Reducing Mortality from Severe Sepsis

1. Reducing Mortality from Severe Sepsis/Septic Shock: A Plan That Can Work for You! Nicki Roderman, RN, MSN, CCRN December 5, 2008 Medical Center of Plano, Clinical Nurse Specialist for Critical Care

2. Nicki Roderman, RN, MSN, CCRN Objectives List common identifying factors of the patient with severe sepsis/septic shock Discuss the nursing-directed care necessary for implementing goal-directed therapy for severe sepsis or septic shock Discuss resources necessary for a successful sepsis program

3. Nicki Roderman, RN, MSN, CCRN Medical Center of Plano 427-bed community, for profit hospital Magnet Certified JCAHO Certified: Stroke, MI, CHF 36-bed adult ICU Hospitalist program

4. Nicki Roderman, RN, MSN, CCRN Medical Center of Plano 44-bed Emergency Department ~50,000 admissions/year Level III Trauma Center Chest Pain II Accredited Medical control for city FD Board certified Emergency Medicine ED physicians 100% ED Nursing Staff Trauma Certified for adult & pediatrics

5. Nicki Roderman, RN, MSN, CCRN U.S. Leading Causes of Death (2005) Heart disease 652,091 Cancer 559,312 Stroke 143,579 Chronic lower respiratory 130,933 Accidents 117,089 Diabetes 75,119 Alzheimer's 71,539 Influenza + pneumonia 63,001 Nephritis 43,091 Septicemia 34,136 www.cdc.gov

6. Nicki Roderman, RN, MSN, CCRN Evidence-Based Medicine STEMI, Door to Balloon, MI/CHF disease certification GTWG/Stroke disease certification Trauma certification Diabetes care, tight glycemic control, disease certification ~Practice Guidelines~

7. Nicki Roderman, RN, MSN, CCRN Alcohol Withdrawal Have you felt you ought to cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you felt bad or guilty by your drinking? Have you ever had a drink first thing in the morning? Was this to steady your nerves, get rid of a hangover, or to get the day started? Have you ever had a problem with drinking? When did you have your last drink? CAGE-AID Questionnaire: Society of Teachers of Family Medicine

8. Nicki Roderman, RN, MSN, CCRN

9. Nicki Roderman, RN, MSN, CCRN Sepsis Statistics 10th leading cause of death overall (US)1 New cases in the US annually: 750,0001,2 Mortality3: Severe sepsis 30%-50% Septic shock 50%-60% Sepsis accounts for ~1,400 deaths worldwide every day! In the US, more than 500 patients dieof severe sepsis daily2

10. Nicki Roderman, RN, MSN, CCRN Sepsis Statistics Sepsis treatment cost ~ $16.7 billion in the U.S. in 2000 The average cost per individual case is $22,000 National goal: reduce mortality from severe sepsis by 25% by 2009

11. Nicki Roderman, RN, MSN, CCRN Severe Sepsis/Septic Shock Is it nationally recognized? Are plans in place? Who wants to save $$$? Who wants better outcomes for their patients??

12. Nicki Roderman, RN, MSN, CCRN What is Sepsis Disturbances in the inflammation, coagulation, and fibrinolytic systems Leads to uncontrolled, systemic inflammation and advanced coagulopathy: Excess coagulation Exaggerated or malignant inflammation Impaired fibrinolysis In severe sepsis, the reaction to an infection does not stay localized

13. Nicki Roderman, RN, MSN, CCRN What is Sepsis? Sepsis: The systemic response to infection; this response is manifested by two or more of the systemic inflammatory response syndrome criteria as a result of infection Severe Sepsis: Sepsis associated with organ dysfunction, hypoperfusion, or hypotension Septic Shock: Sepsis with hypotension, despite adequate fluid resuscitation Frequently see lactic and metabolic acidosis along with change in altered mental status, elevated creatinine, and source of infection

