Sepsis Webinar Series
2018
Presenter:
Angela Craig, APN, MS, CCNS
Please dial your Audio PIN#
which you can find under the Audio tab
• Consultant Angela Craig, APN, MS, CCNS
• For THA HIIN hospitals
• Conducted on site at your hospital
• Tailored to meet your unique interests and
needs
Sepsis Consultation Services
“Our thanks to Angela Craig and THA for this opportunity! We can’t
say enough good things to express how pleasant and encouraging her
visit was. I trust that more hospitals will utilize her expertise services
and look for better opportunities to care for patients with Sepsis!
Thank you very much!
• Save the Date - May 9, 2018
• In partnership with Qsource
– Will include nursing homes, home health
agencies, and other post-acute providers
Sepsis Readmissions Workshop
• 8 webinars: 4 instructional, 4 coaching/sharing 1. Organizational Consensus that Sepsis Be Managed Early and
Aggressively
2. Early Screening with Tools and Triggers
3. Implementation of the Sepsis Bundles
4. Measuring Success
• Instructional webinars are recorded and posted,
along with handout materials, on the Tennessee
Center for Patient Safety website:
www.tnpatientsafety.com/initiatives/sepsis
Sepsis Webinar Series
Touch Point
A N G E L A C R A I G A P N , M S , C C N S
I C U C C N S & S E P S I S F A C I L I T A T O R A T C R M C
SEPSIS PROGRAM DEVELOPMENT TIER II
Angela’s Contact Information:
[email protected] 931-239-4904 (cell)
Infection Prevention
VAE (VAP) Bundle BSI
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
Early Screening with Tools and
Triggers
Implementation of
the Sepsis Bundles
Measuring
Success
CQI1
SECOND TIER: IMPLEMENTATION OF SCREENING TOOLS AND
TRIGGERS
7
CAUTI
Hand Washing
Documentation Improvement
~ Accurate Coding 1Continuous Quality Improvement
Adapted from: Sepsis Solutions International
SCREENING FOR SEPSIS AND PERFORMANCE IMPROVEMENT
1. Performance improvement efforts in severe sepsis
should be employed to improve patient outcomes
(1C).
Dellinger, 2013 CCM
SEVERE SEPSIS: DEFINING A DISEASE CONTINUUM
Systemic Manifestations of
infection
with a
presumed or confirmed infectious process
Sepsis Systemic
Manifestations of infection
Known/Suspected Infection
Severe Sepsis
Sepsis with 1 sign of organ
dysfunction, hypoperfusion or hypotension.
Examples: • Cardiovascular
(refractory hypotension) • Renal • Respiratory • Hepatic • Hematologic • Unexplained metabolic acidosis
Adult Criteria
A clinical response arising from a
nonspecific insult, including ≥ 2
of the following:
Temperature:> 38°C or < 36°C
Heart Rate: > 90 beats/min
Respiration: > 20/min
WBC count: > 12,000/mm3,
or < 4,000/mm3,
or > 10% immature
neutrophils
Altered mental status
BG >140 (non diabetic)
SIRS = Systemic Inflammatory Response Syndrome Bone et al. Chest.1992;101:1644-1654.
Shock
DEFINITIONS
• Sepsis: presence of infection (suspected or
confirmed) with systemic manifestations of infection
• Severe Sepsis: Sepsis-induced tissue hypoperfusion
or organ dysfunction
• Septic Shock: Hypotension that persists despite
adequate fluid resuscitation
SERUM LACTATE IS ASSOCIATED WITH MORTALITY IN SEVERE SEPSIS INDEPENDENT OF ORGAN
FAILURE AND SHOCK MIKKELSEN, MARK ET AL CCM 2009 VOL 37 NO 5
Objective:
• Test whether the association between initial serum lactate level and mortality in patients presenting to the
ED with severe sepsis is independent of organ
dysfunction and shock
Design:
• Retrospective, single center cohort study
• Academic teaching hospital
Patients:
• 830 adults admitted with severe sepsis in the ED
• Stratified lactate into 3 groups: low (<2), intermediate (2-
3.9) and high (> or equal to 4)
SERUM LACTATE IS ASSOCIATED WITH MORTALITY IN SEVERE SEPSIS INDEPENDENT OF ORGAN
FAILURE AND SHOCK MIKKELSEN, MARK ET AL CCM 2009 VOL 37 NO 5
Results: • Intermediate and high
serum lactate significantly
associated with mortality
regardless of the presence of
shock or other organ
dysfunction
•A single serum lactate seems
to risk-stratify patients
independent of organ
dysfunction or hemodynamic
instability
CAN WE PREDICT MORTALITY IN INFECTED PATIENTS?
