months interviewing members at all stages of their careers and in a variety of job types, with the goal of determining what it is like to be a CHEST member of color, a woman, a member of the LGBTQIA community, or a member of any group that has been made to feel “other.” We are currently working to turn their findings into concrete steps to make CHEST the most diverse and inclusive medical society possible. Finally, our consultants are helping us to ensure that the people we hire to work for our organization full time have equitable opportunities in their workplace, and that CHEST headquarters feels inclusive and is diverse for them.
COVID-19 rages on. In fact, daily case numbers at this writing are skyrocketing, higher than at any time during the pandemic, and hospitalization rates, while lower than with some of the previous waves, are following. Many of us are stressed, and in many of our ICUs, we have fewer nurses than we did at the outset of the pandemic. The CHEST COVID-19 task force continues on the job, though, with fresh content to match the current circumstances. These dedicated individuals, who I recognized with a Presidential Citation for 2021, have worked since the early days of the pandemic to scour the literature and the landscape to find the right data and the right experts to inform the topical infographics, reviews, webinars, and podcasts that are freely available to all and are posted on the CHEST website. I hope that you have availed yourself of the material there, and, if not, you have missed some valuable learning opportunities. Missed them in real time, that is; they are all on the site for you to use at will. We are optimistic that someday soon, there will be less of a need for the COVID-19 task force, but the members are all ready to continue their work until that time comes..
I’ve highlighted just a few of the higher profile things that CHEST achieved in 2021. It would be impossible for me to cover all that CHEST has accomplished this past year. My sources tell me that during my presidency, we generated, signed on, or declined to join nearly 100 advocacy statements on topics ranging from recall of home CPAP machines to access to appropriate supplemental oxygen for patients with interstitial lung disease, to the acquisition of a nebulizer company by a tobacco company. We held successful board review sessions and repeated our all online, yet interactive, version of the CHEST annual meeting, with more than 4,000 total attendees– not as large as an in-person meeting, but not terribly far off, either. I will add that our program chairs and their committee pivoted from a meeting in Vancouver to a meeting in Orlando to, with only 6 weeks’ notice, a meeting in the ether. We are fortunate to have worked with such talented and dedicated individuals, and all of us owe them a lot for their efforts.
If, as I say, I have been a wartime president, then the worldwide viral pandemic that directly affects those of us in chest medicine has been the war. In spite of the current tsunami of cases, I am optimistic that the war ends relatively soon. CHEST will not simply return to normalcy, though. Dr. David Schulman, a brilliant and innovative educator, has taken the leadership reins of the organization, and I foresee exhilarating times ahead.
We are making it through a challenging environment, and CHEST is stronger for it. I will look forward to seeing all of you in Nashville, when we, at long last, can look one another in the eye, shake one another’s hand, and enjoy the experience of the CHEST annual meeting together. And if you don’t mind me asking, when you see me in Nashville, will you please do exactly that?
President’s report
As I write, it is 1 degree Fahrenheit and dreary in Kansas City, where I live. That’s minus 17 degrees Celsius for many of you. I hope that it is cheerier and bordering on springtime when you’re reading. You’ll understand, though, why I say Happy 2021! 2020 was a humdinger in many ways.
One of those ways, of course, was the COVID-19 pandemic, which wrought so many things – face masks, social distancing, steep learning curves, over 300,000 excess deaths, and new vaccines. For CHEST, it meant that two of our most important educational opportunities of the year, board review and the annual meeting, were held virtually. Dr. Levine has already written about the board reviews, so I’ll focus on the annual meeting, held in late October.
In many ways, the meeting was a success. We had over 6,800 attendees. There were 88 live online sessions, 22 that were semi-live, and 160 prerecorded sessions. For presenters, this was simultaneously both easy and difficult. They had to ensure that their recording equipment and their Internet access were of sufficient quality, and if prerecorded, the sessions had to be finished weeks ahead of time. But the presentations could be given from presenters’ homes or from their normal work offices. For attendees, the ability for nonsimultaneous playback allowed for fitting the meeting into a work-life schedule. In fact, at least one friend related that he watched sessions with a grandchild on his lap. However, it meant a lack of opportunities to ask clarifying questions of the presenters, which is a common activity at the end of a session, and the opportunity to see and catch up with old friends and colleagues was missing. Simulations, of course, could not be hands-on, but virtual educational games matured significantly. The satisfaction scores from both attendees and faculty were good, if slightly below our usual scores for live meetings. They told us that we all prefer our in-person meetings, but that content is deliverable and receivable in an online format. Overall, we have to consider the CHEST 2020 online platform to be a successful endeavor.
Which brings me to our plans for future meetings. The Board of Regents discussed the alternatives for CHEST 2021. Should we hold a live meeting in Vancouver, as planned? Should we hold another online meeting like the one we just discussed? None of us has the crystal ball that tells us exactly how COVID-19 is going to develop. We don’t know exactly how many people will be vaccinated either north or south of the U.S.-Canada border. While those of us who care for patients in the United States have had the opportunity to be vaccinated, we don’t know if the professional staff from CHEST headquarters who travel to the annual meeting will be vaccinated, even though that prospect is currently looking very reasonable. We don’t know if the Canadian government will be allowing U.S. residents to visit Canada without quarantine. There are just quite a few things that we can’t know. However, convention centers need to know if we will be there, and we needed to decide.
