Sepsis: Getting to ZERO Probable or Impossible?

Transcription

1 Sepsis: Getting to ZERO Probable or Impossible? Carol A Rauen, RN-BC, MS, CCRN, PCCN, CEN Independent Clinical Nurse Specialist & Education Consultant. Burn Trauma ICU, Sentara Norfolk General, VA

2 Sepsis Alliance Sepsis Emergency video

3 Shock Definition A Manifestation of the Rude Unhinging of the Machinery of Life. Gross, 1872 A Momentary Pause in the Act of Death. John Collins Warren, 1895

4 History Pre-World War I Korean War Vietnam War /08/13

5 Septic Shock Definitions 1992 ACCP/SCCM Sepsis: The Systemic Response to Infection, Manifested by Two or More of the Following Conditions as a Result of Infection. Temp > 38 0 C or < 36 0 C HR > 90 RR > 20 or PaC0 2 < 32 mmhg WBC > 12,000 or < 4000 or 10% bands

6 Septic Shock Definitions 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definition Conference General Variables Inflammatory Variables Hemodynamic Variables Organ Dysfunction Tissue Perfusion Variables Levy, et al (2003). CCM

7 Shift in Focus Angus, D. et al Epidemiology of Severe Sepsis in the US: Analysis of Incidence, Outcome, and Associated Cost of Care. Critical Care Med (2001)

8 Angus et al Who was studied? Discharge records of 6,621,559 patients from seven large states and 847 hospitals representing 25% of the US total population

9 Angus et al What? Review of hospital discharge records in 7 states for severe sepsis. Evaluation of these records for mortality, morbidity, cost. Why? To determine the national magnitude of severe sepsis

10 Angus et al What Happened? 192,980 cases of severe sepsis National estimates of 751,000 annually 51.1% ICU & 17.3% required vent Overall mortality was 28.6% Mortality > 85yr 38.4% Avg cost/case $22,100 Estimated annual national $16.7 billion Avg LOS 19.6 days

11 Angus et al What Does it Mean? Conclusion: Severe Sepsis is a Common, Expensive, and Frequently Fatal Condition, with as Many Deaths Annually as Those From Acute Myocardial Infarction. It is Especially Common in the Elderly and is Likely to Increase Substantially as the US Population Ages.

12 Angus Not Alone Martin et al (2000) Dombrovskiy et al (2007) Wang et al (2007) ICD 9 Codes CDC Definitions Big Numbers! Sepsis is #1 Cause of Death of hospitalized pts Maybe #2 Cause of Death Nationally

13 Rivers, et al (2001) NEJM Control Group vs Goal Directed Tx In ED for Septic Shock Pts

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15 Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2004 Pg 236

16 Pg 236 Why? Develop Evidence-Based Guidelines & Change Clinical Behavior Through Implementation of These Guidelines

17 SSC Guidelines 11 International Organizations Critical Care and Infectious Disease Experts Modified Delphi Method

18 Levels of Evidence GRADE System Grades of Recommendation, Assessment, Development and Evaluation A. RCT Randomized Control Trial B. Downgraded RCT or Upgraded Observations Studies C. Well-Done Observational Studies D. Case Series or Expert Opinion Recommendation vs Suggestion 1. Strong Evidence Support Recommend 2. Weaker Evidence Support - Suggest

19 Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 R. Phillip Dellinger, MD; Mitchell M. Levy, MD; Andrew Rhodes, MB BS; Djillali Annane, MD; Herwig Gerlach, MD, PhD; Steven M. Opal, MD6; Jonathan E. Sevransky, MD7; Charles L. Sprung, MD; Ivor S. Douglas, MD; Roman Jaeschke, MD; Tiffany M. Osborn, MD, MPH; Mark E. Nunnally, MD; Sean R. Townsend, MD; Konrad Reinhart, MD; Ruth M. Kleinpell, PhD, RN-CS; Derek C. Angus, MD, MPH; Clifford S. Deutschman, MD, MS; Flavia R. Machado, MD, PhD; Gordon D. Rubenfeld, MD; Steven A. Webb, MB BS, PhD; Richard J. Beale, MB BS; Jean-Louis Vincent, MD, PhD; Rui Moreno, MD, PhD; and the Surviving Sepsis Campaign Critical Care Medicine Feb 2013, vol 41(2) 580

