SUCCESS IN SEPSIS MORTALITY REDUCTION Maryanne Whitney RN MSN CNS Improvement Advisor, Cynosure Health HRET HEN AK Webinar
Got Sepsis? Now What?- Alerts & Bundles Maryanne Whitney RN, MS, CNS Improvement Advisor, Cynosure Health 2
AIM Reduce Sepsis Mortality by 40% by September 2016
SEVERE SEPSIS: A SIGNIFICANT HEALTHCARE CHALLENGE Hospitalizations have doubled 2000-2008 Most costly reason for hospitalization in 2011 20 billion in aggregate hospital cost 1 out of 23 patients in hospital had septicemia Major cause of morbidity and mortality worldwide Leading cause of death in non-coronary ICU 10th leading cause of death overall In the US, more than 700 patients die of severe sepsis daily (1.6 million new cases per year) 1 DEATH EVERY 2 MINUTES
The # 1 cause of inpatient death The same pattern in every hospital
Severe Sepsis vs. Current Care Priorities U.S. Care Priorities # of Deaths Mortality Rate Incidence AMI (1) 900,000 225,000 25% Stroke (2) 700,000 163,500 23% Trauma (3) 2.9 million 42,643 1.5% (Motor Vehicle) (injuries) Severe Sepsis (4) 751,000 215,000 29%
THE PIECES YOU NEED Early Recognition ED Inpt Change the Culture Alerts Drive Treatment w/ Definitions Standard & clear Make Early Treatment Easy Automatic Bundle interventions Leverage Technology EMR BPA- Best Practice Alerts Integrate the 2015 Surviving Sepsis Campaign changes
SCREENING? HOW IS IT GOING?
QUESTIONS ABOUT SEPSIS-3
JUST IN SEPSIS-3! NOW WHAT? New definitions: Sepsis:a life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock: is defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality. Absent from the new definitions is the term severe sepsis a significant change from previous definitions. Sepsis has a mortality rate of 10 percent or higher, making the condition already severe. Reference: http://www.sccm.org/research/quality/pages/sepsis-definitions.aspx
NEW DIAGNOSTIC TRIGGERS quicksofa, or qsofa (Sequential (sepsis induced) Organ Failure Assessment) The qsofa assessment directs physicians to look for these warning signs in patients: An alteration in mental status A decrease in systolic blood pressure of less than 100 mm Hg A respiration rate greater than 22 breaths/min http://qsofa.org/
CREATE ACTION: ALERTS AND BUNDLE IMPLEMENTATION Identify clear and concise action for positive sepsis screen Who does what? By when? Build in concurrent review
Time Sensitive Diseases Changing the Paradigm of Practice AMI Stroke Trauma
Change Culture Think SEPSIS!!! Think Emergency!
Mobilize resources What are they? Mobilize experts Who are they? Consensus in diagnosis Allow for clinical decisions Time sensitive Create action Antibiotics Labs Fluids RRT Can they be involved?
SEPSIS SURPRISES IN THE LITERATURE Highest Mortality Sepsis diagnosed on the floors Lactate >2 mmol/l but < 4 mmol/l Bundle Compliance Worst on the floor Hospitals with RRT/Sepsis Alert as resource saves most lives
What s happening at your hospital?? What happens when a pt screens (+) for sepsis? Do you have an alert? Who responds? Who can initiate?
Bundles EBP Stronger Less distraction Clear action Outcomes
EARLY GOAL DIRECTED THERAPY
DEFINITIONS DRIVE TREATMENT Infection or trauma SIRS Systemic Inflammatory Response Syndrome Sepsis 2 or more SIRS + Infection Severe Sepsis Sepsis + s/s of organ dysfunction Septic Shock Refractory Hypotension +/or lactate >= 4 Sepsis is a Continuum
Standard Definitions SIRS: Systemic Inflammatory Response Syndrome Temp<36 C or >38 C, Heart Rate >90/min, Respiratory Rate >20/min or PaCO2 32mmHg, WBC <4,000 or >12,000 or 10% bands. Sepsis: presence of infection (suspected or confirmed) with systemic manifestations of infection Severe Sepsis: Sepsisinduced tissue hypo-perfusion or organ dysfunction Neuro decreased LOC CV- hypotension Respiratory- hypoxemia Renal- low UO Hematological- Thrombocytopenia Metabolic- Elevated lactate Septic Shock: Hypotension that persists despite adequate fluid resuscitation 21
POSITIVE SEPSIS SCREEN 3HR BUNDLE (TO BE COMPLETED WITHIN 3 HOURS OF PRESENTATION) Measure lactate level Obtain blood cultures prior to administration of antibiotics Administer broad spectrum antibiotics Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L
Time Zero Time Zero Will always be when chart annotations suggest all signs and symptoms are present May be documented in nursing or physician notes, lab flow sheets, anything with a time stamp Equals triage time if all signs & symptoms are present at triage
Two Clocks Severe Sepsis 3 hour counter Starts when all signs and symptoms of Severe Sepsis are present Septic Shock 3 hour counter 6 hour counter Starts when all signs and symptoms of Septic Shock are present
MAKE EARLY EASY Automatic Order sets Protocols for fluid, antibiotics and labs Bundle blood cultures with lactate
LEVERAGE TECHNOLOGY Use EMR for inpatient screening Best Practice Alerts Prompts for Interventions Contact MD or RRT (Rapid Response Team) Request lactate because one has not been drawn in 4 hours Request blood culture because they have not been drawn N/A pt. does not have suspected or known infection
Common Barrier is Communication: Customize
Customize the WAY You Communicate SHARE INFORMATION SHAPE BEHAVIOR General Publications flyers newsletters videos articles posters Personal Touch letters cards postcards Interactive Activities telephone email visits seminars learning sets modeling Public Events Road shows Fairs Conferences Exhibitions Mass meetings Face-to-face one-to-one mentoring seconding shadowing Adapted from Ashkenas, 1995 (C) 2001, Sarah W. Fraser
SO.PUTTING IT ALL TOGETHER Screen every patient in ED @ triage or evaluation. Screen inpatients every shift. Clear and consistent actions after a positive sepsis screen. Administer antibiotics within an hour Bundle blood cultures with lactate. Outcomes will follow.
6 HOUR BUNDLE CONSIDERATIONS Referral ICU Communication 6 hour Bundle Apply vasopressors Re-assess volume status and tissue perfusion and document findings (new for 2015) Re-measure lactate if initial lactate elevated.
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RESOURCES Surviving Sepsis Campaign http://www.survivingsepsis.org Guidelines Bundles Protocols & Checklist Sample sepsis screen Educational videos ProCESS Investigators, Yealy DM, Kellum JA, Juang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370(18):1683-1693. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371:1496-1506. Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015: DOI: 10.1056/NEJMoa1500896. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-137
mwhitney@cynosurehealth.org