Systolic BP ≥ 90 still have ↑ lactate and mortality
ICM 2007 Vol 33: 1892-1899
Lowest ED
reading
Predicting Mortality in Infected Patients
HOMEOSTASIS IS UNBALANCED IN SEVERE SEPSIS
Carvalho AC, Freeman NJ. J Crit Illness. 1994;9:51-75; Kidokoro A et al. Shock. 1996;5:223-8; Vervloet MG et al. Semin Thromb Hemost. 1998;24:33-44.
Coagulation
Inflammation
Fibrinolysis
INFLAMMATION, COAGULATION AND IMPAIRED FIBRINOLYSIS IN SEVERE SEPSIS
Reprinted with permission from the National Initiative in Sepsis Education (NISE).
Endothelium
Neutrophil
Monocyte
IL-6 IL-1 TNF-
IL-6
Inflammatory Response to Infection
Thrombotic Response to Infection
Fibrinolytic Response to Infection
TAFI
PAI-1
Suppressed fibrinolysis
Factor VIIIa Tissue Factor
COAGULATION CASCADE
Factor Va
THROMBIN
Fibrin
Fibrin clot Tissue Factor
MICROCIRCULATION OF SEPTIC PATIENT: OTHOGONAL POLARIZATION SPECTRAL IMAGING
• BP: 120/80
SaO2: 98%
1. www.opsimaging.net. Accessed April 2004. 2. Spronk PE, Ince C, Gardien MJ, et al. Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet. 2002; 360:1395-1396.
MICROCIRCULATION OF SEPTIC SHOCK PATIENT: OTHOGONAL POLARIZATION SPECTRAL IMAGING
• Resuscitated with
• fluids and dopamine
• HR: 82 BPM
• BP: 90/35 mm Hg
• SaO2: 98%
• CVP: 25 mm Hg
1. www.opsimaging.net. Accessed April 2004. 2. Spronk PE, Ince C, Gardien MJ, et al. Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet. 2002; 360:1395-1396.
WHY DO YOU NEED TO HAVE A SCREENING PROCESS?
• TIME IS TISSUE!!
• Similar to trauma, AMI, or stroke, the speed and
appropriateness of therapy administered in the initial
hours after severe sepsis develops are likely to
influence outcomes.1
• To screen effectively, it must be part of the nurses’ daily routines— i.e., part of admission and shift assessment
• Must define a process for what to do with the results of the screen
If you don’t screen you will miss patients
that may have benefited from the interventions 1. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327.
Positive Screen
for Severe
Sepsis?
SCREENING FOR SEVERE SEPSIS
Yes
No
Surviving
Sepsis
Guidelines Monitor frequently
whether on
the ward
or ICU
Standard care
PAPER OR ELECTRONIC….THAT IS THE QUESTION
20
Method Pros Limitations
Paper form • Nurses critically think as they screen the patient
• Easy and quick to develop • No cost
• Screening is intermittent • Paper can be misplaced • Static—no ability to automate
an alert
EMR form • Nurses critically thinks as they screen the patient
• Can automate alerts for positive screens
• Screening is intermittent • Length of programming time • Cost
EMR—real time, continual screening
• 24 hour screening • Can automate alerts for positive
screens
• Nurse does not screen patient—potential loss of screening knowledge and critical thinking
• Computer not reliably able to identify patients who have
infection • Computer not able to discern if
SIRS is valid or organ dysfunction is new
EMR—real time and scheduled
• Form fires and pre populates for nurse to screen upon admission and each shift—nurse critically thinks
• 24 hour screening • Manual screen completed when EMR
alert fires---nurse discerns/validates
appropriateness/correctness of alert
• Screening form needs to be developed in EMR—programing time and costs
SCREENING TOOL EXAMPLE
• Suspicion of / confirmed
infection?
• S/S infection?
• Any 1 organ
dysfunction?
= Severe Sepsis • Lactate > 4 mmol/L?
= Severe Sepsis with
hypoperfusion (30ml/kg
bolus) • SBP < 90 or MAP < 70 or SBP >
40 mmHg below baseline BP?
(30 ml/kg bolus)
• Hypotensive after bolus?