20 SSCG 2013 I. Initial Resuscitation and Infection Issues. 6 Recommendations II. Hemodynamic Support and Adjunct Therapy. 4 Recs II. Other Supportive Therapy of Severe Sepsis. 13 Recs

21 SSCG 2013 I. Initial Resuscitation and Infection Issues. A. Initial Resuscitation B. Screening for Sepsis & Performance Improvement C. Diagnosis D. Antimicrobial Therapy E. Source Control F. Infection Prevention

22 SSCG 2013 I. Initial Resuscitation and Infection Issues. A. Initial Resuscitation 1. Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration 4 mmol/l). Goals during the first 6 hrs of resuscitation: a) CVP 8 12 mm Hg b) MAP 65 mm Hg c) UO 0.5 ml/kg/hr d) Central venous or SVO2 70% or 65%, respectively (grade 1C). 2. In pts w elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

23 SSCG 2013 I. Initial Resuscitation and Infection Issues. B. Screening for Sepsis and Performance Improvement 1. Routine screening of potentially infected seriously ill pts for severe sepsis to allow earlier implementation of tx (grade 1C). 2. Hospital based performance improvement efforts in severe sepsis (UG).

24 Surviving Sepsis Campaign Updated Bundles in Response to New Evidence 04/2015

25 Surviving Sepsis Campaign Updated Bundles To Be Completed w 3 Hrs Measure Lactate Level Obtain Bld Cultures Admin Broad Spectrum ABX Admin 30ml/kg Crystalloid for Hypotension of Lactate > 4mmol/L

26 Surviving Sepsis Campaign Updated Bundles To Be Completed w 6 Hrs Vasopressors (if needed) MAP > 65mmHg If Persistent Hypotension Reassess* Vol Status & Tissue Perfusion Re-Measure Lactate if Initial Lactate > 4

27 Surviving Sepsis Campaign Updated Bundles To Be Completed w 6 Hrs Re-assess* Vol Status & Tissue Perfusion Repeat Focused Exam VS, CV, Cap Refill, Pulse & Skin Findings OR CVP, Scvo2, Bedside Ultrasound, Dynamic Fluid Response

28 Surviving Sepsis Campaign Studies Since 2013 ProCESS Trail: Protocolized Care for Early Septic Shock ARISE Study: Australasian Resuscitation in Sepsis Evaluation ProMISe Trail: Protocolised Management in Sepsis

29 Surviving Sepsis Campaign Was Rivers Wrong? ProCESS Trail, ARISE Study, ProMISe Trail Results Rivers et al (2012) & Stevenson et al (2014) Standard Care has improved Decreasing M&M of Sepsis Goal: Improve Outlines! By Implementing Guidelines

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31 WEARENOWHERE

32 WE ARE NO WHERE WE ARE NOW HERE

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34 Surviving Sepsis Campaign Hospitals Report Results of SSC Implementation 4 hosps in Detroit reported their success in implementing the Surviving Sepsis Campaign (SSC), demonstrating improved frequency of blood culture testing before antibiotic admin and significant improvement in the time to antibiotic tx from a mean of approximately 182 mins to 92 mins. The 4 hosps participated in a study published in the Journal for Healthcare Quality.

35 Surviving Sepsis Campaign While guidelines provide a roadmap for pt care, successful implementation relies on consistent patterns of clinician practice to achieve optimal outcomes, Educating staff is essential to the process of improving pt outcomes, and the results of our study showed the relationship between education and sampling of lactate and blood cultures, as well as timeliness of antibiotic admin. Lead author of the study Maria Teresa Palleschi, CCRN, DNP, ACNP, of Detroit Medical Center.

36 Where to Begin? The Beginning!

37 SSCG 2013 I. Initial Resuscitation and Infection Issues. B. Screening for Sepsis and Performance Improvement 1. Routine screening of potentially infected seriously ill pts for severe sepsis to allow earlier implementation of tx (grade 1C). 2. Hospital based performance improvement efforts in severe sepsis (UG).

38 Targeting Sepsis as a Performance Improvement Metric Kleinpell & Schorr, April 2014 Early recognition and targeted treatment can further improve sepsis care and pt outcomes. The spotlight on quality and safety in health care is well recognized. Performance improvement involves education, protocol development and implementation, data collection, measurement of indicators, and ongoing feedback to stakeholders and clinicians.

