2015 12 15-Sepsis Webinar Entire Presentation [Read-Only] › sites › default › files ›...

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Presented by:

AQKC HAI LANEarly Detection Saves Lives –Think SEPSIS

Kelly Shipley �� QI Director, ESRD Network 14Dr. Stephen Jones �� Director, SERRI: Sepsis Early Recognition and Response InitiativeLevi Njord �� Director, Infection Prevention and Epidemiology, DaVita Healthcare Partners

Objectives

� Sepsis definitions and epidemiology

� Early Goal Directed Therapy – special considerations for the ESRD patient

� Review sepsis incidence and mortality rates for the ESRD patient population

� Identify sepsis early recognition and prompt interventions

� Discuss sepsis screening tools for outpatient dialysis facilities and lessons learned

� Review HAI/Sepsis data collection, tracking, and reporting

2

Leighann Sauls, RN, CDN

Quality Improvement Director

Sheila McMaster, MSN, CNN,

CPHQ


Kelly Shipley, RHIA


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JK

2

4

Speakers

Stephen L. Jones, M.D., M.S.H.I.,

Director, SERRI

Levi Njord, Director, Infectious

Disease Epidemiology, DaVita

Healthcare Partners

Texas Gulf Coast Sepsis NetworkTexas Gulf Coast Sepsis NetworkTexas Gulf Coast Sepsis Network

SSSSepsis: epsis: epsis: epsis: An Equal Opportunity KillerAn Equal Opportunity KillerAn Equal Opportunity KillerAn Equal Opportunity Killer

End Stage Renal Disease Network of TexasEnd Stage Renal Disease Network of TexasEnd Stage Renal Disease Network of TexasEnd Stage Renal Disease Network of Texas

Alliant Quality Kidney CollaborativeAlliant Quality Kidney CollaborativeAlliant Quality Kidney CollaborativeAlliant Quality Kidney Collaborative

SERRI: Sepsis Early Recognition And Response Initiative 5

Stephen L. Jones, M.D., M.S.H.I.

Program Director: SERRI

Chief Clinical Informatics Officer - Department of Surgery

Division Chief of Health Informatics – Center for Outcomes Research

Houston Methodist Hospital

Research Scientist and Assistant Member, The Methodist Hospital Research Institute

Assistant Professor of Medical Informatics in Surgery,

Weill Cornell Medical College of Cornell University

December 15, 2015

Texas Gulf Coast

Sepsis Network

The project described is supported by Funding

Opportunity Number 1C1CMS330975-01-00 from

the U.S. Department of Health and Human

Services, Centers for Medicare and Medicaid

Services. The contents of these slides are solely

the responsibility of the authors and do not

necessarily represent the official views of the U.S.

Department of Health and Human Services or any

of its agencies. The research presented here was

conducted by Houston Methodist. Findings might

or might not be consistent with or confirmed by

the independent evaluation contractor.


DisclaimerTexas Gulf Coast

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Objectives

SERRI: Sepsis Early Recognition And Response Initiative

� Outcomes Data HMH 2008 – Q1 2015

� Introduction

� Epidemiology

� Pathophysiology

� Clinical Presentation

� Early Goal Directed Therapy

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Sepsis NetworkHMH 2008-2015 Sepsis Mortality – TrendTexas Gulf Coast

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6SERRI: Sepsis Early Recognition And Response Initiative

35.4%

18.2%

Jan

20

08

Jan

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Jan

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Jan

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11

Jan

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Sepsis Mortality Rate Trend (Sepsis Mortality)

Data Source: HMH – MIDAS as of 07/08/2015 HMH - Service Line Analytics Dept. (Billy Askary)

16.4%

19.9%

15.0%

13.1%

16.8%

14.9%

18.7%

19.7%

17.8%

16.1%

15.1%

18.2%

Latest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality Rate

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Texas Gulf Coast

Sepsis NetworkWhat Can We do About Sepsis?

Sydney Harris, ©1970, The American Scientist

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Texas Gulf Coast

Sepsis NetworkWhat is SERRI?

