Document

Report
Denise Flook, RN, MPH, CIC
Melissa Nalder, RN, BSN
Mary Whitaker, RN, CIC
Why did we start a Sepsis Program?
• Sepsis was identified as a leading cause of mortalities in
our facility.
• Sepsis mortality rates were within national benchmarks,
but still higher than corporate goals.
• Every sepsis mortality was a person….someone’s loved
one, friend.
• Chart reviews demonstrated inconsistent identification
and treatment of sepsis.
Sepsis Statistics
• Overall sepsis mortality rate for 1Q2014 was
31.7%
• Septic Shock mortality rate for 1Q2014 was
40.3%
• 3 hour bundle incomplete within 3 hours in 35%
of patients.
What did we do?
• Convened a Sepsis Team and reviewed Surviving Sepsis Campaign
best practices.
• Held education sessions for physicians and staff presented by the
President Elect of Society of Critical Care Medicine.
• Developed posters for ED triage and nursing pods with SIRS criteria
and the 3 and 6 hour bundles.
• Revamped our Sepsis Alert Team and gave clearly defined
expectations of the roles for each team member.
• Developed evidence based order sets for the ED and inpatient areas.
• Developed antimicrobial algorithms for appropriate coverage based
on suspected source of infection and local antibiogram.
• Provided education to our EMS partners to call Sepsis Alerts from the
field as they do with STEMI and STROKE.
• Identified methods to incorporate our MEWS system in Sepsis early
identification.
ED Triage Poster
SEPSIS ALERT
 Suspected significant infection with 2 or more of the following:
o Temp ≥ 100.4°F, ≤ 96.8°F
o SBP ≤ 90 or MAP < 65
o Tachycardia ≥ 90
o
o
Tachypnea ≥ 20 or PCo2 < 32
Decreased Mental Status
IMMEDIATELY initiate
Resuscitation Bundle
(complete within 3 hours)
Obtain STAT Lactate Level
Obtain Blood Cultures PRIOR to Antibiotic Treatment
(Draw 2 sets 15 minutes apart)
Administer Antibiotics
(refer to antibiotic guide)
Administer 30 mL/kg crystalloid Fluid Challenge
 For every hour in delay the patients risk of mortality increases by 8%!!
Sepsis Alert Poster
SEPSIS ALERT
 Suspected significant infection with 2 or more of the following:
o
o
o
o
o
o
Temp ≥ 100.4°F, ≤ 96.8°F
SBP ≤ 90 or MAP < 65
Tachycardia ≥ 90
Tachypnea ≥ 20 or PCo2 < 32
Leukocytosis ≥ 12,000 or ≤ 4,000
Platelets < 100,000 or INR > 1.5
IMMEDIATELY initiate
Resuscitation Bundle
(complete within 3 hours)
Obtain STAT Lactate Level
Obtain Blood Cultures PRIOR
to Antibiotic Treatment
(Draw 2 sets 15 minutes apart)
o
o
o
o
o
o
UOP < 0.5 ml/kg/hr after fluid resucitation
Creatinine increase from baseline of > 0.5 mg/dl
Total Bilirubin ≥ 4 mg/dl (new onset)
PaO2/FiO2 ratio ≤ 300 (mechanical ventilation)
Decreased Mental Status
New End Organ Dysfunction Criteria Met
Septic Shock Bundle
for persistent hypotension
(complete within 6 hours)
Apply Vasopressors
(for hypotension that does not
respond to fluid resucitation)
Maintain MAP ≥ 65 mm Hg
Measure CVP
(target is > 8 mm Hg)
Administer Antibiotics
(for persistent hypotension despite fluid
resuscitation or Lactate ≥ 4 mmol/L)
(refer to antibiotic guide)
Administer 30 mL/kg
crystalloid Fluid Challenge
Remeasure Lactate if
Initial Lactate was > 4
mmoL
EMS Poster
SEPSIS ALERT

