Sepsis Program______________________________________

St. Luke’s Cornwall HospitalNYSPFP Presentation

August 10,2016

The Healthcare Impact750,000 patients per year will develop sepsis in

the United States annually; approximately 500,000 will require medical care at the level

of an Intensive Care Unit (ICU).

The total hospital costs for sepsis patients are estimated to be 16.7 billion annually and this diagnosis accounts for a 28% mortality rate.

Early identification and treatment is critical for best outcomes for Sepsis.

The Sepsis Program at SLCH Our Journey

The Sepsis Program TeamFormed in 2012, the

SLCH Sepsis Team was comprised of the following disciplines:

Pharmacy Emergency MedicineCase Management Infection ControlNursing Leadership Infectious MedicineICU Intensivist Program Quality

Health Information Management ITLaboratory Respiratory

* The Team continues to meet monthly to review data & processes

Impetus for Our Team• Length of stay (LOS)- Data demonstrated that the average

LOS for patients with a diagnosis of sepsis was 2.4 days longer than the expected LOS

• NYS DOH Mandate- NYS required the implementation of a Sepsis Program in all hospitals by 12/31/2016; protocols were to be based on EBP standards

• Data Reporting- Measures to include adherence to protocols and time frames (bundles) and risk-adjusted mortality

• GNYHA STOP Sepsis Collaborative- Organizational decision to participate in this initiative to improve care in sepsis

Goals for the Sepsis Program

1. To reduce mortality in patient with severesepsis and septic shock by implementing aprotocol-based approach to identification/resuscitation

2. To enhance communication and patient flowbetween the ED and other areas of thehospital (i.e. ICU)

Early Goal-Directed Therapy

Activation of Sepsis Response

Suspected Sepsis?

For ED CODE SEPSIS

For IP Rapid Response SEPSIS

Any CODE SHOCK Scoop and Run to ICU

Modified Early Warning System (MEWS)Scoring Key 3 2 1 0 1 2 3

RespiratoryRate

< 8 9- 14 15- 20 21- 29 > 30

Heart Rate < 40 41- 50 51- 100 101- 110 110- 129 > 129

Systolic BP < 70 71- 80 81- 100 101- 199 > 200

LOC Non-responsive

Responds to pain

Respondsto voice

Alert New agitation/ confusion

Temperature 95 or less 95.1- 96.8 96.9-100.4

100.5-101.3

>101.3

Urine output for last 2

hours

< 10ml hour

< 30ml hour

<45ml hour

Systemic Inflammatory Response Syndrome (SIRS)

Systemic Inflammatory Response Syndrome (SIRS) – two or more criteria

Temperature < 96.8F- >100.4F Respiratory Rate > 20

Heart Rate > 90 Acute altered mental status

WBC >12 or < 4 Bands > 10%

Vital Signs every 4 hours (MEWS auto calculates, based on VS)

For all patients: MEWS < 2 = Continue to assess Q4H, reviewing vital signs and LOC

MEWS > 3 = RN to assess for:• Documented infection source• Potential new source

MEWS > 3 with NO infection or source?• Consider non-infectious causes (eg: AF/ AFL)• Continue to monitor Q4H with VS, LOC & UO

YES, infection or suspected source?• Evaluate for SIRS/ Sepsis (two or greater

criteria)

MEWS > 3 with NO criteria for SIRS/ Sepsis or other non-infectious cause?• Evaluate need for CBC-D, BMP and lactate if

labs > 6 hours old• Reassessment in 2 hrs with VS, LOC & UO

YES, 2 or more criteria for SIRS/ Sepsis?• Initiate Rapid Response Sepsis• Consider labs (lactate level)• For lactate > 4 repeat Q2H X3• Contact primary physician to implement the

Sepsis Adult Order set

After reassessment in 2 hrs:MEWS > 3 on next assessment?• Initiate Rapid Response Sepsis

• Fluid resuscitation, blood cultures and STATantibiotic given within 1 hour of lab value results

• CODE SHOCK initiated for hypotension that is refractory to fluid resuscitation (SBP <90)

• “Scoop and Run” transport to ICU

Emergency Department Triage• VS are entered into the ED Triage Sepsis Alert; a score > 3

triggers the RN to request a STAT evaluation by the EDprovider for possible Sepsis

• For cases of potential Sepsis, the Call Center will page aCODE SEPSIS overhead and Respiratory/ Radiology/ Labwill respond and begin the Early Goal-Directed Therapyand initiation of the ED Severe Sepsis/ Septic ShockAdult Order Set