SERRISERRISERRISERRI is a bedside nurse driven sepsis screening protocol that

focuses on:

� vital signs

� white blood cell count

� mental status changes

The values of these parameters are entered into a rigorously

validated algorithm that derives a score of the likelihood that a

patient has sepsis.

If the score is high enough, it triggers an evaluation by

second level responderssecond level responderssecond level responderssecond level responders with advanced training in the

recognition of sepsis.

SSSSepsis epsis epsis epsis EEEEarly arly arly arly RRRRecognition and ecognition and ecognition and ecognition and RRRResponseesponseesponseesponse IIIInitiativenitiativenitiativenitiative


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Sepsis NetworkTexas Gulf Coast Sepsis Network

Acute CareAcute CareAcute CareAcute CareLong Term Long Term Long Term Long Term Acute CareAcute CareAcute CareAcute Care

Skilled NursingSkilled NursingSkilled NursingSkilled Nursing

� St. Joseph Regional Health Center

� HCA Bayshore & East Medical

� HCA Rio Grande Regional Hospital

� Houston Methodist Sugar Land Hospital

� Houston Methodist San Jacinto Hospital

� Houston Methodist Hospital

� Houston Methodist West Hospital

� Houston Methodist Willowbrook Hospital

� Kindred Hospital Medical Center

� Kindred Hospital Bay Area

� Select Specialty Medical Center

� Houston Methodist Hospital

� Houston Methodist San Jacinto

Hospital

� St. Joseph Manor

� Burleson St. Joseph Manor


Spanning the continuum of care

Additional sites participating in the Sepsis Screening:

� *Houston Methodist Sienna Emergency Center

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Severe Sepsis/Septic Shock Mortality by ICU

0%

10%

20%

30%

40%

Mo

rta

lity

2006 35% 21% 38%

2007 24% 24% 37%

SICU CVICU MICU

5

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Sepsis NetworkSSC Guidelines 2012

B. Screening for Sepsis and B. Screening for Sepsis and B. Screening for Sepsis and B. Screening for Sepsis and Performance Performance Performance Performance

ImprovementImprovementImprovementImprovement

1. We recommend routine screening of

potentially infected seriously ill patients for

severe sepsis to increase the early

identification of sepsis and allow

implementation of early sepsis therapy

(grade 1C).

Rationale. Rationale. Rationale. Rationale. The early identification of sepsis and

implementation of early evidence-based therapies

have been documented to improve outcomes and

decrease sepsis-related mortality (15). Reducing the

time to diagnosis of severe sepsis is thought to be a

critical component of reducing mortality from sepsis-

related multiple organ dysfunction (35). Lack of early

recognition is a major obstacle to sepsis bundle

initiation. Sepsis screening tools have been developed

to monitor ICU patients (37–41), and their

implementation has been associated with decreased

sepsis-related mortality (15).


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SSC Guidelines 2012:

Updates for Emergency Physicians


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Sepsis NetworkSepsis: A Review of Recent Literature

Conclusion:

This meta-analysis, covering 1001 patients, across 9 studies, found that applying

an early quantitative resuscitation strategy to patients with sepsis imparts a

significant reduction in mortality.

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Sepsis NetworkSepsis: A Review of Recent LiteratureTexas Gulf Coast

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Sepsis NetworkSepsis: ProCESS Trial

1. This RCT was for patients in early septic shock.

2. Majority of the centers participating in this trial were large academic tertiary care referral

centers.

3. This study does *notnotnotnot* address the extent to which any of these strategies offer

advantages where septic shock has not developed.

4. No one can say for sure what care these patients had prior to the recognition of septic

shock. This is going to be a huge source of variability.

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Texas Gulf Coast

Sepsis NetworkSepsis: ProCESS Trial

At least 1L of fluids administered over 30 mins *prior* to randomization.

(Antibiotic administration status prior to randomization is unclear. All patients

received antibiotics *early*.)

18% aggregate mortality rate.

Conclusions: Protocol-based resuscitation of patients in who septic shock was

diagnosed in the ED did not improve outcomes between the 3 arms of the study.

The conclusions found no benefit between the 3 different arms of the RCT for

patients already in septic shock when they were identified in the ED.

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1. This RCT was for patients in early septic shock.