In the end, a couple of things swayed us—the unexpected availability of a U.S. convention center and uncertainty about travel to Canada. We are planning to hold CHEST 2021 in Orlando, Florida, during our usual late October time frame. CHEST 2021 is slated to be the first in-person pulmonary, critical care, and sleep conference to be held in the United States in 2 years. The Executive Program Committee has met, and program selections have been made. Very soon, invitations will go to our prospective faculty, and we will be underway. We are planning CHEST 2021 as what we call a “hybrid” meeting, a meeting that will provide an excellent experience whether one attends in person at the Orlando Convention Center or partakes of the meeting from home. Some sessions will be broadcast live and others will be prerecorded. Needless to say, the experience will not be equal for in-person and at-home learners, but it will be equitable. Regardless of how you choose to partake, CHEST 2021 will have excellent content to suit your needs. This plan also allows us the ability to convert to a fully online meeting, should the COVID-19 circumstances dictate that we must. Having sat in on the program committee meetings, I am excited about what we have to offer. So, dig around and find your old mouse ears or your red forehead scar. CHEST 2021 will be a dynamite experience for us all to share.
Our board review sessions, which are also among the most highly valued of CHEST activities, will be different out of necessity. Again, decisions had to be made many months ahead of time, and we have chosen to hold our board reviews online again this year. COVID-19 uncertainties certainly play into our decision to not put attendees in a room together. However, the ability to play and replay, slow down and speed up video content, and ability to watch any session any time are all well suited to reviewing for an examination. We think this is the appropriate decision for 2021, but we may be back together again for future sessions. Frankly, we are listening to hear which format our attendees like more. And, we are plotting how to make the online platform review even better.
The Board of Regents has been hard at work on a lot of fronts, but I want to focus on one of them, for now. It is important to the Board of Regents and to me, personally, that CHEST be the single most inclusive and diverse professional medical society, bar none. It is of utmost importance that we remove any barriers that might have inadvertently been put into place that would hamper the success of any of our members or their patients. In other words, we hope to find any implicit biases in attitude and behavior and to illuminate and remedy them. We have begun the process by focusing on what CHEST is all about – making a difference with our patients and corporate self and being an inclusive and diverse professional organization.
We believe that we must look at ourselves in three separate, but related, ways. We must examine our patient-facing side and the ways in which we help our members to serve their patients. We must examine our headquarters and our hiring, working, and promoting practices to ensure an inclusive and welcoming environment for the staff who do our day to day business. Finally, we must examine ourselves and our member-based organization, to ensure that all can participate freely in CHEST opportunities and, for those who aspire to lead our organization, to ensure that there are no implicit biases that hold them back.
We began the process with a series of regional listening sessions across the United States, sponsored by the CHEST Foundation, in which we heard from both patients and community leaders of color. We learned of challenges that our patients face in accessing care, communicating with their doctors, and obtaining the medications they need for their illness. Our professional staff has organized an anti-racism task force and is working to ensure that we can be proud of a diverse and inclusive work environment. For our members, we have held two board development sessions, so that our Board of Regents can examine us and our attitudes toward race and toward inclusiveness in our organization. We will soon be holding a listening session with CHEST members of color with the express purpose of allowing those of us who are not persons of color to better understand the challenges faced by our members and to understand where organizational changes could be necessary to help make their professional lives better. As a long time CHEST member, I believe that CHEST is not purposefully exclusive of anyone. We are, nevertheless, a part of the larger fabric of society, and because of that, we are subject to having implicit biases and practices as an organization. Our best path to be aware of them and to deal with them is to hear from our members who experience them, and we shall.
I will end on a note that is somber but important. In the past year, we have all lost friends and colleagues with whom we worked side by side, to COVID-19. Many of them have been CHEST members. Because of the pandemic, we have often not been able to mourn those we have cared about in the same ways that we normally would, in the company of friends and family. Yet, it is important for us to remember our colleagues and to share our memories. So, we established CHEST Remembers, a memorial wall on the CHEST website where we can post the news of our friends’ passing, along with our remembrances of them. If your friend or colleague has died of COVID-19, please feel free to share with the CHEST community. You can find the link to do that at www.chestnet.org.
As I write, it is 1 degree Fahrenheit and dreary in Kansas City, where I live. That’s minus 17 degrees Celsius for many of you. I hope that it is cheerier and bordering on springtime when you’re reading. You’ll understand, though, why I say Happy 2021! 2020 was a humdinger in many ways.
One of those ways, of course, was the COVID-19 pandemic, which wrought so many things – face masks, social distancing, steep learning curves, over 300,000 excess deaths, and new vaccines. For CHEST, it meant that two of our most important educational opportunities of the year, board review and the annual meeting, were held virtually. Dr. Levine has already written about the board reviews, so I’ll focus on the annual meeting, held in late October.
In many ways, the meeting was a success. We had over 6,800 attendees. There were 88 live online sessions, 22 that were semi-live, and 160 prerecorded sessions. For presenters, this was simultaneously both easy and difficult. They had to ensure that their recording equipment and their Internet access were of sufficient quality, and if prerecorded, the sessions had to be finished weeks ahead of time. But the presentations could be given from presenters’ homes or from their normal work offices. For attendees, the ability for nonsimultaneous playback allowed for fitting the meeting into a work-life schedule. In fact, at least one friend related that he watched sessions with a grandchild on his lap. However, it meant a lack of opportunities to ask clarifying questions of the presenters, which is a common activity at the end of a session, and the opportunity to see and catch up with old friends and colleagues was missing. Simulations, of course, could not be hands-on, but virtual educational games matured significantly. The satisfaction scores from both attendees and faculty were good, if slightly below our usual scores for live meetings. They told us that we all prefer our in-person meetings, but that content is deliverable and receivable in an online format. Overall, we have to consider the CHEST 2020 online platform to be a successful endeavor.