= Septic Shock
SCREENING TOOL EXAMPLE
SCREENING TOOL EXAMPLES
MAKE SCREENING FOR SEVERE SEPSIS PROCESS-DEPENDENT
• Weave into fabric of current practice
• Bedside nurse should do the screening
• Define expectation to screen during shift assessment and PRN with changes in patient’s conditions
• Screen for severe sepsis with every rapid response or medical response team call
• Identify strategies for initiation of therapy once patient with positive screen for severe sepsis is identified
ESTABLISH TRIGGER FOR RAPID IMPLEMENTATION OF SSC BUNDLES
• Clearly define next
steps for patients with
positive screen for
severe sepsis
– Alert RRT/Med Team
– Notify Physician
– Begin 3 hour bundle:
lactate, blood cultures, antibiotics, fluid
SBAR
Situation:
Screened Positive for Severe Sepsis
Background:
1. Positive Systemic Response to Infection
2. Known or suspected infection
3. Organ dysfunction: share which organs
Assessment:
Any other pertinent data or information to share
Recommendations:
1. I need you to come and evaluate the patient to
confirm if they have severe sepsis
2. It is recommended that I get an ABG, lactate, blood
cultures and a CBC (if > 12 hrs since last one). Can I
proceed and get these?
3. Any other labs you would like me to obtain? Do you
want to order antibiotics?
4. If patient is hypotensive: Can I start an IV and give a
bolus of NS—30ml/kg
Date/time of call: ________________
RRT called: Yes No
DEVELOP A PROTOCOL BASED ON THE SSC GUIDELINES
• Obtain lactate when have 2 SIRS and suspected
infection
• When screen positive for severe sepsis:
• Nurse protocol to draw labs and give fluid bolus
• Protocol done by RRT/Medical Response Team or all nurses
• Get medical staff approval
Severe Sepsis Algorithm
Screened Positive for Severe Sepsis
OTHER STRATEGIES TO FIND PATIENTS WITH SEVERE SEPSIS
Unit sepsis champions
Sepsis coordinator
ED and ICU rounding
RRT screen on every call
Prospective patient log
Part of nursing shift handoff
Discuss sepsis screen as part of Interdisciplinary Rounds
Reports
• Patients who screened positive
• Lactate
30
COMMON BARRIERS
• Providers not trusting the severe sepsis screen
– Steep learning curve
• Lack of education regarding the early signs and symptoms of
sepsis progression
– Screening is not sensitive only for severe sepsis
– Positive screen is not a diagnosis of severe sepsis
• Screening compliance
– Inconsistent screening process on the wards
– Improper evaluation of the screen
• False positives, false negatives
– Negative response from physician when notified of a
positive screen
STRATEGIES FOR BARRIER RESOLUTION
• Formal education regarding 3 and 6 hour bundles improves screening and compliance with EGDT – Physician and Nursing grand rounds
• Put education in nursing/physician orientation
– House staff lunch and learn
– Feedback on specific cases to providers, staff
– Physician champion • Reinforce education and process
• Perform audits to measure compliance and identify problems
• Round on unit and ask team how it is going and discuss issues
• Must assign responsibility and enforce accountability
• Sepsis team members report feedback to their disciplines
• Re-define the physician and nurses’ standard of care for sepsis
AUDIT SCREENING PROCESS
WHAT IS AN ‘AUDIT’
• An AUDIT
is a planned and documented activity performed
by qualified personnel to determine by
investigation, examination, or evaluation of
objective evidence, the adequacy and
compliance with established procedures, or
applicable documents, and the effectiveness of
implementation. [1]
1. "Audit defined in Six Sigma and Beyond: The Implementation
Process Volume VII, D.H. Stamatis (CRC Press, 2002)
WHAT DO WE WANT TO LEARN?
• Screening compliance = all of the patients are
being screened for severe sepsis
• Screens are valid = Are the screens being done
correctly
• Screens are reliable = Screens are consistent from
RN to RN
WHAT DO WE WANT TO COLLECT?
Screening compliance: Denominator: The total number of patients/charts eligible for inclusion
• e.g. the total number of patients on the unit
Numerator: The total number of patients/charts where the activity was completed
• e.g. the total number of patients on your unit for whom a sepsis screen was performed.
.
Recommend: upon admission, once per shift (within 2 hours of start of shift) and PRN
-
DEFINITIONS FOR SCREENING COMPLIANCE
• Denominator: The total number of patients/charts
eligible for inclusion
• e.g. the total number of patients on the unit
• Numerator: The total number of patients/charts
where the activity was completed
• e.g. the total number of patients on your unit for whom a
sepsis screen was performed.
