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1 Disclosures No conflicts of interest to disclose Sepsis: Improving Early Recognition Patricia Conlon, APRN, CNS, CNP & Kelly Fjerstad, MSN, MBA/HCM, RN, NE-BC Objectives Define sepsis and the scope of the problem Explain the sepsis screening and team huddle process Demonstrate accurate use of the tool Recognize benefits of using a structured screening and assessment process What is Sepsis? Sepsis is a potentially life-threatening response to an infection which can lead to tissue damage, organ failure, and death Most common cause of death in infants and children worldwide Can be caused by bacterial, viral, or fungal infection Most common cause of pediatric sepsis: pneumonia (Randolph & McCulloh, 2014)

2 Background Severe sepsis has a mortality rate estimated between 8.2%-21.2% in the United States Prevalence estimated at 4.4% of hospitalizations in 2012 Median hospital length of stay: days Median hospital costs per patient: Between $52,000- $65,600 Why are we concerned? (Balamuth et al., 2014) It is more in the headlines Tennis champion dies of sepsis, Novato widow wants to raise awareness Sepsis death highlights need to adapt care for disabled patients (September, 2018) Hospital deaths from sepsis rise by more than a third (August, 2018) Raising Awareness Of Sepsis Could Save 14,000 Lives Every Year... (Feb 2016) A Family s Perspective The Brutality of Sepsis will Haunt Us for the Rest of Our Lives (CDC) Sepsis Killed My Dad But Knowing the Signs May Save a Life I nearly died from sepsis and ignorance of this condition is killing millions

3 Defining Sepsis Systemic Inflammatory Response Syndrome Sepsis (SIRS + suspected infection) Severe Sepsis (sepsis + organ dysfunction) Septic Shock (sepsis + cardiovascular dysfunctionunresponsive to fluid bolus) It is about TIME: advice to patients and families on when to consider sepsis Temperature: higher/lower than normal Infection (signs and symptoms) Mental decline (confused/sleepy/difficult to arouse) Extremely ill (I feel like I might die, severe pain or discomfort) Sepsis takes a life every 2 minutes (Sepsis Alliance) (Goldstein et al., 2005) Health care professionals: if sepsis, what should you look for? Inflammatory High white blood cell count Immature white blood cells in the circulation Elevated plasma C-reactive protein Elevated procalcitonin (PCT) Hemodynamic Low blood pressure Low central venous or mixed venous oxygen saturation High cardiac index Organ Dysfunction Low oxygen level Low urine output High creatinine in the blood Coagulation (clotting) abnormalities Absent bowel sounds Low platelets in the blood High bilirubin levels Tissue Perfusion High lactate in the blood Decreased capillary filling or mottling

4 Pediatric Challenges Symptoms can vary Age-specific guidelines Children can compensate well Hypotension presents later Immature immune system relative to adults Labs WBCs (high or low) Blood cultures Lactate Creatinine (renal dysfunction) Bilirubin (hepatic dysfunction) (Randolph & McCulloh, 2014) (Goldstein et al., 2005) Improving Pediatric Sepsis Outcomes (IPSO) National collaborative through the Children s Hospital Association with 50 hospitals as of September 2018 Motto: all share, all learn Aim: Reduce mortality and hospital-onset severe sepsis by 75% in the United States pediatric acute care setting by 12/2020 Key Areas of Focus Prevention Recognition Diagnostic Evaluation Resuscitation/Stabilization De-escalation Patient and Family Engagement Optimize performance

5 Newer members: Johns Hopkins, FL Beacon Children s Hospital, IN MUSC Children s Hospital, SC St Luke s Children s Hospital, ID Real Life Examples Erin's Campaign for Kids- Sepsis Alliance Nathan's Story- Children's Hospital Association Importance of Early Recognition Improved outcomes (Balamuth et al., 2015) Decreased mortality (Jones et al., 2015; Moore et al., 2009; Westphal et al., 2011) Decreased length of stay (Larsen, Mecham, & Greenberg, 2011) Decreased hospital costs (Jones et al., 2015) Decreased morbidity and long term sequelae Peri-anesthesia RN s role Awareness of signs and symptoms of sepsis Monitoring VS changes inflammatory markers hemodynamic and tissue perfusion parameters, watching for organ dysfunction Identify those at greatest risk (Flynn Makic, 2012)