Which brings me to our plans for future meetings. The Board of Regents discussed the alternatives for CHEST 2021. Should we hold a live meeting in Vancouver, as planned? Should we hold another online meeting like the one we just discussed? None of us has the crystal ball that tells us exactly how COVID-19 is going to develop. We don’t know exactly how many people will be vaccinated either north or south of the U.S.-Canada border. While those of us who care for patients in the United States have had the opportunity to be vaccinated, we don’t know if the professional staff from CHEST headquarters who travel to the annual meeting will be vaccinated, even though that prospect is currently looking very reasonable. We don’t know if the Canadian government will be allowing U.S. residents to visit Canada without quarantine. There are just quite a few things that we can’t know. However, convention centers need to know if we will be there, and we needed to decide.
In the end, a couple of things swayed us—the unexpected availability of a U.S. convention center and uncertainty about travel to Canada. We are planning to hold CHEST 2021 in Orlando, Florida, during our usual late October time frame. CHEST 2021 is slated to be the first in-person pulmonary, critical care, and sleep conference to be held in the United States in 2 years. The Executive Program Committee has met, and program selections have been made. Very soon, invitations will go to our prospective faculty, and we will be underway. We are planning CHEST 2021 as what we call a “hybrid” meeting, a meeting that will provide an excellent experience whether one attends in person at the Orlando Convention Center or partakes of the meeting from home. Some sessions will be broadcast live and others will be prerecorded. Needless to say, the experience will not be equal for in-person and at-home learners, but it will be equitable. Regardless of how you choose to partake, CHEST 2021 will have excellent content to suit your needs. This plan also allows us the ability to convert to a fully online meeting, should the COVID-19 circumstances dictate that we must. Having sat in on the program committee meetings, I am excited about what we have to offer. So, dig around and find your old mouse ears or your red forehead scar. CHEST 2021 will be a dynamite experience for us all to share.
Our board review sessions, which are also among the most highly valued of CHEST activities, will be different out of necessity. Again, decisions had to be made many months ahead of time, and we have chosen to hold our board reviews online again this year. COVID-19 uncertainties certainly play into our decision to not put attendees in a room together. However, the ability to play and replay, slow down and speed up video content, and ability to watch any session any time are all well suited to reviewing for an examination. We think this is the appropriate decision for 2021, but we may be back together again for future sessions. Frankly, we are listening to hear which format our attendees like more. And, we are plotting how to make the online platform review even better.
The Board of Regents has been hard at work on a lot of fronts, but I want to focus on one of them, for now. It is important to the Board of Regents and to me, personally, that CHEST be the single most inclusive and diverse professional medical society, bar none. It is of utmost importance that we remove any barriers that might have inadvertently been put into place that would hamper the success of any of our members or their patients. In other words, we hope to find any implicit biases in attitude and behavior and to illuminate and remedy them. We have begun the process by focusing on what CHEST is all about – making a difference with our patients and corporate self and being an inclusive and diverse professional organization.
We believe that we must look at ourselves in three separate, but related, ways. We must examine our patient-facing side and the ways in which we help our members to serve their patients. We must examine our headquarters and our hiring, working, and promoting practices to ensure an inclusive and welcoming environment for the staff who do our day to day business. Finally, we must examine ourselves and our member-based organization, to ensure that all can participate freely in CHEST opportunities and, for those who aspire to lead our organization, to ensure that there are no implicit biases that hold them back.
We began the process with a series of regional listening sessions across the United States, sponsored by the CHEST Foundation, in which we heard from both patients and community leaders of color. We learned of challenges that our patients face in accessing care, communicating with their doctors, and obtaining the medications they need for their illness. Our professional staff has organized an anti-racism task force and is working to ensure that we can be proud of a diverse and inclusive work environment. For our members, we have held two board development sessions, so that our Board of Regents can examine us and our attitudes toward race and toward inclusiveness in our organization. We will soon be holding a listening session with CHEST members of color with the express purpose of allowing those of us who are not persons of color to better understand the challenges faced by our members and to understand where organizational changes could be necessary to help make their professional lives better. As a long time CHEST member, I believe that CHEST is not purposefully exclusive of anyone. We are, nevertheless, a part of the larger fabric of society, and because of that, we are subject to having implicit biases and practices as an organization. Our best path to be aware of them and to deal with them is to hear from our members who experience them, and we shall.
I will end on a note that is somber but important. In the past year, we have all lost friends and colleagues with whom we worked side by side, to COVID-19. Many of them have been CHEST members. Because of the pandemic, we have often not been able to mourn those we have cared about in the same ways that we normally would, in the company of friends and family. Yet, it is important for us to remember our colleagues and to share our memories. So, we established CHEST Remembers, a memorial wall on the CHEST website where we can post the news of our friends’ passing, along with our remembrances of them. If your friend or colleague has died of COVID-19, please feel free to share with the CHEST community. You can find the link to do that at www.chestnet.org.
As I write, it is 1 degree Fahrenheit and dreary in Kansas City, where I live. That’s minus 17 degrees Celsius for many of you. I hope that it is cheerier and bordering on springtime when you’re reading. You’ll understand, though, why I say Happy 2021! 2020 was a humdinger in many ways.
One of those ways, of course, was the COVID-19 pandemic, which wrought so many things – face masks, social distancing, steep learning curves, over 300,000 excess deaths, and new vaccines. For CHEST, it meant that two of our most important educational opportunities of the year, board review and the annual meeting, were held virtually. Dr. Levine has already written about the board reviews, so I’ll focus on the annual meeting, held in late October.
