Mortality Rate was unsightly!!! 4/24/2013. Sepsis Quality Improvement Project

Transcription

1 Libby, MT Sepsis Quality Improvement Project Barb Dumont RN, Director of Quality and Risk Management Mike Julius RN, ED Manager Cathy Wolfe RN, Chief Nursing Officer. Mortality Rate was unsightly!!! percent Mortality Rate 100% 80% 60% 40% 20% 0% Discharge Status Alive 52.9% Transferred 11.8% Deceased 35.3% 1

2 Our Emergency Physician Team 2

3 Mike Julius, RN, ED Manager Dr. Raymond Zurcher, Emergency Physician Nursing Physicians Pharmacy Respiratory Laboratory Everyone 3

4 Up grade equipment that allows for invasive monitoring in ED and ICU Develop pre printed orders everyone on the same page Aggressive and early antibiotic therapy initiated Maintain SVO2 > or equal 70% Continued Quality Improvement through Emergency Medicine Committee Up graded our telemetry and monitoring (with Mindray) 4

5 Developed Approved by all committees Crossed over and implemented them in electronic documentation in Meditech Use the paper tool during down time Review Sepsis Orders Check for Antibiotics that appropriate Continue with our process improvement 5

6 First Draft Reviewed by nursing staff and physician staff. REMINDER: All orders must be dated, timed, and signed by the prescribing physician. ORDERS AND SIGNATURE 1. If Lactic acid greater than recheck Lactic Acid every hours X 2. If Lactic Acid greater than 4: central line placement and monitor ScvO 2 3. INITIAL FLUID RESUSCITATION minimum 30 ml/kg bolus recommended Pt wt: kg X 30 ml/kg = ml for initial bolus. NS 1000 ml over minutes and repeat bolus of NS 500ml until 30ml/kg met. Repeat Lactic Acid one hour after initial 30ml/kg bolus and every 4 hours X 4. Continue boluses of NS 500ml X for target CVP of greater than 8 mm Hg (greater than 12 mm Hg if mechanically ventilated) and/or MAP greater than 65 mm Hg. If unable to meet parameters contact physician for further fluid orders. 4. ANTIBIOTICS Administer the following antibiotics within 3 hours of presentation (see page two for recommendations) STAT antibiotic # 1 STAT antibiotic # 2 For meningitis: give Decadron 10 mg IV 20 minutes prior to antibiotics Goals for first six hours of resuscitation: CENTRAL LINE PLACEMENT TO ACHIEVE THE FOLLOWING CVP 8 12 mm Hg (Greater than 12 is goal if on mechanical ventilation) MAP > 65 mm Hg ScvO2 > 70% (draw sample from central line) 5. HEMODYNAMIC/TISSUE PERFUSION MONITORIN: Monitor and document CVP, MAP, and ScvO 2 every 30 minutes 6. VASOPRESSORS: Consider vasopressors if patient remains hypotensive after 30 ml/kg fluid resuscitation Norepinephrine is first choice in sever sepsis. 7. ADDITIONAL SUPPORTIVE THERAPY: If ScvO 2 remains less than 70% despite a CVP of 8 12 mm Hg non-intubated (or mm Hg if mechanically ventilated) and the addition of vasopressors consider: Transfusion Therapy: 1 unit packed red cells if Hgb less than 7 mg/dl Inotropic Therapy: DOBUTAMINE Start IV infusion at 2.5 mcg/kg/min and may titrate by 2.5 mcg/kg/min every 10 minutes to maintain ScvO 2 > 70%. Maximum dose is 40 mcg/kg/min. 8. GLUCOSE CONTROL (Goal blood glucose: mg/ml) Finger-stick blood stick every 4 hours Initiate IV insulin drip order set (non-dka) if glucose greater than 180 mg/dl 9. Other orders Date: Time: Physician Signature P a g e 1 6

