Our Journey on the Road

to Surviving Sepsis

Debbie Sober, RN, MSN

Community Hospital of the Monterey

Peninsula

Community Hospital of

the Monterey Peninsula

• 205 bed acute care hospital

• 28 bed skilled nursing

• Primary Stroke Center

• TJC Diabetes Certification

• Bariatric Center Excellence

• Cardiac Surgery

• Electrophysiology

• Invasive/diagnostic cardiology

• Behavioral Health Services

• Comprehensive Cancer Center

• Interventional Radiology

• Hospice

• Outpatient Surgery Center

Objectives

• Discuss current state of sepsis

management at Community Hospital of

the Monterey Peninsula

• Discuss importance of a

multidisciplinary team to implement

early goal directed therapy on medical-

surgical units, emergency department

and the intensive care unit.

• Discuss importance of standardizing

order sets for the hospitalist,

emergency department and intensivist

using evidence from the Surviving

Sepsis Campaign

How the need was

identified

• Critical Care Work Group

– Multiple anecdotal case

reviews

• Identified knowledge deficit

among different staff and

physicians

– Rapid Response Team

Performance Improvement

Report

• Number of ICU transfers

• Number of RRT calls

How the need was

identified

• Critical Care Work Group asked

– for small subgroup to evaluate the

problems and provide solutions

– for a Grand Rounds on Managing

Sepsis

SURVIVING SEPSIS TEAM

First team meeting April 2011

Reviewed 2010 data to identify scope of problem

Admission Source # Patients % Column1

Total 497

Transfer to ICU # Patients % Average time to transfer

from Med-surg 63 5.2 days

from Main Pavilion 16 1.8 days

Total Transfer of all pop. 79 16% 4.5 days

Possible savings if no transfer to ICU* # Patients Days

from Med-surg ($3870/day) 63 400 $1,548,000

from Main Pavilion ($1407/day) 16 262 $368,634

Total 79 $1,916,634*Bed charges only, does not inc. supplies

Overall sepsis rate (admissions) 4.0%

Overall sepsis rate/ 1000 patient days 6.6

Total patient days 5300

Average LOS, days 10.6

Mortality 129 26.0%

Surviving Sepsis

Team

• Data revealed problem with

identifying “early sepsis”

• Inadequate fluid resuscitation

prior to starting Dopamine

• Resulting in transfer to ICU in

Septic Shock

“Intubation is not a failure"

-Dr Karim Tadlaoui,

Intensivist, CHOMP

SURVIVING SEPSIS TEAM

• Identified the evidence-based literature and adopted as standard of

care Institute for Healthcare Improvement Surviving Sepsis

Campaign (Early Goal Directed Therapy)

• Identified current state in the Emergency Department, Intensive Care

Unit and Nursing Units

• Identified desired workflow and targeted patient placement and

began development of refinement of order sets.

SURVIVING SEPSIS TEAM

Sepsis Guideline “unofficial” Update

Highlights

2012 SCCM Congress

• Will be published in June 2012

• Bundles include Initial and Septic

Shock Bundle (delete

Management bundle)

• Two blood cultures w/in 45

minutes prior to antibiotics

• Use crystolloids initial fluid

resusitation

• Add Albumin if needed

• Do not recommend use of

Hetastarch

• 30ml/kg fluids first 4-6 hours

Update (cont)

• Fluid challenges ok only if progress

being made

• MAP > 65

• Recommend Norepinephine as first

choice

• Then Epinephrine as second choice

• Dopamine only used on highly selected

patients (low cardiac output, etc.)

