Terri Lee Roberts BSN, RN, CIC, FAPIC

Infection Prevention Analyst Pennsylvania Patient Safety Authority

Early Detection of Sepsis in Long-Term Care Residents

10/24/2016 1 © 2017 Pennsylvania Patient Safety Authority

Objectives

• Relate the importance of early recognition of sepsis and implementation of evidence-based therapies to optimize patient safety

• Name two sepsis screening tools appropriate for use in the long-term care setting

• Utilize simulation to communicate effectively among healthcare team members leading to reduced errors in patient care

• Use the electronic medical health record to identify sepsis early

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Sepsis Historical Facts

• One of the oldest syndromes known in medicine

• First introduced by Hippocrates

– (ca. 460-370 BC)

• Derived from the Greek word sipsi

– “to make rotten”

Welty

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Sepsis Today

• Remains an ongoing and significant challenge

• Serious concern to healthcare providers, policymakers, patients

– large number of cases

– high mortality rates

– associated costs

Agency for Healthcare Research and Quality

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"Sepsis is a 'ninja' disease — it quietly sneaks up on unsuspecting victims and rapidly causes overwhelming illness and death. It's one of the biggest draws on national healthcare resources.“ - Henry E. Wang, MD, MS, University of Alabama at Birmingham

National Statistics

• Impacts between 900,000 and 3 million people in the U.S. each year

• Leading cause of death in the U.S. – mortality rate of 15% to 30%

• Adults age 65 years or older are five-fold more likely to have sepsis than younger adults – 6.5% vs. 1.3%

Gaieski, et al.

Ginde, et al.

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National Statistics

• Nursing home residents are seven-fold more likely to have sepsis, compared with sepsis rates in adults not residing in a nursing home

– 14% vs. 1.9%

• Cost of care related to sepsis for older U.S. adults has been documented to be $13.8 billion annually

Ginde, et al.

Angus, et al.

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Pennsylvania’s Long-Term Care (LTC) Statistics

• PA Patient Safety Authority Infection Prevention Analysts

– reviewed LTC events reported through PA’s Patient Safety Reporting System (PA-PSRS)

– used the date reported from April 1, 2014, through March 31, 2016.

• Over the defined two-year period:

– 486 potential occurrences of sepsis

– 17 potential sepsis-related fatalities

• Patient safety concern for PA’s 702 long-term care facilities (LTCFs)

Roberts & Davis

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2016 Definitions

• New definitions for sepsis and septic shock – first revisions since 2001 – reflect considerable advances made in the pathophysiology,

management, and epidemiology of sepsis – offer more specificity in describing the life-threatening conditions and

are aimed at achieving greater clarity and consistency in how sepsis is diagnosed, reported, and treated

• Sepsis – “life-threatening organ dysfunction caused by a dysregulated host

response to infection” • Septic shock

– “manifested by profound circulatory, cellular, and metabolic abnormalities associated with a greater risk of mortality than sepsis alone”

Singer, et al.

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The Infection

• Sepsis – often originates with an infection in the lungs, urinary tract, abdomen, or a

surgical site

• Respiratory tract infections – most common site of infection causing sepsis – associated with the highest mortality

• Respiratory tract infections and urinary tract infections – top two types of infection causing sepsis in LTC

• Common pathogens – Staphylococcus aureus – E. coli – Types of Streptococcus

Agency for Healthcare Research and Quality Mayr, et al. Mylotte, et al. CDC

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Effects on Sepsis Survivors

• Sepsis worsens health status and increases disability among its survivors.

• Long-term effects include: – sepsis-induced

inflammation

– immunosuppression

– functional disability

– cognitive impairment

Yende, et al.

Jones, et al.

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The Surviving Sepsis Campaign (SSC)

• Joint effort between the Society of Critical Care Medicine and the European Society of Intensive Care Medicine

• Goal:

– reduce mortality from sepsis and septic shock globally

Surviving Sepsis Campaign

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SSC’s Guidelines

• 2012 International Guidelines for Management of Severe Sepsis and Septic Shock:

– “early recognition of sepsis and implementation of evidence-based therapies improves outcomes and decreases mortality”

– “routine screening of potentially infected, seriously ill patients for sepsis, to improve the early identification of sepsis and allow implementation of sepsis therapy, is listed as a grade 1C recommendation*”

* “a strong recommendation with low quality evidence”

Dellinger, et al.