In many ways, the meeting was a success. We had over 6,800 attendees. There were 88 live online sessions, 22 that were semi-live, and 160 prerecorded sessions. For presenters, this was simultaneously both easy and difficult. They had to ensure that their recording equipment and their Internet access were of sufficient quality, and if prerecorded, the sessions had to be finished weeks ahead of time. But the presentations could be given from presenters’ homes or from their normal work offices. For attendees, the ability for nonsimultaneous playback allowed for fitting the meeting into a work-life schedule. In fact, at least one friend related that he watched sessions with a grandchild on his lap. However, it meant a lack of opportunities to ask clarifying questions of the presenters, which is a common activity at the end of a session, and the opportunity to see and catch up with old friends and colleagues was missing. Simulations, of course, could not be hands-on, but virtual educational games matured significantly. The satisfaction scores from both attendees and faculty were good, if slightly below our usual scores for live meetings. They told us that we all prefer our in-person meetings, but that content is deliverable and receivable in an online format. Overall, we have to consider the CHEST 2020 online platform to be a successful endeavor.
Which brings me to our plans for future meetings. The Board of Regents discussed the alternatives for CHEST 2021. Should we hold a live meeting in Vancouver, as planned? Should we hold another online meeting like the one we just discussed? None of us has the crystal ball that tells us exactly how COVID-19 is going to develop. We don’t know exactly how many people will be vaccinated either north or south of the U.S.-Canada border. While those of us who care for patients in the United States have had the opportunity to be vaccinated, we don’t know if the professional staff from CHEST headquarters who travel to the annual meeting will be vaccinated, even though that prospect is currently looking very reasonable. We don’t know if the Canadian government will be allowing U.S. residents to visit Canada without quarantine. There are just quite a few things that we can’t know. However, convention centers need to know if we will be there, and we needed to decide.
In the end, a couple of things swayed us—the unexpected availability of a U.S. convention center and uncertainty about travel to Canada. We are planning to hold CHEST 2021 in Orlando, Florida, during our usual late October time frame. CHEST 2021 is slated to be the first in-person pulmonary, critical care, and sleep conference to be held in the United States in 2 years. The Executive Program Committee has met, and program selections have been made. Very soon, invitations will go to our prospective faculty, and we will be underway. We are planning CHEST 2021 as what we call a “hybrid” meeting, a meeting that will provide an excellent experience whether one attends in person at the Orlando Convention Center or partakes of the meeting from home. Some sessions will be broadcast live and others will be prerecorded. Needless to say, the experience will not be equal for in-person and at-home learners, but it will be equitable. Regardless of how you choose to partake, CHEST 2021 will have excellent content to suit your needs. This plan also allows us the ability to convert to a fully online meeting, should the COVID-19 circumstances dictate that we must. Having sat in on the program committee meetings, I am excited about what we have to offer. So, dig around and find your old mouse ears or your red forehead scar. CHEST 2021 will be a dynamite experience for us all to share.
Our board review sessions, which are also among the most highly valued of CHEST activities, will be different out of necessity. Again, decisions had to be made many months ahead of time, and we have chosen to hold our board reviews online again this year. COVID-19 uncertainties certainly play into our decision to not put attendees in a room together. However, the ability to play and replay, slow down and speed up video content, and ability to watch any session any time are all well suited to reviewing for an examination. We think this is the appropriate decision for 2021, but we may be back together again for future sessions. Frankly, we are listening to hear which format our attendees like more. And, we are plotting how to make the online platform review even better.
The Board of Regents has been hard at work on a lot of fronts, but I want to focus on one of them, for now. It is important to the Board of Regents and to me, personally, that CHEST be the single most inclusive and diverse professional medical society, bar none. It is of utmost importance that we remove any barriers that might have inadvertently been put into place that would hamper the success of any of our members or their patients. In other words, we hope to find any implicit biases in attitude and behavior and to illuminate and remedy them. We have begun the process by focusing on what CHEST is all about – making a difference with our patients and corporate self and being an inclusive and diverse professional organization.
We believe that we must look at ourselves in three separate, but related, ways. We must examine our patient-facing side and the ways in which we help our members to serve their patients. We must examine our headquarters and our hiring, working, and promoting practices to ensure an inclusive and welcoming environment for the staff who do our day to day business. Finally, we must examine ourselves and our member-based organization, to ensure that all can participate freely in CHEST opportunities and, for those who aspire to lead our organization, to ensure that there are no implicit biases that hold them back.
We began the process with a series of regional listening sessions across the United States, sponsored by the CHEST Foundation, in which we heard from both patients and community leaders of color. We learned of challenges that our patients face in accessing care, communicating with their doctors, and obtaining the medications they need for their illness. Our professional staff has organized an anti-racism task force and is working to ensure that we can be proud of a diverse and inclusive work environment. For our members, we have held two board development sessions, so that our Board of Regents can examine us and our attitudes toward race and toward inclusiveness in our organization. We will soon be holding a listening session with CHEST members of color with the express purpose of allowing those of us who are not persons of color to better understand the challenges faced by our members and to understand where organizational changes could be necessary to help make their professional lives better. As a long time CHEST member, I believe that CHEST is not purposefully exclusive of anyone. We are, nevertheless, a part of the larger fabric of society, and because of that, we are subject to having implicit biases and practices as an organization. Our best path to be aware of them and to deal with them is to hear from our members who experience them, and we shall.