• Vasopressin can be added to Norepi

but should not be used as initital

vasopressor

• Dobutamine after resuscitation with

signs hypoperfusion

More “unofficial”

updates

• Only use steroids if

vasopressors/fluids do not

restore hemodynamic stability

• 200mg IV daily

• No stim test recommended

• Suggest proning for severe

ARDS patients

• Do not recommend

neuromuscular blockades unless

severe ARDS <48 hours

• Keep blood glucose < 180

• Recommend CRRT rather then

intermittent hemodialysis

Rotoprone

SURVIVING SEPSIS TEAM

• Joined Beacon Collaborative – share improvement strategies and allow

comparison of performance

Participated in SimSuite Sepsis Quality Initiative Training

(Sponsored by Hospital Council and Anthem Blue Cross)

“The

Bus”

SURVIVING SEPSIS TEAM

NEXT STEPS

• Strategic Initiative -Team Charter developed, seek approval

• Implement Order Sets

• Education - Several Avenues

• Physicians – Targeted training: Central Line insert

• Staff – Critical Care Competency Camp, Education Fair

• All – Return of the bus; expand

• Focused monitoring and mentoring ongoing

Sepsis

April 2011

RN Education Fair

Objectives

• Identify clinical indicators (signs

and symptoms) of sepsis

• Verbalize difference between

warm and cold sepsis

• State the definition of SIRS,

sepsis, severe sepsis & septic

shock

• Verbalize treatment plans for

sepsis

SEPSIS = Systemic Inflammatory Response Syndrome + Infection

If patient has symptoms in all three categories below, suspect Severe Sepsis. Notify the

physician and consider calling the Rapid Response Team.

□ A. Suspected or Confirmed Infection Criteria

□ Positive culture

□ Diagnosis of pneumonia

□ Any condition with a known risk of associated infection

(immunosuppression, etc.)

□ Any suspected source of infection (PICC line, Foley, wound, etc.)

□ B. Systemic Inflammatory Response Syndrome (SIRS)

□ Altered mental status

□ Temp >100.4 F or < 96.8 F

□ HR > 90

□ RR > 20

□ WBC > 12,000 or < 4,000/mm³, or normal with more than 10 % bands

□ Hyperglycemia BG > 120 (in the absence of diabetes)

□ Significant edema or positive fluid balance (> 20ml/kg over 24 hrs)

□ C. Organ Dysfunction

□ Cardiovascular: SBP < 90 or decrease in SBP >40 mm Hg

□ Respiratory: O2 sats <93 % (in the absence of known CO2 retention) or if

ABG available - PaCO2 <32

□ Renal: Significant decrease in urine output in the absence of renal failure or

creatinine >2.0 mg/dL (normal U/O = 1ml/kg/hr, Sig decrease = < 0.5

ml/kg/hr for more than 2 hrs)

□ Hepatic: Total bilirubin > 2.0 mg/dL

□ Metabolic: lactate level > 4 or if ABG available pH < 7.30

□ Hematologic: Platelets < 100,000mm³ or INR > 1.5 or aPTT >60 secs

When communicating the physician, be sure to use SBAR technique.

Situation – What is the patient’s condition? Explain why you suspect sepsis.

Background – Diagnosis and relevant history (possible source of infection).

Assessment – Include vital signs, O2 sats, BG, LOC, I&Os and any significant

changes from baseline assessment.

Recommendation – Ask the physician to consider the following….

□ IV bolus for BP support and maintenance IVF

□ Oxygen to keep sats > 93%

□ ABGs

□ Transfer to a monitored bed or ICU if unstable or requires vasopressors.

□ Cultures – Blood / Urine / Sputum / Wound (if applicable)

- Cultures should always be obtained before administering antibiotics.

If patient has a PICC or CL obtain an order for one BC to be drawn from the line

and one drawn peripherally.

□ Antibiotics (broad-spectrum)

- Remember to report patient allergies to antibiotics and elevated creatinine

as this may change the dosage and frequency of the antibiotic ordered.

□ Diagnostic tests (Chest X-ray, EKG)

□ Labs – CBC, CMP, BNP, PT/INR, Lactate (elevated in patients at risk for septic

shock even before patient becomes hypotensive)

We still have a ways to go……

Only 24

patients

on ED

order

sets

What’s next…

• Finalize order sets

• Finalize algorithm and post on all

nursing units and ED

• Ongoing education- Hospitalists

• Ongoing education- Nursing

• Develop Sepsis Screening tool

integrated in computer

• Develop a report system to alert

RRT for at risk septic patients on

other units

• Daily review order set use

• Performance Improvement

• Immediate feedback to MD/RN

Thank you