Sepsis Collaborative: Simulation Outreach to Address Patient Safety (SOAPS) CAUTI, CLABSI and Sepsis Module

Sepsis Collaborative: Simulation Outreach to Address Patient Safety (SOAPS) CAUTI, CLABSI and Sepsis Module Author: Cathy Buzbee, MHA, BSN, RNP, OCN Director of Accreditation and Compliance UAMS Office of Continuing Education 2/13/18 to 2/13/21

UAMS Disclosure Statement It is the policy of the University of Arkansas for Medical Sciences (UAMS) to ensure balance, independence, objectivity, and scientific rigor in all directly or jointly provided educational activities. All individuals who are in a position to control the content of the educational activity (course/activity directors, planning committee members, staff, teachers, or authors of CE) must disclose all relevant financial relationships they have with any commercial interest(s) as well as the nature of the relationship. Financial relationships of the individual s spouse or partner must also be disclosed, if the nature of the relationship could influence the objectivity of the individual in a position to control the content of the CE. The ACCME, ACPE, and ANCC describe relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose will be disqualified from participation in the development, management, presentation, or evaluation of the CE activity.

Accreditation Statement and Disclosures from Planners and Authors In support of improving patient care, University of Arkansas for Medical Sciences is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. The following authors and planners of this CE activity have no relevant financial relationships with commercial interests to disclose: Travis Hill, M.Ed Cathy Buzbee, MHA, BSN, RNP, OCN Lea Mabry, M.Ed

Credit Designation Statements The University of Arkansas for Medical Sciences designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The University of Arkansas for Medical Sciences designates this enduring material for a maximum of 1.0 ANCC contact hours. Nursing contact hours will be awarded for successful completion of program components based upon documented attendance and completion of evaluation materials.

Target Audience Physicians, Nurses, Pharmacists and other Direct Patient Care Personnel.

Criteria for Successful Completion of this Module In order to receive Continuing Education Contact Hours or CME credit you must meet these conditions: View the entire module. Pass the post test with 80% or better score. Complete an evaluation of the module.

Objectives of this Module Describe and define Healthcare Associated Infection (HAI), Catheter Associated Urinary Tract Infection (CAUTI) and Catheter Associated Blood Stream Infection (CLABSI). Review the incidence, morbidity and mortality of CAUTI, CLABSI and sepsis. Discuss the precipitating factors that may lead to CAUTI, CLABSI and sepsis. Recognize the clinical presentation of CAUTI, CLABSI and sepsis. Discuss preventive measures for CAUTI, CLABSI and sepsis. Apply the goals of management for sepsis.

On the National level, between 2008 and 2013 the Healthcare Associated Infections (HAI) progress report found: A Few Statistics A 46% decrease in Central Line Associated Blood Stream Infections (CLABSI). A 19% decrease in Surgical Site Infections (SSI) related to the 10 select procedures. A 6% increase in Catheter Associated Urinary Tract Infections (CAUTI). An 8% decrease in hospital onset MRSA bacteremia. A 10% decrease in hospital onset C.difficile infections. http://www.cdc.gov/hai/surveillance/

Centers for Disease Control Healthcare Associated Infection Data for Arkansas Click image to enlarge

Centers for Disease Control Healthcare Associated Infection Data for Arkansas Click image to enlarge

Catheter Associated Urinary Tract Infections (CAUTI)

Financial Impact of CAUTI Most common type of healthcare associated infection (HAI). Estimated to have more than 560,000 nosocomial UTI annually at an average cost of an additional $2836.00 per episode. Increased morbidity and mortality. Estimated to cause 13,000 attributable deaths annually. Leading cause of secondary Blood Stream Infections. Increased length of stay (LOS) 2 to 4 days per episode of CAUTI. Adding about 0.5 billion dollars per year. Unnecessary antimicrobial use. www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

A Few Statistics on CAUTI http://www.cdc.gov/hai/surveillance/

All of these criteria must be met to be considered CAUTI Patient has an indwelling urinary catheter that has been in place for > 2 days on the date of event, OR removed the day before the date of event Criteria for CAUTI Patient has at least one of the following signs or symptoms: Fever (>38.0 C) Suprapubic tenderness Costovertebral angle pain or tenderness If catheter has been removed Urinary urgency Urinary frequency Dysuria Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of 105 CFU/ml 1 https://www.cdc.gov/nhsn/