I will end on a note that is somber but important. In the past year, we have all lost friends and colleagues with whom we worked side by side, to COVID-19. Many of them have been CHEST members. Because of the pandemic, we have often not been able to mourn those we have cared about in the same ways that we normally would, in the company of friends and family. Yet, it is important for us to remember our colleagues and to share our memories. So, we established CHEST Remembers, a memorial wall on the CHEST website where we can post the news of our friends’ passing, along with our remembrances of them. If your friend or colleague has died of COVID-19, please feel free to share with the CHEST community. You can find the link to do that at www.chestnet.org.
On Diagnosing Sepsis
Two years ago, a panel appointed by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, referred to as a consensus conference, proposed a new definition for sepsis and new diagnostic criteria for sepsis and septic shock, known as Sepsis-3 (Singer M, et al. JAMA. 2016;315[8]:801). The panel proposed that sepsis be defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Upon reflection, one could see that what we had called definitions of sepsis, severe sepsis, and septic shock for over 2 decades actually represented diagnostic criteria more than concise definitions. In that regard, a concise definition is a useful addition in the tool kit for training all health-care professionals to recognize sepsis and to treat it early and aggressively.
However, the diagnostic criteria leave something to be desired, in terms of both practicality and sensitivity for detecting patients whose infection has made them seriously ill. Those who participate in quality improvement efforts in their own hospitals will recognize that to promote change and to achieve a goal of better, higher quality care, it is important to remove obstacles in the system and to structure it so that doing the right thing is easier than not doing it. For sepsis, the first step in the process, recognizing that sepsis is present, has always been complex enough that it has been the bane of the enterprise. As many as two-thirds of patients with sepsis presenting to the ED with severe sepsis never receive that diagnosis while in the hospital. (Deis AS, et al. Chest. 2018;153[1]:39). As any sepsis core measure coordinator can attest, diagnostic criteria that are readily visible on retrospective examination are often unnoticed or misinterpreted in real time.
The crux of this issue is that the very entity of sepsis is not a definite thing but a not-quite-focused idea. Much is known of pathophysiologic features that seem to be important, but there is no one unifying pathologic condition. Contrast that with another critical illness, myocardial infarction. The very name states the unifying pathology. Our predecessors were able to work backward from an understanding that acute blockage of a small artery led to ischemia and infarction, in order to identify methods to detect it while it is happening—measuring enzymes and evaluating an ECG. For sepsis, we don’t even understand why patients are sick or why they die. There is a complex interaction of inflammation, microcirculatory thrombosis, mitochondrial dysfunction, immune suppression, but there is no one combination of those things that is yet understood in a way that lends itself to diagnostic testing. The best we can say is that the patient reacted to their infection in a way that was detrimental to their own body’s functioning. Rather than recognizing a few symptoms and sending a confirmatory test, with sepsis, we must tote up the signs and symptoms in the domains of recognizing infection and recognizing organ dysfunction, then determine whether they are present in sufficient amounts; it is an exercise that requires mental discipline.
If the diagnostic criteria we use, whether Sepsis-1, 2, or 3, are all gross descriptions of complex internal interactions that are not specific, then the syndrome that any of these criteria identifies is also not specific for anything particular. It falls to the medical community, as a whole, to determine exactly what it is that we desire a given syndrome to be indicative of. The Sepsis-3 authors decided that the appropriate syndrome should predict death or prolonged ICU stay. They used several large data sets to develop and validate infection-associated variables that would have good predictive ability for that outcome, and they compared what they found with sepsis by the Sepsis-1 definition, infection plus SIRS (Seymour C, et al. JAMA. 2016;315[8]:762). Infection + SIRS is a strawman in this comparison, because they tested its predictive ability for the outcome against that of the Sequential Organ Failure Assessment (SOFA) and the Logistic Organ Dysfunction Score (LODS). These two scoring systems were developed as severity of injury scales and validated as mortality predictors; the higher the score, the likelier mortality, whereas SIRS clearly contains no information about organ dysfunction. The comparator of interest for this outcome is actually severe sepsis, infection plus SIRS plus organ dysfunction.
Although the criteria the Sepsis-3 investigators used for defining patients with suspected infection were novel and reasonable, we lack additional important information about the patients they studied. They did not report the spectrum of treatments for sepsis in their cohort, whether early or late, adequate or inadequate, so it is impossible to determine whether the criteria address patients who are undertreated, patients who are treated late, patients who will die regardless of adequate therapy, or some combination. In other words, there is no way to tell whether patients who were recognized early in their course via Sepsis-1 criteria and treated aggressively and effectively may have avoided shock, ICU admission, and death. It is, of course, the business of physicians and nurses to help patients avoid exactly those things. Multiple studies have now demonstrated that SIRS criteria are more sensitive than SOFA-based screens, specifically qSOFA, for identifying infection with organ dysfunction, and that qSOFA is more specific for mortality (Serafim, et al. Chest. 2017; http://dx.doi.org/10.1016/j.chest.2017.12.015).
In contrast, the Sepsis-1 authors proposed infection plus SIRS as a sensitive screening tool that could warn of the possibility of an associated organ dysfunction (Sprung, et al. Crit Care Med. 2017;45[9]:1564). Previous to the Sepsis-1 conference, Bone and colleagues had defined the sepsis syndrome, which incorporated both SIRS and organ dysfunction (Bone, et al. Crit Care Med. 1989;17[5]:389). It was the collective insight of the Sepsis-1 participants to recognize that SIRS induced by infection could be a harbinger of organ failure. The Sepsis-3 authors believe that SIRS is a “normal and adaptive” part of infection and that it is “not useful” in the diagnosis of sepsis. That analysis neglects a couple of important things about SIRS. First, numerous studies demonstrate that infection with SIRS is associated with a mortality rate of 7% to 9%, which is by no means trivial (Rangel-Frausto MS, et al. JAMA. 1995;273[2]:117). Second, the components of SIRS have been recognized as representative of serious illness for millennia; the assertion that the Sepsis-1 definitions are not evidence-based is mistaken and discounts the collective experience of the medical profession.