DEFINITIONS FOR SCREENING VALIDITY
Correct screens: • TRUE POSITIVE: THE NUMBER OF PATIENTS WHO
SCREENED POSITIVE THAT WHEN VALIDATED TRULY
MET CRITERIA FOR SEVERE SEPSIS
• TRUE NEGATIVE: THE NUMBER OF PATIENTS WHO
SCREEN NEGATIVE THAT WHEN VALIDATED TRULY DID
NOT MEET CRITERIA FOR SEVERE SEPSIS
SEVERE SEPSIS SCREENING AUDIT TOOL Unit
Date Bed # Screened Yes No
Screen done correctly Yes No
Positive Screen for severe sepsis Yes No
Urgent Measures implemented appropriately
Yes No
Fluid bolus of 30ml/kg for patients with hypotension
Yes No N/A
Which labs were sent? Lactic acid, venous pH, CBC, blood culture
Were the General Care/Intermediate care bundle implemented?
Yes No N/A
If no, which elements were not completed
Vital signs, serial lactic acid, strict intake and output
Did patient with severe sepsis have a lactic acid >4mmol/L or septic shock (SBP<90 after 30ml/kg fluid bolus or requires vasopressors)
Yes No
If met above criteria, was the patient transferred to the appropriate level of care (ICU)
Yes No
Comments
39
EARLY IDENTIFICATION
• Timely identification of patients with severe sepsis
and septic shock is essential
• Components of the Surviving Sepsis bundles are all
time sensitive interventions:
• 3 Hour Bundle
• 6 Hour Bundle • Bundles should be applied to all patients with
severe sepsis and septic shock
• Will always be when the chart annotation suggests
signs and symptoms are all present.
• May be from nursing charting, lab flow sheets,
physician documentation, anything with a time
stamp.
• Will = triage time if all signs and symptoms are
present at triage.
41
SEP-1 Time Zero
• Severe Sepsis: 3 Hour and 6 Hour Counters
• Septic Shock: 3 Hour and 6 Hour Counters
• Clinical Example follows
42
SEP-1 Two Clocks
• A patient developed severe sepsis at 3:00 pm but
did not become hypotensive and fail to respond to
fluids until 5:00 pm, does the “shock clock” starts at
5 pm?
• If so, then does the physical exam requirement
“between hours 3-6” begin at 5 pm with the shock
clock or at 3 pm when severe sepsis was first noted?
43
SEP-1 Two Clocks
• The severe sepsis clock would start with the presentation of severe sepsis (3:00 pm) and the septic shock clock would start with presentation of septic shock (5:00 pm).
• The presentation of severe sepsis at 3:00 pm will trigger the
following counters with the start time being 3:00 pm:
"Sepsis Three Hour Counter" would require the following be completed by 6:00 pm: • Initial lactate level measurement • Antibiotic Administration • Blood Cultures prior to antibiotics
• "Sepsis Six Hour Counter" would require the following be completed by 9:00 pm: • Repeat lactate if initial lactate is > 2
44
SEP-1 Two Clocks
• The presentation of Septic Shock at 5:00 will trigger the following counters with the start time being at 5:00 pm:
• "Shock Three Hour Counter" would require the following be completed by 8:00 pm:
• Resuscitation with 30 mL/kg of crystalloid fluids
• "Shock Six Hour Counter" ONLY If hypotension persists would require the following be completed by 11:00 pm:
• Vasopressor administration
• Repeating the volume status and tissue perfusion assessment (item F)
45
SEP-1 Two Clocks
CASE EXAMPLES
CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION
• 88 year old, 51.6kg,white, female admit from ED;
resided in ECF
• History: CAD, COPD, dementia, Alzheimer
disease, depression, SVT
• Chief Complaint: rib pain, chest congestion and
SOB
• Awake, alert and oriented, slight combative
(history of combative behavior)
CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION
• Triage: Initial VS: (10 am)
• Temp: 101.6 F
• RR: 31
• HR: 109, atrial fib with occasional SVT
• B/P: 79/51
• 2L of O2, O2 sat of 96%
• Does this patient screen positive for severe sepsis?
Positive Screen for severe sepsis:
SIRS: HR >90; RR> 20; Temp > 38
Organ dysfunction: SBP<90mmHg
WHAT ARE THE NEXT STEPS?
