How Cookeville Regional Medical Center Set Up a Sepsis Program

How Cookeville Regional Medical Center Set Up a Sepsis Program Angela Craig APN,MS,CCNS Clinical Nurse Specialist Intensive Care Unit Cookeville Regional Medical Center acraig@crmchealth.org SepsisSolutionsInternational 2012

Cookeville Regional Medical Center 247 Bed Community Hospital (Non- Teaching) Regional referral center in the heart of the Upper Cumberland in middle Tennessee

CRMC Sepsis Initiative Go live ICU/CVICU ED and Rapid Response September 2009 Go live Hospital Wide October 2010 Cost Savings per patient Mortality Decrease = Lives Saved!!!

Sepsis Disease Specific Certification CRMC March 2015 Shout out to Maury Regional as well who certified this year

CRMC Sepsis Initiative JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 2009 Pre-Sepsis Data Obtained 23 Pts Mortality 70% September 2009 Go live for ICU, CVICU and ED Sep-Dec 2009 29 pts Mortality 49% 2010 Jan-Mar 2010 39 Pts Mortality 31% Apr-Jun 2010 33 Pts Mortality 33% October 2010 Hospital Go Live Jul-Sep 2010 47 Pts Mortality 15% Oct-Dec 2010 49 pts Mortality 14% 2011 Jan-Mar 2011 64 Pts Mortality 16% Apr-Jun 2011 67 Pts Mortality 17% Jul-Sep 2011 66 Pts Mortality 25% Oct-Dec 2011 59 Pts Mortality 27% 2012 Jan-Mar 2012 67 Pts Mortality 17% Apr-Jun 2012 67 Pts Mortality 17% Jul-Sep 2012 67 Pts Mortality 17% Oct Dec 2012 67 Pts Mortality 17%

4-Tier Process for Severe Sepsis Program Implementation Credit to Pat Posa and Kathleen Vollman who built this model and have implemented this successfully in over 50 health systems!! Measuring Success Implementation of the Sepsis Bundle Early Screening with Tools and Triggers Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

4-Tier Process for Severe Sepsis Program Implementation Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Organization Support Executive management at hospital actively supports the Target Severe Sepsis Program Improving care of severe sepsis is aligned with hospital s current year goals Willingness to align resources with program Minimum.5 FTE for project management, data collection & teachable moments

Adult Sepsis/Severe Sepsis/Septic Shock Program Charter CRMC Problem Statement: Severe sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, killing one in four (and often more), and increasing in incidence (1 5). Similar to polytrauma, acute myocardial infarction, or stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome. ("Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 " appeared in the February 2013 issues of Critical Care Medicine and Intensive Care Medicine) Team Members: Facilitator of Team Angela Craig APN/MS/CCNS Physician Support: Dr. Sully Smith ED, Dr. Pierce Infectious Disease, Dr. Carey Hospitalist, OB/Nursery, 4E, 4N/4W, Education, Nsg Admin, Pharmacy, Respiratory, Lab, ICU, CVICU, 5E, 6E, 5N, 6N, In Pt Rehab, Surgery/PACU, Quality, ED, Hospitalist, Auditor, Infection Prevention Mission: CRMC aspires to be the leading Sepsis Treatment Center of the Upper Cumberland Area. We will expect best outcomes for our septic patients by utilizing national guidelines and evidence to treat them to the best of our ability. Performance Measures: Measure 1: Decrease time to Central Venous Pressure (CVP) goal for septic shock patients in addition to increasing compliance with CVP monitoring. Measure 2: Decrease the time to SCVO2 goal for septic shock patients in addition to increasing compliance with SCVO2 monitoring. Measure 3: Decrease time to administration of antibiotics to within one hour of time zero. Measure 4: Improve the accuracy of initial screening and recognition of severe sepsis/septic shock. Scope: Severe sepsis/septic Shock patients Housewide at CRMC Target Population: Adult Business Case: In comparison to other patients, severe sepsis patients have a higher mortality rate, increased LOS, and an increased need for a ventilator Goals/ Objectives: Become Disease Specific Certified from The Joint Commission Reduce Severe Sepsis Mortality Proper Placement of patients initially (Step-down for severe sepsis and Critical Care for Septic Shock) Milestones: ICU, CVICU, ED, Rapid Response Team Sepsis go live Sept 2009 Housewide sepsis go live October 2010 Working toward disease specific certification 2014 Goal Certification 2015 2/15

