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Sepsis Initiative

Sepsis Initiative. Jake Lyons, MD. TAKE HOME POINTS. Sepsis is SIRS with infection Severe Sepsis = Sepsis with organ dysfunction You are on the clock once sepsis recognized - Time is Tissue. Sepsis Get cultures Check Lactate Order ABX Determine whether IVF’s necessary.

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Sepsis Initiative

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  1. Sepsis Initiative Jake Lyons, MD

  2. TAKE HOME POINTS • Sepsis is SIRS with infection • Severe Sepsis = Sepsis with organ dysfunction • You are on the clock once sepsis recognized • - Time is Tissue

  3. Sepsis Get cultures Check Lactate Order ABX Determine whether IVF’s necessary TAKE HOME POINTSWhat do you need to do? • Severe Sepsis • Get cultures • Check Lactate • Order ABX • Gives IVF’s Goal is to get these completed or started within 1 hour!!!

  4. Background • Rory Staunton • Scraped arm in gym class • Evaluated by PCP and ED • - Sepsis not recognized • - Discharged from ED • Returned to ED • Died 4 days after scraping arm of invasive Group A Strep infection with septic shock

  5. NYS Regulations • Screening and early recognition of patients with sepsis, severe sepsis and septic shock • A process to identify and document individuals appropriate for treatment through severe sepsis protocols • Guidelines for treatment including for early delivery of antibiotics

  6. NYS Regulations • Hospitals will be required to ensure that appropriate hospital staff members are trained in the protocols • Require hospitals to collect data and quality measures to make internal quality improvements • Report data to the Department of Health for use in monitoring compliance and updating best practices

  7. Common and Expensive Disease • Severe Sepsis- 2% of admitted patients • - 50% treated in ICU • - 10% of all ICU admissions • - 750,000 cases/year • - 550 deaths/day • ~30% mortality • - Frequently have neurocognitive dysfunction • - Mood disorders • - Decreased QOL • $16 Billion per year

  8. Inpatient MortalityWrong Direction

  9. Definitions • SIRS • - 2 or more of the following: • Temp >38.3, <36.0; RR >20, HR >90, WBC >12,000 or <4,000; >10% bands • Sepsis • - SIRS plus source or suspected source of infection • Severe Sepsis • - Sepsis plus end organ dysfunction • Septic Shock • - Persistent hypotension despite adequate fluid resuscitation

  10. Organ Dysfunction

  11. Oxygen Delivery and Utilization

  12. Oxygen Delivery and Utilization SEPSIS LACTIC ACIDOSIS

  13. PathophysiologyVicious Cascade

  14. 10% mortality Lactic Acidosis 20% mortality 30% mortality Mmol/L mg/dl 1 = 9 2 = 18 3 = 27 4 = 36 Intensive Care Med 2007;33(6):970–7

  15. In hospital mortality • 30.5% in EGDT group • 46.5% in standard therapy • Set end points • CVP • MAP • ScvO2

  16. Dellinger et al. CCM. 2013;41(2):580-637.

  17. Initial Resuscitation Bundle • Should occur ASAP • Location independent • Management Bundle • After the 6 hour bundle completed • Typically managed in the ICU Dellinger et al. CCM. 2013;41(2):580-637.

  18. First 6 hours - “Golden Hours” Goal within 1 hour “This protocol should not be delayed pending ICU admission” Dellinger et al. CCM. 2013;41(2):580-637.