39 Schorr C, 2009 & Kleinpell & Schorr, 2014

40 Has it made a difference? Performance Metrics and Outcomes Levy et al (2015) CCM. 7.5 yr follow up. 30,000 pts from 218 hospitals This analysis, over a pd of 7.5 yr, demonstrates that increased compliance w a global sepsis quality improvement initiative was associated with a 25% relative risk reduction in mortality.

41 Performance Metrics and Outcomes Levy et al (2015) CCM. 7.5 yr follow up. 30,000 pts from 218 hospitals Conclusion Consistent w the literature, these results lend strength to the argument that performance metrics can be used to drive change in clinical behavior and, therefore, improve the quality of care and lead to decreased mortality in pts w severe sepsis and septic shock. pg 11

42 Getting to Zero Best Practice Alerts on EHR Checklists: Rounding, Handoff Goal Sheets Protocols Pocket Cards Treatment Algorithms Templates

43 Getting to Zero Education Webcasts Journal Clubs Conferences Like This Networking and Collaborating Feedback Feedback Feedback Real Time Monitoring & Feedback Web sites: survivingsepsis.org

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46 Septic Pts are Very Vulnerable!

47 We Should! We Must! We Will! It s Possible!

48 References Angus DC, van der Poll T. Severe sepsis and septic shock. NEJM, 2013;169: ARISE Investigator and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients w early septic shock. NEJM. 2014;371; Dellinger RP, Levy MM, Rhodes A, et al. surviving Sepsis Campaign: International guidelines or management of severe sepsis and septic shock: Crit Care Med. 2013;41: Dombrovskiy, et al. Rapid increase in hospitalization and mortality rates in severe sepsis in the US:A trend analysis from CCM:2007:35:1244. Gaieski D, Edwards M, Kallan M, et al. Benchmarking the incidence and mortality of severe sepsis in the US. Crit Care Med. 2013;41:1167. Kleinpell R, Aitken L, Schorr CA. Implications of the new sew sepsis guidelines for nursing care. Am J Crit Care. 2013;22: Kleinpell R, Schorr CA. Targeting sepsis as a performance improvement metric: Role of the Nurse. AACN Adv Crit Care, 2014;29: Larosa JA, Ahmad N, Feinber M, et al. The use of an early alter system to improve compliance with sepsis bundles and to assess impact on mortality. Crit Care Res Pract. 2012;98:369.

49 References Levy MM, Dellinger RP, Townsend SR, et al. Surviving Sepsis Campaign: The surviving sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepss. Crit Care Med. 2010;38: Levy MM, Rhodes A, Phillips GS, et al. Surviving sepsis campaign: associated between performance metrics and outcomes in a 7.5 year study. Crit Care Med 2015;43:3. Levy MM, Rhodes A, Phillips GS, et al. Surviving sepsis campaign: associated between performance metrics and outcomes in a 7.5 year study. Inten Care Med 2014;40: Martin, et al. The epidemiology of sepsis in the US from NEJM:2003:348;1546. Montpetit AJ, Sessler CN. Optimizing safe, comfortable ICU care through multi-professional quality improvement: just do it. Crit Care. 2013;17:138. Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial Investigators. Trial of early, goal directed resuscitation for septic shock. NEJM. 2015;1301. ProCESS Investigator, Yearly DM, Kellum JA, Juang ST, et al. A randomized trial of protocol based care for the early septic shock. NEJM. 2014;18;

50 References Rivers EP, Jaehne KA, Brown S, et al. Early interventions in severe sepsis and septic shock: a review of the evidence one decade later. Minerva Anest 2012;78;6:712. Schorr C: Performance improvement in the management of sepsis. Crit Care Clin 2009; 25: Schramm GE, Kashyap R, Mullon JJ, et al. Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality. Crit Care Med. 2011;39: Stevenson E, Rubenstein A, et al. Two decades of mortality trends among patients w severe sepsis: A comparative Meta-Analysis. Crit Care Med 2014;42:625. Wang. Et al. National estimates of severe sepsis in US emergency departments. CCM;2007;35:1928. Web sites with great resources: Surviving sepsis campaign: Survivingsepsis.org Sepsis alliance: Sepsis.org

51 Sepsis: Getting to ZERO Probable or Impossible? Carol A Rauen, RN-BC, MS, CCRN, PCCN, CEN Independent Clinical Nurse Specialist & Education Consultant. Burn Trauma ICU, Sentara Norfolk General, VA