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I Screen, You Screen, We All Screen for Sepsis! Sepsis Virtual Event February 9, 2017 11am-12p CT 1
I Screen, You Screen, We All Screen for Sepsis!
Sepsis Virtual Event February 9, 2017
11am-12p CT
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WELCOME AND INTRODUCTIONS
Mallory Bender, MA, LCSWProgram Manager | HRET
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Today’s Agenda
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11:00 – 11:05 am Welcome and introductions Mallory BenderProgram Manager, HRET
11:05 – 11:10 am Sepsis measurement Mariana LesherDirector, Data, HRET
11:10 – 11:15 am Sepsis Recognized as a Medical Emergency Maryanne Whitney RN MSNCynosure Improvement Advisor
Review and understand the recent guideline released from Surviving Sepsis Campaignand Society of Critical Care Medicine
11:15 – 11:50 am Screening in all the right places
Learn from a panel of experts how their screening process began, the tools they use, the barriers they overcame and how they did it. This will be a facilitated discussion that will include HIIN hospitals and you!
HRET HIIN Hospitals
Facilitators: Maryanne Whitney RN MSN & Steve Tremain MD
Cynosure Improvement Advisors
11:50 am – 12:00 pm Bring it Home Mallory BenderProgram Manager, HRET
Action items and tying together of material
Who is in the Room?
• Quality leader• State Partner• Hospital Leader• Nurse Leader• Physician Champion• Infection Preventionist
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Sepsis Measurement• HIIN measures
– Post-operative sepsis (AHRQ PSI-13)• 20131: 4.19 per 1,000
– Hospital-onset sepsis mortality– Overall sepsis mortality
• Sepsis impact2
– Most expensive reason for hospitalization– Patients stay in the hospital 75% longer
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1 https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V60-ICD09/Version_60_Benchmark_Tables_PSI.pdf2 https://blogs.cdc.gov/safehealthcare/the-cost-of-sepsis/
Just in….
• Sepsis is now recognized as a “Medical Emergency”
• Sepsis 3 definitions are validated– Sepsis defined as a “life-threatening organ dysfunction due to a
dysregulated host response to infection”– Septic shock defined as a “subset of sepsis where underlying
circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality”
• Term “sepsis” takes the place of “severe sepsis”
www.survivngsepsiscampaign.orgwww.sccm.org
Essential Elements
• Early identification in all patient settings– Using SIRS in the setting of infection remains a
preferred method for sepsis and septic shock detection.
– qSOFA assessment results in greater prognostic accuracy for in-hospital mortality than either SIRS or severe sepsis alone.
Raith EP, et al. for the Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resource Evaluation (CORE). Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit. JAMA. 2017;317(3):290-300. doi:10.1001/jama.2016.20328
Essential Elements
• Early treatment including:– Early source control – Early antibiotics (ASAP within one hour)
• Empiric coverage with one or more antibiotics• Narrowed once pathogens and sensitivities are known• Daily assessment for de-escalation of antibiotics
Essential Elements
• Early treatment con’t– 30ml/kg fluid within the first 3 hours for
hypotension or elevated lactate using crystalloids– Frequent volume status assessments during
critical resuscitation (passive leg raise or other dynamic measurements)
– Use of lactate clearance as a useful guide for determining resuscitation end points
www.survivngsepsiscampaign.orgwww.sccm.org
Chat in…...
• What departments are screening for sepsis in your hospital?
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One more…....
• What department will you start screening for sepsis in next?
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HOSPITAL PANELIST
Mary Oyler, RN BSNInfection Preventionist
Golden Valley Memorial Healthcare, Missouri
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ABOUT US
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Golden Valley Memorial Healthcare 56-bed, not-for-profit, short term, general acute community hospital
Inpatient, outpatient, emergency and home care services
Primary care services at 4 physician clinics
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HOSPITAL PANELIST
Stacy Card, Quality RNChoctaw Regional, MS
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ABOUT US
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CRMC Quality Team: Jamie Rodgers (administrator), Brad Huffman (IT RN), Debbie Davis FNP (CNO), Brooke Eaves (ST), Charles Davis (RT), Stacy Card (Quality RN), Anthony Morrow (Facilities Director), Meredith Brown (MT) and Dr. S. Patel M.D. (Quality Physician)
Sepsis Screening Algorithm
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CRMC Sepsis Screening Algorithm
SIRS CRITERIA
Temp > 101 or < 96.8, Pulse > 90 Tachypnea > 20, ALT Mental Status
Notify MD and begin sepsis order set.
