Surviving Sepsis Campaign Sepsis e learn Module 1 Situation & Background Understand Learning Objectives Module 1 The impact sepsis has on patient mortality and healthcare costs. The importance of improving the identification and treatment of sepsis at BSLMC. The plan at BSLMC is to improve all sepsis outcomes. 1
1.6 million cases in US hospitals per year 800 deaths occur due to severe sepsis and septic shock daily in the US SEPSIS in USA (CDC, 2016) (Sepsis Alliance) One of the top 10 causes of diseaserelated death Cost > $20 BILLION per year Source: Torio CM, Andrews RM. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. HCUP Statistical Brief No. 160. Rockville, MD: Agency for Healthcare Research and Quality; August 2013. http://www.hcup us.ahrq.gov/reports/statbriefs/sb160.pdf. Source 1: Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief No. 62. Atlanta, GA: National Center for Health Statistics; June 2011. https://www.cdc.gov/nchs/data/databriefs/db62.pdf. Source 2: Wood KA, Angus DC. Pharmacoeconomic implications of new therapies in sepsis. PharmacoEconomics. 2004;22(14):895 906. Source 3: New Jersey Sepsis Learning Action Collaborative. Toolkit for Post Acute Care Settings: To Save Lives: Early Identification Early Treatment. Princeton, NJ: Health Research and Educational Trust of New Jersey; 2015. http://www.njha.com/media/328416/njsepsislactoolkitpost AcuteCareSettings.pdf. 2
Source 4: Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief No. 62. Atlanta, GA: National Center for Health Statistics; June 2011. https://www.cdc.gov/nchs/data/databriefs/db62.pdf. Sepsis Situation BSLMC is no exception. In 2015 and 2016, 3060 patients were diagnosed with sepsis, severe sepsis, or septic shock; 572 of these patients expired. Source: Internal Data, Baylor St. Luke's Medical Center Sepsis Initiative. 3
What is SEPSIS? Life threatening organ dysfunction caused by a dysregulated host response to infection. (Singer, Deutschman, et al., 2016, pg. 805) Life threatening condition that arises when the body s response to an infection injures its own tissues and organs. (Singer, Deutschman, et al., 2016, pg. 805) Source: Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3). JAMA. 2016 Feb 23;315(8):801 810. Sepsis Background BSLMC launched a Surviving Sepsis Working group in 2015 to improve sepsis related outcomes. The work group has built an early detection program and treatment tools for sepsis from the SSC bundles that additionally promote compliance with the CMS quality metrics for sepsis care. 8 4
The Surviving Sepsis Campaign (SSC) is a partnership of the European Society of Intensive Care Medicine and the Society of Critical Care Medicine formed in 2002 to promote advances in sepsis care, in order to improve outcomes. The SSC has created evidence based bundles of care for early recognition and treatment of sepsis, severe sepsis and septic shock. These bundles are grouped by timing of interventions into three hour and six hour bundles. A large landmark international study (62 countries) showed that use of these bundles decreased severe sepsis and septic shock mortality by 40 %. 1 Source 1: Rhodes A, Phillips G, Beale R, et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med. 2015 Sep;41(9):1620 1628. DOI: 10.1007/s00134 015 3906 y. Steps in Recognizing SEPSIS? The SIRS criteria reflect inflammation. BSLMS sepsis working group / CMS bundles based upon SSC (still in effect) definitions of SIRS, sepsis, severe sepsis, and septic shock Infection 5
The Future Revised Sepsis Definitions Society of Critical Care Medicine and European Society of Intensive Care Medicine Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) JAMA 2016 New definition emphasizes host of patient response to infection not so much as SIRS but as organ dysfunction due to SIRS that is harmful. Source: Antonelli M, DeBacker D, Dorman T, et al, Surviving Sepsis Campaign Responds to Sepsis 3. March 1 2016. Available at: http://www.survivingsepsis.org/sitecollecti ondocuments/ssc Statements Sepsis Definitions 3 2016.pdf. As the extent and severity of sepsis related syndromes is so significant, and the Surviving Sepsis Campaign bundles so effective in treatment of sepsis, that CMS began requiring hospitals to report compliance with the Surviving Sepsis Campaign three and six hour bundles for sepsis syndromes. 6
Minutes Saves Lives! We encourage the implementation of international sepsis guidelines to enable healthcare workers to recognize sepsis earlier, and treat it more effectively. Global Alliance for Sepsis 2016 If sepsis is recognized and treated within the first hour, the chance of survival is over 80%. Widespread effective early recognition and treatment systems are critical to increasing sepsis survival rates For every hour of delay in recognition and treatment of sepsis, mortality goes up 7.6 %. (World Sepsis Day, 2016). Source: Daniels R. Surviving the first hours in sepsis: getting the basics right (an intensivist's perspective), J Antimicrob Chemother. 2011 Apr;66 Suppl 2:ii11 ii23. DOI: 10.1093/jac/dkq515. Sepsis Fact At BSLMC sepsis mortality rate is almost 150% less if recognized and treated early. Recognized & Treated early Diagnosed & Treated late Source: Internal Data (Premier), Baylor St. Luke's Medical Center Sepsis Initiative. 7
