The Sepsis Continuum: Overcome Barriers and Create Momentum. September 7, :00 am. 12:15 p.m. CT

Transcription

1 The Sepsis Continuum: Overcome Barriers and Create Momentum September 7, :00 am. 12:15 p.m. CT 1

2 Emily Koebnick Program Manager, HRET WELCOME AND INTRODUCTIONS 2

3 Today s Agenda 11:00-11:05 am Welcome and Introductions 11:05-11:10 am Data Updates 11:10-11:25 am Fluid Resuscitation: Overcoming Physician Resistance Understand the science behind the recommended fluid resuscitation in Septic Shock. Learn ways to best influence physicians who may be resistance to this recommendation. 11:25-11:35 am Nursing Empowerment to Accelerate Sepsis Care Explore strategies that enhance nursing practice and empower them to recognize and treat sepsis as a medical emergency. Emily Koebnick Program Manager, HRET Mariana Lesher Data Analyst, HRET Dr. Sean Townsend M.D. Dr. Steve Tremain M.D. Improvement Advisor, Cynosure Deborah Campbell, RN Infection Prevention Improvement Advisor, Kentucky Hospital Association 3

4 Agenda 11:35-11:45 am Family and Patient Engagement and Education Discover creative ways of engaging families in sepsis awareness and educational opportunities for patients discharged with sepsis. 11:45-11:55 am Sepsis in Your Neighborhood Community awareness around sepsis is a necessary component for a sepsis program that spans the continuum, review ideas to improve this vital need. 11:55-12:10 pm Let s hear from YOU! Facilitated discussion to gather updates on your sepsis month activities. 12:10-12:15 pm Bring it Home Brett Hartkopp BSN, RN, CPPS Market Director Quality and Infection Prevention, Wesley Medical Center Patricia Stahura ECRI Institute Maryanne Whitney Dr. Steve Tremain Improvement Advisors, Cynosure Emily Koebnick Program Manager, HRET 4

5 WEBINAR PLATFORM QUICK REFERENCE Mute computer audio Today s presentation Chat with participants Download slides/resources Register for upcoming events

6 How Did You Hear About This Event? A) HRET HIIN flyer B) HRET HIIN website C) HRET LISTSERV D) State hospital association E) QIN-QIO F) Your organization/colleague G) Other, please specify.

7 Sepsis Measurement HIIN Measures Post-operative sepsis (AHRQ PSI-13) 2013¹: 4.19 per 1,000 Sepsis Impact² - Most expensive reason for hospitalization - Patients stay in the hospital 75% longer

8 Post-operative sepsis (AHRQ PSI 13) 8

9 Fluid Resuscitation in Sepsis Why 30ml/kg Cyrstalloid is Reasonable Sean R. Townsend, MD Vice President Quality & Safety California Pacific Medical Center September 6,

10 Why Do All Severe Sepsis Patients Need Volume?? 1. Vascular volume is lost into interstitial space do to diffuse capillary leaking from cytokine release 2. Both venous and arteriolar tone is reduced & blood volume occupies a larger intravascular space than normal 3. Many patients also have GI and Skin losses

11 Does Early Aggressive Therapy Make a Difference?

12 Trauma Patients From Am. College of Surgeons ATLS Manuel

13 Fluids Prevent Intubation From Rivers: % Ventilated patients Hours after start of Therapy Standard Therapy 53.8% 16.8% 70.6% 53% 2.6% 55.6% Early Goal Directed Therapy P Value < Chronic coexisting conditions--chf: 30.2% EGDT 36.7% Control N Engl J Med 2001;345:

14 FACT: One liter of normal saline adds 275 ml to the patient s plasma volume

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17 The PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock A Patient-Level Meta-Analysis. N Engl J Med 2017; 376: Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher lactate, hypotension, predicted risk of death). EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics.

