Think Sepsis…. A Multidisciplinary approach

1. Think Sepsis….A Multidisciplinary approach Keith Knepp, MD Tammy Duvendack, RN, PhD

2. Methodist Medical Center of Illinois 2011 Statistics: 329 Licensed Beds Annual Admissions: 17,388 ED admissions: 59,000 CMI= 1.27 11,0000 surgeries Minor teaching residency program (Family Practice and Psychiatry) Hospitalist , Intensivist, Palliative Care Services

3. Learning Objectives • Describe the concept of nurse to nurse consultation as an integral component of early recognition and initial treatment of sepsis • Discuss the use of specific order sets and algothrims for ED, clinical inpatient units, and critical care. • Analyze patient outcomes realized at Methodist Medical Center based on the “think sepsis” campaign • Identify education strategies for front line staff caring for high risk of sepsis • Discuss strategies for physician engagement and education

4. Overview • Sepsis is MMCI’s Top mortality diagnosis. • 2004-2005 ICU CVICU Intensivists implemented order sets based on SCCM standards. • 2006-2007 – Initiated quarterly mortality rate monitor • Mid 2008 - Evaluation of data demonstrated that over 80% of all sepsis patients came through the ED. Baseline analysis of ED records using the IHI Think Sepsis standards demonstrated considerable variability in identification and intervention for patients that met Sepsis criteria. • 2009 through present very stringent multi disciplinary review of all ED records using consistent guidelines. As a result, sepsis patient standards in the ED have been standardized and considerable improvement in their documented process of care. • 2010 Added as indicator on Intensivist dashboard. • 2011 Committee restructured and assumed by Acute Care Interdisciplinary committee

5. Outcomes • Initiated through Critical Care unit-based councils • Standardization of the sepsis definition (Think Sepsis) • ED composite care standards improved from 63% to 93% measures include • Antibiotic w/I 3 hours • NS bolus of 1000 cc • BC prior to antibiotic • As the diagnosis has been standardized the patient volume has increased • Mortality rates have dropped • Use of comfort care/Palliative Care/Hospice has increased • Incorporation of “Think Sepsis” in UAT calls and orders

6. Purpose of the UATNurse-to-Nurse consult • Worried about the patient • Acute change in HR <50, >100 or 20 beat change • Acute change in systolic B/P <90 or >160 or a 20 mm change • Acute change in RR, <12 or >24/min • Acute change in O2 Sat requiring increasing need for oxygen

7. More “activation triggers” • Acute change in LOC, onset of lethargy, agitation, delusions • Acute change in urinary output, <20 ml/hr • Acute change in temp, <97º or > 101º

8. Multi-disciplinary Team • CNS or Nursing Supervisor • ICU Nurse • Respiratory Therapist • Dial 122 and state Urgent Assessment Team needed to room # (or location) • 3 types of UAT calls: • Adult UAT • Pediatric UAT • Non-Patient UAT

9. RCA Learning Points • Majority of RCA’s participants note the UAT would have been a helpful resource • Most common reason cited for not using • Unaware of • Forgot…..did not think of • Was getting orders from the MD so thought “ok” • To busy to call • Did not seek out teammates help to stop and “think” outside of the problem

10. Action Plan • Increase use of UAT…UAT saves lives…the outcome data is clear! • Follow up education • Introduced into new nurse orientation • Annual Unit-Based Education Days (Use of SimMan) • Preventing a Crisis Sessions (Spring and Fall reinforcing early recognition of Sepsis and oxygen management as a result of RCA trends • Sharing of events to promote Organizational Learning during monthly Clinical Practice Council meetings

11. Early Warning Signs 2/18/12 2012. Duncan. K.D., C McMulan & B Mills. Early Warning Systems, Nursing 2012: Feb, 38-39 • Documented observations show 84% of patients have clinical deterioration or new complaints < 8hrs before they cardiac arrest • 70% of patients showed deterioration of either respiratory or mental function • 17% of cardiac arrests occur in patients who were being cared for in an inappropriate clinical area. • Significant ↑ or ↓ in any VS OR trending of ↑ oxygen needs should trigger a call to either the provider or UAT.

