Sepsis Initiative
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Sepsis Initiative. Jake Lyons, MD. TAKE HOME POINTS. Sepsis is SIRS with infection Severe Sepsis = Sepsis with organ dysfunction You are on the clock once sepsis recognized - Time is Tissue. Sepsis Get cultures Check Lactate Order ABX Determine whether IVF’s necessary.

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Sepsis Initiative

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Sepsis initiative

Sepsis Initiative

Jake Lyons, MD


Take home points

TAKE HOME POINTS

  • Sepsis is SIRS with infection

  • Severe Sepsis = Sepsis with organ dysfunction

  • You are on the clock once sepsis recognized

    • - Time is Tissue


Take home points what do you need to do

Sepsis

Get cultures

Check Lactate

Order ABX

Determine whether IVF’s necessary

TAKE HOME POINTSWhat do you need to do?

  • Severe Sepsis

    • Get cultures

    • Check Lactate

    • Order ABX

    • Gives IVF’s

Goal is to get these completed or started within 1 hour!!!


Background

Background

  • Rory Staunton

  • Scraped arm in gym class

  • Evaluated by PCP and ED

    • - Sepsis not recognized

    • - Discharged from ED

  • Returned to ED

  • Died 4 days after scraping arm of invasive Group A Strep infection with septic shock


Nys regulations

NYS Regulations

  • Screening and early recognition of patients with sepsis, severe sepsis and septic shock

  • A process to identify and document individuals appropriate for treatment through severe sepsis protocols

  • Guidelines for treatment including for early delivery of antibiotics


Nys regulations1

NYS Regulations

  • Hospitals will be required to ensure that appropriate hospital staff members are trained in the protocols

  • Require hospitals to collect data and quality measures to make internal quality improvements

  • Report data to the Department of Health for use in monitoring compliance and updating best practices


Common and expensive disease

Common and Expensive Disease

  • Severe Sepsis- 2% of admitted patients

    • - 50% treated in ICU

    • - 10% of all ICU admissions

    • - 750,000 cases/year

    • - 550 deaths/day

  • ~30% mortality

    • - Frequently have neurocognitive dysfunction

    • - Mood disorders

    • - Decreased QOL

  • $16 Billion per year


Inpatient mortality wrong direction

Inpatient MortalityWrong Direction


Definitions

Definitions

  • SIRS

    • - 2 or more of the following:

      • Temp >38.3, <36.0; RR >20, HR >90, WBC >12,000 or <4,000; >10% bands

  • Sepsis

    • - SIRS plus source or suspected source of infection

  • Severe Sepsis

    • - Sepsis plus end organ dysfunction

  • Septic Shock

    • - Persistent hypotension despite adequate fluid resuscitation


Organ dysfunction

Organ Dysfunction


Oxygen delivery and utilization

Oxygen Delivery and Utilization


Oxygen delivery and utilization1

Oxygen Delivery and Utilization

SEPSIS

LACTIC ACIDOSIS


Pathophysiology vicious cascade

PathophysiologyVicious Cascade


Lactic acidosis

10% mortality

Lactic Acidosis

20% mortality

30% mortality

Mmol/L mg/dl

1 = 9

2 = 18

3 = 27

4 = 36

Intensive Care Med 2007;33(6):970–7


Sepsis initiative

  • In hospital mortality

    • 30.5% in EGDT group

    • 46.5% in standard therapy

  • Set end points

    • CVP

    • MAP

    • ScvO2


Sepsis initiative

Dellinger et al. CCM. 2013;41(2):580-637.


Sepsis initiative

  • Initial Resuscitation Bundle

    • Should occur ASAP

    • Location independent

  • Management Bundle

    • After the 6 hour bundle completed

    • Typically managed in the ICU

Dellinger et al. CCM. 2013;41(2):580-637.


First 6 hours golden hours

First 6 hours - “Golden Hours”

Goal within 1 hour

“This protocol should not be delayed pending ICU admission”

Dellinger et al. CCM. 2013;41(2):580-637.