Sources of CAUTI http://www.cdc.gov/ncidod/eid/vol7no2/ pdfs/maki.pdf

Extra-luminal Outside the Catheter Biofilm encrustation at the tip Organism migration Fecal incontinence and contamination Mechanism of CAUTI Intra-luminal Inside the Catheter Biofilm and encrustation inside the catheter Disconnection of catheter/drainage system Contamination at sample port

Indications for Use of an Indwelling Urinary Catheter Acute urinary retention/bladder outlet obstruction Peri-operative use in selected surgical procedures Assist in healing of open perineal and sacral wounds in incontinent patients Hospice/comfort/palliative care Prolonged immobilization for trauma or surgery Accurate measurement of urinary output in critically ill patients Chronic indwelling urinary catheter on admission from other healthcare facilities www.cdc.gov/hicpac/cauti/001_cauti.html

Hand hygiene and standard (or appropriate isolation) precautions Insert catheters only for appropriate indications Core Prevention Strategies Leave catheters in place only as long as needed Ensure that only properly trained persons insert and maintain catheters Insert catheters using aseptic technique and sterile equipment Following aseptic insertion, always maintain a closed drainage system Maintain unobstructed urine flow at all times https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html

Following aseptic insertion of the urinary catheter, maintain a closed drainage system Clinical Practice Pearls to Prevent CAUTI If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment Use urinary catheter systems with preconnected, sealed catheter-tubing junctions https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf

Clinical Practice Pearls to Prevent CAUTI Maintain unobstructed urine flow Secure the catheter and collecting tube to keep free from kinking Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor Empty the collecting bag regularly using a separate, clean collecting container for each patient https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf

Clinical Practice Pearls to Prevent CAUTI Care of the indwelling urinary catheter Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine change of indwelling catheters or drainage bags at fixed intervals is not recommended https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf

Central Line Associated Blood Stream Infections (CLABSI) Click image to enlarge

Major Veins Used for Central Venous Access Click image to enlarge

Types of Central Venous Access Devices: Tunneled and Non- Tunneled Tunneled: a catheter inserted into a central vein and the remainder is tunneled subcutaneously to a distant exit site. Subcutaneous cuff Non-Tunneled: a catheter inserted directly into a central vein

Types of Central Venous Access Devices: Peripherally Inserted Central Catheters (PICC) Click images to enlarge

Click images to enlarge Types of Central Venous Access Devices: Implanted Venous Access Devices (I-Ports) Ports come in a variety of shapes and sizes.

Ports come in a variety of shapes and sizes.

A Few Facts About CLABSI Central Line Associated Blood Stream Infection (CLABSI) 80,000 reported in ICU patients per year. Estimated 250,000 cases outside ICU. Influencing factors for CLABSI Patient related: Severity of illness Type of illness Catheter related: Catheter type (tunneled, non-tunneled, midline) Conditions under which the catheter was placed Institutional Size of hospital Academic medical center https://www.cdc.gov/hai/bsi/bsi.html

Routes of Contamination Migration of skin organisms at the insertion site into the catheter tract and along the surface of the catheter to the tip. Direct contamination of the catheter hub via contact with hands or contaminated fluids or devices. Catheter is seeded from another source of infection in the body. Very rarely contamination of the catheter from an infusate. https://www.cdc.gov/hai/bsi/bsi.html

Guidelines for the Prevention of CLABSI Hand Hygiene before and after any inserting, palpating, replacing, accessing or dressing an intravascular catheter. Aseptic technique for insertion and care of a central venous catheter. Use of maximal sterile barrier precautions (gown, gloves, mask, patient drapes) for insertion of arterial, central and midline catheters. https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines.pdf

Guidelines for the Prevention of CLABSI Dressing changes every 2 days for gauze dressings and weekly for transparent dressings, unless loose, torn or soiled. Sterile gloves and sterile kits for CVL dressings. Chlorhexidine swabs for cleaning and chlorhexidine impregnated sponges at exit site. Aseptic technique for CVL cap changes. https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines.pdf

CVL Dressings: What s Wrong With These Pictures? Click here to enlarge and learn the answer

This CVL dressing 1. Exit site too close to edge of dressing, and edge is loose. 2. Exit site is reddened and has an exudate. 3. No CHG impregnated patch at exit site. 4. No date dressing was done.