12. UAT Statistics 2/18/12

13. 2/18/12

14. MMCI IP MORTALITY TRENDS

15. Mortality Trends by Year

16. MMCI IP SEPSIS MORTALITY TREND Sepsis was identified in 2005 as a mortality driver. Several interventions have been placed since that time and although mortality dropped we were unable to sustain that gain. In 2011 that goal was achieved.

17. Sepsis Driver Diagram

23. Physician Leadership • Physician leadership provided by Chief Quality Officer, along with • Intensivists • ED physicians • Literature review, protocol and order set development done with assistance of this group

24. Physician Education/Engagement • Sepsis Initiative rolled out to the following: • Acute Care Interdisciplinary Team • Multidisciplinary Team with nursing and physician representation (Acute care medical director, hospitalist, residency faculty physician) • ED Department Meetings • Quality and Safety Council – broad physician representation • Reports to Medical Executive Committee • Specific presentations to hospitalists, residents

25. Physician Concerns • Hard to accept this sepsis definition • Most physicians trained that “sepsis” is what we now call septic shock or severe sepsis • Sepsis definition of “SIRS with source of infection” is a much broader net. • Concerns about fluid management being too aggressive in some patients • Still navigating these issues over time • Ongoing committee oversight • Peer review discussions

26. Staff knowledge Retention Assessment 2012

27. i Use I- clickers • When using the Sepsis Algorithm, which two would be considered a positive screening (In Step 1)? • HR 110 and Temp 101 orally • HR > 90 & T > 100.4 • WBC 10 and RR 30 • WBC <4 & RR >20 • WBC 3 and Temp 99 orally • WBC < 4 but no temp • Serum glucose120 in non-diabetic and HR 100 • HR > 90 but glucose not > 140

28. i You go down to ED to get your patient and receive the following report: B/P 88/50, HR 120 and irreg, T 96.5⁰, RR 28. What additional information do you need? • Time of last VS • Was pt screened for sepsis? • Meds/IV fluids given/Lab results • Is this pt appropriate for admission to my unit? • All of the above

29. i Your newly admitted pt was treated for sepsis in the ED. They received an ATB, an IV bolus & are now on standing orders of NS at 250cc/hr X 4. Because you don’t have any further IV orders and VS are stable, IV is changed to SL. 6 hrs later, the pt’s B/P is now 80/48. What happened? • Pt has a new problem, call the Dr • Pt didn’t receive enough fluid to correct hypovolemia and is still septic, should have gotten orders for maintenance IV fluids • Hang another IV of NS and administer fluid bolus, consider calling UAT • B & C • All of the above

30. Preventing a Crisis Case Study • 81 yo male presented to the ED with hyperkalemia, kidney failure, hyponatremia, dehydration, afib, and GI bleed • C/O • abd pain and cramping • Hx • recent ileostomy formation (1 month prior), HF, Stroke, diverticulitis, & multiple hospitalizations for dehydration • Admitted to an acute care unit

31. Treated with Kayexalate • What’s concerning about this information? • Does it meet the sepsis criteria?

32. 29.6 167 Recent surgery, abd pain, ???? 2.9

33. Oh no!… • Unfortunately this patient was not screened… • Fluid resuscitation was not started • Antibiotic therapy was not started • Where can you find the algorithm? • Care organizer – resources menu – sepsis screening algorithm

34. Urinalysis clear • What should concern you? • ↓ temp, K+ still ↑, Crt ↑ ing, ↑ Glucose (not diabetic)

35. Baseline on floor at 2200: HR 69, BP 164/93, Temp 98.9 • 2200 (day of admission) – 1600 (next day): • Patient appeared “OK” throughout the day, staff were in contact with MD. • Sometimes gives us a false sense of security • 1600  • Marked deterioration ↑ HR, RR, & O2 needs, and ↓ BP, weakness, difficult to understand, • 1700RR 32 – BP 122/76 – 83% (2L O2 placed ) • 1730 RR 28 – BP 88/48 -- 89% (kept taking O2 off)

36. Not screened for sepsis in ED or acute care unit. • what was the WBC in ED? • 29.6 • Sepsis identified too late – treatment delayed • 1800- - RR 25 - BP 75/46 - Sats 67% on 10 L O2  pt transferred to the unit • 1827 – intubated • Next day …Made “comfort measures” • ICU Dx – septic shock, severe lactic acidosis, acute tubular necrosis, respiratory failure.