14. Nicki Roderman, RN, MSN, CCRN Lactic Acid Elevated lactate is associated with severe sepsis and septic shock Usually secondary to anaerobic metabolism due to hypoperfusion High lactate=severe tissue hypoperfusion Normal 0.4-2.0 mmol/L (18-36mg/dL) >2.0mmol/L or 18mg/dL indicates severe sepsis >4 mmol/L or 36mg/dL indicates shock

15. Nicki Roderman, RN, MSN, CCRN Risk Factors Extremes of age: <1 year or >65 years Surgical/invasive procedures Malnutrition Use of broad-spectrum antibiotics Chronic illness DM CRF Hepatitis Immunodeficiency disorders

16. Nicki Roderman, RN, MSN, CCRN Risk Factors Compromised Immune Status: AIDS Use of cytotoxic and immunosuppressive agents Alcoholism Malignant neoplasms Transplant Increase in the number of drug-resistant microorganisms

17. Nicki Roderman, RN, MSN, CCRN The Sepsis Picture Sepsis presentation often starts at home, and they present to PCP for a variety of illnesses: Respiratory infections turning to pneumonia Persistent UTI Recent surgery Abdominal pain, especially post-procedure Infected incision or wound Spider or dog bite May not be anything �obvious�

18. Nicki Roderman, RN, MSN, CCRN The Sepsis Picture Patients in long term care present most frequently with: Altered mental status Pneumonia UTI Infected incision or wound Infected central line site Abdominal pain, especially post-procedure C-Diff from antibiotics

19. Nicki Roderman, RN, MSN, CCRN The Sepsis Picture Common physical parameters: Fever Low blood pressure or ~20mmHg drop from baseline (SBP <100mmHg) Tachycardia (HR>100) Increased respiratory rate Change in mental status Suspicious wound drainage Little or no urine output

20. Nicki Roderman, RN, MSN, CCRN Screening for Sepsis History Suggest New Infection (or old site)? UTI Wound infection Pneumonia Abdominal infection Infected central line SIRS (two or more): Temperature (>38?C or <36?C) Heart Rate (>90bpm) Respiratory Rate (>20/min) WBC Count (>12,000, <4,000, or >10% bands) SBP (<90mmHg), MAP (<65mmHg)

21. Nicki Roderman, RN, MSN, CCRN Screening for Sepsis Acute Organ Dysfunction (one or more): Altered LOC SBP<90mmHg, MAP<65mmHg SaO2<90% on room air Creatinine >2.0mg/dL or UO<0.5ml/kg/hr for >2 hours Bilirubin >2mg/dL PLT<100,000 Lactate >2mmol/L (18mg/dL) Coagulopathy: INR>1.5 or PTT >60sec

22. Nicki Roderman, RN, MSN, CCRN Screening for Sepsis (1) (2) (1) Infection + SIRS + Organ = Positive Screen Dysfunction Suggestive of Severe Sepsis

23. Nicki Roderman, RN, MSN, CCRN Identifying Sepsis Now what? What is the appropriate treatment and how do we identify patients with severe sepsis or septic shock? Evidence-based guidelines for sepsis management

24. Nicki Roderman, RN, MSN, CCRN Define Your Goal The goal for Medical Center of Plano was to reduce mortality from severe sepsis and septic shock through the use of a systematic screening process, aggressive treatment, and monitoring.

25. Nicki Roderman, RN, MSN, CCRN Getting Started First things First! ?Order the Implementing the Surviving Sepsis Campaign book from the Society of Critical Care Medicine www.sccm.org 847-827-6869 Get bundle information and audit tools from www.IHI.org Examine the evidence: Literature Review

26. Nicki Roderman, RN, MSN, CCRN Literature Volume 345:1368-1377 November 8, 2001 Number 19 Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early Goal-Directed Therapy Collaborative Group

27. Nicki Roderman, RN, MSN, CCRN How do we achieve the goal? Society of Critical Care Medicine (SCCM), European Society of Intensive Care Medicine, & International Sepsis Forum developed the Surviving Sepsis Campaign: Increase awareness Improving early diagnosis Provide treatment guidelines