Organization Support Understanding that this is a 2 to 3+ year program to make this the standard of practice for this patient population Existing culture that supports change Successfully implemented other major change programs e.g., vent bundle, tight glucose control, CR-BSI Established team in place with ICU physician and nurse champion, ED physician and nurse champion that are recognized leaders in the hospital

The Team Is KEY! Can Be Major Barrier If Not Functioning Well Must have nurse and physician champions from ED and ICU (need at least one physician at all meetings) Must be linked in the organization s quality or operational structure Must meet at least 1-2 times per month Team members must be well educated on the evidence and armed with tools and knowledge to change behavior at the bedside MUST have bedside nurses on team provide reality check and best knowledge of barriers

Economic Implications of an Evidence-based Sepsis Protocol Objective To determine financial impact of a sepsis protocol designed for use in the ED Design Analysis of results from recent prospective study comparing outcomes in patients with septic shock before and after initiation of sepsis protocol Setting Academic, tertiary care hospital in US Subjects: Adults (n=120) who sequentially presented to ED with septic shock, specifically: ED = Emergency Department Shorr AF et al. Crit Care Med. 2007;35:1257 1262.

Summary of Results Post-protocol, savings of ~$6,000/patient observed Translated into total cost difference of $573,000 between the two groups Post-protocol, ICU costs reduced by ~35% (p=0.026) and ward costs fell by 30% (p=0.033) Protocol resulted in a reduction in overall hospital LOS of 5 days (p=0.023) Pre-protocol, 28-day mortality rate was 48.3% vs. 30.0% following protocol initiation (p=0.040) ICU, intensive care unit; LOS, length of stay Shorr AF et al. Crit Care Med. 2007;35:1257 1262.

Tier I: Organizational Consensus Milestones and Checklist Define Sepsis Program Goals Team Charter

Tier I: Organizational Consensus Milestones and Checklist Define Sepsis Program Goal Team Charter Collect Baseline Data

Baseline Data Collection Process Pick time period for medical record query Sample size: minimum of 20 pts per ICU Query strategies: ICD 9 codes: 785.52 and 995.92 Patients in ICU on 1-2 antibiotics, ventilator, vasopressor (review charts to see if meet criteria for severe sepsis or septic shock before include in outcome data or process data) Select Data Collection Elements Outcome Process

Tier I: Organizational Consensus Milestones and Checklist Sepsis Goals aligned with organizational goals Develop sepsis team (do we have all the right people here?) and schedule monthly (minimum) meeting for at least 6 months Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting Begin to define action plan and timeline for program development and implementation

Action Plan Tier Gap Action Steps Tier I: Organizational consensus

Action Plan Tier Gap Action Steps Tier I: Organizational consensus Team not meeting regularly anymore Re-formulate a team Meet with unit manager or nursing director to talk about a plan to reformulate the team

Second Tier: Implementation of Early Screening Tools and Triggers Early Screening with Tools and Triggers Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Severe Sepsis: Defining a Disease Continuum Infection SIRS Sepsis Severe Sepsis Adult Criteria A clinical response arising from a nonspecific insult, including 2 of the following: Temperature:> 38 C(100.4) or < 36 C (96.8) Heart Rate: > 90 beats/min Respiration: > 20/min WBC count: > 12,000/mm 3, or < 4,000/mm 3, or > 10% immature neutrophils SIRS = Systemic Inflammatory Response Syndrome Bone et al. Chest.1992;101:1644-1654. SIRS with a presumed or confirmed infectious process Sepsis with 1 sign of organ dysfunction, hypoperfusion or hypotension. Examples: Cardiovascular (refractory hypotension) Renal Respiratory Hepatic Hematologic CNS Unexplained metabolic acidosis Shock

Signs & Symptoms of Sepsis Chills Alteration in LOC Tachypnea Unexplained metabolic acidosis Heart rate Altered blood pressure Platelets Bands Skin perfusion Urine output Skin mottling Poor capillary refill Hyperglycemia Purpura/petechia Levy M, et al. Crit Care Med 2003;31:1250-6.

Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis Respiratory Increased Oxygen Requirements Cardiovascular Tachycardia SBP<90mmHg MAP < 70mmHg (despite fluid) Need for Vasopressors Renal Metabolic Unexplained metabolic acidosis Lactate > 1.5 times upper normal UO < 0.5 ml/kg per hr (despite fluid) Hematologic Platelets <80,000/mm 3 Decline in platelet count of 50% over 3 days

TIME IS TISSUE!! Why Do You Need to Have a Screening Process? Similar to polytrauma, AMI, or stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcomes. 1 To screen effectively, it must be part of the nurses daily routines i.e., part of admission and shift assessment Must define a process for what to do with the results of the screen If you don t screen you will miss patients that may have benefited from the interventions. 1. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327.

Where do you screen patients for Severe sepsis/ Septic Shock Currently? A: Housewide, all floors do sepsis screening B: Emergency Dept. Only C: Critical Care Areas and Emergency Dept. only D. We have no formal screening process at our hospital

Make Screening for Severe Sepsis Process-Dependent Weave into fabric of current practice Assess for on a daily basis Identify strategies for initiation of therapy response once patient is identified

Incorporate Screening and Early Identification Throughout the Hospital Emergency Department ICUs Patient Care Units Rapid Response Team

ED Screening Tool

Rapid Response Team Tool

What About Automation for Early Recognition? MICU, single center, 442 consecutive patients who met modified SIRS Randomized to automated identification of SIRS with notification to MD or usual care Measure impact on early antibiotics and outcomes in patients with sepsis Results No difference in median time to antibiotic No difference in amount of fluid administered No diff in LOS or mortality Hooper MH, et al. Crit Care Med. 2012;40

Screening: Barriers/Strategies Barriers Time for nurses to do it (perception vs. reality) Screening is not sensitive only for severe sepsis Positive screen is not a diagnosis of severe sepsis Strategies Must assign responsibility and enforce accountability Perform audits to measure compliance and identify problems Round on unit and ask nurses how it is going and discuss issues

Screening: Barriers/Strategies Lesson learned: Bedside nurse must do daily screening. Education/Simulation/Education Every 6 months Build into orientation Must be part of your documentation structure Practice-Practice-Practice www.icu-usa/pro

Is Sepsis Training part of your Unit based or hospital based orientation? A: Yes, Unit Based Orientation B: Yes, Hospital Based Orientation C: Yes, Both Hospital and Unit Based Orientation D: No This is an opportunity for my hospital

Nursing Care Essentials to Complement SSC Infection Prevention Education: Multimodal/interactive Accountability: Culture of patient safety Surveillance: Continuous Hand Hygiene: Alcohol based gel 1 st, if soiled soap & H 2 0 Prevention of VAP Prevention of CR-BSI Prevention of SSI Prevention of UTI Source control (catheter removal, isolation etc.) Educated to recognize signs of severe sepsis & septic shock Use of early warning system Use of screening tools for early recognition Aitken LM, et al. Crit Care Med;2011;39;39:1800-1818

Nursing Care Essentials to Complement SSC Communications tools be used to improve communication (i.e. SBAR, RSVP (reason, story, vital signs & plan) Initial resuscitation of patients be provided through the use of a rapid response system Education Adequate resources Adequate nurse staffing levels Sepsis six should be promoted in non-critical care areas (care within 1 st hour) (protocol directed care) Starting high oxygen flow Obtaining blood cultures Administering antibiotic therapy Starting IV therapy Obtaining lab work (hgb & lactate levels) Measuring I & O Pre-mixed antibiotics for 1 st dose Tracking systems & daily sepsis rounds Aitken LM, et al. Crit Care Med;2011;39;39:1800-1818

Clinical Scenario I: Early identification and intervention 88 year old, 51.6kg,white, female admit from ED; resided in ECF History: CAD, COPD, dementia, Alzheimer disease, depression, SVT Chief Complaint: rib pain, chest congestion and SOB Awake, alert and oriented, slight combative (history of combative behavior)

Clinical Scenario I: Early Identification and Intervention Initial VS: Temp: 101.6 F RR: 31 HR: 109, atrial fib with occasional SVT B/P: 79/51 2L of O2, O2 sat of 96% Does this patient screen positive for severe sepsis?