Goals lactate clearance

GOALS - Lactate Clearance

  • Predictors of survival

    • Lactate normalization

    • Relative lactate clearance of 50%

  • 10% lactate clearance was non-inferior to ScvO2

Nguyen et al. CCM 2004. 32;8:1637-42


Give the abx

GIVE THE ABX!!

Initiation of antibiotics within the first hour- ~80% survival

-every additional hour to effective antimicrobial initiation

-survival decreased by 7.6%/hour


Give the right abx

Give the RIGHT ABX!!!


Goals fluids

GOALS - FLUIDS

  • Severe sepsis

  • Lactate >4

  • Hypotension

2 Liters should cover it


Goals source of infection

GOALS - Source of Infection

  • After initial resuscitation has started

  • Evaluate for removable/drainable source of infection

    • Will be prompted by nursing


After initial resuscitation management bundle

After Initial Resuscitation Management Bundle

  • Vasopressors

    • Norepinephrine

    • SAY NO TO DOPAMINE

    • Vasopressin

      • Low Dose


Management bundle

Management Bundle

  • CVP

  • ScvO2

  • Mechanical Ventilation

    • Low Tidal Volume Ventilation

    • Prone positioning

    • Paralytics

  • Steroids

    • Vasopressor refractory shock

  • PRBC’s

  • Dobutamine


Icu involvement

ICU Involvement

  • Can call any time

  • No response to fluid bolus

    • BP

    • Persistently elevated lactate (if elevated initially)

      • Goal would be 10-20% clearance within first few hours

    • Urine output


The power of u net

The Power of U .net

  • Web Crawler

    • Constantly searching the EMR for the presence of SIRS/Sepsis


Sepsis initiative

EARLY RECOGNITION

WEB CRAWLER


Early recognition web crawler

Early RecognitionWeb Crawler

  • SIRS alert

  • Severe Sepsis Alert


Sepsis stratification

Sepsis Stratification

  • Nurse will contact provider

  • Provider will be responsible for filling out form within 15 minutes of contact

  • Prompting provider to initiate appropriate power plan

  • Relationship established with primary nurse to ensure completion of resuscitation bundle


Stratification form

Stratification form


Sepsis initiative

Stratification form cont.


Sepsis initiative

Stratification form cont.

  • Central Line/PICC

  • A-line

  • Mechanical Ventilation

  • Fluid Resuscitation

  • Pressors

  • PRBC’s


Time tissue

Time = Tissue


Nursing pivotal role

NursingPivotal Role

  • Team approach

    • Provider

    • Laboratory services

    • Pharmacy

  • Recognition of need for timely intervention

  • Dedication to identifying a “sepsis point person”

    • Day shift: Clinical Nurse Leader/Charge Nurse

    • Evening & Night: Charge Nurse/Clinical Resource Nurse/Nursing Supervisor

  • Assist in ensuring tasks completed

  • Utilize reference card to determine follow-up evaluation and prompt provider in timing of further testing/procedures/diagnostic testing


Nursing pivotal role1

NursingPivotal Role


Multidisciplinary approach pharmacy

Multidisciplinary ApproachPharmacy

  • Have committed to delivering antibiotics in a timely manner

  • Understand the importance of administering antibiotics within 1 hour


Multidisciplinary approach laboratory acm

Multidisciplinary ApproachLaboratory/ACM

  • Have committed to drawing cultures and labs promptly

    • Cultures to be drawn before antibiotic administration

    • Sites to be labeled

    • Lactic acid level to be drawn and reported STAT


Education works

Education Works!!!


Take home points1

TAKE HOME POINTS

  • Sepsis is SIRS with infection

  • Severe Sepsis = Sepsis with organ dysfunction

  • You are on the clock once sepsis recognized

    • Time is Tissue


Take home points what do you need to do1

TAKE HOME POINTSWhat do you need to do?