28. Nicki Roderman, RN, MSN, CCRN Baseline Data Admit time ED to ICU time Antibiotic & BC timing IV Access ICU & Hospital LOS Discharge disposition Lactic Acid Mortality Fluids given Pressors given Steroids given Blood glucose control Use of Xigris Source of sepsis APACHE II scores

29. Nicki Roderman, RN, MSN, CCRN Results �Houston we have a problem!!� Mortality 62.2%!!! Time for Action�..

30. Nicki Roderman, RN, MSN, CCRN Moving Forward Who is going to drive the bus?

31. Nicki Roderman, RN, MSN, CCRN Form the Team ICU Medical Director ED Medical Director Hospitalist Director Clinical Nurse Specialist ICU Director of Critical Care Clinical Pharmacist ED Nurse Clinician Nurse Practitioner

32. Nicki Roderman, RN, MSN, CCRN Teamwork Set regular meetings Review the Data Hospital Forum to present proposal � administrative support Examine equipment and diagnostic testing ability Develop order sets/bundles � plagarism is fastest!! Collaboration is essential! Timeline ~ 6 months

33. Nicki Roderman, RN, MSN, CCRN Considerations Lab Capabilities Monitoring equipment Who will insert line? ED nurse staffing ED LOS Xigris use ICU staffing

34. Nicki Roderman, RN, MSN, CCRN Developing Your Sepsis Bundles Emergency Department: Suspected Sepsis Orders Screening tool Initiating Early Goal Directed Therapy Treatment within 6 hours yields the best results Admission to ICU Bundle: Initial work-up if admitted from inpatient area Continuing fluid resuscitation as necessary Monitoring oxygenation

35. Nicki Roderman, RN, MSN, CCRN Primary Bundle Elements-1st Six Hours Initial labs Blood cultures before antibiotics Antibiotic timing & selection Central IV access Fluid resuscitation 20ml/kg vs. 2 liters initially Vasopressors

36. Nicki Roderman, RN, MSN, CCRN Appropriate Antibiotics** ? Merrem 500mg q6 hours ? Levaquin 750mg IV daily OR AND OR ? Zosyn 3.375 mg q8 hours ? Tobramycin 7mg/kg qday. OR Random level 8 hours after Inf. ? If patient has anaphylactic Reaction with penicillin or Cephalosporins, begin Azactam 2gm IVPB q8 hours Vancomycin 15mg/kg IV, pharmacy to dose, any patient admitted from other facility ** MCP does phamacodynamic dosing for all antibiotics

37. Nicki Roderman, RN, MSN, CCRN ScvO2 Monitoring Measurement of saturation of central venous oxygenation End point of resuscitation=tissue oxygenation Important measure after fluid resuscitation Continued low ScvO2 may indicate need for Dobutamine

38. Nicki Roderman, RN, MSN, CCRN Tissue Oxygenation Monitoring SvO2 is a balance between oxygen consumption and oxygen delivery Normal: 60-80% Measured with right heart volumetric swan ScvO2 (Pre-Sep) catheter is placed in superior vena cava or right atrium ScvO2 is always 5-18% >SvO2 in septic shock Goal: ScvO2>70% Use just like any other central line

39. Nicki Roderman, RN, MSN, CCRN Equipment Continuous Oxygenation Monitoring: Triple lumen catheter ScvO2 monitoring Rapid fluid infusion Optimally placed in ED Requires calibration before insertion IJ or subclavian access Edwards Vigilance II or Vigileo monitor with PreSep catheter www.edwards.com

40. Nicki Roderman, RN, MSN, CCRN CVP Monitoring Must have central venous pressure monitoring Goal: 8-12 mmHg Assures fluid balance Need bedside monitor Optimally started in ED Central line: Subclavian, IJ, PICC

41. Nicki Roderman, RN, MSN, CCRN Ongoing Care: Admission Bundle Antibiotic dosing/adjustments Ongoing fluid resuscitation to maintain CVP >8-12mmHg and MAP >65mmHg Vasopressors Levophed, Vasopressin, Dopamine Xigris Blood glucose control Steroids