Clinical Scenario II: Early Identification and Intervention 62 yr. old male, 2 days post op s/p colectomy, 73kg, receiving antibiotics Vital signs: HR 120. RR 24, BP 80/40, temp: 102.2; urine output 100ml over last 4 hrs. Does patient screen positive for severe sepsis?

Clinical Scenario II: Early identification and intervention 62 yr. old male, 2 days post op s/p colectomy, 73kg,receiving antibiotics Vital signs: HR 120. RR 24, BP 80/40, temp: 102.2; urine output 100ml over last 4 hrs. Screen patient for severe sepsis Positive Screen for Severe Sepsis SIRS: HR>90; RR>20; Temp> 100.4 Infection: on antibiotics Organ dysfunction: BP 80/40

Tier II: Screening for Severe Sepsis Milestones and Checklist Develop screening process for ED, rapid response team and ICU (eventually housewide) Develop audit process to evaluate compliance and effectiveness Ensure screening process has clear next steps defined for nursing staff

Screening Compliance Audit Tool Pt. Account # (enter #) Screened Y/N (circle) Y N Patient transferred to appropriate level of care Y/N (circle) (Severe Sepsis Stepdown Septic Shock (ICU/CVICU) Y N Pt. Have known suspected infection Y N Antibiotics hung within 1 hour of time zero? Y N T 100.4 or < 96.8 HR > 90 RR >20 or PACO 2 <32 WBC >12,000 <4,000 or > 10% Bands SIRS Present Screen done correctly Y/N (circle) Organ Dysfunction Respiratory (increased oxygen requirements) Cardiovascular (SBP less than 90 or MAP less than 65 or on a vasopressor) Renal (Urine output less than 05.ml/kg/hr., creatinine greater than 2) Metabolic (Lactate greater than or equal to 4mmoL/dl) Hematologic (Serum total bilirubin greater than or equal to 4mg/dl) Hepatic (Serum total bilirubin greater than or equal to 4mg/dl) CNS (Altered consciousness unrelated to primary neuro pathology) If screen not done correctly, why? Which labs were sent? ( =obtained) Bld Cult x2 Bld Cult CVAD >48 hr Lactic Acid Was Central Line Inserted? (Critical Care Only) Y N Fluid bolus (30ml/kg) provided for hypotension Y/N (circle) Y N If no how much given 500 ml 1 liter Screened positive for severe sepsis (Y/N) (circle) Y N Comments Pos feedback letter given Neg feedback letter given Other (Explain) Screened positive for Septic Shock Y/N (circle) Y N Positive Screenings If screened positive for Septic Shock in CVICU/ICU was Septic Shock Clinical Pathway (Form 1112- PRN) started Y N If screened positive for Severe Septic or Septic Shock (floors other than ICU/ED/ CVICU) was Initial Management of Patient with Severe Sepsis (Form 1135-PRN) completed Y N Unit: Date: Shift: # Audits Completed (Every shift checked considered an audit): # Audit Screened (numerator = number of screenings completed, denominator = audits completed Example: 7 screenings done, 10 audits completed = 70% audits screened) % # of Audits screened correctly? (numerator = number audits screened correctly, denominator = number audits completed ) % % of follow up on incorrect screens (numerator = number of audits followed up on, denominator = number of incorrect audits) %

Action Plan Tier Gap Action Steps Tier I: Organizational consensus Tier II: Screening and Early Identification Team not meeting regularly anymore Re-formulate a team Meet with unit manager or nursing director to talk about a plan to re-formulate the team

Action Plan Tier Gap Action Steps Tier I: Organizational consensus Tier II: Screening and Early Identification Team not meeting regularly anymore No formal process for screening or follow through Re-formulate a team Meet with unit manager or nursing director to talk about a plan to re-formulate the team Start to develop screens and implement for the ICU and ED

Homeostasis Is Unbalanced in Severe Sepsis COAGULATION INFLAMMATION FIBRINOLYSIS Homeostasis Carvalho AC, Freeman NJ. J Crit Illness 1994;9:51-75. Kidokoro A, et al. Shock 1996;5:223-8. Vervloet MG, et al. Semin Thromb Hemost 1998;24:33-44.