This CVL dressing 1. Exit site in center of transparent dressing. Edges are sealed and secured. 2. CHG impregnated patch centered over exit site 3. Dressing is signed and dated.

Sepsis https://www.sepsis.org/

A Few Statistics More than 1.5 million people are diagnosed with sepsis each year in the United States. Sepsis is responsible for 258,000 deaths in the United States each year and around 8 million deaths across the world. Leading cause of death in hospitals 1 of every 3 people that die in a hospital have sepsis Leading cause of hospital readmissions Biggest cost to hospitals at 24 billion dollars per year! www.cdc.gov/sepsis/datareports/index.html https://www.sepsis.org/

Arkansas ranks number 41 out of 50 for sepsis mortality 15.0 deaths per 100,000 total population Stats for Arkansas California is number 1, with the fewest deaths 3.5 deaths per 100,000 total population Mississippi is number 50 for the highest number of deaths 20.2 deaths per 100,000 total population NCHS-Septicemia Mortality by State

What is Sepsis? Sepsis is defined by the presence (probable or documented) of infection together with systemic manifestations of infection. Severe sepsis is sepsis plus sepsisinduced organ dysfunction or tissue hypoperfusion. International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Risk Factors for Sepsis People with chronic medical conditions Adults 65 or older People with weakened immune systems Children younger than 1 year of age https://www.sepsis.org/

Risk Factors for Sepsis The four types of infections most often linked to sepsis: Pneumonia or other lung infections Urinary Tract Infections ( indwelling catheters, kidney disease) Infections from breaks in the skin (Central Venous Line, decubitus, surgical incisions or other wounds) Gastrointestinal infections The most common pathogens associated with sepsis: Staphylococcus aureus Escherichia coli Streptococcus strains https://www.sepsis.org/

Definitions of Sepsis SIRS (Systemic Inflammatory Response Syndrome): An inflammatory state, affecting the whole body, frequently a response of the immune system to infection, but not necessarily so. Sepsis: SIRS that is due to a suspected infection, but has not been diagnosed clinically. Severe Sepsis: Sepsis plus signs of organ dysfunction, such as liver or kidney failure. Septic Shock: Severe Sepsis with cardiovascular system failure and refractory hypotension. https://www.cdc.gov/sepsis/index.html

Subtle Signs of Sepsis Altered Mental Status Tachycardia (>90 beats per minute) Hypotension (SBP<9o, MAP<70, or a SBP drop of >40 mmhg) Cough, dyspnea and/or tachypnea> 22 breaths per minute Temperature 38.3 C (101 F) or below 36 C (96.8 F) Decreased capillary refill, cyanosis or mottling https://www.cdc.gov/sepsis/index.html

Systemic Symptoms of Sepsis Inflammatory Symptoms Hemodynamic Organ Dysfunction Tissue Perfusion

Inflammatory Symptoms Systemic Symptoms of Sepsis Elevated WBC or Neutropenia WBC > 12,000 Elevated C-Reactive Protein (CRP) CRP>8 Elevated procalcitonin (PCT) PCT >0.5 ng/ml https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3613962 https://www.cdc.gov/sepsis/index.html

Systemic Symptoms of Sepsis Hemodynamic Low Blood Pressure <90/60 or MAP<65 Low O2 saturation Tachypnea>20 bpm High Cardiac index Tachycardia >90 bpm https://www.cdc.gov/sepsis/index.html

Systemic Symptoms of Sepsis Organ Dysfunction Low urine output <0.5ml/kg/hr x 2 hours High creatinine >2.0mg/dl Coagulation abnormalities INR>1.5 Low platelets <100,000 High bilirubin >2.0 https://www.cdc.gov/sepsis/index.html

Systemic Symptoms of Sepsis Tissue Perfusion High lactate >2.0 Decreased capillary filling or mottling https://www.cdc.gov/sepsis/index.html

