Our Journey on the Road to Surviving Sepsis. Debbie Sober, RN, MSN Community Hospital of the Monterey Peninsula

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1 Our Journey on the Road to Surviving Sepsis Debbie Sober, RN, MSN Community Hospital of the Monterey Peninsula

Cardiac Surgery Electrophysiology Invasive/diagnostic cardiology Behavioral Health

2 Community Hospital of the Monterey Peninsula 205 bed acute care hospital 28 bed skilled nursing Primary Stroke Center TJC Diabetes Certification Bariatric Center Excellence Cardiac Surgery Electrophysiology Invasive/diagnostic cardiology Behavioral Health Services Comprehensive Cancer Center Interventional Radiology Hospice Outpatient Surgery Center

3 Objectives Discuss current state of sepsis management at Community Hospital of the Monterey Peninsula Discuss importance of a multidisciplinary team to implement early goal directed therapy on medicalsurgical units, emergency department and the intensive care unit. Discuss importance of standardizing order sets for the hospitalist, emergency department and intensivist using evidence from the Surviving Sepsis Campaign

4 How the need was identified Critical Care Work Group Multiple anecdotal case reviews Identified knowledge deficit among different staff and physicians Rapid Response Team Performance Improvement Report Number of ICU transfers Number of RRT calls

5 How the need was identified Critical Care Work Group asked for small subgroup to evaluate the problems and provide solutions for a Grand Rounds on Managing Sepsis

6 SURVIVING SEPSIS TEAM First team meeting April 2011 Reviewed 2010 data to identify scope of problem Admission Source # Patients % Column1 Total 497 Transfer to ICU # Patients % Average time to transfer from Med-surg days from Main Pavilion days Total Transfer of all pop % 4.5 days Possible savings if no transfer to ICU* # Patients Days from Med-surg ($3870/day) $1,548,000 from Main Pavilion ($1407/day) $368,634 *Bed charges only, does not inc. supplies Total 79 $1,916,634 Overall sepsis rate (admissions) 4.0% Overall sepsis rate/ 1000 patient days 6.6 Total patient days 5300 Average LOS, days 10.6 Mortality %

7 Surviving Sepsis Team Data revealed problem with identifying early sepsis Inadequate fluid resuscitation prior to starting Dopamine Resulting in transfer to ICU in Septic Shock Intubation is not a failure" -Dr Karim Tadlaoui, Intensivist, CHOMP

8 SURVIVING SEPSIS TEAM Identified the evidence-based literature and adopted as standard of care Institute for Healthcare Improvement Surviving Sepsis Campaign (Early Goal Directed Therapy) Identified current state in the Emergency Department, Intensive Care Unit and Nursing Units Identified desired workflow and targeted patient placement and began development of refinement of order sets.

10 SURVIVING SEPSIS TEAM

11 Sepsis Guideline unofficial Update Highlights 2012 SCCM Congress Will be published in June 2012 Bundles include Initial and Septic Shock Bundle (delete Management bundle) Two blood cultures w/in 45 minutes prior to antibiotics Use crystolloids initial fluid resusitation Add Albumin if needed Do not recommend use of Hetastarch 30ml/kg fluids first 4-6 hours

12 Update (cont) Fluid challenges ok only if progress being made MAP > 65 Recommend Norepinephine as first choice Then Epinephrine as second choice Dopamine only used on highly selected patients (low cardiac output, etc.) Vasopressin can be added to Norepi but should not be used as initital vasopressor Dobutamine after resuscitation with signs hypoperfusion

More unofficial updates Only use steroids if vasopressors/fluids do not restore hemodynamic stability 200mg IV daily No stim test recommended Suggest proning for

13 More unofficial updates Only use steroids if vasopressors/fluids do not restore hemodynamic stability 200mg IV daily No stim test recommended Suggest proning for severe ARDS patients Do not recommend neuromuscular blockades unless severe ARDS <48 hours Keep blood glucose < 180 Recommend CRRT rather then intermittent hemodialysis