Inflammation, Coagulation and Impaired Fibrinolysis In Severe Sepsis Endothelium COAGULATION CASCADE Tissue Factor Monocyte IL-6 IL-1 TNF-α Factor VIIIa Factor Va THROMBIN PAI-1 Suppressed fibrinolysis Neutrophil Fibrin Tissue Factor IL-6 Fibrin clot Inflammatory Response to Infection Thrombotic Response to Infection Fibrinolytic Response to Infection Adapted from Bernard GR, et al. N Engl J Med. 2001;344:699-709.

MICROCIRCULATION: SUBLINGUAL BLOOD FLOW Healthy Volunteer BP: 120/80 mm Hg SaO 2 : 98% 1. www.opsimaging.net. Accessed April 2004. 2. Spronk PE, et al. Lancet. 2002;360:1395-1396. Septic Shock Patient Resuscitated with fluids and dopamine HR: 82 BPM BP: 90/35 mmhg SaO 2 : 98% CVP: 25 mmhg

Pathophysiologic Characteristics in Severe Sepsis Maldistribution of blood flow Imbalance of oxygen supply & demand Metabolic alterations & activation of the stress response

Imbalance of Oxygen Supply & Demand SUPPLY DEMAND Vollman 2001

OXYGEN SUPPLY/DEMAND DYNAMICS ScvO2 CVP, CO, CI, SV, SVI, SVV

Optimize Cardiac Performance Fluid Bolus to define place on curve: Record Stroke Volume (SV) Give 250-500 NS bolus over 10-15minutes Record SV If see greater than a 10% increase in SV pt. is on steep portion of curve and will still respond to fluid

O 2 Supply/Demand Compensatory Mechanisms Improve pulmonary gas exchange Increase oxygen delivery Alter the distribution of blood flow

Monitoring Oxygen Dynamics Lactates within 3 hours, then if elevated obtain another one prior to 6 hour mark, every 6 hrs. until cleared Correlates with mortality; Expect clearance within 24 hours ScvO2 Subclavian or IJ triple lumen intermittent sampling or continuous monitoring Baseline and then hourly till > 70%;

Cornerstones of Multidisciplinary Management of Severe Sepsis/MODS Prevention Screening and Early Identification Early Intervention: Source control, Blood cultures and broad spectrum antibiotics May want to protocolize lactic acid/blood culture collection 3 Hour Bundle 6 Hour Bundle

Third Tier: Implementation of Evidence-Based Sepsis Bundles Implementation of the Sepsis Bundle(s) Early Screening with Tools and Triggers Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Tier III: Implementation of Sepsis Bundles Milestones and Checklist Define who will put in the CVP line for patients when the come from the floor, especially on off shifts and weekends Develop easy to use order sets (ED and ICU should be the same), organized by bundle Order sets approved by appropriate medical and nursing leadership/committees Assess physician/provider skill level with CVP insertion. Create strategy to deal with gap in skill if present We have had classes for physicians for hemodynamics and central line placement

Tier III: Implementation of Sepsis Bundles Milestones and Checklist Ability to get lactate results in 30 minutes or less Ability to get antibiotics administered within one hour of diagnosis or first hypotensive episode Identify equipment needs and make capital requests Identify education needs

If lactate 2.1-3.9: target resuscitation to normalize the lactate (2C) Dellinger, etal, Critical Care Medicine, Feb 2013, Vol 41 Number 2

SSC Guidelines A: Initial Resuscitation Should be protocolized, quantitative resuscitation of patients with sepsis induced hypoperfusion (defined as hypotension persisting after initial fluid challenge or blood lactate > 4mmol/L) Goals during the first 6 hours of resuscitation: Central venous pressure: 8-12 mmhg Higher with altered ventricular compliance or increased intrathoracic pressure Mean arterial Pressure (MAP) 65mmHg Urine Output 0.5mL/kg/hr Central Venous (superior vena cava) or mixed venous oxygen saturation 70% or 65% respectively (1C)