Screening for Sepsis

Screening for Sepsis Screening all patients for sepsis includes the following: Identifying patients at risk Assessment of changes in vital signs Assessment of changes in mental status Assessment of sites or potential sites of infection Assessment of lab results: WBC >12,000 or <4,000 If normal WBC, >10 % bands on differential Serum lactate (baseline and assess for elevations) Serum glucose >140mg/dl without a history of diabetes https://www.cdc.gov/sepsis/index.html

Bundles are a small, straightforward set of evidencebased practices that, when performed collectively and reliably, have been proven to improve patient outcomes. Surviving Sepsis: Resuscitation Bundles There are 2 resuscitation bundles for sepsis: 3 Hour Bundle: actions to be taken within the first 3 hours of initial recognition of symptoms in adult patients and with within 60 minutes of initial recognition in pediatric patients. 6 Hour Bundle: actions to be taken within the first 6 hours of initial recognition of symptoms in adult patients and 60 minutes in pediatric patients. https://www.cdc.gov/sepsis/index.html

Implementation of the 3 Hour Bundle: Triage Are two or more Sepsis criteria present? Is there a possible source of infection present? If the answer to these 2 questions is Yes then implement the 3 hour bundle. Nurses role Start two large bore IV s Draw blood cultures, CBC, electrolytes and serum lactate Physicians role Start broad spectrum antibiotics Initiate 2L Normal Saline bolus if SBP < 90 mmhg or initial lactate is > 4 mmol/l https://www.cdc.gov/sepsis/index.html

The 3 hour bundle contains the following elements, and should be completed within 3 hours after presentation of severe sepsis symptoms: Components of the 3 Hour Bundle Measure the lactate level Obtain 2 sets of blood cultures prior to the administration of antibiotics Additional cultures to determine source of infection. Administer broad spectrum antibiotics Administer 30ml/kg of fluids (NS or RL) for hypotension (<90/60 or MAP <65) OR a lactate level 4mmol/L https://www.cdc.gov/sepsis/index.html

After completing the steps of the 3 hour bundle: Components of the 6 Hour Bundle Apply vasopressors for hypotension that does not respond to initial fluid resuscitation, to maintain a Mean Arterial Pressure (MAP) 65mmHg. If hypotension persists after initial resuscitation (MAP < 65 mmhg) OR if initial lactate was 4 mmol/l, reassess volume status and tissue perfusion and document findings. Re-measure lactate if initial result was elevated. https://www.cdc.gov/sepsis/index.html

Supportive Therapies for Sepsis Corticosteroids Blood Products RBC transfusion is recommended when the hemoglobin decreases to <7.0 g/dl Mechanical Ventilation Glucose Control Blood glucose should be maintained below 180mg/dl Nutrition Therapy Oral or enteral feedings as tolerated, avoid complete fasting

Long Term Effects of Sepsis Many people recover from sepsis completely and resume their normal lives. Some persons, especially with pre-existing conditions may have permanent organ damage. There is evidence that severe sepsis can disrupt the immune system and increase the risk for future infections and other medical conditions, even years later. Other long term effects of surviving sepsis include: Hospitalization for infections Cognitive impairment Cardiovascular complications https://www.cdc.gov/sepsis/pdfs/life-after-sepsis-fact-sheet.pdf

The Nurses Role in Triage and Treatment of Sepsis Early recognition of patients with signs and symptoms of sepsis Sepsis screening as part of routine assessment Early initiation of sepsis protocol Blood cultures, antibiotics, fluid resuscitation Prevention of Infections Central line associated blood stream infection (CLABSI), UTI, pressure sores Disposition of patient to higher level of care

So Remember SEPSIS

Sepsis Case Study Mr. B, 70 presents to the ED with a history of cutting his left hand with a knife while fishing 3 days ago. He stopped the bleeding with his handkerchief and put a bandage on it. His wife reports he is not feeling well for a couple of days and has been acting funny. The skin on his hand is warm to touch, swollen and has some erythema and some crusted matter around the wound. He can t remember the last time he urinated. He is being treated for COPD, Hypertension and Type 2 Diabetes by his PCP He is oriented to person, place and time, but does not know why he is in the ED. His vital signs are as follows: Oral temperature 101 F (38.3 C) Pulse 102, BP 88/42, Respirations 24 What is the presumed issue for Mr. B? What would you do next?

