1 Resident Education

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Sepsis Overview

• Cost of sepsis care in the US ~$400 billion annually1

• Mortality ranges from 16-49%2

• One of top ten most common principal causes for hospitalizations2

• Compliance with the 3- and 6- hour bundles decreases: mortality length of stay cost of care

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• Sepsis will become a Core Measure starting with October 1, 2015 discharges

• Compliance with the bundles will be tied to payment from CMS

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GCH Sepsis Project team review our current processes and

procedures identify barriers in processes goals of

• enhance nursing Sepsis screening/assessment

• improve compliance with Severe Sepsis/Septic Shock bundles

• standardize care for adult sepsis, severe sepsis and septic shock patients

• ultimately decrease Sepsis mortality

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(Any 2)

HR > 90

Temp > 38.3 C / 101 F OR < 36.0 C / 96.8 F

RR > 20

WBC > 12,000 OR < 4,000 OR > 10% bands

SEPSIS

2 SIRS

+

Confirmed OR

Suspected Infection

SEVERE SEPSIS

Sepsis +

Organ Damage (1 of the following):

SBP < 90 mmHg MAP < 65 SBP decrease of

> 40 mmHg Bili > 2 Creat >2 PLT < 100 INR > 1.5 PTT > 60 Lactate > 2

Severe Sepsis +

Persistent ** : SBP <90 mmHg OR MAP < 65 OR SBP decrease of

> 40 mmHg

** In hour after 30mL/kg fluid bolus

OR

Lactate > 4

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Surviving Sepsis Campaign revised 3-hour and 6-hour

bundles

Received within three hours of presentation of Severe Sepsis: • Initial lactate level measurement • Blood cultures drawn prior to antibiotics • Broad spectrum or other antibiotics administered

AND received within six hours of presentation of Severe Sepsis: • Repeat lactate level measurement only if initial lactate level is elevated > 2

AND if Septic Shock present: Received within three hours of presentation of Septic Shock: Resuscitation with 30 ml/kg crystalloid fluids

AND if hypotension persists after fluid administration, received within six hours of presentation of septic shock: Vasopressors

AND if hypotension persists after fluid administration OR initial lactate > 4 mmol/L: received within six hours of presentation of Septic Shock: Repeat volume status and tissue perfusion assessment consisting of either: A focused exam by physician including all of the following: Vital signs AND Cardiopulmonary exam AND Capillary refill evaluation AND Peripheral pulse evaluation AND Skin examination OR Any two of the following four: Central venous pressure measurement Central venous oxygen measurement (ScvO2)Bedside cardiovascular ultrasound Passive leg raise by physician or fluid challenge given

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Improvements to Processes at GCH

Sepsis Policy and Procedure revised Hospital-wide policy

Lactate > 4 Critical Value

Sepsis order sets

Inpatient Nursing Sepsis Screening Assessment enhancement in EMR ED - upon triage and every 2 hours ICU and inpatient units - on admission and Q4H “New and Worsening conditions” added to when to call physician Inpatient will notify physician with + sepsis screen/ call RRT with

+ severe sepsis screen ICU nurse will notify ICU physician with + sepsis/severe sepsis

screen Sepsis, Severe Sepsis and Septic Shock Bundle Checklist

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Sepsis, Severe Sepsis and Septic Shock Bundle Checklist

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Fluids 3-hour bundle Crystalloid- LR or 0.9% Normal Saline only

Volume - ordered and documented as 30ml/kg, or an amount > 30ml/kg

Timeframe - duration or rate at which to administer must also be ordered

New order set default to 2000mL/hr, or can be manually changed to adjust the rate

Minimum requirement- last liter must be delivered within 3 hours of septic shock

   

 

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Focused exam by physician: ALL of the following vital signs including all of

temperature, heart rate, blood pressure, respiratory rate

cardiopulmonary exam assess both the heart and lungs- typically documented as heart - ‘RRR’, ‘Irregular’, ‘S1,S2,S3,S4’ lungs - ‘clear’, ‘crackles’, ‘diminished’ or other language

capillary refill evaluation assess superficial circulatory status

document ‘capillary refill’, ‘nail bed refill’ ‘brisk’, ‘<2seconds’, ‘>2seconds’ or similar

peripheral pulse evaluation to assess circulatory status. Document ‘pulses ‘1+,’ or ‘2+’ or absent, or other language. Need to make reference to any of the following: Peripheral pulse(s),

Radial pulse(s), Dorsalis pedis pulse(s), Posterior tibialis pulse(s) 

skin exam to assess superficial circulatory status May include such terms as ‘flushed’, ‘mottled’, ‘not mottled’, ‘knee caps

mottled’, pale’, ’pallor’, ‘pink’, ‘, ‘pale’, flushed’ or other language Must include reference to color 

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Any two of the following Central Venous Oxygen measurement

expressed as SvO2 or ScvO2 & needs to be obtained via blood gas currently. CVP

Bedside cardio US may be referred to as echocardiogram, trans-thoracic echo, trans-

esophageal echo, IVC Ultrasound, 2D echo, cardiac echo, Doppler echocardiogram, echocardiogram with Doppler, esophageal Doppler monitoring or Doppler ultrasound of the heart

Does not necessarily have to be performed at bedside Passive Leg Raise With the patient in a semi-recumbent position, both legs are

raised to a 45 degree angle to evaluate the vital sign response to additional fluid load

documented as ‘passive leg raise ‘, ‘PLR’ with findings ‘positive’, ‘negative’, ‘fluid responsive’ or other language

OR Fluid challenge to assess responsiveness to fluids Similar to crystalloid fluid administration but is done after the crystalloid fluid

administration if the patient remains hypotensive. Fluid challenge is a rapid infusion of 0.9% NS or LR typically 500 mL in fifteen minutes or 1000 mL in 30 minutes

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Documentation tips Document time patient met criteria for Severe sepsis and septic

shock on Checklist (if not done by nursing)

Document time of known of suspected infection when documenting a suspected source of infection, document

it “possible infection from xx”, “suspect infection from xx”, not “SIRS secondary to xx”

If your patient is in severe sepsis, document it. When documenting severe sepsis, make a relationship

statement between it and the end-organ dysfunction “Severe sepsis with acute respiratory failure”

If your patient is in septic shock, document it. “Hypotension” is not equivalent to shock.

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References1. Lopez-Bushnell K, Demaray W, Jaco C. Reducing sepsis mortality. Medsurg Nurs 2014 JanFeb;23(1):9-14.  2. National Quality Institute. (2015). Implementation of Severe Sepsis and Septic Shock: Management Bundle Measure (NQF #0500). Retrieved from http://www.hqinstitute.org/post/implementation-severe-sepsis-and-septic-shock-management-bundle-measure-nqf-0500

Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine. 2013 Feb;41(2):580-637. (http://www.sccm.org/Documents/SSC-Guidelines.pdf )

Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5 –year study. Intensive Care Med 2014; 40: 1623-1633. (http://www.ncbi.nlm.nih.gov/pubmed/2527022)

Tseng, J and Nugent, K. (2015). Utility of the Shock Index in patients with sepsis. The American Journal of the Medical Sciences.349: 531-535.

Surviving Sepsis Campaign. (2015). Updated Bundles in Response to New Evidence. Retrieved from http://www.survivingsepsis.org/Bundles/Pages/default.aspx