37. What could have been done better? High Potassium No telemetry No IV fluids No cultures No sepsis screening Proper pt placement on admission Face-to-face report

38. Use the sepsis algorithm: Allows us to: ID sepsis earlier & get order from MD for ATB & fluids Call MD and ask to implement sepsis orders for labs (procalcitonin and lactic acid) and fluids. Transfer to higher level of care if necessary If response if negative and you believe patient meets criteria. . . . . . . . . . . Call the UAT!!!

39. Sepsis Orders (to be used if the patient has screened positive for sepsis and is not currently under active treatment for sepsis) • The nurse is to initiate orders 1 through 4: • Activate the urgent assessment team • Complete the screening algorithm for organ dysfunction • Initiate the following if they have not been done in the last 4 hours: • CBC • CMP • Serum lactate • Serum procalcitonin • UA • Blood culture x2 • Urine culture • Start second IV (if patient has only 1 IV site)  • IV fluids: Ask MD for fluid bolus of at least 500ml NS

40. Chain of Command? • Staff was in contact with MD throughout the day but at times was difficult to contact. • What do you do when this happens? • Initiate the chain of command • How do you do this? • Find your lead/supervisor/manager and state “I need to activate the chain of command for…” • Remember…if the plan doesn’t feel right, you can’t get in touch with the MD, or if you have a fast decline don’t hesitate to initiate the chain of command or call a UAT.

41. Procalcitonin (PCT) • Rises in response to a pro-inflammatory stimulus, especially of bacterial origin • Produced mainly by the cells of the lung and the intestine • In septic conditions, increased PCT levels can be observed 3-6 hours after infectious challenge • PCT blood levels may rise to 100 ng/ml • PCT results can help reduce unnecessary antibiotic use : starts to fall with effective ATBs WBC

42. What do you think is the primary problem? • 78 y/o male with dyspnea/cough • BP 89/51 • HR 110 • RR 14 • Temp 99.2 oral • WBC 4.2 • SpO2 96 on 3 l/np • Weight 122 lb (55 kg), baseline is 127 lb • HF exacerbation • Dehydration • Sepsis • B and C • All of the above i

43. After 500 ml normal saline bolus.What should be next? • BP 90/56 • Pt’s Normal BP = 143/76 • HR 98 • Pt’s normal HR = 65 • RR 20 • Temp 99.2 oral • SpO2 96 on 3 l/np • Weight 55 kg Pt is septic and dehydrated, give another 500ml bolus to = 20 ml/kg, then IV at 100 ml/hr Pt is septic and dehydrated with HF/kidney insufficiency, hold additional bolus and start IV at 100ml/hr Patient is septic, start inotropes (dopamine) to increase BP i

44. After 1500 mL bolus, based on the vital signs, what is the appropriate unit for this patient? • BP 90/56 • Pt’s Normal BP = 143/76 • HR 98 • Pt’s normal HR = 65 • RR 20 • Temp 99.2 oral • SpO2 96 on 3 l/np • Weight 55 kg 5C since the patient is HF 7 Ham since the patient is septic ICU i

45. Is your unit appropriate? • What questions would you ask before bringing this patient to your unit? • Did patient meet Sepsis criteria? • Were the fluid and antibiotics given? • When was the last set of vitals taken? • IF still abnormal, were they seen and patient okay’d for admission to selected floor by the ED physician • Above and beyond the “SHARE” form….

46. Future Opportunities • Nursing Home outreach education • ????

47. Questions?