Finally, SIRS is criticized on the basis of being nonspecific. “If I climb a flight of stairs, I get SIRS.” This is clearly a true statement. In fact, one could propose that the name could more accurately be Systemic Stress Response Syndrome, though “scissors” is certainly less catchy than “sirs” when one says it aloud. However, the critique neglects an important concept, encapsulated in Bayes’ Theorem. The value of any positive test result is largely dependent on the prevalence of the disease being tested for in the population being tested. It is unlikely that the prevalence of sepsis is very high among patients whose SIRS is induced by climbing a flight of stairs. On the other hand, tachycardia and tachypnea in a patient who is indulging in no activity while lying on a bed feeling miserable should prompt a search for both the infection that could be causing it and the organ dysfunction that could be associated with it. The specificity of SIRS derives from the population in which it is witnessed, and its sensitivity is to be respected.
To quote a friend, the remarkable CEO of a small Kansas hospital, “If a patient with an infection feels bad enough that they climb up on that gurney and place themselves at our mercy, we owe it to them to prove why they don’t have sepsis, rather than why they do.”
Editor’s Comment
The progress made in the last several years emphasizes the importance of early identification and aggressive treatment of sepsis. The Third International Consensus Definitions (Sepsis-3) have sparked great controversy in the sepsis community, because they delay the recognition of sepsis until organ damage occurs. In this Critical Care Commentary, Dr. Steven Q. Simpson asserts with solid arguments that the use of a screening tool with higher specificity for mortality, at the expense of sensitivity, is not a step in the right direction. Moving away from criteria that have been widely adopted in clinical trials and quality improvement initiatives throughout the world can be a setback in the battle to improve sepsis outcomes. Until prospectively validated criteria that allow earlier identification of sepsis are developed, there is no compelling reason for change.
Angel Coz, MD, FCCP
Section Editor
Dr. Simpson is Professor, Interim Director; Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas.
Two years ago, a panel appointed by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, referred to as a consensus conference, proposed a new definition for sepsis and new diagnostic criteria for sepsis and septic shock, known as Sepsis-3 (Singer M, et al. JAMA. 2016;315[8]:801). The panel proposed that sepsis be defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Upon reflection, one could see that what we had called definitions of sepsis, severe sepsis, and septic shock for over 2 decades actually represented diagnostic criteria more than concise definitions. In that regard, a concise definition is a useful addition in the tool kit for training all health-care professionals to recognize sepsis and to treat it early and aggressively.
However, the diagnostic criteria leave something to be desired, in terms of both practicality and sensitivity for detecting patients whose infection has made them seriously ill. Those who participate in quality improvement efforts in their own hospitals will recognize that to promote change and to achieve a goal of better, higher quality care, it is important to remove obstacles in the system and to structure it so that doing the right thing is easier than not doing it. For sepsis, the first step in the process, recognizing that sepsis is present, has always been complex enough that it has been the bane of the enterprise. As many as two-thirds of patients with sepsis presenting to the ED with severe sepsis never receive that diagnosis while in the hospital. (Deis AS, et al. Chest. 2018;153[1]:39). As any sepsis core measure coordinator can attest, diagnostic criteria that are readily visible on retrospective examination are often unnoticed or misinterpreted in real time.
The crux of this issue is that the very entity of sepsis is not a definite thing but a not-quite-focused idea. Much is known of pathophysiologic features that seem to be important, but there is no one unifying pathologic condition. Contrast that with another critical illness, myocardial infarction. The very name states the unifying pathology. Our predecessors were able to work backward from an understanding that acute blockage of a small artery led to ischemia and infarction, in order to identify methods to detect it while it is happening—measuring enzymes and evaluating an ECG. For sepsis, we don’t even understand why patients are sick or why they die. There is a complex interaction of inflammation, microcirculatory thrombosis, mitochondrial dysfunction, immune suppression, but there is no one combination of those things that is yet understood in a way that lends itself to diagnostic testing. The best we can say is that the patient reacted to their infection in a way that was detrimental to their own body’s functioning. Rather than recognizing a few symptoms and sending a confirmatory test, with sepsis, we must tote up the signs and symptoms in the domains of recognizing infection and recognizing organ dysfunction, then determine whether they are present in sufficient amounts; it is an exercise that requires mental discipline.
If the diagnostic criteria we use, whether Sepsis-1, 2, or 3, are all gross descriptions of complex internal interactions that are not specific, then the syndrome that any of these criteria identifies is also not specific for anything particular. It falls to the medical community, as a whole, to determine exactly what it is that we desire a given syndrome to be indicative of. The Sepsis-3 authors decided that the appropriate syndrome should predict death or prolonged ICU stay. They used several large data sets to develop and validate infection-associated variables that would have good predictive ability for that outcome, and they compared what they found with sepsis by the Sepsis-1 definition, infection plus SIRS (Seymour C, et al. JAMA. 2016;315[8]:762). Infection + SIRS is a strawman in this comparison, because they tested its predictive ability for the outcome against that of the Sequential Organ Failure Assessment (SOFA) and the Logistic Organ Dysfunction Score (LODS). These two scoring systems were developed as severity of injury scales and validated as mortality predictors; the higher the score, the likelier mortality, whereas SIRS clearly contains no information about organ dysfunction. The comparator of interest for this outcome is actually severe sepsis, infection plus SIRS plus organ dysfunction.