• The ED Severe Sepsis/ Septic Shock Adult Order Setprovides pre-checked elements of care to expedite thebest practice interventions expeditiously

ED Severe Sepsis/Septic Shock Order Set

Rapid Response- Sepsis

•In the inpatient setting, a patient with a known orsuspected source and two or more criteria for SIRS,the RN will initiate a Rapid Response- Sepsis

•Responders will include a Critical Care RN, aRespiratory Therapist and a Laboratory Tech; aninitial Lactate- Sepsis will be drawn, per protocol

•The primary RN will notify the provider toimplement the Adult Sepsis Order Set and toconsider transfer to the ICU setting, if indicated

Severe Sepsis/ Septic Shock

Severe Sepsis is defined as the presence of sepsisand at least one clinical sign of multiple organdysfunction syndrome (MODS) and a lactate of > 4

(Note: 3.2 is considered a critical value)

Septic Shock is defined as Severe Sepsis withrefractory hypotension (SBP < 90 mmHg) and/orlactate > 4, despite appropriate fluid resuscitationof 30 mL/kg

Code ShockFor hypotension (SBP < 90 mmHg) that is

refractory to 30mL/kg fluid resuscitation and/or Lactate > 4, a CODE SHOCK will be initiated and

paged overhead by the Call Center.

The Intensivist or Hospitalist and the assigned ICU RN will respond to the

CODE SHOCK.

Code Shock• The ED physician notifies the primary provider of

the need to hospitalize the patient; the provider willaccept care and provide admission orders

• The ICU Intensivist (or Hospitalist during off hours)will respond to the CODE SHOCK and initiate theAdult Sepsis Order set to expedite care, if notalready in place

• A hand off will occur between the ED physician andIntensivist/ Hospitalist prior to a “Scoop and Run”approach to transferring the patient to the ICU

ICU Admission/ Transfer• The Scoop and Run process to the ICU includes a

targeted report from ED provider Intensivist• The ED RNICU RN handoff without delay in transport• Focus of care continues to be on the elements of the

three and six hour bundles; resuscitation is guided byinvasive or non-invasive methods:– CVP and ScvO2 monitoring via a central venous catheter OR– Monitoring of fluid status via an IVC ultrasound

• The Adult Sepsis Order Set and Nursing Sepsis/ RapidResponse documentation are guides to following thebest practice pathways

Adult Sepsis Order Set

Sepsis Documentation

Lactate- Sepsis• For Sepsis, a venous Lactate-Sepsis will be

drawn by Lab Staff, handed off to Respiratoryand resulted, using the Blood Gas Analyzer inthe ICU

• Subsequent lactate levels (Q2 hours X3 for atotal of four lactate levels) will be drawn by Labw/ hand off to Respiratory, using the sameprocess

Modified Early Warning System (MEWS)

The MEWS Scoring System is designed to identify patients who are at risk for sudden deterioration in condition. Key scoring features of the MEWS:

Respiratory rate Level of consciousnessHeart rate TemperatureSystolic BP Urine output for previous

two (2) hours

Scoring the MEWSPCA takes vital signs:

• Enters VS into the computerwithin one hour of obtaining

• PCA enters the T, BP, HR, RR andMeditech adds the vital signscore automatically

Note: Vital signs are obtained at:

0001 0800 1600

0400 1200 2000

RN reviews vital signs:• Enters the LOC and urine output

into the vital signs screen withinone hour of obtaining VS

• Obtains the two scores (LOC andUO) and adds them to the vitalsigns score

• RN arrives at the MEWS scoreand enters it into box

• A MEWS of > 3 w/ known sourceof infection and two SIRS criteriarequires a Rapid ResponseSepsis and call to provider

RN adds the LOC and UO, arrives at the MEWS Score and enters it into box

Scoring the MEWS

So… how are we doing with the Program?Glad you asked!The success of our program was largely due to thecollective efforts of the SLCH Sepsis Team and stafffrom ED, ICU, Medicine, Nursing, Pharmacy,Laboratory, Respiratory, Pharmacy, Quality, IT andothers.The Sepsis Program touched many areas of thehospital that are not involved in direct care but arecritical to our processes~ and share in the accolades.

Sepsis Management: 97th % in NYS

80

52

0

20

40

60

80

100

4/1/15-3/31/16

Three Hour Bundle

SLCH NYS Avg

72

32

0

20

40

60

80

100

4/1/15-3/31/16

Six Hour Bundle

SLCH NYS Avg

Source: NYSDOH Report (6/30/16)