  • Sepsis

    • Get cultures

    • Check Lactate

    • Order ABX

    • Check Lactate

    • Determine whether IVF’s necessary

  • Severe Sepsis

    • Get cultures

    • Check Lactate

    • Order ABX

    • Give IVF’s

    • Reevaluate

Goal is to get these completed or started within 1 hour!!!


Clinical informatics education

Clinical Informatics Education


Where the sepsis crawler is evaluating patients

Where the Sepsis Crawler is Evaluating Patients

  • 2100

  • 2200

  • 2300

  • 2600

  • 2700

  • 3100

  • 3200

  • 3300

  • 3400

  • 3600

  • (future 5100)

  • 2400 IMCU

  • ED EOU

  • ED Nurse Station

  • ICU

  • PR4100

  • PR4200

  • PR4300

  • PR4400

  • ED Ambulatory

  • PACU ES


Who will be alerted

Who will be alerted

  • All Providers, including Residents and APP

  • All nurses – who have a relationship with patient – 17 hours


Workflow provider

Workflow - Provider

  • SIRS or Severe Sepsis Alert fires


Workflow verifying patient name

Workflow – VerifyingPatient Name

  • Provider should always confirm the patient they are working on when the Alert fires

  • This is important during down times as you will receive multiple alerts when system becomes available


Sepsis initiative

Sepsis Screening and Stratification


Sepsis initiative

Sepsis Screening and Stratification


Sepsis initiative

Sepsis Screening and Stratification – cont.


Sepsis initiative

Sepsis Screening and Stratification – cont.


Powerplans suggested based on location

PowerPlans – suggested based on Location

  • Sepsis – Used for Admission

  • PRED Sepsis – ED only

  • ICU Sepsis – ICU only

  • Sepsis – Post Admission Med/Surg: PowerPlan already present


Suggested powerplan accept or reject

Suggested PowerPlan – Accept or Reject

Accepted allows you to add and modify the PowerPlan

Reject removes the PowerPlan

Do Not select Initiate from Suggested Plans folder


Workflow bypassing the alert

Workflow – Bypassing the Alert

When to select Bypass?

  • For further review of chart

  • If you are Not the Attending, Covering Attending, APP or Resident


Recommended workflow upon bypassing alert on chart entry

Recommended Workflow upon Bypassing Alert on Chart Entry

  • Before exiting the chart:

  • Click Ad Hoc on your toolbar

  • Click the Sepsis Screening and Stratification form

  • Complete Form

  • Place appropriate PowerPlan based on Location (if suggested PowerPlan is available Accept or Reject)


Alert on chart exiting not the recommended workflow

Alert on Chart Exiting – (Not the recommended workflow)

  • Alert was Bypassed on Chart Entry

  • Alert will continue to fire until following items are addressed

    • Completion of the Stratification Form

    • Diagnosis (SIRS/SEPSIS/SEVERE SEPSIS/SEPTIC SHOCK) – Done by form completion

    • PowerPlan placed based on location

  • You will need to go back into the patients chart to place the PowerPlan – No need to re-stratify the patient


Sepsis screening and stratification form what it looks like documents tab

Sepsis Screening and Stratification Form(What it looks like – Documents tab)


Patient has sirs sepsis severe sepsis septic shock gets better

Patient has SIRS/SEPSIS/SEVERE SEPSIS/SEPTIC SHOCK – Gets Better!!

  • Patient better, Alert will not trigger again if patient LOS is less than 7 days

  • Patient LOS is 7 days or more – The crawler will include patient back into analysis and re-alert if SIRS/SEVERE SEPSIS is found again.


Alert fired on wrong patient does happen

Alert fired on Wrong Patient – Does happen!

  • How it happens –

    • Bad typing

    • Wrong patient/Wrong Chart Entry

  • What to do –

    • Should receive phone call from Nurse

    • Nurse will cancel the SIRS/Sepsis order that triggers the Alert.

    • Do NOT document on Stratification form

    • Wait a few minutes – go back into chart – Confirm Alert no longer presenting


Questions

Questions?


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