Although the criteria the Sepsis-3 investigators used for defining patients with suspected infection were novel and reasonable, we lack additional important information about the patients they studied. They did not report the spectrum of treatments for sepsis in their cohort, whether early or late, adequate or inadequate, so it is impossible to determine whether the criteria address patients who are undertreated, patients who are treated late, patients who will die regardless of adequate therapy, or some combination. In other words, there is no way to tell whether patients who were recognized early in their course via Sepsis-1 criteria and treated aggressively and effectively may have avoided shock, ICU admission, and death. It is, of course, the business of physicians and nurses to help patients avoid exactly those things. Multiple studies have now demonstrated that SIRS criteria are more sensitive than SOFA-based screens, specifically qSOFA, for identifying infection with organ dysfunction, and that qSOFA is more specific for mortality (Serafim, et al. Chest. 2017; http://dx.doi.org/10.1016/j.chest.2017.12.015).
In contrast, the Sepsis-1 authors proposed infection plus SIRS as a sensitive screening tool that could warn of the possibility of an associated organ dysfunction (Sprung, et al. Crit Care Med. 2017;45[9]:1564). Previous to the Sepsis-1 conference, Bone and colleagues had defined the sepsis syndrome, which incorporated both SIRS and organ dysfunction (Bone, et al. Crit Care Med. 1989;17[5]:389). It was the collective insight of the Sepsis-1 participants to recognize that SIRS induced by infection could be a harbinger of organ failure. The Sepsis-3 authors believe that SIRS is a “normal and adaptive” part of infection and that it is “not useful” in the diagnosis of sepsis. That analysis neglects a couple of important things about SIRS. First, numerous studies demonstrate that infection with SIRS is associated with a mortality rate of 7% to 9%, which is by no means trivial (Rangel-Frausto MS, et al. JAMA. 1995;273[2]:117). Second, the components of SIRS have been recognized as representative of serious illness for millennia; the assertion that the Sepsis-1 definitions are not evidence-based is mistaken and discounts the collective experience of the medical profession.
Finally, SIRS is criticized on the basis of being nonspecific. “If I climb a flight of stairs, I get SIRS.” This is clearly a true statement. In fact, one could propose that the name could more accurately be Systemic Stress Response Syndrome, though “scissors” is certainly less catchy than “sirs” when one says it aloud. However, the critique neglects an important concept, encapsulated in Bayes’ Theorem. The value of any positive test result is largely dependent on the prevalence of the disease being tested for in the population being tested. It is unlikely that the prevalence of sepsis is very high among patients whose SIRS is induced by climbing a flight of stairs. On the other hand, tachycardia and tachypnea in a patient who is indulging in no activity while lying on a bed feeling miserable should prompt a search for both the infection that could be causing it and the organ dysfunction that could be associated with it. The specificity of SIRS derives from the population in which it is witnessed, and its sensitivity is to be respected.
To quote a friend, the remarkable CEO of a small Kansas hospital, “If a patient with an infection feels bad enough that they climb up on that gurney and place themselves at our mercy, we owe it to them to prove why they don’t have sepsis, rather than why they do.”
Editor’s Comment
The progress made in the last several years emphasizes the importance of early identification and aggressive treatment of sepsis. The Third International Consensus Definitions (Sepsis-3) have sparked great controversy in the sepsis community, because they delay the recognition of sepsis until organ damage occurs. In this Critical Care Commentary, Dr. Steven Q. Simpson asserts with solid arguments that the use of a screening tool with higher specificity for mortality, at the expense of sensitivity, is not a step in the right direction. Moving away from criteria that have been widely adopted in clinical trials and quality improvement initiatives throughout the world can be a setback in the battle to improve sepsis outcomes. Until prospectively validated criteria that allow earlier identification of sepsis are developed, there is no compelling reason for change.
Angel Coz, MD, FCCP
Section Editor
Dr. Simpson is Professor, Interim Director; Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas.
Two years ago, a panel appointed by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, referred to as a consensus conference, proposed a new definition for sepsis and new diagnostic criteria for sepsis and septic shock, known as Sepsis-3 (Singer M, et al. JAMA. 2016;315[8]:801). The panel proposed that sepsis be defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Upon reflection, one could see that what we had called definitions of sepsis, severe sepsis, and septic shock for over 2 decades actually represented diagnostic criteria more than concise definitions. In that regard, a concise definition is a useful addition in the tool kit for training all health-care professionals to recognize sepsis and to treat it early and aggressively.
However, the diagnostic criteria leave something to be desired, in terms of both practicality and sensitivity for detecting patients whose infection has made them seriously ill. Those who participate in quality improvement efforts in their own hospitals will recognize that to promote change and to achieve a goal of better, higher quality care, it is important to remove obstacles in the system and to structure it so that doing the right thing is easier than not doing it. For sepsis, the first step in the process, recognizing that sepsis is present, has always been complex enough that it has been the bane of the enterprise. As many as two-thirds of patients with sepsis presenting to the ED with severe sepsis never receive that diagnosis while in the hospital. (Deis AS, et al. Chest. 2018;153[1]:39). As any sepsis core measure coordinator can attest, diagnostic criteria that are readily visible on retrospective examination are often unnoticed or misinterpreted in real time.
