CRT Sepsis Response Guidelines

Transcription

1 CRT Sepsis Respnse Guidelines ***Immediate Actins f CRT RN*** CRT shuld call x (Intensivist APP) fr any questins / cncerns re: Sepsis Alerts SEPSIS ALERT (T be cmpleted in 60 minutes) Review exclusin and inclusin criteria: Lactate POC CRT RN t draw, RT t run STAT n Bld Gas Analyzer Draw and hld the fllwing labs at the bedside while awaiting Prvider rders: 2 sets f bld cultures CBC with differential, CMP, PT/PTT If initial lactate >2, place timed rder fr repeat lactate at 4 hurs after Time Zer (phlebtmy draw) Cnfirm / establish IV access x 1, cnsider 2 nd IV if lactate >4 r patient is hyptensive Ntify Prvider nce lactate is knwn see scripting Orders t be given by Prvider Assist Bedside RN in cmpletin f bedside rders, as needed ANTIBIOTIC ADMINISTRATION: A sepsis alert will mbilize the sepsis pharmacist t the bedside. It is extremely imprtant that a pharmacist is dispatched t the bedside f a psitive screen. The pharmacist will review the antibitic rder and deliver it t the bedside as rapidly as pssible. Time Zer (TZ) The CMS definitin-tz fr severe sepsis is when 3 f the fllwing ccur within 6 hurs f each ther: 2 r mre SIRS 1 sign f rgan dysfunctin Suspected/pssible surce f infectin The CMS definitin TZ fr septic shck is criteria fr severe sepsis plus ne f the fllwing: Lactate > 4 Hyptensin in the 1 hur fllwing a 30 ml/kg blus f crystallid fluid When respnding t a sepsis alert and a psitive sepsis screen (2 r mre SIRS + pssible infectin r suspected infectin), it is imprtant t activate the sepsis alert asap t facilitate rapid turnarund fr a lactate result via Nurse Draw> RT > MICU analyzer. Determine Time Zer via chart review and discussin with staff Initiate Handff Tl (cmpleted handff tls can be delivered t the MICU managers ffice)

2 Review determinatin f Time Zer with bedside RN Opprtunity fr sepsis educatin and emphasis n early recgnitin Ensure bedside RN cmpletin f handff tl ***Fllw-up Actins f CRT RN - Sepsis Alert If lactate >2, patient will need repeat lactate drawn (CRT RN t ensure phlebtmy is scheduled t arrive n time) at 4 hurs after Time Zer and after initiatin f IV fluids Ntify Prvider with repeat lactate result if >2 and inquire re: additinal rders If lactate >4 r patient is hyptensive Initiate NS 30 ml/kg blus - pressure bag infused clarify MD rder if needed entire vlume needs t be ORDERED AND STARTED within 3 hurs f Time Zer. Recmmended t run as rapidly as pssible, but must run at a rate t exceed >125 ml/hr fr CMS cmpliance Cnsult with Prvider re: Intensivist invlvement and cnsideratin f ICU transfer Repeat lactate draw at 4 hurs after Time Zer Phlebtmy t draw and run in lab drawn (CRT RN t ensure phlebtmy is scheduled t arrive n time) Ntify Prvider at as sn as 4 hur lactate is resulted with lactate value, and t prmpt Prvider t cmplete bedside assessment and dcument Prvider Repeat Assessment via.sepsisexam feature in Epic, needs t be cmpleted by Prvider nce IV fluids are initiated and within 6 hurs f Time Zer fr septic shck EXCLUSIONS: If patient is actively receiving treatment fr sepsis / severe sepsis / septic shck, then n sepsis alert is required fr 24 hurs unless the patient is deterirating frm sepsis severe sepsis r severe sepsis septic shck. Pst-p 48 hurs (elective cases), pst-partum 48 hurs if called t evaluate these patients, assess fr ther etilgies, but d nt activate sepsis alert. Directive fr Cmfrt Care r palliative care within 3 hurs f presentatin f severe sepsis Directive fr Cmfrt Care r palliative care within 6 hurs f presentatin f septic shck Administrative cntraindicatin t care ONLY acceptable surces are: Physician/APN/PA dcumentatin that patient/decisin-maker refused either bld draw, fluid administratin, r antibitic administratin; r A signed r unsigned cnsent frm marked refused that is witnessed by MD/PA/APN r ther hspital persnnel.