7 ANTI-INFECTIVE EMPERIC THERAPY Culture should be obtained prior to administration Administer antibiotics within the first hour of recognition of severe sepsis, initiate in ER Consider combination therapy in neutropenic patients or those with Pseudomonal infections Once cultures and sensitivity have been reported begin transporting from empiric broad spectrum antibiotics to more specific antibiotic drug regimens. Reassess anti-infective regimen daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs. Duration of therapy is 14 days (bloodstream) or 10 days (non-bloodstream): longer durations may be necessary in certain situations (i.e. endocarditis/osteomyellitis). Consider stopping anti-infective therapy if cause is found to be non-infectious. Pharmacy to renal dose adjusts medications as needed per protocol. Select anti-infective empiric regimen based on probable site of infection below: 1. Intra-abdominal Zosyn gm IV every six hours (consider renal dosing) or Tigecycline 100mg IV x 1dose then 50 mg IV every 12 hours. 2. Skin/soft tissue infection Vancomycin 1 gm IV every 12 hours. Adjust dose for goal trough levels between 10 15, or Linezolid 600 mg IV every 12 hours If necrotizing infection add Zosyn gm IV every six hours (consider renal dosing) 3. Central Line Infection: Line removal plus antibiotic therapy If MRSA suspected: Vancomycin 1 gm IV every 12 hours. Adjust dose for goal trough levels between 10 15, or Daptomycin 6 mg/kg IV every 24 hours or Linezolid 600 mg IV every 12 hours If non-mrsa (empiric therapy) Cefepime 2 gm IV every 12 hours or if PCN allergy may give Levofloxacin 750 mg IV every 24 hours (consider renal dosing) 4. Lungs (Healthcare Associated Pneumonia) Zosyn 4.5 gm IV every six hours (consider renal dosing) and Gentamycin 7 mg/kg IV every 24 hours If PCN allergy may give : Aztreonam 2 gm IV every 6 hours and Gentamycin 7 mg/kg IV every 24 hours If MRSA is suspected add to either regimen: Linezolid 600 mg IV every 12 hours or Vancomycin 1 gm IV every 12 hours, adjust dose for goal trough levels between 15 and Lungs (Community Acquired Pneumonia) Ceftriaxone 2 gm IV every 24 hours and Azithromycin 500 mg every 24 hours. If PCN allergy: may give Levofloxacin 750 mg IV every 24 hours (consider renal dosing) and Aztreonam 2 gm IV every 6 hours. If MRSA is suspected add to either regimen: Linezolid 600 mg IV every 12 hours or Vancomycin 1 gm IV every 12 hours, adjust dose for renal trough levels between Urosepsis Zosyn gm IV every 6 hours (consider renal dosing) If PCN allergy: may give Levofloxacin 750 mg IV every 24 hours (consider renal dosing) If VRE suspected give: Linezolid 600 mg IV every 12 hours. 7. Sepsis with Purpura (asplenia or hyposplenia) Ceftriaxone 2 gm IV every 24 hours or Levofloxacin 500 mg IV every 24 hours (consider renal dosing) 8. Sepsis secondary to chronic high dose steroids (Aspergillus Pneumonia) Voriconazole 6 mg/kg IV every 12 hours X 2 doses, then 3 mg/kg IV every 12 hours (consider renal dosing) or Micafungin 100 mg IV every 24 hours (preferred when CrCl < 50 ml/min 9. Persistent Fever and neutropenia after 5 days of empiric antibacterial therapy Micafungin 100 mg IV every 24 hours or Voriconazole 6 mg/kg IV every 12 hours X 2 doses, then 3 mg/kg IV every 12 hours. 10. Unknown site Vancomycin 1 gm IV every 12 hours. Adjust dose for trough levels between and Zosyn gm IV every 6 hours (consider renal dosing) and Gentamycin 7 mg/kg IV every 24 hours. P a g e 2 P a g e 1 7

8 This image cannot currently be displayed. 4/24/2013 P a g e 2 Our ED Manager manages and views the process Brings to Committee 8

9 We improved Input the data (have the numbers) 100% Mortality Rate 80% percent 60% 40% 20% 0% Discharge Status Alive % Alive % Transferred % Transferred % Deceased % Deceased % 9