Two Most Important Factors in Decreasing Sepsis Mortality Early Recognition RN/MD Early Intervention MD/RN Timely screening & Assessment in the ED Acute Care Units ICU Timely & appropriate medical treatment utilizing the Sepsis Order Set with accurate documentation with Sepsis Notes 1 & 2 Early Recognition The screening/assessment process vary slightly depending on the location of the patient... ED 1. Triage Sepsis Screen 2. RN Delegated Lab Orders Lactic Acid, Glucose, CMP, CBC 3. Secondary Sepsis Screen 4. MD Intervention Acute Care Units 1. qsofa/qshift Sepsis Screen &/or Electronic SIRS Best Practice Alert (BPA) 2. RN Delegated Lab Orders Lactic Acid, Glucose, CMP, CBC 3. Secondary Sepsis Screen (Rapid Response Team) 4. MD Intervention ICU 1. Electronic SIRS Best Practice Alert (BPA) 2. Secondary Sepsis Screen (ICU RN) 3. MD Intervention 8
RN Physical Sepsis Assessment (PSA) Pneumonia/Emphysema Urinary tract infection Acute abdominal infection Meningitis Skin/soft tissue infection A C T Are any 2 of following signs & symptoms of organ failure present and new to the patient? Altered mental status Systolic Blood Pressure 100 Tachypnea 22 breaths/min What is qsofa Sepsis Screening? Bone/joint infection Wound infection Blood stream catheter infection Endocarditis Implantable device infection Post surgical procedure Other 2 signs & symptoms of qsofa + probable source of infection: If YES: Initiate Sepsis Delegated Orders (STAT Lactic Acid, CBC, CMP) Perform STAT Point of Care (POC ) Glucose Notify Secondary Sepsis Screening Nurse (RRT or Designated Nurse) RRT or Designated Nurse will notify MD of Positive Secondary Sepsis If NO: Continue to Monitor Patient (PSA) Communicate at Transition of Care Potential for Sepsis *qsofa: quick Sequential Organ Failure Assessment Is the patient s history suggestive of a new infection, or Sepsis? Probable Source qsofa* CHI Sepsis Acute Care_9/2016_GJ Think Sepsis First Timely & Appropriate Medical Treatment MD Assessment required for a positive sepsis screen Sepsis Notes 1 is required documentation for MDs responding to a positive sepsis screen. This note also helps in determining SIRS, Sepsis, Severe Sepsis or Septic Shock. Sepsis Order Set If the patient has severe sepsis or septic shock the sepsis order set based on early intervention bundles is required, unless contraindicated. If the patient has simple sepsis the order may or may not be used based on the physician's clinical judgment Sepsis Notes 2 is required documentation for MDs treating Severe Sepsis or Septic Shock. It helps MDs track course of severe sepsis and septic shock and intervention effect. At BSLMC proven that Sepsis Order Set delivers tremendous outcome advantage over ad hoc sepsis treatments.. 9
Fact: A study at BSLMC demonstrated a marked decrease in mortality when the order set was utilized properly (all component of the 3 hour sepsis bundle). Sepsis 2014 Summary 5.9 % Pulmonary Section Meeting 3/11/2015 Mortality Order Set Utilization & Sepsis Mortality John Sabo RN RRT CHI St. Luke s Health Baylor St. Luke s Medical Center 3 20 51 53 37.7 % Mortality Treated with Order Set Treated without Order Set Expired 3 20 n 51 53 Source: Ike C, Freibott P, Myers K, et al. Impact of order set utilization for the treatment of patients with severe sepsis and septic shock. Crit Care Med. 2015 Dec;43:12(Suppl):267. Abstract 1061. Fact: Statistics demonstrate at BSLMC the months with the lowest Severe Sepsis & Septic Shock mortality were when the order set was utilized the most. 60% Severe Sepsis/Septic Shock Mortality & Order Set Utilization 50% 40% 30% 20% 10% 34% 30.2% 34.4% 14% 26.3% 20% 35.0% 23% 47% 32.5% 50% 46% 20.6% 20.2% 43% 36.1% 26% 26.3% 38% 37.5% 31% 30.9% 35% 34% 29.4% 34.7% 0% 2015 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Order Set Utilization (%) Severe Sepsis & Septic Shock Mortality (%) Source: Internal Data, Baylor St. Luke s Medical Center Sepsis Initiative. 10
By the way, an interesting fact: The Sepsis Order Set is only utilized 30% of the time. The following chart indicates why MDs at BSLMC do not use the order set n = 34 Source: Internal Data, Baylor St. Luke's Medical Center Sepsis Initiative. Sepsis What has been done to decrease mortality Improved Sepsis Assessment & recognition Doing the Right Things at the Right Time Assessment & Recognition 1. Improved ED Triage process with documentation & delegated orders. 2. Improve the current electronic Best Practice Alert (BPA). 3. Improved Acute Care Sepsis Screening with Q Shift Sepsis Assessment. 11
Sepsis What has been done to decrease mortality Improved Sepsis Interventions Doing the Right Things at the Right Time Intervention Tools & Processes to improve MD Sepsis Documentation Tools & Processes to increase MD Sepsis Order Set Utilization At the March 2016 the Medical Executive Committee (MEC) motioned, seconded & carried to require the utilization of the Sepsis Notes & Sepsis Order Set in appropriate patients Dynamic Sepsis Assessment and Intervention Critical Sepsis is a highly dynamic process, especially at onset. It requires ongoing assessment of severity, organ dysfunction, intervention effect, and stepwise escalation or de escalation of care. Ivor Douglas MD, co chair Surviving Sepsis Campaign Writing Committee at BSLMC 11/16/2016 12
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