Call physician—follow SBAR
Expected orders:
Give fluid bolus of 30ml/kg bolus
Labs drawn(lactate, CBC, ABG)
CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION
• Labs: • WBC: 11.5
• Hgb: 15.8
• Hct: 47.4
• BUN: 28 Creatinine:1.6
• Glucose:158
• BNP:78 (moderate CHF); troponin:0.03
• Lactic acid: 4.6
• U/A: positive for bacteria
• Blood cultures X 2 drawn
CLINICAL SCENARIO 1: EARLY IDENTIFICATION AND INTERVENTION
• CXR: RLL consolidation
• Additional Interventions:
• Broad spectrum antibiotics given STAT
• Lactic acid >4mmol/L so need a central line inserted and transfer to the ICU
• Fluid resuscitation continued until transfer
• Foley inserted
• Diagnosis: Septic Shock, Pneumonia , UTI, CHF
• Transferred to MICU
CLINICAL SCENARIO 2: EARLY IDENTIFICATION AND INTERVENTION
• 62 yr old male, 2 days post op s/p
colectomy, 73kg,receiving antibiotics
• Vital signs: 11am- HR 120. RR 24, BP 80/40,
temp: 102.2; urine output 100ml over last
4 hrs
• Screen patient for severe sepsis
Positive Screen for Severe Sepsis
SIRS: HR>90; RR>20; Temp> 100.4
Infection: on antibiotics
Organ dysfunction: BP 90
CLINICAL SCENERIO II (CONT)
What are your next steps?
SBAR:
•Call doctor, ask for ABG, lactate and CBC
and fluid bolus of 1800 cc of NS in one hour
•Doctor to come and evaluate the patient
One Hour later: 12pm
VS: BP 86/48, HR 132, RR 18, on 2L with sat 92%; lactate: 5.5
ABG: pH 7.08, pCO2-35, pO2-77; sat 92% with bicarb:10
What orders should you expect from the physician?
Because of both continued hypotension and increased
Lactate---this patient should be transferred to the ICU
TIER II: SCREENING FOR SEVERE SEPSIS MILESTONES AND CHECKLIST
• Develop screening process for ED, rapid response
team, ICU, and all floors (housewide)
• Develop audit process to evaluate compliance and
effectiveness
• Ensure screening process has clear “next steps”
defined for nursing staff
SEPSIS PROGRAM ACTION PLAN
Item Responsibility Due Date Status
1. Assemble team
2. Identify
executive
sponsor
3. Educate team
on evidence
4. Project
Charter
5. Baseline data
6. Define
screening tool
and process—for
ED, ICU, Floor, RRT
7. Define
screening audit
process 56
AGENDA ITEMS FOR FIRST COUPLE MEETINGS
• Out of meeting work for members: review SSC
guideline article and key research studies
• Educate team on sepsis and evidence based sepsis
management
• Begin work on Sepsis Project Charter
• Team composition---do we have all the right people
• Set up plan for baseline(or current state) data
collection
• Define, how charts will be identified, what data will be
collected, by whom and by when
• Define screening tool and process
• Define screening audit process 57
AGENDA ITEMS FOR FIRST COUPLE MEETINGS
• Out of meeting work for members: review SSC guideline
article and key research studies
• Educate team on sepsis and evidence based sepsis
management
• Review highlights from MHA Sepsis Collaborative—Jan and
Feb Calls
• Begin work on Sepsis Project Charter
• Team composition---do we have all the right people
• Set up plan for baseline(or current state) data collection
• Define, how charts will be identified, what data will be collected,
by whom and by when
• Draft timeline for implementation of each of the Tiers
• Develop screening process and screening audit process 58
STRATEGIES FOR KEEPING SEPSIS FRONT AND CENTER
• Align team with clinical and quality structures in
organization
• Sepsis program/goals part of hospital quality plan
• Reporting progress and data quarterly to executive
leadership
• Report to hospital board annually
• Standing agenda item on department meetings
• Communication plan---includes flyers, newsletters,
postings in units etc.
59
NEXT STEPS SEPSIS PROGRAM ACTION PLAN
Item Responsibility Due Date Status
1. Assemble team
2. Identify
executive
sponsor
3. Educate team
on evidence
4. Project
Charter
5. Baseline data
6. Define
screening tool
and process—for
ED, ICU, Floor, RRT
7. Define
screening audit
process 60
QUESTIONS?
© 2013 CHE Trinity Health 61
Questions:
Rhonda Dickman, MSN,
RN, CPHQ
Clinical Quality
Improvement Specialist
615-401-7404 - office
706-570-5700 - mobile
Angela Craig, APN, MS,
CCNS
ICU CCNS & Sepsis
Facilitator at CRMC
931-239-4904 - mobile