Obtain orders for: Cardiac Monitor, VS q 15 mins in ER, continuous pulse OX in ER, oxygen to maintain sat > 90%, obtain large bore IV line access, obtain UA w/ C&, CMP, CBC, lactate level (pre & post bolus), blood C & S x 2 sets @ different sites. CXR, ABG.
Proceed with 3-hour bundle:
1) Review lactate level within one hour post-bolus. 2) Obtain blood and urine C&S prior to first antibiotic being started. 3) Administer broad spectrum antibiotic within three hours of arrival. 4) Administer 30ml/kg of body wt crystalloid solution, or at least 125ml/hr. 5) VS taken within one hour of IVF administration and post-bolus.
Post-bolus: If hypotension and/or respiratory distress continues-consider transfer to ICU.
Or
Proceed with 6-hour bundle (if positive for septic shock)
1) Obtain acceptance in a nearby ICU. 2) Vasopressor (Levophed) for hypotension 3) MD must document review of VS 4) Fluid challenge 5) Echo must be completed within six hours of the fluid bolus. 6) MD must document cap refill exam, passive leg exam, peripheral pulse
exam and skin exam with VS.
Mandatory MD documentation: The MD focus exam contains the VS, cardiopulmonary exam, capillary refill evaluation, peripheral pulse evaluation and the skin examination.
TESTS OF CHANGE AND WHAT WE LEARNED
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• Engage physician leaders from the beginning • Empower your Physician Leader to instruct other
physicians• Place your screening tool in an easily accessible spot• Compliance with protocols needs to be stressed• Follow up to ensure everyone understood
expectations• There should be an expectation of the same level of
care, no matter the size of the hospital
HOSPITAL STORY
Cam Brandt, MS, RN, CEN, CPEN, CPNStaff Nurse, Trauma Nurse Leader
Cook Children’s Medical CenterFort Worth, TX
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ABOUT US
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COOK CHILDREN’S SEPSIS SCORING TOOL
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Predisposition Primary Screen: Secondary Screen:Yes 2 No 0 Yes 2 No 0
Predisposition includes but is not limited to:Transfer from any healthcare facility for diagnosis of sepsis, rule out sepsis, or serious bacterial infection; History of confirmed flu with new fever after 5 days or symptoms lasting more than 5 days; Age less than 60 days; Use of tampons uring current menses; Indwelling catheters; Previous admission to the hospital with diagnosis of a serious bacterial infection; Acute or chronic immunosuppression; Chronic medical problems (i.e. Status Post Bone Marrow Transplant, Chronic Respiratory Failure, Sickle Cell Disease, Complex Congenital Heart, Chronic Liver Failure, Chronic Renal Failure, Profound Neurological Impairment)
If yes, circle applicable predispositionInfectious symptoms Primary Screen: Secondary Screen:
Yes 2 No 0 Yes 2 No 0History or physical exam suggests infection such as fever or hypothermia, rash, reddened draining area of skin, joint pain, dysuria, productive cough
If yes, circle applicable symptomsResponse (vital signs) Primary Screen: Secondary Screen:Tachycardia/ tachypnea
Yes 2 No 0 Yes 2 No 0If BOTH abnormal heart rate and tachypnea choose yes:0 -<2 months: < 100 or > 180 HR and > 50 RR2 months - < 1 y.o.: < 90 or > 180 HR and > 40 RR1 - < 2 y.o.: < 90 or > 180 HR and > 35 RR2 - < 6 y.o.: > 140 HR and > 25 RR6 - < 13 y.o.: > 130 HR AND > 20 RR 13 - < 18 y.o.: >110 HR and > 14 RR
Organ Dysfunction Primary Screen: Secondary Screen:Yes 2 No 0 Yes 2 No 0
Organ dysfunction can include any of the categories below. Positive screening will get 2 points AND additional points as outlined below.