CRMC Septic Shock Clinical Pathway

SBAR Report Form

Antibiotic Challenges Appropriate selection determined based upon consensus guidelines and pathogen sensitivity at your institution Timing issues How? Delivery time challenges of antibiotics Possible solutions

Clinical Scenario II: Early identification and Intervention 88 year old, 51.6kg,white, female admit from ED; resided in ECF History: CAD, COPD, dementia, Alzheimer disease, depression, SVT Chief Complaint: rib pain, chest congestion and SOB Awake, alert and oriented, slight combative (history of combative behavior) The Rest of the Story

Clinical Scenario II : Early Identification and Intervention-ER Labs: WBC: 11.5 Hgb: 15.8 Hct: 47.4 BUN: 28 Creatinine:1.6 Glucose:158 BNP:78 (moderate CHF); troponin:0.03 Lactic acid: 4.6 U/A: positive for bacteria ScvO2: 49.1% Blood cultures X 2 drawn

Clinical Scenario II : Early Identification and Intervention-ER CXR: RLL consolidation Additional Interventions: Broad spectrum antibiotics given within 3 hours of presentation Lactic acid >4mmol/L so CVP inserted Fluid resuscitation continued Foley inserted Received total of 3 Liters of NS during 3 hour ED stay ED diagnosis: Severe Shock, Pneumonia, UTI, CHF Transferred to MICU

Clinical Scenario II : Early Identification and Intervention--MICU Additional Interventions: Day 1 Continued fluid resuscitation 7 L Low dose vasopressor Low dose steroids Remained on 2 L nasal cannula Labs: ScvO2: 72.8 (after resuscitation) Lactic acid: 4 hours after ICU admission: 6.7 12 hours after ICU admission: 3.0

Clinical Scenario II : Early Identification and Intervention Day 2: Vasopressor weaned off Lasix to assist with fluid mobilization Lactic acid: 3.0 Day 3: Lactic acid: 1.2 O2 sat 93% on room air Central line discontinued Transferred to intermediate care on Day 3 Discharged from hospital on day 7

Tier III: Sepsis Bundle Implementation Milestones and Checklist Identify resistance and barriers to bundle implementation and develop solutions Define educational plan for all staff: Develop implementation plan

Action Plan Tier Gap Action Steps Tier I: Organizational consensus Tier II: Screening and Early Identification Tier III: Implementing the Bundles Team not meeting regularly anymore No formal process for screening or follow through Re-formulate a team Meet with unit manager or nursing director to talk about a plan to re-formulate the team Start to develop screens and implement for the ICU and ER

Action Plan Tier Gap Action Steps Tier I: Organizational consensus Tier II: Screening and Early Identification Tier III: Implementing the Bundles Team not meeting regularly anymore No formal process for screening or follow through Getting lactate & antibiotics in < 1hr Getting the Central line inserted Re-formulate a team Meet with unit manager or nursing director to talk about a plan to re-formulate the team Start to develop screens and implement for the ICU and ER Lactate: explore point of care & measurement from the ABG machine Antibiotic: Broad spectrum in the Pyxis Central Line: Around the clock Power PICC team

Is it difficult to get a central line placed in your institution A: Yes B: No

Implementation Hospital resources often focus on planning phase and then back off after implementation. The implementation phase is the most critical. Frequent rounds by project champion recommended on unit to support staff and answer questions. Defined resources for bedside nurse: Project champion has pager to be available 24/7 initially Clinical nurse champions identified on each ICU unit, ED, and all Nsg Care Units to be resources to bedside staff (these staff should be members of the sepsis team/committee from the beginning)

Tier III: Develop and Implement the Education Plan Content: (present to physicians, nurses, Pharmacy, and RTs) Significance of problem Sepsis continuum Pathophysiology of severe sepsis Prevention and management (share the evidence) Case studies for staff to practice with bedside tools Methods: Self learning modules Classroom and/or small groups of staff on unit Web-based Ongoing: build into orientation monthly for residents every 6 months for all staff one-on one during rounds

TIER III: Develop Implementation Plan Identify who will oversee the implementation and the expectations of that person (sepsis nurse or program coordinator) Define Critical Care/ED/Floor resources for staff that they can call at any time for questions and assistance Example OB Floor