Suspected significant infection with 2 or more of the following:
o Temp ≥ 100.4°F, ≤ 96.8°F
o SBP ≤ 90 or MAP < 65
o Tachycardia ≥ 90
o
o
Tachypnea ≥ 20
Decreased Mental Status
IMMEDIATELY Call SEPSIS ALERT to ED
Initiate Fluid Resuscitation
For every hour in delay the patient’s risk of mortality increases by 8%!!
Antimicrobial Coverage Algorithm
Antibiotic Therapy Recommendations for severe sepsis/septic shock: administer first dose within 1 hour
Pneumonia:
 Rocephin (ceftriaxone) 1 gm IV every 24 hours AND Levaquin 750 mg IV every 24 hours
 Rocephin (ceftriaxone) 1 gram IV every 24 hours and Azithromycin 500 mg IV every 24 hours
 Clindamycin 600 mg IV every 8 hours (if aspiration pneumonia suspected)
 Zosyn 3.375 Gm IV q 8 hours AND Levaquin 750 mg IV every 24 hrs (if pseudomonas risk)
Risk for MRSA Add:
 Vancomycin 1 gm IV every 12 hours
 Vancomycin for pharmacy to dose
 Vancomycin ____q ____hours
 Zyvox 600 mg IV every 12 hours (Restricted to Infectious Disease & Intensivist Providers)
Sepsis due to UTI: Gentamicin 5 mg/kg IV x 1 dose AND Choose One:
 Rocephin (ceftriaxone) 1 gram IV every 24 hours
 Cefepime (Maxipime) 1 gm IV every 6 hours
Intra-abdominal sepsis/unknown source:
 Zosyn (Pip/Tazo) 3.375 gms IV every 8 hours
 Merrem 500 mg IV every 6 hours
Skin and soft tissue infections:
 Unasyn (ampicillin/sulbactam) 3 grams IV q 6 hours
If patient is allergic to PCN, use:
 Ancef (cefazolin) 2 gm IV q 8 hr
If suspected abscess or risk for community acquired MRSA: Choose one:
 Vancomycin 1 gm IV every 12 hours
 Zyvox 600 mg IV every 12 hours (Restricted to Infectious Disease & Intensivist Providers)
Recommendations based on SCCM, IDSA and SHEA Guidelines for Sepsis and local epidemiology and antibiogram
Screening for Sepsis and Process
Improvement
• The recommendation is for routine screening of
potentially infected seriously ill patients for severe
sepsis to increase the early identification of sepsis and
allow implementation of early sepsis therapy.
• Sepsis Screening is built into every nursing assessment in
EMR including ED.
FOR EVERY 1 HOUR IN DELAY THE RISK OF
MORTALITY INCREASES BY 8%!!!
Since there were 2 or more “Y” to the queries in Tier 1
– the Nurse is automatically taken to Tier 2.
These are only Y/N and the nurse has to answer them.
The answers are not defaulted in Tiers 2 or 3.
In Tier 2 – if either of the queries is answered “Y” – the Nurse is taken to Tier 3
Only 1 organ dysfunction in Tier 3 needs to be
answered Y in order for a positive alert to be
triggered
How did we implement this?
• Lots of education!!!!
• Focus on Sepsis in every
meeting
• Engaged hospital leaders
• Demonstrated how sepsis is
everyone’s responsibility
• Perseverance
• Chart reviews and using
data to guide changes to
the program
• Modeled the program after
STEMI and STROKE
programs
• Looked for barriers in
compliance
• Got feedback from
frontline staff during every
step
• Did we mention
perseverance???
• Celebrated successes
• Reviewed every fallout and
used missed opportunities
as teachable moments
• Included physicians
Lessons Learned
• Check and double check that your EMR works as intended
• Verify your data and coding
• iStat ABGs with Lactate are a key to success. However, unless Wi-Fi
enabled, the results do not reflect the time the test was done.
• Engage the frontline staff in fixing the issues
• If you have a program that works well such as STEMI or STROKE, build
on that for Sepsis. “Time is Tissue” is true for all three. This helps
build in a sense of urgency.
• DO NOT GIVE UP!!!!!!!!
• You are very unlikely to get it right the first time. We sure didn’t.
• Celebrate successes and use your misses as teachable moments.
• Do not assume everyone knows what Sepsis is.
• You have to build accountability into the program.
• Use existing systems: MEWS, EMR, iStat
Opportunities
• Sepsis screening tool does not work in all situations.
• iStat has to be docked immediately to reflect accurate
test time
• Physician buy in is tough to hard wire…we are working
on it
• Non-present on admission sepsis alerts are not being
called routinely
• We still have fall outs.
• We are not meeting the 3 hour bundle 100% of the time.
Where are we now?
Eastside Medical Center Sepsis Mortality Rates 2014
60%
June 2014: Began our
intense focus on
improving sepsis
50%
40%
30%
20%
10%
0%
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Severe Sepsis Mortality Rate
Jan-14
17%
Feb-14
0%
Mar-14
22%
Apr-14
24%
May-14
14%
Jun-14
0%
Jul-14
0%
Aug-14
0%
Septic Shock Mortality Rate
42%
25%
54%
25%
38%
35%
23%
0%
Overall Sepsis Mortality Rate
36%
18%
41%
23%
29%
25%
19%
0%
Success Story
• 89 year old male
• Past Medical History
– Hypertension
– COPD
– Coronary Artery Disease
– Chronic Kidney Disease
– Hyperlipidemia
– Recurrent Aspiration
Recently discharged with
pneumonia.
• Presented to ED at
approximately 4am with fever
>104, AMS, Cough
• Sepsis Alert called in triage.
• All 3 hour bundle elements
started within 34 minutes.
• Admitted to ICU with Septic
Shock, on Levophed
• After 3 days in ICU,
transferred to Medical Unit.
• Discharged home on Day 8.
A Family’s Perspective
Questions

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