18 Differences between treatment and control groups in the ProCESS, ARISE, and ProMISE Trials: Clinical Trial Cohort Intravenous Fluids (milliliters) Central Line Placement Vasopressor Utilization ProCESS May 2014 EGDT / /439 (93.6%) 241/439 (54.9%) Usual Care / /456 (57.9%) 201/456 (44.1%) Δ 526ml 35.7% 10.8% ARISE October 2014 EGDT 1964+/ /793 (90%) 528/793 (66.6%) Usual Care 1713+/ /798 (61.9%) 461/798 (57.8%) Δ 251ml 28.1% 8.8% ProMISE May 2015 EGDT 2000 ( ) 575/624 (92%) 332/623 (53.3%) Usual Care 1784 ( ) 318/625 (50.9%) 291/625 (46.6%) Δ 216ml 41.1% 6.7% 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): The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371: 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: /NEJMoa

19 MD Ability to Predict Hemodynamics Survey administered pre-pa catheterization % correct prediction of Variable N measured range of actual value Wedge Pressure % Cardiac Output 97 51% SVR 88 44% R Atrial Pressure 98 55% CCM 1984 Vol 12, No. 7 pp

20 Can We Predict Mortality in Infected Patients? Systolic BP 90 still have lactate and mortality Lowest ED reading ICM 2007 Vol 33:

21 Lathan HE, Bengston CD, Satterwhite, L et al. Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes. Journal of Critical Care 42 (2017)

22 Lathan HE, Bengston CD, Satterwhite, L et al. Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes. Journal of Critical Care 42 (2017)

23 Seymour CW, Gesten F, Prescott H et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med 2017; 376:

24 Seymour CW, Gesten F, Prescott H et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med 2017; 376:

25 Liu VX, Morehouse J, Marelich G et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values. Am J Respir Crit Care Med Vol 193, Iss 11, pp

26 Liu VX, Morehouse J, Marelich G et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values. Am J Respir Crit Care Med Vol 193, Iss 11, pp

27 Influencing Physician Practice 27

28 Nurse Empowerment in Sepsis Improvement Deborah R. Campbell, RN-BC, MSN, CPHQ Infection Prevention Improvement Advisor Kentucky Hospital Improvement Innovation Network 28

29 Role of nurses in sepsis Is it only assessment/recognition? Current literature search- Yes, BUT. 29

30 Why? Nurses are often the first healthcare providers to interact with and assess the patient who presents with sepsis. 30

31 Why? Nursing is often a more stable, consistent group than physicians, e.g., residents and fellows rotations. 31

32 WHY? Nurses are almost always employees as opposed to medical providers who may be contract staff, locum tenens, etc. 32

33 Where are you? Do your nurses have a sepsis screen? Can the triage nurse (or first on the scene) call a code sepsis if that is appropriate? Can the nurse instigate a sepsis huddle? Can the nurse initiate an order set/protocol? Draw blood cultures, lactates, etc. Start an IV, fluid bolus Can the nurse mix antibiotics in urgent situations? 33

34 Nurse Protocol for Antibiotics If patient is assessed for sepsis and is deemed high risk requiring early antibiotic intervention, a nurse will access the Peds Sepsis Kit as follows: Select patient in pyxis machine* Remove med OVERRIDE Peds Sepsis Kit Administer medications selected by provider according to guidance Complete the documentation at the bottom of this form. Place unused antibiotics and Peds Sepsis sheet in return bin to pharmacy for charging and restocking. Obtain EPIC medication orders from provider to document the administration of the antibiotics used via the sepsis kit. EPIC Pediatric Sepsis Order set can be used for this. Courtesy of Golisano Children s Hospital 34

35 Nursing Pathway At any time If YES to Question 1 AND Hypotensive (SBP < 90 or MAP < 65) OR Lactate 4 Activate a CODE SEPSIS Then notify a provider immediately Start pathway to right 35