2. Conducted in 51 tertiary and non-tertiary care metropolitan and rural hospitals (most in

Australia or New Zealand, with 6 centers in Finland, Hong Kong and Ireland).

3. Study centers did not have sepsis-resuscitation protocols in place at time of site

selection.

4. Eligibility criteria included refractory hypotension (sbp < 90, MAP < 65 after 1L bolus.).

Sepsis: ARISE and ANCIZSTexas Gulf Coast

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5. The initiation of the first dose of antibiotics was mandated before randomization.

6. Primary outcome was death from any cause within 90 days after randomization.

19% aggregate mortality rate.

Conclusion:

EGDT vs. “Usual Care” did not reduce 90-day mortality, nor 28-day in-house mortality in

patients that presented to the ED in early septic shock.

Sepsis: ARISE and ANCIZSTexas Gulf Coast

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* Same inclusion criteria as ARIZE.

Randomization occurred *after* 1L fluid bolus and *after* administration of antimicrobial

drugs.

Conclusion:

On average, EGDT increased costs, and the probability that it was cost effective was below

20%.

Sepsis: ProMISe TrialTexas Gulf Coast

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Texas Gulf Coast

Sepsis NetworkProCESS, ProMISe & ARISE:

� Required monitoring of CVP and ScvO2 via a central venous line as part of EGDT does not confer survival benefit in all patients with septic shock in who have received timely antibiotics and fluid who have received timely antibiotics and fluid who have received timely antibiotics and fluid who have received timely antibiotics and fluid administrationadministrationadministrationadministration compared with controls.

Key Themes:

� Administration of appropriate antibiotics as soon as sepsis is suspected is *critical**critical**critical**critical*

� Initial fluid challenge (30 ML/KG in one hour) is essential.

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Excerpted from a presentation given by: Sean R. Townsend, MD, June 22, 2015 during a CMS sponsored webinar: pg

43 http://www.qualityreportingcenter.com/wp-content/uploads/2015/06/IQR-Sepsis_20150622_FINAL1s508.pdf

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35.4%

18.2%

Jan

20

08

Jan

20

09

Jan

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10

Jan

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11

Jan

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Data Source: HMH – MIDAS as of 07/08/2015 HMH - Service Line Analytics Dept. (Billy Askary)

16.4%

19.9%

15.0%

13.1%

16.8%

14.9%

18.7%

19.7%

17.8%

16.1%

15.1%

18.2%

Latest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality Rate

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Texas Gulf Coast

Sepsis NetworkSepsis is a BIG PROBLEM

� Sepsis is the leading cause of death in non coronary ICUs11

� There were 1.1 million cases of sepsis in 2008 and this number is projected to increase.2

� 11th leading cause of death in the United States overall3

� Nearly 1 out of every 23 patients in the hospital has septicemia51

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� Sepsis-related hospitalization has more than doubled from 2000 through 20086

Sepsis is a BIG PROBLEM: Texas Gulf Coast

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Texas Gulf Coast

Sepsis NetworkSepsis is a BIG PROBLEM

� Sepsis was the 6th most common principal reason

for hospitalization in the US in 2009

� Sepsis was the most expensive reason for

hospitalization in 2009 - totaling ~ $15.4 billion in

aggregate hospital costs

� Septic patients spent 75% more time in the hospital

and were 8 times as likely to die in the hospital as

patients with other diagnoses.7

� Sepsis associated mortality rate of > 30%.7

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Sepsis NetworkSepsis in real life

� CurrentlyCurrentlyCurrentlyCurrently, more Americans die from severe sepsis

than from breast cancer, lung cancer and stroke

combined.

� The number of sepsis associated deaths in the US is

comparable to the number of Acute Myocardial

Infarction associated deaths in the US.

� Sepsis mortality *has* decreased in the last 6-7

years.

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Sepsis NetworkWho gets sepsis?

Sepsis can affect anyone at any age

Carol Decker, a 32 y/o pregnant

mom, survived sepsis secondary to

pneumonia. She subsequently lost

her sight and is now a triple

amputee. It took 12+ days for

health professionals to realize

she was septic.