42. Nicki Roderman, RN, MSN, CCRN Xigris (Drotecogin Alfa) Indication: For the reduction of mortality in adult patients with severe sepsis who have a high risk of death What is it? Recombinant form of human Activated Protein- C Stops the cascade Expensive Up to 13% absolute mortality reduction when used for the sickest patients

43. Nicki Roderman, RN, MSN, CCRN Xigris Used in ICU only Considered for an APACHE II score >25 Patient is screened for appropriateness Bleeding is the most common serious adverse effect Monitor PT and S/S of bleeding Infuses for 96 hours

44. Nicki Roderman, RN, MSN, CCRN Blood Glucose Control Monitor BG every 4 hours Two consecutive BG >150mg/dL, start IV tight glycemia control BG Goal: 80-110mg/dL Monitor closely for hypoglycemia

45. Nicki Roderman, RN, MSN, CCRN Ongoing Care Cortisol level (adrenal insufficiency): IV steroids, hydrocortisone or florinef, for 7 days recommended for septic shock with vasopressors Ongoing studies regarding benefits Monitor UO closely: Goal > 0.5ml/kg/hr Dietary consult on day of admit

46. Nicki Roderman, RN, MSN, CCRN Implementing Bundles Education of physicians, ED staff, ICU staff, & pharmacy staff before starting program Budget for education time Equipment/medication inservices as needed All forms, bundles/order sets accessible All equipment available, functioning, and staff knows how to use it

47. Nicki Roderman, RN, MSN, CCRN Case Study A 54 y.o. female with a history of spina bifida, previous left hip decubitus with wound vac, and colostomy being cared for at home by her mother. Arrived in the ER via EMS with altered level of consciousness and fever. She was intubated immediately. VS on arrival. 0906: T 105?F, HR 144, RR 38, BP 54/44

48. Nicki Roderman, RN, MSN, CCRN Case Study Labs 0932: Na 133 WBC 36.5 CXR: Clear K 6.9 HgB 14.9 Urine: Cloudy Cl 93 HCT 43.2 ABG: CO2 20 Plts 709 pH 7.23 BUN 47 PTT 41.2 CO2 36 Creat 5.1 PT/INR 1.4 PaO2 64.9 Glucose 230 BNP 177 HCO3 14.8 Lactic Acid 3.3 BE -11.8 Sat 89%

49. Nicki Roderman, RN, MSN, CCRN Case Study 0913 Intubated 0915 VS: 143-72/49, 1st Liter NS up, PICC in place 1000 VS: 125-64/48, 2nd Liter NS up, Dopamine & Levophed gtts started, BC completed 1005 Merrem IV up 1020 To ICU 1200 No urine output, remains hypotensive, Pulmonary medicine consult. Inserted Pre-sep catheter. APACHE II score 45. Initial CVP 12, Initial ScvO2 72%. Vasopressin drip added. IV Insulin tight control started.

50. Nicki Roderman, RN, MSN, CCRN Case Study: Next Day 1900: Xigris started ?Total fluids in first 24 hours: 19,104ml Levophed and Dopamine gtts off, Vasopressin infusing Labs: Na+ 142 WBC 24.2 K+ 3.3 HgB 9.8 Cl- 113 HCT 29.3 CO2 16 Plts 148 BUN 25 CXR: Mild bibaslar atelectasis Creat 2.3 Glucose 91 Lactic Acid 1.7

51. Nicki Roderman, RN, MSN, CCRN Outcome Xigris infused x4 days Off ventilator on day 5 All vasopressors off day 2 Cultures: positive urine, yeast and pseudomonas Transferred out of ICU day 6 Creatinine 1.5 on discharge Discharged home with home health day 10