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Developed and validated sepsis screening

tools generally evaluate three areas:

• Known or suspected infection

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• Systemic manifestations: – Hyperthermia or

hypothermia

– Tachycardia

– Tachypnea

– Acute mental status change

– Leukocytosis or leukopenia

– Hyperglycemia

• New or worsened organ dysfunction: – Hypotension

– Increasing oxygen requirements

– Elevated lactate, creatinine, bilirubin level

– Thrombocytopenia

– Coagulopathy

Dellinger, et al.

Signs of Sepsis in Older Adults

• The signs of both infection and organ dysfunction may be subtle and difficult to recognize in older adults with multiple comorbidities.

Dellinger, et al.

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Signs of Sepsis in Older Adults

• Fever – may be absent

• Tachycardia and hypoxemia – lower incidence

• Confusion, delirium, weakness, falls, anorexia, incontinence – can be non-specific

Dellinger, et al.

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LTC Early Detection Screening Tools

• Validated sepsis screening tool – should be adopted and used routinely on all

residents

• Certified nursing assistant (CNA) – could perform the initial screening at the bedside

• Positive screening results – reported to and verified immediately by the

licensed nurse

Severe Sepsis and Septic Shock Change Package

High, et al.

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LTC Early Detection Screening Tools

• Licensed nurse

– evaluate and document any acute changes

– communicate the resident’s status to the nurse practitioner, physician assistant, physician

• Clinician

– evaluate the resident

– review the resident’s advance directive

– may direct medical management and/or transfer to a higher level of care within the facility or the hospital

High, et al.

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Interventions to Reduce Acute Care Transfers (INTERACT)

• INTERACT – provides educational and clinical tools to detect early

acute changes in LTC residents

• STOP and WATCH – vertical acronym that lists conditions that identify a

potential change in a resident’s condition

• “Stop and Watch Early Warning Tool” – can be used by CNAs, therapists, dietary, environmental

service workers, family members to alert the licensed nurse that a resident has a potential change in condition that needs further clinical evaluation

Ouslander & Shutes

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INTERACT

• Situation, Background, Appearance, and Review and Notify (SBAR) – assessment and communication tool that guides the

nurse when a resident has a change in condition

• “SBAR Communication Form and Progress Note for RNs/LPN/LVNs” – evaluate the resident’s condition before contacting

the clinician/other healthcare professional – document the primary care clinician’s

recommendations Ouslander & Shutes

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Minnesota Hospital Association (MHA)

• MHA – developed LTC-specific Seeing Sepsis Tool Kit

• MHA’s LTC resources – Seeing Sepsis cards and posters that alert the user to

notify the nurse to screen for sepsis if • the resident’s temperature is higher than 100° F, • heart rate is greater than 100 beats per minute, and/or • systolic blood pressure is lower than 100 mmHg and the resident

“doesn’t look right”

– Act Fast document for LTC • same screening alerts plus next steps for medical providers in the

event of a positive sepsis screen MHA

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Screening for and Recognizing LTC Residents with Sepsis

• The key to survival is to identify sepsis early

• Screening in LTCFs could promote treatment while awaiting transfer – saving precious time!

Dellinger, et al.

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Treatment First Steps Include:

• Measuring the lactate level and drawing blood cultures

– initial steps in the SSC bundle could be accomplished in LTCFs with laboratory capabilities

• Intravenous access and administration of broad spectrum antibiotics and crystalloids

– next steps in the SSC bundle could be accomplished prior to transfer

Dellinger, et al.

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Simulation Training in Healthcare

• Experiential education – allows participants to develop new knowledge and skills in

a controlled, supported learning environment

– without direct risk to patients

• Simulation – improves critical thinking, performance skills, knowledge

of subject matter

– increases clinical reasoning in certain areas

• Core benefit – the measurable improvement in patient safety

Deutsch

Alexander, et al.