TIER III: Develop Implementation Plan Create rounding schedule and process Should begin as daily in the ICU and ED Keep master list of all patients who go on the bundles (and those who should have but didn t if possible) Do real time interventions to ensure patients get the evidence based practices Define follow up process for review and evaluate missed opportunities

Fourth Tier: Measuring Process & Outcome Changes Use of evidence-based approach Measuring Success Implementation of the Sepsis Bundle Early Screening with Tools and Triggers Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Tier IV: Measurement Milestones and Checklist Define outcome and process data elements that will be collected Develop and implement a data collection process Revise and update goals and action plan as needed Execute implementation plan

Data Collection Patient Log Define how will find all patients that receive the bundles Real time data collection is optimal then used as checklist to ensure patient receives all appropriate interventions Outcome Mortality (ICU and Hosp) Hosp LOS Cost per case (total and direct) Process SSC database Data elements that measure implementation of resuscitation and management bundle

CRMC Data Sample CRMC Septic Shock Data Post Sepsis Protocol Group VIII Oct-Dec 2012 (49 pts) Where Septic Shock Identified ED 14% ICU 82% CVICU 4E 2% 5E 2% 6N 5N 4N 6E Outside Facility Post Sepsis Protocol Group IX Jan-Mar 2013 (65 pts) 43% 55% 2% Serum Lactate Drawn within 6 hr from time zero Blood cultures drawn times 2? Were Bld Cultures drawn w/in 1 hr of time zero? Was 20mL per kg infused? If No was bolus of any amount given? If Yes How much given? Yes 98% No 2% Yes 100% No Yes 71% No 29% Yes 65% No 35% Yes 71% No 29% 100% 94% 6% 72% 28% 65% 35% 57% 43% 500mL 44% 1 liter 56% 2 liter 1.5 liter 38% 62%

CRMC Data Sample Was patient hypotensive after fluid bolus? Yes 80% No 20% Not Documented 84% 16% Pt received antibiotic within first hour (added field) Yes 60% No 40% 57% 43% Initial lactate > or equal to 4 Yes 31% No 69% 54% 46% CVP Placed? Yes 49% No 51% Not Documented 61% 39% Was patient on vasopressors > 6 hours? Yes 68% No 32% 71% 29% Patient Expired? *** Yes 33% No 67% 18% 82%

Indicator/ Month Jan 26 Feb 25 March 20 1 st Q 71 Apr 11 May 18 Lactate drawn within 3 hrs. of time zero 100% (26/26) 92% (23/25) 95% (19/20) 96% (68/71) 82% (9/11) 100% (18/18) Blood C/S drawn prior to antibiotics 88% (23/26) 92% (23/25) 95% (19/20) 92% (65/71) 100% 89% (16/18) Broad Spectrum antibiotic within 3 hrs. of time zero 92% (24/26) 84% (21/25) 75% (15/20) 85% (60/71) 82% (9/11) 67% (12/18) Administer 30ml/kg crystalloid 65% (17/26) 60% (15/25) 80% (16/20) 68% (48/71) 73% (8/11) 72% (13/18) Administer 30ml/kg crystalloid within 3hrs of time zero 82% (14/17) 100% (15/15) 81% (13/16) 88% (42/48) 100% 8/8 100% (13/13)

Central line placed 88% (23/26) 64% (16/25) 75% (15/20) 76% (54/71) 73% (8/11) 78% (14/18) Central line placed within 6 hrs. of time zero 57% (13/23) 94% (15/16) 40% (6/15) 63% (34/54)) 63% (5/8) 43% (6/14) MAP goal met within 6 hrs. of time zero 85% (22/26) 88% (22/25) 60% (12/20) 79% (56/71) 91% (10/11) 56% (10/18) CVP goal met within 6 hrs. of time zero 15% (4/26) 8% (2/25) 10% (2/20) 11% (8/71) 9% (1/11) 0% (0/18) Scv02 goal met within 6 hrs. of time zero 4% (1/26) 0% (0/25) 5% (1/20) 3% (2/71) 0% (0/11) 0% (0/18) Survival Rate 77% (20/26) 64% (16/25) 60% (12/20) 68% (48/71) 82% (9/11) 94% (17/18) Readmission Rate 3.8% (1/26) 4% (1/25) 10% (2/20) 5.6% (4/71) 9% (1/11) N/A (No readmits)