Triage What are the key pieces of information in his history and vital signs? 70 years old History of COPD, Hypertension and Type 2 Diabetes Infected wound on his hand Decreased urine output Altered mental status Temp 101 F Pulse 102 Blood Pressure 88/42 Respirations 24

Triage Ask the triage questions: Are there 2 or more risk factors for sepsis? YES! Age Chronic health conditions Is there a probable source of infection present? YES! Infected wound on hand Decreased urine output, possible Urinary Tract Infection

Next Steps Initiate 3 Hour Bundle

Sepsis Case Study Mr. B s history, symptoms and assessment indicate severe sepsis. Within an hour he has a set of aerobic and anaerobic blood cultures, CBC with diff, BMP, PT/PTT and lactate drawn. An IV is started and he receives a dose of a broad spectrum antibiotic and a NS IV bolus of 1000 ml every hour x 3. BP is assessed frequently and his MAP is 65. A Foley catheter is placed because he could not recall his last void. A urine specimen is obtained. Drainage from the wound is also collected for culture. The goals for his resuscitation at this point are a urine output of 0.5ml/kg/hr (or more) and a MAP of at least 65mmHg What would you expect to happen now?

Vital signs are monitored frequently What Happens Now? Fluid resuscitation continues Follow 6 hour bundle: Apply vasopressors if needed Reassess lactate

Sepsis Case Study At the 2 hour mark after severe sepsis was recognized, Mr. B s blood pressure is 92/36 (MAP 55), he has received his third bag of normal saline and has a urine output of 0.4mL/kg/hr. The initial lactate is 4.6 mmol/l. Because he is not responding to the initial fluid resuscitation, has a MAP < 65 and a low urine output, the physician decides to start him on a vasopressor. What is the next step the nurse should anticipate?

Next Step Patient should be moved to a higher level of care, such as the Intensive Care Unit for: Continued vital sign monitoring, especially blood pressure Respiratory assessment to evaluate for possible mechanical ventilation Evaluation for organ damage Monitoring lab results for kidney and liver abnormalities.

Sepsis Case Study Mr. B is transferred to the ICU, where the physician places a central venous catheter and a central venous pressure (CVP) of 5mmHg is obtained. Two hours after starting norepinephrine, Mr. B has a lactate level done, it is now 2.8mmol/L, his skin is warm and moist and urine output has increased to 0.7ml/kg/hr. He is more alert and is asking why he is in the hospital. His blood glucose is in the 150-170 range. Blood gases are normal with a PO² of 98 on 2L of oxygen via nasal cannula.

Sepsis Case Study Mr. B continues to improve with fluid resuscitation, IV antibiotics and supportive care. His blood cultures are positive for S. aureus and the organism is sensitive to amoxicillin/clavulanic acid among several other antibiotics. He is afebrile, his hand wound is clean and healing and he is feeling back to his old self. He is discharged home on oral antibiotics and has an appointment to see his PCP in a few days. What are some take home messages for nurses in this case study?

Take Home Messages Screen all patients for sepsis using the 2 questions: Are there 2 or more risk factors for sepsis? Is there a probable source of infection present? If screening is positive-initiate the 3 hour bundle: Lab tests including lactate and blood cultures Fluid resuscitation Monitor vital signs and lactate levels Move to higher level of care Follow 6 hour bundle Vasopressors for continued hypotension Measure lactate again Assess for tissue perfusion.

Thank you for your participation in this educational module.

References Biomarkers of Sepsis https://www.ncbi.nlm.nih. gov/pmc/articles/pmc361 3962/ Sepsis Alliance https://www.sepsis.org/ National Institute of General Medical Sciences https://www.nigms.nih.go v/education/pages/factshe et_sepsis.aspx For more information on accreditation contact : UAMS Office of Continuing Education 4301 W. Markham, #525 Little Rock, AR 72205 501-661-7962 CDC Sites https://www.cdc.gov/s epsis/pdfs/life-aftersepsis-fact-sheet.pdf https://www.cdc.gov/s epsis/index.html https://www.cdc.gov/s epsis/get-ahead-ofsepsis/index.html https://www.cdc.gov/ hai/surveillance/index. html