Sepsis: The Golden Hours Early Identification and Management: Role of the Bedside Nurse Mary D. Still, MSN APRN ACNS ANP-BC CCRN FCCM Emory University Hospital, Atlanta Georgia
Objectives/ Disclaimer Discuss benefit of early screening, diagnosis and intervention Describe the role of the bedside nurse in protocol management Identify process for nurses role in screening and early intervention Describe program development for early intervention No conflict of interest or relevant financial relationship exist with any organization or person.
CDC identifies early recognition of sepsis as key to decrease mortality Knowledge of patient demographics, risk factors, and infections leading to sepsis is needed to develop comprehensive infection prevention and sepsis early recognition and treatment strategies. More than 1.5 million people get sepsis each year in the U.S One in three patients who die in a hospital have sepsis MMWR Report- Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention Weekly / August 26, 2016 / 65(33);864 869
What is the Nurse s Role? Grap, M. et al. (2003 ) Collaborative practice: Development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. American Journal of Critical Care, 12: 454 460. Danckers M, Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians: Journal of Critical Care (2013) 28, 433 441 Drolet A, et al. Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings (2013) Vol. 93 Number 2 Physical Therapy Mori C, et al. A-Voiding Catastrophe: Implementing a Nurse-Driven Protocol; Medsurg Nursing: Vol. 23, Iss.1 ( Jan/ Feb 2014): 15-21, 28. Dreyfus et al. Implementation and evaluation of a pediatric nurse-driven sedation protocol in a pediatric intensive care unit; Ann. Intensive Care (2017) 7:36
ED Nurse Driven Protocol I Median time to initial antibiotic administration (in minutes) by month. Bruce HR. et al. Impact of Nurse-Initiated ED Sepsis Protocol on Compliance With Sepsis Bundles, Time to Initial Antibiotic Administration, and In- Hospital Mortality : Journal of Emergency Nursing Volume 41, Issue 2, Pages 130-137 (March 2015)
Potential Barriers Burney M, et al. Early Detection and Treatment of Severe Sepsis in the Emergency Department: Identifying Barriers to Implementation of a Protocol-based Approach Journal of Emergency Nursing Volume 38, Issue 6, Pages 512-517 (November 2012)
2013 Began the Test Of Change in ED PRESENTED AT:
Sepsis Screening Form If the patient meets VS criteria (discern notification) and the history is suggestive of an infection, the patient has a positive sepsis screen. An S was placed in the core measures column and the patient is elevated to a triage code 1 pending MD/AP evaluation.
Initial Test Of Change in the ED: May 2013, June 2013, Sept 2013 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 73% 95% 100% 100% 100% 85% Lactate ordered Cultures before antibiotics 45% 70% 55% Antibiotics < 3 hrs from triage * Sept 2013 data are based on all patients with suspected sepsis in the ED from September 15-21, 2013.
Initial PRESENTED AT:
Goals align with System Plan Leadership/Administrative Support Financial Commitment of Resources Culture that supports Change Establish Inter professional Team Committed Leaders and staff!! Data Support to evaluate metrics/ performance! Current State/ Future State Elements Critical for Success Define Goals, Metrics and electronic tools PRESENTED AT:
The Nurse s Role in sepsis management! 1. Prevention of infection for all patients (Hand hygiene, central line dsg change with sterile technique/ bio patch), urinary catheter with Nurse driven protocol to remove etc) 2. Development of efficient electronic trigger based on defined parameters that the bedside nurse assesses during care to identify potential sepsis patients 3. Identify/ differentiate between early sepsis and other causes of the SIRS response 4. Electronic Systems that supports early initiation of evidence-based practice therapies (antibiotics, fluids/blood, and vasopressors) 5. Transition of patient to appropriate level of care that can support management of remaining bundle components and monitoring. Code Sepsis Process! 5T Team at work at bedside of sepsis patient! PRESENTED AT:
Screening Barriers/ Strategies Barriers: Time for nurses to screen in triage and initiate Powerplan Screen positive could be done for strep throat, simple UTI, or other simple infections not just sepsis Positive screening is not diagnosis for severe sepsis Disagreement with screening criteria and potential false positives Provider and nurse familiarity with protocol Question if ongoing infection vs new? Strategies: Accountability to complete screening in a timely manner Audits to identify compliance Round on unit to ask how the process is going and any barriers to screening.