36 Overview There were great examples of nursing empowered protocols described on the ListServe. Limitations: EDs and ICUs tend to allow more interventions initially by nurses than less high acuity areas Continue to see limits on what nurses can do based on criteria v. having to wait for a physician to arrive, assess and order interventions 36

37 Summary Processes which allow nurses to perform to the limit of their scope of practice is optimal for early recognition and timely treatment. Questions? Deb Campbell, RN-BC, MSN, CPHQ, CCRN alumna

38 Patient & Family Engagement in Sepsis Brett Hartkopp BSN, RN, CPPS Market Director Quality & Infection Prevention Wesley Medical Center 38

39 About us 859 Bed Hospital Level 1 Trauma Only PEDs Trauma in Kansas 39

40 Discharge Opportunities Education to patient and families during alert process Questions encouraged Follow-up by sepsis coordinator when inpatient Education from sepsis coordinator during discharge planning phase of hospitalization Coordination with case management 40

41 Community Awareness Community Health Fairs Patient stories Survivor Videos 41

42 Sepsis in Your Neighborhood Patricia Stahura RN,MSN Senior Analyst and Consultant ECRI Institute 42

43 About ECRI Institute Independent & Research Driven International Non-Profit with strict conflict of interest rules Evidence Based Practice Center - Agency for Healthcare Research and Quality Federally Certified Patient Safety Organization (PSO) Clinical risk management provider to all HRSA federally funded health clinics Patient safety and clinical quality resources to 1,000s of healthcare organizations for nearly 50 years ACCME accredited CME provider Nursing CEU provider in patient safety 400+ multidisciplinary staff 43

44 Sepsis in the United States 80% sepsis cases start outside the hospital 70% patients with sepsis were seen or had chronic diseases requiring frequent medical care One million discharges/year include sepsis diagnosis 62% sepsis patients are readmitted within 30 days Source: CDC 44

45 Why Community Outreach? 1 billion ambulatory visits occur annually More Hospitalists, less Attending Physicians Less than half of US adults have heard of sepsis September is Sepsis awareness month Source: NCHS; CDC 45

46 Community Outreach Plan What s in it for me? Community needs Make contact Schedule a meeting Mobilize resources Community Collaborative Follow Up 46

47 Healthcare Provider Awareness Primary Care Centers Urgent Care Centers Dialysis Centers Geriatricians Pediatricians Obstetricians Birthing Centers Home Health Agencies Pharmacy Community Flu shot programs 47

48 Public Awareness Schools Churches Group Homes Clubs and community organizations Athletic and fitness centers Support Groups Senior Centers City Council 48

49 Topics for Community Education Prevent infections Get immunizations Keep scrapes and wounds clean Manage chronic conditions Recognize signs of worsening condition Seek medical care if not better or worse Say I am concerned about sepsis 49

50 Informational Resources Press and Radio Release Surviving Sepsis App Fact sheets Brochures Articles Infographics Screening tools Pocket cards Algorithms 50

51 References and Resources CDC Sepsis National Center for Health Statistics (NCHS) FastStats A to Z. Ambulatory Care, and Hospital Utilization. Sepsis Alliance Surviving Sepsis HRET HIIN ECRI Institute 51

52 Let s hear from you! Open the Lines 52

53 Emily Koebnick, Program Manager, HRET BRING IT HOME 53

54 on the HRET HIIN website Sepsis Resources 54

55 Sepsis Resources LISTSERV Join the LISTSERV Ask questions Share best practices, tools and resources Learn from subject matter experts Receive follow up from this event and notice of future events 55

56 Sepsis Awareness Month Please continue to send us your inspirational stories and photos! You can tweet with the hashtags #sepsisawareness or #whyimhiin and/or us your information at 56

57 HRET HIIN Sepsis SNAP Join the HRET HIIN SNAP! Register for the information call on Monday, September 11 to learn more.

58 Thank You! Find more information on our website: Questions or Comments: 58