14 Rotoprone

15 SURVIVING SEPSIS TEAM Joined Beacon Collaborative share improvement strategies and allow comparison of performance

16 Participated in SimSuite Sepsis Quality Initiative Training (Sponsored by Hospital Council and Anthem Blue Cross) The Bus

19 SURVIVING SEPSIS TEAM NEXT STEPS Strategic Initiative -Team Charter developed, seek approval Implement Order Sets Education - Several Avenues Physicians Targeted training: Central Line insert Staff Critical Care Competency Camp, Education Fair All Return of the bus; expand Focused monitoring and mentoring ongoing

21 Sepsis April 2011 RN Education Fair

22 Objectives Identify clinical indicators (signs and symptoms) of sepsis Verbalize difference between warm and cold sepsis State the definition of SIRS, sepsis, severe sepsis & septic shock Verbalize treatment plans for sepsis

Suspected or Confirmed Infection Criteria Positive culture Diagnosis of pneumonia Any condition with a known risk of associated infection (immunosuppression, etc.

23 SEPSIS = Systemic Inflammatory Response Syndrome + Infection If patient has symptoms in all three categories below, suspect Severe Sepsis. Notify the physician and consider calling the Rapid Response Team. A. Suspected or Confirmed Infection Criteria Positive culture Diagnosis of pneumonia Any condition with a known risk of associated infection (immunosuppression, etc.) Any suspected source of infection (PICC line, Foley, wound, etc.) B. Systemic Inflammatory Response Syndrome (SIRS) Altered mental status Temp >100.4 F or < 96.8 F HR > 90 RR > 20 WBC > 12,000 or < 4,000/mm³, or normal with more than 10 % bands Hyperglycemia BG > 120 (in the absence of diabetes) Significant edema or positive fluid balance (> 20ml/kg over 24 hrs) C. Organ Dysfunction Cardiovascular: SBP < 90 or decrease in SBP >40 mm Hg Respiratory: O2 sats <93 % (in the absence of known CO2 retention) or if ABG available - PaCO2 <32 Renal: Significant decrease in urine output in the absence of renal failure or creatinine >2.0 mg/dl (normal U/O = 1ml/kg/hr, Sig decrease = < 0.5 ml/kg/hr for more than 2 hrs) Hepatic: Total bilirubin > 2.0 mg/dl Metabolic: lactate level > 4 or if ABG available ph < 7.30 Hematologic: Platelets < 100,000mm³ or INR > 1.5 or aptt >60 secs

24 When communicating the physician, be sure to use SBAR technique. Situation What is the patient s condition? Explain why you suspect sepsis. Background Diagnosis and relevant history (possible source of infection). Assessment Include vital signs, O2 sats, BG, LOC, I&Os and any significant changes from baseline assessment. Recommendation Ask the physician to consider the following. IV bolus for BP support and maintenance IVF Oxygen to keep sats > 93% ABGs Transfer to a monitored bed or ICU if unstable or requires vasopressors. Cultures Blood / Urine / Sputum / Wound (if applicable) - Cultures should always be obtained before administering antibiotics. If patient has a PICC or CL obtain an order for one BC to be drawn from the line and one drawn peripherally. Antibiotics (broad-spectrum) - Remember to report patient allergies to antibiotics and elevated creatinine as this may change the dosage and frequency of the antibiotic ordered. Diagnostic tests (Chest X-ray, EKG) Labs CBC, CMP, BNP, PT/INR, Lactate (elevated in patients at risk for septic shock even before patient becomes hypotensive)

25 We still have a ways to go Only 24 patients on ED order sets

26 What s next Finalize order sets Finalize algorithm and post on all nursing units and ED Ongoing education- Hospitalists Ongoing education- Nursing Develop Sepsis Screening tool integrated in computer Develop a report system to alert RRT for at risk septic patients on other units Daily review order set use Performance Improvement Immediate feedback to MD/RN

27 Thank you

Northwell Sepsis Collaborative Evidence Based Best Practice

Northwell Sepsis Collaborative Evidence Based Best Practice M. Isabel Friedman, DNP, MPA, RN, BC, CCRN, CNN, CHSE Director of Clinical Initiatives Department of Clinical Transformation Nicholas DaCosta,