52. Nicki Roderman, RN, MSN, CCRN Results

53. Nicki Roderman, RN, MSN, CCRN Results

54. Nicki Roderman, RN, MSN, CCRN Results

55. Nicki Roderman, RN, MSN, CCRN Pressor Days

56. Nicki Roderman, RN, MSN, CCRN Ventilator Days

57. Nicki Roderman, RN, MSN, CCRN Discharge Disposition

58. Nicki Roderman, RN, MSN, CCRN ICU LOS

59. Nicki Roderman, RN, MSN, CCRN Hospital LOS

60. Nicki Roderman, RN, MSN, CCRN Mortality

61. Nicki Roderman, RN, MSN, CCRN Statistical Analysis

62. Nicki Roderman, RN, MSN, CCRN Cost $avings ICU LOS Fluids in 1st 24 hours Pressor Days Dialysis/CRRT days Central line/ScvO2 Ventilator days Xigris

63. Nicki Roderman, RN, MSN, CCRN Cost $avings Estimated Cost Savings 2007: *Cost Savings: ~$6,000 per patient on bundle in ED Our $avings: $9,772 per patient $9,772 x 59 patients = $576,548 For 18 months: $859,936 * Shorr AF et al. Crit Care Med. 2007; 35:1257-1262

64. Nicki Roderman, RN, MSN, CCRN Lives Saved 2006 Mortality = 62.2% 2007 Mortality = 22% Sepsis bundle cases 2007 = 59 59 x .622 (2006 rate) = 36.6 - 59 x .22 (2007 rate) = 12.98 More Patients Lived 2007 = 23.62

65. Nicki Roderman, RN, MSN, CCRN Making Work! Data, data, and more data�. Convince the skeptics, show them the data Keep your administration happy, show them the data Keep your overworked ED and ICU staff happy, show them the data Best of all�. Do what�s best for your patients!!!

66. Nicki Roderman, RN, MSN, CCRN Moving Forward Readjustment to order sets Education of inpatient floors and physicians Direct reports to Hospitalist group Target Oncology patients Incorporating Rapid Response Team Ongoing data collection & reporting Celebrating the results! Sharing with others

67. Nicki Roderman, RN, MSN, CCRN Trigger Tool: RRT

68. Nicki Roderman, RN, MSN, CCRN Keys Keys to success: Buy-in of key ICU and ED physicians Timely communication and feedback Ongoing improvements Data-driven approach Regular communication of results COLLABORATION!

69. Nicki Roderman, RN, MSN, CCRN Do you find septic shock to be a challenge? Have you felt you ought to cut down on your mortality from sepsis? Have people annoyed you by criticizing your sepsis protocol? Have you felt bad or guilty by your high mortality rate? Have you ever considered instituting an evidence-based sepsis bundle? Have you ever had a problem with non-compliance with evidence-based medicine/practice? When did you have your last round of data collection? CAGE-AID Questionnaire: Society of Teachers of Family Medicine

70. Nicki Roderman, RN, MSN, CCRN Questions? Thank You! Nicki.Roderman@hcahealthcare.com 972-519-1255

71. Nicki Roderman, RN, MSN, CCRN References Angus, D., Linde-Zwirble, W., Lidicker, J., Clermont, G. Carcillo, J., & Pinsky, M. (2001). Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical Care Medicine, 29(7), 1303-1320 Bernard, G., Vincent, J., Laterre, P., LaRosa, S., Dhainaut, J., Lopez-Rodriguez, A., et al. (2001). Efficacy and saftey of recombinant human activated protein C for severe sepsis. NEJM, 344(10), 699-709 Nguyen, B., & Rivers, E. (2005). The clinical practice of early goal-directed therapy in severe sepsis and septic shock. Advances in Sepsis, 4(4), 126-133 Nguyen, B., Rivers, E., Abrahamina, F., Moran, G., Abraham, E., Trzeciak, S. et al. (2006). Severe sepsis and septic shock: review of the literature and emergency department management guidelines. Annals of Emergency Medicine, 48(1), 28-48 Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., et al. (2001). Early goal directed therapy in the treatment of severe sepsis and septic shock. NEJM, 345(19), 1368-1377 Townsend, S., Dellinger, R.P., Levy, M., & Ramsay, G. (2005). Implementing the Surviving Sepsis Campaign www.clevelandclinic.org www.xigris.com