  19. GOALS - Lactate Clearance • Predictors of survival • Lactate normalization • Relative lactate clearance of 50% • 10% lactate clearance was non-inferior to ScvO2 Nguyen et al. CCM 2004. 32;8:1637-42

  20. GIVE THE ABX!! Initiation of antibiotics within the first hour- ~80% survival -every additional hour to effective antimicrobial initiation -survival decreased by 7.6%/hour

  21. Give the RIGHT ABX!!!

  22. GOALS - FLUIDS • Severe sepsis • Lactate >4 • Hypotension 2 Liters should cover it

  23. GOALS - Source of Infection • After initial resuscitation has started • Evaluate for removable/drainable source of infection • Will be prompted by nursing

  24. After Initial Resuscitation Management Bundle • Vasopressors • Norepinephrine • SAY NO TO DOPAMINE • Vasopressin • Low Dose

  25. Management Bundle • CVP • ScvO2 • Mechanical Ventilation • Low Tidal Volume Ventilation • Prone positioning • Paralytics • Steroids • Vasopressor refractory shock • PRBC’s • Dobutamine

  26. ICU Involvement • Can call any time • No response to fluid bolus • BP • Persistently elevated lactate (if elevated initially) • Goal would be 10-20% clearance within first few hours • Urine output

  27. The Power of U .net • Web Crawler • Constantly searching the EMR for the presence of SIRS/Sepsis

  28. EARLY RECOGNITION WEB CRAWLER

  29. Early RecognitionWeb Crawler • SIRS alert • Severe Sepsis Alert

  30. Sepsis Stratification • Nurse will contact provider • Provider will be responsible for filling out form within 15 minutes of contact • Prompting provider to initiate appropriate power plan • Relationship established with primary nurse to ensure completion of resuscitation bundle

  31. Stratification form

  32. Stratification form cont.

  33. Stratification form cont. • Central Line/PICC • A-line • Mechanical Ventilation • Fluid Resuscitation • Pressors • PRBC’s

  34. Time = Tissue

  35. NursingPivotal Role • Team approach • Provider • Laboratory services • Pharmacy • Recognition of need for timely intervention • Dedication to identifying a “sepsis point person” • Day shift: Clinical Nurse Leader/Charge Nurse • Evening & Night: Charge Nurse/Clinical Resource Nurse/Nursing Supervisor • Assist in ensuring tasks completed • Utilize reference card to determine follow-up evaluation and prompt provider in timing of further testing/procedures/diagnostic testing

  36. NursingPivotal Role

  37. Multidisciplinary ApproachPharmacy • Have committed to delivering antibiotics in a timely manner • Understand the importance of administering antibiotics within 1 hour

  38. Multidisciplinary ApproachLaboratory/ACM • Have committed to drawing cultures and labs promptly • Cultures to be drawn before antibiotic administration • Sites to be labeled • Lactic acid level to be drawn and reported STAT

  39. Education Works!!!

  40. TAKE HOME POINTS • Sepsis is SIRS with infection • Severe Sepsis = Sepsis with organ dysfunction • You are on the clock once sepsis recognized • Time is Tissue

  41. TAKE HOME POINTSWhat do you need to do? • Sepsis • Get cultures • Check Lactate • Order ABX • Check Lactate • Determine whether IVF’s necessary • Severe Sepsis • Get cultures • Check Lactate • Order ABX • Give IVF’s • Reevaluate Goal is to get these completed or started within 1 hour!!!

  42. Clinical Informatics Education

  43. Where the Sepsis Crawler is Evaluating Patients • 2100 • 2200 • 2300 • 2600 • 2700 • 3100 • 3200 • 3300 • 3400 • 3600 • (future 5100) • 2400 IMCU • ED EOU • ED Nurse Station • ICU • PR4100 • PR4200 • PR4300 • PR4400 • ED Ambulatory • PACU ES

  44. Who will be alerted • All Providers, including Residents and APP • All nurses – who have a relationship with patient – 17 hours

  45. Workflow - Provider • SIRS or Severe Sepsis Alert fires

  46. Workflow – VerifyingPatient Name • Provider should always confirm the patient they are working on when the Alert fires • This is important during down times as you will receive multiple alerts when system becomes available

  47. Sepsis Screening and Stratification

  48. Sepsis Screening and Stratification

  49. Sepsis Screening and Stratification – cont.

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