Sepsis screening/ Protocol utilization Encounters with (%) Mar 2016 YTD A completed sepsis screen 75 76 A positive sepsis screen 27 26 Encounters with (%) Mar 2016 YTD Suspected sepsis protocol initiated 50 45 Severe sepsis protocol initiated 8 12
Sepsis Alert Trigger modified PRESENCE OF TWO OR MORE OF THESE WILL RESULT IN A TRIGGER BEING FI RED. SBP < 90 OR MAP < 65 (BEHIND THE SCENES) HR > 110 TEMP < 35 C OR > 38 C RR (TOTAL) > 22 WBC > 12.0 (MOST RECENT IN LAST 24 HOURS) WBC < 4.0 (MOST RECENT IN LAST 24 HOURS) THE NURSE ALWAYS HAS THE RESPONSIBILITY TO SCREEN A PATIENT WHO IS AT RISK FOR SEPSIS BUT DOES NOT FIRE THE ELECTRONIC SEPSIS TRIGGER. 16
Electronic Sepsis Trigger Implemented in all areas ED, ICU and general care units! Alert Criteria Alerts the PERSON WHO CHARTED the Vital Signs!! If negative: 2 hour snooze in the ED (Sepsis Screening Power Form completed. Regardless of positive or negative) 12 hour snooze(all in patient units when screen completed) If screened positive and Sepsis: Initial Power plan is initiated and screening trigger will not return until 48h
Nursing assessment screening tool (symptoms of potential sepsis) 18
Operator/ Call Center will page Lab and Pharmacy, and ICU Nurse via group page to respond to the identified location At EUH and EUHM- Response team: ICU Nurse, Lab and Pharmacy Lab to draw labs and Blood cultures Pharmacy to verify antibiotics to place on MAR and expedite to unit. Code Sepsis Algorithm YES Nurse receives alert to screen patient for sepsis! YES Sepsis screen positive: Nurse calls provider then Code Sepsis via emergency operator YES Nurse to initiate, Sepsis: Initial PowerPlan : Initial Fluid Bolus (500 cc) Lab: Lactate & Blood Cultures AND Provider to complete focused assessment and order antibiotics and any additional interventions via the Sepsis Maintenance PowerPlan if determined to be appropriate. NO YES If screen negative no further action required, continue monitoring and screen again if sepsis alert occurs At EJCH & ESJH Response team: Phlebotomy to draw STAT labs, lactate and Blood cultures. IV Team or nurse to start IV YES Antibiotic therapy should be initiated within 45mins from order placement, even in the absence of blood cultures being collected. NO If septic shock: transfer to ICU YES Does patient have infection( sepsis) or septic shock If sepsis and remain on the floor end Code and continue to monitor and treat per orders.
Bedside nurse: ICU nurse Lab: Provider: Pharmacy: Respiratory Therapy: RN: Code Sepsis Nurse Driven Response Initiate Sepsis Initial Orders Per Protocol after a positive screen. Call the provider Assess and obtain appropriate vascular access May assist with peripheral access as needed. (IO access in the ED only) Help with initiation of fluids and antibiotic and help transport to ICU if determined to be appropriate. Draw ordered labs( Lactate, CP Basic etc. and Blood cultures). Deliver to Core Lab. (2 sets of blood cultures before the first dose antibiotics.) Assess patient to determine sepsis or not. Order Antimicrobial and other management components per Sepsis: Plan for Providers power plan Verify antibiotic and be sure sent to appropriate location Assess oxygenation and support as needed per Sepsis initial Power plan. May draw ABG s or VBG s if needed. Do not be delayed administration of antibiotic >45 minutes from protocol activation for cultures to be drawn. Antibiotics: Vancomycin and Zosyn are found in ED and ICU Omnicells Provide volume resuscitation as ordered a) Initial choice of volume 500 ml or 1000 ml is included in the Sepsis Initial Plan b) If septic shock: Initial resuscitation should be 30 ml/kg If in shock.(provider will order in the Sepsis: Plan for Providers PowerPlan) c) Initiate Sepsis Checklist to identify progress with sepsis management. This tool should follow the patient and is NOT a part of the medical record. 20
Sepsis Initial Power plan( Nurse initiated) 21