Respiratory dysfunction
Yes 1 No 0 Yes 1 No 0If hypoxemia or <91% on RA, orNeed for ventilatory support (BVM or ETT)
Neurological dysfunctionYes 1 No 0 Yes 1 No 0
GCS <11 or decreased by 3; OR Acute change in mental status; OR Irritable or confused
Circulatory dysfunctionHypotension Yes 2 No 0 Yes 2 No 0
SBP mmHg:0 -<2 months: < 652 months - < 1 y.o.: < 701 - < 2 y.o.: < 802 - < 6 y.o.: < 906 - < 13 y.o.: < 100 13 - < 18 y.o.: < 110
Count these points if patient has any TWO of the following:
Decreased urine output; Yes 1 No 0 Yes 1 No 0Capillary refill: immediate (flash) OR > 3 seconds; Yes 1 No 0 Yes 1 No 0Decreased OR bounding pulses; Yes 1 No 0 Yes 1 No 0Skin cool, mottled, red, pale, cyanotic OR gray Yes 1 No 0 Yes 1 No 0
Lactate >4 Not Applicable Yes 1 No 0Metabolic base deficit as defined by blood gas > -4 Not Applicable Yes 1 No 0
TOTAL PRIMARY POINTS: TOTAL SECONDARY POINTS:If ≥5, initiate Sepsis Pathway If ≥5, initiate Severe Sepsis Protocol
PROCESS
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Sepsis Flowchart ER
Primary Screen by Triage Nurse with a score ≥ 5 or Oncology patient
Responder
Improvement in VS, Sepsis score < 5
Non-responder
Continued abnormal VS, Sepsis score ≥ 5
1- Consider Foley Catheter, obtain UA and Urine culture 2-Vital signs q10 min until pt has a negative sepsis score 3-ERP to consider PICU Consult 4-In the event of hypotension and/or serum lactate > 4 mmol/L.: -Deliver a minimum of an additional 20 ml/kg of isotonic solution to maintain normal SBP for age -Repeat lactate -If your patient does not required additional boluses, SBAR provider with expectations for maintenance fluids at 1.5x maintenance. -Administer vasopressors for hypotension not responding to fluid bolus 5-CXR if respiratory distress or decreased SaO2
Repeat Sepsis score with changes in VS
and assessment
Vital signs q30 min
INITIATE SEPSIS PATHWAY 1-Patient placed on continuous pulse oximetry and cardiac monitoring; obtain a full set of VS q10 minutes, including blood pressure 2-Patient placed on oxygen regardless of O2 saturation level 3-Start peripheral intravenous line; order and draw the following laboratory work: blood gas, lactate, glucose, CBC, blood culture 4-Administer a rapid fluid bolus of 20 mL/kg NS by push method/pressure bag (depending on volume of fluid). May repeat bolus if needed. Newborn (0-28days) and CHD patients give 10 ml/kg bolus
**H/O requests BBK, and to culture all lumens. 5-Antibiotics to be ordered by provider and initiated by nursing staff within 60 minutes
Admission
Repeat Primary Score
Suspicious for Sepsis Notify provider and document on scoring tool, Vocera alert
Consider admission
Repeat Primary Sepsis score upon admission or discharge
SECONDARY SCORE WITH RECENT VS, LACTATE & BASE EXCESS
WRAP UP AND NEXT STEPS
• Roll out hospital wide– Additional criteria
• New goal: Sepsis alert to bolus: 20 minutes
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Elements of our sepsis programthat are working well
• Early identification• Ongoing sepsis
awareness• Engagement of bedside
staff• 3-Hour bundle
compliance• 6 Hour bundle
compliance
• Integration of the Sepsis-3 definitions
• Leadership support• Community
involvement• Education and
understanding
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Our priorities for sepsis improvementduring the HIIN
• Early identification• Ongoing sepsis
awareness• Engagement of bedside
staff• 3-Hour bundle
compliance• 6 Hour bundle
compliance
• Integration of the Sepsis-3 definitions
• Leadership support• Community
involvement• Education and
understanding
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BRINGING IT HOME
Mallory Bender, MA, LCSWProgram Manager | HRET
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Sepsis Resources - LISTSERV
• Join the LISTSERV® – Ask questions– Share best practices, tools and resources– Learn from subject matter experts– Receive follow up from this event and notice of
future events
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Fellowship
The HRET HIIN offers two fellowship opportunities free of charge for participating HIIN hospitals.
1. Quality Improvement Fellowships 1. Learn more 2. Register for Foundations for Change or Accelerating
Improvement
2. PFE Fellowship1. Learn more2. Register
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Upcoming Events!• ADE Virtual Event: February 14, 2017 12:00p.m. - 12:50p.m. CT
Register today!• HRET HIIN QI Fellowship: February 15, 2017
Foundations for Change: 11:00a.m.-12:00p.m. CT – Register today!Accelerating Improvement: 12:30p.m.-1:30p.m. CT – Register today!
• HRET HIIN Up Campaign | The Way UP: February 16, 201711:00a.m.-11:50a.m. CT
Register today!
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Thank You!
Find more information on our website: www.hret-hiin.org
Questions or Comments: [email protected]
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