In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine...

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Com pliance w ith Severe Sepsis Protocol: Com pliance w ith Severe Sepsis Protocol: Im pacton PatientO utcom es Im pacton PatientO utcom es Lisa H urstR N B SN C C R N and K im R aines R N C C R N Lisa H urstR N B SN C C R N and K im R aines R N C C R N

Transcript of In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine...

Page 1: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Compliance with Severe Sepsis Protocol:Compliance with Severe Sepsis Protocol:Impact on Patient OutcomesImpact on Patient Outcomes

Lisa Hurst RN BSN CCRN and Kim Raines RN CCRNLisa Hurst RN BSN CCRN and Kim Raines RN CCRN

Page 2: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed the Surviving Sepsis Campaign.

The purpose of this initiative was to improve diagnosis, management, and treatment of sepsis.

Background

Page 3: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHITo be accomplished as soon as possible and

scored over first 6 hours:Serum lactate measuredBlood cultures obtained prior to antibiotics

administeredPerform imaging studies promptly to find

sourceAdministration of broad-spectrum antibiotics

within 1 hour of diagnosis of septic shock and severe sepsis without septic shock

Dellinger, 2008

Page 4: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHI

For hypotension and/or lactate > 4 mmol/L:Deliver an initial minimum of 20 mL/kg of crystalloid

(or colloid equivalent)Apply vasopressors for hypotension not responding to

initial fluid resuscitation to maintain MAP > 65 mmHg. For persistent hypotension despite initial fluid

resuscitation (septic shock) and/or lactate > 4 mmol/L:Achieve CVP of 8-12 mmHg & MAP > 65 mmHg &

UO > 0.5mL/kg/hrAchieve ScVO₂ of > 70% or SvO2 > 65%.if ScVO₂ not > 70%, consider blood or dobutamine

Dellinger, 2008

Page 5: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Purpose

The purpose of this study is to establish the current level of medical compliance with the Severe Sepsis Protocol at UPMC Hamot.

Page 6: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

SEVERE SEPSIS: DEFINING A DISEASE CONTINUUM

SIRS with a

presumed or confirmed

infectious process

SepsisSIRSInfection Severe Sepsis

Sepsiswith 1 sign of organ

dysfunction, hypoperfusion or

hypotension.

Examples:• Cardiovascular (refractory hypotension)

• Renal• Respiratory• Hepatic• Hematologic• CNS• Unexplained metabolic acidosis

Adult CriteriaA clinical response arising from a nonspecific insult, including ≥ 2

of the following:

Temperature:> 38°C or < 36°CHeart Rate: > 90 beats/minRespiration:> 20/minWBC count: > 12,000/mm3,

or < 4,000/mm3,or > 10% immature neutrophils

SIRS = Systemic Inflammatory Response SyndromeBone et al. Chest.1992;101:1644-1654.

Shock

Page 7: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Methods: UPMC Hamot Institutional Review Board (IRB) approval obtained Retrospective chart review of 50 patients admitted during 2010 Diagnosis of severe sepsis or sepsis with organ dysfunction

Data collected: Age Length of stay Source of sepsis Mortality/functional status at admission and discharge

Time of: Admission ScVO₂ value ≥70% noted PreSep (ScVO₂) catheter insertion Initiation of severe sepsis order set First CCM order obtained after severe sepsis diagnosis Blood cultures, lactate, and antibiotics post sepsis diagnosis

Methods

Page 8: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Findings

*Dx=diagnosis Cx=blood cultures Lact=lactate Abx=antibiotics

Recommended time: Blood cultures drawn, 1 hour Antibiotics administered, 1 hour Lactate levels drawn, 6 hours

Page 9: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Findings

22 patients (44%) had CCM consult 9 patients (18%) placed on protocol 5 patients (10%) protocol + CCM consult 8 patients (16%) received PreSep (ScVO₂) catheter 6 patients (12%) received PreSep (ScVO₂)

+ CCM consult

Page 10: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Findings

56% of patients discharged to SNIF/Rehab 22% of patients died 22% discharged home

78% of patients came from home; only 22% were able to return directly home due to change in functional status

Page 11: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Discussion

Time to treatment longer than recommended

Important measures of sepsis diagnosis not available:• Lactate not drawn• ABG drawn without panel• Cultures not obtained

CCM management• Frequency of consult• Time to first order

Page 12: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Regional transfers

Floor patients

Documentation

Sample Size

Limitations

Page 13: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Recommendations

Sepsis Alert Teams

Screening Tools

Education• Regional facilities• Medical staff

Recommendations

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Consistent use of a standardized protocol “ensures implementation of evidence based guidelines, decreases variability in management among clinicians…and monitors quality of care” (Moore, 2009).

Conclusion

Page 15: In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed.

Thank You!

Jean Bulmer and Debbie Hess, our Research Residency mentors

Diane Voelker and Linda Jeffrey, Library services

Becky Stokes, EBP expert and role model, our inspiration

Ginny DiGello and Matt Niles, for their support of the residency program

Our MICU Colleagues

Acknowledgements