6 Peri-anesthesia RN s role Children of any age can develop sepsis. However, it is more common in children who have: A weakened immune system. Recently had major surgery. A chronic illness such as cancer, heart disease, diabetes, kidney or liver disease. A temporary or permanent central catheter. Had a heart, liver, kidney or stem cell (bone marrow) transplant. A severe cognitive disability Tackling sepsis here Baby steps Initiating timely fluid resuscitation and antimicrobial therapy as prescribed (Flynn Makic, 2012) Pilot conducted of sepsis screening tool on general pediatrics IPSO collaborative shared many screening tool examples MCCC Multidisciplinary Pediatric Sepsis Collaborative Group chose 1 Practice committee members used paper version shared by the IPSO consortium group as a PDSA Further group of Gen Peds RNs assisted in screening patients Charge RNs were aware Results collated Pilot Results The tool was easy to use. Majority of people estimated that it took less than 60 seconds to complete Accurate assessment of potential sepsis

7 Tool moved to the electronic environment Bedside RN completes Sepsis Screening Tool at 0800 and 2000 and PRN for clinical changes (i.e. patient spikes a fever) Currently a separate flowsheet How to fill out Sepsis Screening Tool How to fill out Sepsis Screening Tool Will screen positive if 1 High Risk Conditions + 2 Clinical Criteria OR 3 Clinical Criteria Positive Screenings - Team Huddles Contact the service and charge nurse Structured clinical assessment to occur within 30 minutes Team-based discussion Determine if possible/probable severe sepsis and how to proceed with care

8 Testimonial Improve both safety of patients and communication between residents, nurses, RT, consultants, etc. as well as promote good patient care to have everyone on the same page with contingency plans in place Nurses- objective report of concerns Prioritizes the patient and the response to concerns What about positive screens in patients who do not have sepsis? Huddle now Huddle later (deferred) Service writes orders for when future huddles are needed

9 Sepsis It is common It is becoming more frequent It can be fatal or result in long term morbidity It can result in prolonged hospitalization It costs a lot of money. But We can all have a significant impact on it Educating ourselves about sepsis Educating our patients and families about sepsis Empower them to speak up Practicing formalized screening for sepsis Asking could this be sepsis needs to be in our vocabulary more We can all have a significant impact on it Frequently reassessing after IV fluid boluses and other interventions Collective goal: early recognition and treatment to prevent severe sepsis, shock, death Increasing Awareness September 13 th World Sepsis Day Remember to consider could this be sepsis? Sepsis begins outside of the hospital in 80% of cases per the CDC

10 References Balamuth, F., Weiss, S.L., Neuman, M.I., Scott, H., Brady, P.W., Paul, R.,... Alpern, E. R. (2014). Pediatric severe sepsis in US children s hospitals. Pediatric Critical Care Medicine, 15(9), doi: /PCC Flynn Makic, MB (2012). Surviving Sepsis Campaign Guideline Update 2012: What Does it Mean for Perianesthesia Nursing? Journal of PeriAnesthesia Nursing, 28(4), Issue 4, pages Goldstein, B., Giroir, B., Randolph, A., & Members of the International Consensus Conference on Pediatric Sepsis. (2005). International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatric Critical Care Medicine, 6(1), 2-8. doi: /01.PCC E6 Hartman, M.E., Linde-Zwirble, W.T., Angus, D.C., & Scott, W.R. (2013). Trends in the epidemiology of pediatric severe sepsis. Pediatric Critical Care Medicine, 14(7), doi: /pcc.0b013e fad Jones, S.L., Ashton, C.M., Kiehne, L., Gigliotti, E., Bell-Gordon, C., Disbot, M.,.... Wray, N.P. (2015). Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program. Joint Commission Journal on Quality and Patient Safety, 41(11), References continued Larsen, G.Y., Mecham, N., & Greenberg, R., (2011). An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics, 127(3, e1585-e1592. doi: /peds Moore, L.J., Jones, S.L., Kreiner, L.A., McKinley, B., Sucher, J.F., Todd, S.R.,... Moore, F.A. (2009). Validation of a screening tool for the early identification of sepsis. The Journal of Trauma: Injury, Infection, and Critical Care, 66(6), doi: /TA.0b013e3181a3ac4b Randolph, A.G., & McCulloh, R.J. (2014). Pediatric sepsis: Important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence, 5(1), doi: / viru Reeson, D. (2017). Families and clinicians fight against sepsis. Children s Hospitals Today. Retrieved from Westphal, G.A., Koenig, A., Filho, M.C., Feijó, J., Trindade de Oliveira, L., Nunes, F.... Roman Goncalves, A.R. (2011). Reduced mortality after the implementation of a protocol for the early detection of severe sepsis. Journal of Critical Care, 26(1), Retrieved from #!/browse/journal/ /latest Questions?