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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

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

Take home points what do you need to do


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!!!


  • 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


  • 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

Oxygen delivery and utilization1
Oxygen Delivery and Utilization



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

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

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

-every additional hour to effective antimicrobial initiation

-survival decreased by 7.6%/hour

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


    • 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 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

Sepsis initiative

Stratification form cont.

  • Central Line/PICC

  • A-line

  • Mechanical Ventilation

  • Fluid Resuscitation

  • Pressors

  • PRBC’s

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

Take home points1

  • 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!!!

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


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

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 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