Nurses responsibility: Process of care! UNIT TIME CRITICAL ACTIONS RN Time of positive sepsis screen Time Hospitalist Notified AND Attending MD Time Phlebotomy Notified Suspected Sepsis order set initiated by RN Initial fluid bolus given (500cc) EUH & EUHM- RT to draw STAT ABG with electrolytes and lactic acid AND phlebotomy to draw Blood cultures (including one set from any existing central line). * Nurse to draw blood cultures after 30mins if phlebotomy not available. EJCH- Phlebotomy to draw STAT Comprehensive Metabolic Panel, Lactic Acid, Lipase, Complete Blood Count with Differential, Prothrombin Time, Type and Screen AND Blood cultures (including one set from any existing central line). * Nurse to draw blood cultures after 30mins if phlebotomy not available. Antibiotics* (GOAL: 1 hour from positive screen) #1 Antibiotic: Next dose: #2 Antibiotic: Next dose: #3 Antibiotic: Next dose: *Vancomycin may be initiated 30 minutes after piperacillin-tazobactam (Zosyn ivpb) if no evidence of drug reaction. Data tool to be initiated with each positive screen Then sent with the patient to unit as part of handoff CENTRAL LINE PLACEMENT- consider placing in the event there is a delay to the ICU. CODE SEPSIS TERMINATED EGDT Central line placement: Site Provider Name Patient does not have infection / sepsis Dx: Patient has sepsis, but not severe sepsis / septic shock DISPOSITION Patient remained in present room Patient transferred to Intensive Care Unit Transferring RN (name) Receiving RN (name)
Management of sepsis: Nurse goal We CARE! C cultures before antibiotics A antibiotics within 1 hours of + screen R resuscitation with 30mL/kg IV fluid E evaluate for source of infection
Top 4 diagnosis identified w/ > opportunity Time line Formation of Team and initial design phase for Sepsis management! Implementation of Phase 1-2 over 6 month period Changed diagnosis to symptoms. Phase 3 May Began development of Code Sep[sis Began Maintenance Phase Goals set! Began analysis of true state, opportunities and development of Protocol PRESENTED AT:
5TS ICU Team
References Angus D, Van der Poll T, Severe Sepsis and Septic Shock: N Engl J Med 2013; 369:840-851 August 29, 2013 DOI: 10.1056/NEJMra1208623 Bruce H, et al. Impact of nurse-initiated ED sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality. Journal of Emergency Nursing volume 41 issue 2 March 2015 Coates E, et al. (2015) Sepsis Power Hour: A Nursing Driven Protocol Improves Timeliness of Sepsis Care. J Hosp Med10 Daniels R, Nutbeam T, McNamara G, Galvin C (2011) The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J 28: 507-512 Fowle E, Bettielou C (2011) Implementing a nurse driven sepsis protocol in the emergency department Registry of Nursing Research Conference Abstracts. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis (2005) International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. PediatrCrit Care Med 6: 2-8 Grap, M. et al. (2003 ) Collaborative practice: Development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. American Journal of Critical Care, 12: 454 460. Kumar et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock* Crit Care Med 2006;34:1589-1596 McClelland H, Moxon A (2014) Early identification and treatment of sepsis. Nurs Times 110: 14-17. Meddings J, et al. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review BMJ Qual Saf 2013;0:1 13. Moore L, et al. Validation of a Screening Tool for the Early Identification of Sepsis. Journal of Trauma-Injury Infection & Critical Care. 66(6):1539-1547, June 2009. Rivers EP, Ahrens T (2008) Improving outcomes for severe sepsis and septic shock: tools for early identification of at-risk patients and treatment protocol implementation. Crit Care Clin 24: S1-47. Schell- Chaple (2014) Reducing Sepsis deaths: A systems approach to early detection and management. American Nurse Today9:26-31. Tromp M, Hulscher M, Bleeker-Rovers CP, Peters L, van den Berg DT, et al. (2010) The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: a prospective before-andafter intervention study. Int J Nurs Stud 47: 1464-1473