Sepsis

Denise Flook, RN, MPH, CICMelissa Nalder, RN, BSNMary Whitaker, RN, CIC

• 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.

Why did we start a Sepsis Program?

• 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.

Sepsis Statistics

• 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.

What did we do?

ED Triage PosterSEPSIS ALERT

Suspected significant infection with 2 or more of the following: o Temp ≥ 100.4°F, ≤ 96.8°F o Tachypnea ≥ 20 or PCo2 < 32 o SBP ≤ 90 or MAP < 65 o Decreased Mental Status o Tachycardia ≥ 90

IMMEDIATELY initiate Resuscitation Bundle

(complete within 3 hours)

For every hour in delay the patients risk of mortality increases by 8%!!

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

Sepsis Alert PosterSEPSIS ALERT

Suspected significant infection with 2 or more of the following: o Temp ≥ 100.4°F, ≤ 96.8°F o UOP < 0.5 ml/kg/hr after fluid resucitation o SBP ≤ 90 or MAP < 65 o Creatinine increase from baseline of > 0.5 mg/dl o Tachycardia ≥ 90 o Total Bilirubin ≥ 4 mg/dl (new onset) o Tachypnea ≥ 20 or PCo2 < 32 o PaO2/FiO2 ratio ≤ 300 (mechanical ventilation) o Leukocytosis ≥ 12,000 or ≤ 4,000 o Decreased Mental Status o Platelets < 100,000 or INR > 1.5 o New End Organ Dysfunction Criteria Met

IMMEDIATELY initiate Septic Shock Bundle Resuscitation Bundle for persistent hypotension (complete within 3 hours) (complete within 6 hours)

Obtain STAT Lactate Level

Obtain Blood Cultures PRIORto Antibiotic Treatment

(Draw 2 sets 15 minutes apart)

Administer Antibiotics (refer to antibiotic guide)

Administer 30 mL/kg crystalloid Fluid Challenge

Apply Vasopressors (for hypotension that does not respond to fluid resucitation) Maintain MAP ≥ 65 mm Hg

Measure CVP (target is > 8 mm Hg)

(for persistent hypotension despite fluid resuscitation or Lactate ≥ 4 mmol/L)

Remeasure Lactate if Initial Lactate was > 4

mmoL

EMS PosterSEPSIS ALERT

Suspected significant infection with 2 or more of the following:

o Temp ≥ 100.4°F, ≤ 96.8°F o Tachypnea ≥ 20 o SBP ≤ 90 or MAP < 65 o Decreased Mental Status o Tachycardia ≥ 90

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 hourPneumonia:

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 hoursIf 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

• 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%!!!

Screening for Sepsis and Process Improvement

Sepsis Parameters Tier 1

Sepsis Parameters Tier 2

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

Sepsis Parameters 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

• 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

Lessons Learned

• 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.

Opportunities

Where are we now?

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14

Severe Sepsis Mortality Rate 0.17 0 0.22 0.24 0.14 0 0 0

Septic Shock Mortality Rate 0.42 0.25 0.54 0.25 0.38 0.35 0.23 0

Overall Sepsis Mortality Rate 0.36 0.18 0.41 0.23 0.29 0.25 0.19 0

5%

15%

25%

35%

45%

55%

Eastside Medical Center Sepsis Mortality Rates 2014

June 2014: Began our in-tense focus on improving sepsis outcomes

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