Durst

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Simulation Training for LTC Staff in Early Recognition of Sepsis

• Should include:

– recognizing early sepsis symptoms

• Utilizing a standardized screening tool

– promptly communicating those symptoms among the healthcare team

• Utilizing a communication algorithm

• Facilitator should lead participants through realistic scenarios

Durst

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Simulation Debriefing

• Group reflects and engages in safe conversations to: – identify strengths,

– weaknesses, and

– opportunities for improvement

• Participants gain confidence while discussing what went well and what could be improved.

Durst

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A Study

• Mihaljevic and Howard incorporated interdisciplinary sepsis simulations:

– in 19 LTCFs in western PA

– included licensed nurses, CNAs, therapy staff

– used INTERACT’s Stop and Watch and SBAR tools

• Goal:

– to communicate effectively and intervene quickly on behalf of residents in sepsis

Mihaljevic & Howard

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Study Findings

• Participants completed a survey to provide feedback on their experience: – Overwhelming majority

• found a high level of satisfaction with the experience

• looked forward to similar education and training in the future

– Simulation • helped implement sepsis education

• reinforced interdisciplinary communication in the LTC setting

• stimulated adoption of these tools in many LTC organizations

Mihaljevic & Howard

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Electronic Health Records (EHRs)

• The United States is moving toward implementing EHRs in all healthcare facilities. – LTC settings have been slow to adopt such technology due

to cost

• In 2004, 1,174 nursing homes responded to the National Nursing Home Survey conducted by National Center for Health Statistics at the Centers for Disease Control and Prevention. – 42% of the nursing home respondents used an electronic

information system for patient medical records

Broughton, et al.

Cherry, et al.

Richard, et al.

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EHRs Aid in Detection

• Automated access to information – has the potential to streamline clinicians’ workflow

• Clinical decision tools – offer the possibility of identifying patients in sepsis

• Diagnosis of sepsis may be elusive to clinicians – may not recognize the constellation of clinical, physiologic,

laboratory abnormalities that comprise the sepsis syndrome

• Strong potential to improve the detection of sepsis early – by collecting and organizing the clinical data required to make

the diagnosis

Centers for Medicare and Medicaid Services Nguyen, et al.

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A Study

• Nguyen et al. sought to evaluate the accuracy of an automated EHR sepsis-detection system.

• Authors concluded: – a specific EHR clinical support system identified

patients presenting with sepsis – provided a viable strategy for sepsis identification

• Given the success of Nguyen’s study: – LTCFs that use EHRs could consider incorporating their

chosen sepsis screening tool into their system to aid in early identification of sepsis.

Nguyen, et al.

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Sepsis Prevention

• Prevent sepsis from occurring by preventing infections!

• Follow infection control recommendations – Hand hygiene – Implement device-related bundles – Ensure residents receive recommended vaccines – Educate patients

CDC

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Conclusions

• Early recognition of sepsis and implementation of evidence-based therapies have the potential to save lives.

• Despite the prevalence and serious consequences of sepsis, its early diagnosis is challenging for LTC team members; therefore, sepsis may be under-diagnosed when it is still potentially reversible.

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Conclusions

• The use of a validated sepsis screening tool by LTCFs to identify sepsis early and to standardize communication among LTC team members, may decrease adverse outcomes.

• Simulation sessions using a sepsis screening tool have been shown to improve the user’s ability to effectively recognize and communicate changes in a resident’s condition that may indicate sepsis.

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References

• Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project. Septicemia in U.S. hospitals, 2009 [online]. 2011 Oct [cited 2016 Feb 10]. Available from Internet: http://hcup-us.ahrq.gov/reports/statbriefs/sb122.pdf

• Alexander M, Durham CF, Hooper JI, et al. NCSBN simulation guidelines for prelicensure nursing programs. J Nurs Regul 2015 Oct;6(3):39-42.

• Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29(7):1303-10.

• Broughton W, Lashlee H, Marcum C, et al. Health information technology: a new world of nursing homes. J Gerontol Geriat Res 2013;2(2):122.