The crux of this issue is that the very entity of sepsis is not a definite thing but a not-quite-focused idea. Much is known of pathophysiologic features that seem to be important, but there is no one unifying pathologic condition. Contrast that with another critical illness, myocardial infarction. The very name states the unifying pathology. Our predecessors were able to work backward from an understanding that acute blockage of a small artery led to ischemia and infarction, in order to identify methods to detect it while it is happening—measuring enzymes and evaluating an ECG. For sepsis, we don’t even understand why patients are sick or why they die. There is a complex interaction of inflammation, microcirculatory thrombosis, mitochondrial dysfunction, immune suppression, but there is no one combination of those things that is yet understood in a way that lends itself to diagnostic testing. The best we can say is that the patient reacted to their infection in a way that was detrimental to their own body’s functioning. Rather than recognizing a few symptoms and sending a confirmatory test, with sepsis, we must tote up the signs and symptoms in the domains of recognizing infection and recognizing organ dysfunction, then determine whether they are present in sufficient amounts; it is an exercise that requires mental discipline.
If the diagnostic criteria we use, whether Sepsis-1, 2, or 3, are all gross descriptions of complex internal interactions that are not specific, then the syndrome that any of these criteria identifies is also not specific for anything particular. It falls to the medical community, as a whole, to determine exactly what it is that we desire a given syndrome to be indicative of. The Sepsis-3 authors decided that the appropriate syndrome should predict death or prolonged ICU stay. They used several large data sets to develop and validate infection-associated variables that would have good predictive ability for that outcome, and they compared what they found with sepsis by the Sepsis-1 definition, infection plus SIRS (Seymour C, et al. JAMA. 2016;315[8]:762). Infection + SIRS is a strawman in this comparison, because they tested its predictive ability for the outcome against that of the Sequential Organ Failure Assessment (SOFA) and the Logistic Organ Dysfunction Score (LODS). These two scoring systems were developed as severity of injury scales and validated as mortality predictors; the higher the score, the likelier mortality, whereas SIRS clearly contains no information about organ dysfunction. The comparator of interest for this outcome is actually severe sepsis, infection plus SIRS plus organ dysfunction.
Although the criteria the Sepsis-3 investigators used for defining patients with suspected infection were novel and reasonable, we lack additional important information about the patients they studied. They did not report the spectrum of treatments for sepsis in their cohort, whether early or late, adequate or inadequate, so it is impossible to determine whether the criteria address patients who are undertreated, patients who are treated late, patients who will die regardless of adequate therapy, or some combination. In other words, there is no way to tell whether patients who were recognized early in their course via Sepsis-1 criteria and treated aggressively and effectively may have avoided shock, ICU admission, and death. It is, of course, the business of physicians and nurses to help patients avoid exactly those things. Multiple studies have now demonstrated that SIRS criteria are more sensitive than SOFA-based screens, specifically qSOFA, for identifying infection with organ dysfunction, and that qSOFA is more specific for mortality (Serafim, et al. Chest. 2017; http://dx.doi.org/10.1016/j.chest.2017.12.015).
In contrast, the Sepsis-1 authors proposed infection plus SIRS as a sensitive screening tool that could warn of the possibility of an associated organ dysfunction (Sprung, et al. Crit Care Med. 2017;45[9]:1564). Previous to the Sepsis-1 conference, Bone and colleagues had defined the sepsis syndrome, which incorporated both SIRS and organ dysfunction (Bone, et al. Crit Care Med. 1989;17[5]:389). It was the collective insight of the Sepsis-1 participants to recognize that SIRS induced by infection could be a harbinger of organ failure. The Sepsis-3 authors believe that SIRS is a “normal and adaptive” part of infection and that it is “not useful” in the diagnosis of sepsis. That analysis neglects a couple of important things about SIRS. First, numerous studies demonstrate that infection with SIRS is associated with a mortality rate of 7% to 9%, which is by no means trivial (Rangel-Frausto MS, et al. JAMA. 1995;273[2]:117). Second, the components of SIRS have been recognized as representative of serious illness for millennia; the assertion that the Sepsis-1 definitions are not evidence-based is mistaken and discounts the collective experience of the medical profession.
Finally, SIRS is criticized on the basis of being nonspecific. “If I climb a flight of stairs, I get SIRS.” This is clearly a true statement. In fact, one could propose that the name could more accurately be Systemic Stress Response Syndrome, though “scissors” is certainly less catchy than “sirs” when one says it aloud. However, the critique neglects an important concept, encapsulated in Bayes’ Theorem. The value of any positive test result is largely dependent on the prevalence of the disease being tested for in the population being tested. It is unlikely that the prevalence of sepsis is very high among patients whose SIRS is induced by climbing a flight of stairs. On the other hand, tachycardia and tachypnea in a patient who is indulging in no activity while lying on a bed feeling miserable should prompt a search for both the infection that could be causing it and the organ dysfunction that could be associated with it. The specificity of SIRS derives from the population in which it is witnessed, and its sensitivity is to be respected.
To quote a friend, the remarkable CEO of a small Kansas hospital, “If a patient with an infection feels bad enough that they climb up on that gurney and place themselves at our mercy, we owe it to them to prove why they don’t have sepsis, rather than why they do.”
Editor’s Comment
The progress made in the last several years emphasizes the importance of early identification and aggressive treatment of sepsis. The Third International Consensus Definitions (Sepsis-3) have sparked great controversy in the sepsis community, because they delay the recognition of sepsis until organ damage occurs. In this Critical Care Commentary, Dr. Steven Q. Simpson asserts with solid arguments that the use of a screening tool with higher specificity for mortality, at the expense of sensitivity, is not a step in the right direction. Moving away from criteria that have been widely adopted in clinical trials and quality improvement initiatives throughout the world can be a setback in the battle to improve sepsis outcomes. Until prospectively validated criteria that allow earlier identification of sepsis are developed, there is no compelling reason for change.
Angel Coz, MD, FCCP
Section Editor
Dr. Simpson is Professor, Interim Director; Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas.