surviving sepsis, 2013 kristy molnar, critical care consultants

SURVIVING SEPSIS: Improving Care …

Saving Lives

Kristy Molnar

Professional Education Services, Critical Care Consultants

Critical Care Consultants, 2013

Sepsis … Claiming LivesLeading cause of morbidity and

mortality worldwide


The “Face” of SepsisSystemic inflammatory response initiated by a source of infection


http://www.sepsisalliance.org/resources/video/


Rory Staunton’s Story(Profiled on Today’s Show & Dr. Oz)

Performance Gaps!http://www.youtube.com/watch?v=k3qz9wCc69w

http://www.youtube.com/watch?v=MTeBukCSot8

http://www.youtube.com/watch?v=xwOKZsKlwWs

http://www.youtube.com/watch?v=J-bLDoVHYSs

Leading to NY State Department’s Cuomo Initiative & Legislation


http://www.youtube.com/watch?v=k3qz9wCc69w

http://www.youtube.com/watch?v=k3qz9wCc69w





http://www.youtube.com/watch?v=J-bLDoVHYSs

What does this mean?

Critical Care UpdateSponsored By


ICU admissions from EDs up nearly 50% in U.S. U.S. researchers looked at data from the National Hospital Ambulatory Care Survey and found that intensive care admissions from the emergency department rose by nearly 50%, from 2.79 million in 2002-2003 to 4.14 million in 2008-2009. Of all the ED patients, those aged 85 and older had the highest increase in the rate of ICU admissions. The findings appear in the journal Academic Emergency Medicine. Nurse.com (5/15)

http://r.smartbrief.com/resp/ewafCdlUspCiychcCidncVCicNsScL?format=standard

http://r.smartbrief.com/resp/ewafCdlUspCiychcCidncVCicNsScL?format=standard

THE BURDEN OF SEPSISHealthcare Resources



Human Costs?

Sepsis Costs!

• 40% of total ICU expenditure• Average cost per individual case is

approximately $22,000.00


GAPS IN CAREQuality Improvement Initiatives - IHI



Sepsis Detection & ManagementRapid

Response Systems

Patient Flow for Efficiency &

Safety

Early Warning Systems

DIFFUSE SYMPTOMSOccult, systemic wide responses


CRITICAL SIGNS …MEDICAL EMERGENCY!




SCORING SYSTEMSAPACHE II, SOFA … not Screening Systems


Phases & Degrees of Sepsis

“A Clinical Spectrum”



TERMSSIRS, SEPSIS, SEVERE SEPSIS, SEPTIC SHOCK, MODS …


SUSPICION OF SIRSSystemic Inflammatory Response Syndrome


INTERVENTION IN SIRSSpeedy Intervention & Response for Survival


The Challenge … The Campaign

The Response


SEPSIS IS A TRAGIC & DEADLY DISEASE

Increasing Awareness


ESTABLISHING BEST PRACTICE

Surviving Sepsis Guideline updates (using the GRADE system)


TRIAGEImproving Identification & Initiating Timely Intervention


TIMELINESSaving Tissue, Reducing Mortality


WHO IS RESPONSIBLE?Fighting the War on Sepsis


TRANSITIONS IN CARE

Seamless


Recommendations & Guidelines

The Global Sepsis Alliance


THE GLOBAL SEPSIS ALLIANCE

International Guidelines for the Management of Severe Sepsis & Septic Shock


GUIDELINES & ALGORITHMS2004, 2008 … Current Updates


Sepsis updates (2004, 2008, 2012)

2012 update on YouTube (1 hr, 28 min): https://www.youtube.com/watch?v=v08mYfxBJAE


https://www.youtube.com/watch?v=v08mYfxBJAE




2005 Manual/User’s Guide (SCCM, ESICM, ISF) Participation in the Surviving Sepsis CampaignSurviving Sepsis Campaign Web site. www.survingsepsis.org

“Implications of the New International Sepsis Guidelines for Nursing Care”


Kleinpell, R., Aitken, L., & Shorr, C.A.: AJCC, May 2013, Volume 22, No 3, 212-222.

ENSURING BEST PRACTICES





EDUCATION & COMMITMENTTo ALL on the “Front Line” … a Call to Action …


Sepsis video resources: YOUR SEPSIS TEAM




GAP ANALYSISWhere do you stand in Sepsis Detection & Management?


THE SCIENCE & MODEL FOR IMPROVEMENT

Evidence-Based, Organized & Efficient Care


SCREENING & IMPLEMENTATION OF THE BUNDLES


ENSURING EFFECTIVE & SEAMLESS TRANSITIONS

The Clinical Environment


Clinical Decision Support Tools & Documentation

Clinical Approaches


CONSISTENT APPLICATION OF EVIDENCE-BASED PRACTICE


GOALS & WORKFLOWImproving Communication


PROTOCOLSPaper-Based and/or Electronic Clinical Decision Support Tools?



http://www.ajcconline.org

http://www.ajcconline.org/

The “Bundles” & SSC Algorithm


“BUNDLE”

Evidence-Based, Organized Practice Guidelines within an Organized Process


PROTOCOLS & PATHWAYSCustomization within Clinical Environments


WORKING TOGETHERAchieving Better Outcomes?


Screening Bundle: Timely Triage


EARLY RECOGNITION!Clinical Assessment, Screening, Monitoring & Surveillance


TAKING ACTION!Early Warning and Rapid Response Systems


SCREENING TOOLS FOR SIRSCritical Care Consultants, 2013

TIMELY NOTIFICATION & COMMUNICATION

Standarized Orders/Protocols?


Initial Resuscitation Bundle: Time for Action!


BLOOD CULTURESPrior to Antibiotic Administration


BROAD-SPECTRUM ANTIBIOTICS

Improve Time to Administration


SERUM LACTATE

Early identification: Lactate Measures … When, Why and How Much?

http://www.youtube.com/watch?v=LVqt0z4-k6E


http://www.youtube.com/watch?v=LVqt0z4-k6E

QUESTIONS & DEBATES ABOUT SERUM LACTATE

Identification of Hyperlactatemia &/or Reduced Lactate Clearance


Hyperlactatemia

• Regardless of the mechanism of hyperlactatemia, numerous studies show that blood lactate is a relevant prognostic marker of morbidity and mortality in various critical care settings, including patients with Sepsis.

• Increased lactate also correlates well with ScvO2


SSC International Guidelines

• Lactate levels of > 4 mmol/L• Is Lactate > 4 mmol/L or impaired Lactate

clearance an obligatory criterion for the diagnosis of septic shock?

• No significance difference in 28-day mortality across Lactate categories (non, intermediate & high)


Missed Identification?

• Although a useful adjunct for hypoperfusion … lactate is not present in 45% of septic patients … it may not be adequate as the only marker … we may miss 45% of patients if Lactate used as a sole obligatory criteria.


Lactate as sole indicator?

• One of the fundamental problems of using lactate clearance as a sole resuscitation target is that a normal lactate (< 2mM/L) can be present in 25-50% of septic shock patients.

• The mortality of these patients is 20-50% even with aggressive therapy.


2012 findings

• 2012 studies by the Shock Society found that aggressive resuscitation may be beneficial even in the “normal range” lactate concentration.

• How Low? … Lactates of 1.4 – 2.3 mmol/L may also be associated with an adverse outcomes! (2 – 2.5 should be a trigger at admission!)


2012 findings

• Yes, Hyperlactatemia had a good sensitivity (86%) for prediction of mortality

• But, Lactate cannot be used in isolation due to a low specificity (27%)

• The clinician must use other perfusion markers such as ScvO2 and UO to enhance the prediction value.


Lactate as an endpoint for Resuscitation?• These observations indicate that using

lactate and ScvO2 are complimentary endpoints, and not mutually exclusive.

(8 references; 1993 - 2012)


Lactate as an Indicator of Tissue Hypoxia?• Journal of Critical Care - 2012 study• Almost ½ of patients with vasopressor-

dependent septic shock did not express lactate on presentation, although a high mortality remains in this population!


Lactate as an Indicator of Tissue Hypoxia?• Use of lactatemia as the sole indicator for

additional IV fluid or an end point of resuscitation in septic shock may be inadequate.


FLUID MANAGEMENTTreat Hypotension, Hypoperfusion & Elevated Lactates


MAINTAIN APPROPRIATE PRELOAD STATUS

CVP, SVV, PPV, SV for Volume Responsiveness


Hemodynamics…Blood Flow!


MAINTAIN MAPVasopressors for ongoing Hypotension?


Administration of Blood Products?


VENOUS OXYGEN SATURATION

Maintain Adequate Central Venous Oxygen Saturation


(Management) Septic Shock Bundle:

Meeting the Goals


Source Control

• Within 12 hours• Surgical debridement, draining• Removal of infected devices• Infection prevention!


STEROIDS?Critical Care Consultants, 2013

GLYCEMIC CONTROL GOALCritical Care Consultants, 2013

INSPIRATORY PLATEAU PRESSURE GOAL


Patient OutcomesReducing Sepsis Mortality & Morbidity


Implications for Practice

• Integration of the new recommendations can help ensure that critically ill patients with sepsis receive expert nursing care to promote optimal outcomes.


Implications for Practice

• By initiating resuscitative measures and indicated sepsis care that are based on the new guidelines, critical care nurses can improve care for patients with sepsis.


Resources, Workflow & Efficiencies


Early Identification

“ Observe for the convergence of nonspecific diagnostic criteria and physical assessment cues early in the development of the condition and positively affect outcomes”.Karen Giuliano, 2006



Continuous Monitoring, Physical Assessment & Surveillance Giuliano KK, Kleinpell R.AACN Clin Issues. 2005 Apr-Jun;16(2):140-8

Comprehensive Sepsis Treatment• Antibiotic administration• Circulatory assessment & support …

Fluids, inotropic agents, vasopressors• Supportive treatment with oxygenation &

ventilation


Comprehensive Sepsis Treatment• Use of measures recommended in sepsis

guidelines• Monitoring & Surveillance• Reporting patients’ response to treatment


World Federation of Critical Care Nurses (WFCCN)International task force – produced/published a companion guide to the 2008 guidelines in 2011 that outlines 63 additional recommendations.• http://en.wfccn.org/resources_sepsis.php• Crit Care Med. 2011; 39(7):1800-1818


http://en.wfccn.org/resources_sepsis.php

World Federation of Critical Care Nurses (WFCCN)Crit Care Med. July 2011; 39(7):1800-1818

“Nursing considerations to complement the Surviving Sepsis Campaign guidelines”

http://journals.lww.com/ccmjournal/Fulltext/2011/07000/Nursing_considerations_to_complement_the_Surviving.25.aspx





“EXTEND THE CHAIN”Improve the Flow of Care


SEPSIS PRACTICE SUPPORTIndustry, Professional Associations & Practice Groups


Critical Care Survival Guide – Sepsis Managementhttps://www.youtube.com/watch?v=rSIoG_QuMmg


https://www.youtube.com/watch?v=rSIoG_QuMmg



iMedicalSchool:Update in Sepsis, 2013

http://www.youtube.com/watch?annotation_id=annotation_377513&feature=iv&src_vid=o8K3IC1RrP8&v=UcivGHBfSb4





Documentation & Reporting

Compliance & Quality Improvement


COMPLIANCE & QUALITY IMPROVEMENT

Achieving Compliance within the Resuscitation & Management Bundles?


DATA COLLECTION & REPORTING


Call to Action

Implementing the Surviving Sepsis Campaign … 10 years later!


2012 Surviving Sepsis Guidelines - Summary

http://www.youtube.com/watch?v=v08mYfxBJAE



“From Time Zero ….” http://www.youtube.com/watch?v=v08mYfxBJAE



World Sepsis Day (September 13, 2013)


Winning the War on Sepsis

Stories of Success & Improvement


Phase IVSCCM Surviving Sepsis Campaign

2012 Guidelines – YouTube video

2013 … Winning IF we stay in the game

2016 - Focus on Guidance, Involvement, Compliance, Quality,

Technologies/Processes … ongoing Mortality reductions!


Surviving SepsisImproving Care … Saving Lives


http://www.survivingsepsis.org


THANK YOUCongratulations

surviving sepsis, 2013 kristy molnar, critical care consultants

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