Goals 4-Tier Process for Severe Sepsis Program Implementation Tier 1 Complete by May 1 st, 2009 Tier 2 Complete by May 26 th, 2010 Measuring Success Implementation of the Sepsis Bundle Tier 4 Complete by October 2010 Plan in place Tier 3 Complete by August 2010 Educate for 3 weeks Early Screening with Tools and Triggers Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Three Biggest Challenges

Challenge #1: Finding the Patients Redefining what a septic shock patient looks like Before Supine in bed Ventilator Fluids wide open Increasing vasopressors Minimally responsive NOW Sitting up in bed Nasal cannula IV boluses Weaning vasopressors Awake Don t look sick enough to be in ICU or to have a central line Must correct this misperception

Additional Strategies: Finding the Patient Unit sepsis champions Sepsis coordinator ED and ICU rounding RRT screen on every call Prospective patient log Discuss sepsis screen as part of Multidisciplinary Rounds Reports Patients who screened positive Lactate

Finding the Patients: Prospective Patient Log Unit Pt # Point of Entry Date of Septic Shock Dx Time of Septic Shock Dx Data Obtained Data Complete Comments / Follow-up

Sepsis Management: Challenges #2 Physician Buy-in Strategies: Redefining what a septic shock patient looks like Physician Champions-ED and ICU Part of sepsis team Follow up with physician when bundles not followed ED and ICU rounding Unit sepsis champions Sepsis coordinator Data--- Often and detailed Physician specific Administrative support

Challenges #3: Not Meeting 3hr and 6hr goals Focused Incremental Goals First hour of care Lactate, blood cultures, antibiotics and 30ml/kg fluid bolus Other goals within 6 hours CVP greater than or equal to 8mmHg MAP greater than or equal to 65mmHg ScvO2 greater than or equal to 70 % Work on 3 hour Bundle First then the 6 hour Bundle

Communication Policy Environment **Poor between RN & MD re:diagnosis. (2) **RN not comfortable discussing w/ MD Poor between ER-ICU & OR-ICU (2) Lack of guidance on MN & Weekends (5) No IV line holders at head of bed Nurse does not know where to look for information re:bundles Delay in antibiotic verification in pharmacy. (4) Unclear process (4) No ICU beds to transfer patient to. (4) **Nurse/Patient ratio 1:2 with high acuity (10) Staff overwhelmed with other initiatives. **Signs go unrecognized (8) **Unsure how to follow bundle (8) -RN forgot to screen (2) -Unsure how to measure CVP from PICC (4) **-No sense of urgency (6) goals not achieved in 3hours or 6 hours Materials Order sets not being used. (3) Process **-MD buy in (3) -RN: lack of knowledge -Reoccurrence goes unrecognized -Lack of critical thinking/cant put it all together (3) -RN/MD refuses to follow bundles People

Sustaining and Improving: Strategies Independent checks Checklists, pathway Multidisciplinary rounds Real time feedback and on-going education Unit rounds Unit champions Staff meetings Orientation---RN and residents Quarterly with current staff

Sustaining and Improving: Strategies Creating sense of urgency Code Sepsis or Sepsis Alert Staffing ratio for initial 6 hours of ICU or ED care Clock on the door Protocol Watch

Keys to Success Team in place with key stakeholders overseeing implementation Project coordinator with lead clinical staff on each unit Sepsis resource/coordinator rounds frequently on units Strong physician leadership on team Reminders to staff through use of bedside sepsis tools/checklist

Keys to Success Empowerment of nursing staff to prevent errors Administrative support to help manage barriers Review data monthly to identify opportunities for improvement Support from state-wide collaborative/surviving sepsis campaign EDUCATION, DATA, PROCESS, EDUCATION, COMPLIANCE

The Nurses Role Early recognition of patients with signs of sepsis Early initiation of evidence based practice therapies appropriate for your area of practice (antibiotics, fluids/blood & pressors) Swift disposition to care areas where the rest of the bundle can be started.

References: Dellinger et al, Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Critical Care Medicine. 2013; 41:580-637. Vollman, Kathleen and Pat Posa Critical Care Solutions developed the pyramid