Mariana Bridi da Costa, a 20 y/o

Brazilian model, died of sepsis

secondary to a UTI. She had

undergone amputations of both

hands, had part of her stomach and

both kidneys removed to stem the

disease before she died.

Jen Ludwin, a graduate student,

had sepsis due to a viral infection after

presenting with flu-like symptoms.

She was hospitalized for ~ 5 ½ months,

survived after undergoing 20+ major

surgeries, lost all of her fingers & had

bilateral BKAs.

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http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?pagewanted=all

12 year old boy scrapes his arm playing basketball, ~132 hours

later, he dies from septic shock (NYT, June 12, 2012)

Wednesday, March

28th, mid-afternoon

Thursday, March

29th, mid-

afternoon


Texas Gulf Coast

Sepsis NetworkEpidemiology

� Incidence varies among racial groups, but appears highest among African-American males

� Incidence is greatest during the winter

� Respiratory source

� Patients over the age of 65 years account for almost 60% of severe sepsis cases

� Severity is increasing

� Urinary tract is the most common source of nosocomial infection

� GI or pulmonary infections have the highest mortality rate

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Preliminary Admit Sources of Sepsis

Associated Encounters

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Preliminary 3 Main Sub-cohorts of Sepsis

Associated Encounters

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Preliminary Stage of Sepsis Associated

Encounters Present on Admission

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Sepsis NetworkWhich patients are at risk?

� Extended hospitalization

� In/from a nursing home

� Malnourished

� ICU stay

� Chronic diseases

� History of sepsis

� Transplant

� Immunosuppression

� Radiation/chemotherapy

� A central line / PICC

� A Foley catheter

� A dialysis catheter

� Drains

� Pressure/diabetic ulcers

� Prosthetic devices/implants

� Recent surgeries/procedures

� Dialysis

� Heart valve replacement

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Sepsis NetworkWhich patients are at risk?

� Any implant or foreign body

� Any recent procedure (30 days)

� Any comorbidity (e.g. DM, HTN, ESRD)

� Immunocompromised for any reason

(e.g. Age, Medications, etc.)

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Risk Factors for Developing SepsisRisk Factors for Developing SepsisRisk Factors for Developing SepsisRisk Factors for Developing Sepsis� Age Age Age Age 60 years or 60 years or 60 years or 60 years or olderolderolderolder

� Need Need Need Need for Emergency for Emergency for Emergency for Emergency SurgerySurgerySurgerySurgery

� AnyAnyAnyAny Other health Other health Other health Other health problemsproblemsproblemsproblems

• e.ge.ge.ge.g. . . . Diabetes,Diabetes,Diabetes,Diabetes,

• High High High High blood pressureblood pressureblood pressureblood pressure

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Sepsis NetworkESRD and Sepsis:

There is very little published research focused on

septic patients with ESRD!

� Patients with ESRD on HD or PD are at *significantly

increased risk* for mortality from sepsis over the

general population: 100 – 300X!! (Sarnak, Jaber 2000)

� Over a 7 year study period, 11.7% of HD patients and

9.4% of PD patients had at least one episode of sepsis. (Powe, et. al. 1999)

� ESRD patients are *severely* under-resuscitated (Dagher, et. al. 2015)

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Texas Gulf Coast

Sepsis NetworkESRD and Sepsis: The Bugs

� The most common sources of infection:

� HD Catheters

� Lower respiratory tract (Dagher, et. al. 2015)

� The most common bugs:

� Eschericia coli

� Staphylococcus coagulase negative. (Dagher, et. al. 2015)

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ESRD and Sepsis: The Mechanism of

of Susceptibility

� Polymorphonuclear (PMNL) cell function in

dialysis patients is impaired. (Vanholder, Ringoir, 1992, Rao et. al. 2004)

� Glycolysis in uremic patients is disturbed

� This disturbance is intensified during dialysis with

cuprophan (not observed with non-complement

activating dialyzers)

� Response is especially suppressed towards

Staphylococcus Aureus.

� Uremia impairs the PMNL

� Dialyzer membrane bio(in)compatibility

� Uremic anemia

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2015 12 15-Sepsis Webinar Entire Presentation [Read-Only] › sites › default › files ›...

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