3 INCLUSIONS: Bld cultures prir 48 hurs prir t TZ repeat nt required ANY IV Antibitics given within 24 hurs prir t TZ - repeat antibitics are nt technically required, but patient may need additinal r different antibitics. Pharmacy t review and make recmmendatins. Labs are valid fr up t 6 hurs prir and t 3 hurs fllwing Time Zer, but be mindful f lactate value and need fr timely repeat if initial is >2 SCRIPTING: Scripting fr phne call t Prviders, and suggested Orders fr Severe Sepsis and Septic Shck Hell Dr. {name f prvider}, this is {yur name}, I m the Critical Respnse Nurse taking care f {patient name} in rm {rm number}. I ve just cmpleted a sepsis screening f the patient. He/she meets SIRS criteria based n the fllwing: {state SIRS criteria met} and has a suspected infectin f {state suspected surce f infectin}. The current lactate level is {state serum lactate}. Based n my assessment, I believe this patient has {severe sepsis / septic shck}, based n the fllwing criteria: {Severe sepsis: Hyptensin: SBP < 90 r MAP < 65 r drp in SBP > 40 pints frm baseline Creatinine > 2 r UOP < 0.5mL/kg/hr fr > 2 hrs T. bili > 2 Platelets < 100K Lactate > 2mml/L INR > 1.5 r aptt > 60secs Acute respiratry failure as evidenced by new need fr invasive/nninvasive mechanical ventilatin Septic shck: AS ABOVE and Lactate 4 Hyptensin in first hur after cmpletin f 30ml/kg blus Last labs drawn: {state date/time and whether they were drawn within 6 hurs f Time Zer, in which case repeat labs are nt indicated} Last Bld cultures were drawn: {state date/time r nne during this admissin and whether they were drawn within 48 hurs f Time Zer, in which case repeat bld cultures are nt indicated} I have already {state interventins cmpleted here}, and recmmend the fllwing rders t cntinue with the sepsis bundle interventins:

4 Recmmend: Bld cultures x 2, CBC, CMP, PT/PTT, and if initial lactate >2 rder fr repeat lactate draw (phlebtmy) in 4 hurs after Time Zer If patient has severe sepsis with hyptensin r septic shck: I wuld like t recmmend a 30 ml/kg blus f NS IV. Ideally this shuld run as rapidly as pssible, but must be >125ml/hr t be CMS cmpliant. Clarify timing f blus with Prvider at the time f rder placement. The full fluid amunt MUST BE ORDERED AND STARTED within the first 3 hurs f TZ, but infusin can exceed the 3 hur mark. Are there any additinal rders yu wuld like me t initiate t search fr infectin? (Cnsider Urinalysis, Chest Xray, etc.) Wuld yu like t change the frequency f vital sign mnitring fr the next 24 hurs? Wuld yu like t place a cnsult t {Hspitalist fr severe sepsis / Intensivist fr septic shck}? Wuld yu like me t call yu nce rders are resulted? If initial lactate >2: I will be calling yu if the repeat lactate remains >2. The sepsis Pharmacist is at the bedside and is available t speak with yu abut antibitics at this time. Wuld yu like t speak with them? Give phne t Pharmacist fr antibitic discussin. If Prvider des nt need t speak with Pharmacist, the get antibitic rders as indicated. ***If the sepsis prtcl is nt initiated by the physician, ask fr the reasn r alternate diagnsis that he/she wuld like recrded in the patient s chart/n screening tl fr nt initiating the sepsis rders.*** Revised: 6/30/2016

5 Patient Presents t UNC Rex Healthcare Flr/ICU RN ED Sepsis Dx CRT ED r Direct Admit Nn- Sepsis Dx CNA VS Entry Sepsis Alert Prcess Map Gd Handff Cntinue Sepsis Bundle 4 Hr Assessment (if applicable) RN Psitive Sepsis Screen * Sepsis Alert Prvider Call List: Rex Surgical patients: Call the Rex Surgicalist x2227 NC Heart and Vascular patients: Call the Cardilgy APP x3542 (they will cmplete bedside evaluatin and invlve Hspitalist as indicated) All Internal Medicine patients: Call the Hspitalist (include curtesy ntificatin t Attending if nn-hspitalist patient) Fr patients wh have a lactate 4 r des nt respnd t 30ml/kg Fluid Blus, Call the intensivist x1535. ** Immediate Actins f Sepsis Alert Order Set (T be cmpleted in 60 minutes) Negative Cntinue per CRT Prtcl Cnsult CRT Severe Sepsis Screen Once lactate resulted: Ntify Prvider per Sepsis Alert Call List Psitive Activate "Sepsis Alert" CRT Initiates Sepsis Alert Order Set ** Assist in establishing time zer based n when patient met criteria Prvider Assessment: Cntinue with Sepsis Bundle? *55 Sepsis Alert Bedside Respnse = CRT, AC, RT, Primary RN, Charge Nurse Ntify = Pharmacy Lactate POC CRT RN t draw, RT t run STAT n Bld Gas Analyzer Draw and hld the fllwing labs at the bedside while awaiting Prvider rders: 2 sets f bld cultures CBC with differential, CMP, PT/PTT If initial lactate >2, place timed rder fr repeat lactate at 4 hurs after Time Zer (phlebtmy draw) Cnfirm / establish IV access x 1, cnsider 2 nd IV if lactate >4 r patient is hyptensive Ntify Prvider nce lactate is knwn see scripting Orders t be given by Prvider Assist Bedside RN in cmpletin f bedside rders, as needed NO Cntinue per CRT Prtcl YES Initiate Antibitics per Prvider rder Stable - Remains Unstable - n RNF Transfer t ICU CRT Debrief CRT 4 Hrs Cnitnue per CRT Prtcl CRT 4 Hrs Cntinue per CRT Prtcl Revised 6/30/2016