• Centers for Disease Control and Prevention. CDC Vital Signs Sepsis Fact Sheet, 2016 [online]. [cited 2016 Oct 26]. Available from Internet: http://www.cdc.gov/vitalsigns/pdf/2016-08-vitalsigns.pdf

• Centers for Medicare and Medicaid Services. Electronic health records [website]. [cited 2016 Mar 17]. Baltimore, MD. Available from Internet: https://www.cms.gov/Medicare/E-Health/EHealthRecords/index.html

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References

• Cherry BJ, Ford EW, Peterson LT. Experiences with electronic health records: early adopters in long-term care facilities. Health Care Manage Rev 2011;36(3):265-74.

• Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013 Feb;41(2):580-637.

• Deutsch ES. Simulation in otolaryngology: smart dummies and more. Otolaryngol Head Neck Surg 2011 Dec;145(6):899-903.

• Durst KW. Society for Simulation in Healthcare [website]. [cited 2016 Mar 17]. Washington (DC). Available from Internet: http://www.ssih.org/

• Gaieski DF, Edwards JM, Kallan MJ, et al. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med 2013 May;41(5):1167-74.

• Ginde AA, Moss M, Shapiro NI, et al. Impact of older age and nursing home residence on clinical outcomes of U.S. emergency department visits for severe sepsis. J Crit Care 2013 Oct;28(5):606-11.

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References

• High KP, Bradley SF, Gravenstein S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009 Jan 15;48(2):149-71.

• Jones TK, Fuchs BD, Small DS, et al. Post-acute care use and hospital readmission after sepsis. Ann Am Thorac Soc 2015 Jun;12(6):904-13.

• Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence 2014 Jan 1;5(1):4-11.

• Mihaljevic SE, Howard, VM. Incorporating interprofessional evidenced-based sepsis simulation education for certified nursing assistants (CNAs) and licensed care providers within long-term care settings for process and quality improvement. Crit Care Nurs Q 2016 Jan/Mar;39(1):24-33.

• Nguyen SQ, Mwakalindile E, Booth JS, et al. Automated electronic medical record sepsis detection in the emergency department. PeerJ 2014 Apr 10;2:e343.

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References

• Minnesota Hospital Association. Seeing sepsis: early identification saves lives [Seeing Sepsis Long Term Care Resources online]. [cited 2016 Feb 10]. Available from Internet: http://www.mnhospitals.org/patient-safety/current-safety-quality-initiatives/severe-sepsis-and-septic-shock

• Mylotte JM, Tayara A, Goodnough S. Epidemiology of bloodstream infection in nursing home residents: evaluation in a large cohort from multiple homes. Clin Infect Dis 2002 Dec 15;35(12):1484-90.

• Ouslander JG, Shutes J. INTERACT [website]. [cited 2016 Feb10]. Boca Raton (FL): Florida Atlantic University. Available from Internet: http://interact2.net/index.aspx

• Richard A, Kaehny M, May K, et al. Literature review and synthesis: existing surveys on health information technology, including surveys on health information technology in nursing homes and home health. Washington, DC: US Department of Health and Human Services (2009).

• Roberts TL & Davis J. Early detection of sepsis in Pennsylvania’s long-term care

residents. Pa Patient Saf Advis [online] 2016 Sep;13(3):108-113.

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References

• Severe Sepsis and Septic Shock Change Package: 2016 [website]. [cited 2016 Mar 15]. Chicago (IL): Health Research and Educational Trust. Available from Internet: http://www.hret-hen.org/topics/sepsis/HRETHEN_ChangePackage_Sepsis.pdf

• Singer M, Deutschman CS, Seymore CW, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 2016 Feb 23;315(8):801-10.

• Surviving Sepsis Campaign [website]. [cited 2016 Mar 15]. Mount Prospect (IL): Society of Critical Care Medicine. Available from Internet: http://www.survivingsepsis.org/About-SSC/Pages/History.aspx

• T Welty. Sepsis history [website]. [cited 2016 June 27]. Jena, Germany: German Sepsis Society. Available from Internet: http://sepsis-gesellschaft.de/DSG/Englisch/Disease+pattern+of+Sepsis/Sepsis+History?iid=2

• Yende S, Iwashyna TJ, Angus DC. Interplay between sepsis and chronic health. Trends Mol Med 2014 Apr;20(4):234-8.

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