Search and Rescue: The keys to Surviving Sepsis
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1 Search and Rescue: The keys to Surviving Sepsis July 22, 2008 Emmel B. Golden, Jr., MD, ICU Medical Director Melanie Polzin, RN, CCRN, ICU Head Nurse Mary Ann Northern, PI Specialist
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Search and Rescue: The keys to Surviving Sepsis. Emmel B. Golden, Jr., MD, ICU Medical Director Melanie Polzin, RN, CCRN, ICU Head Nurse Mary Ann Northern, PI Specialist. July 22, 2008. Baptist Memorial Hospital- Memphis. 706 bed tertiary care hospital 38 bed general ICU - PowerPoint PPT Presentation
Transcript of Search and Rescue: The keys to Surviving Sepsis
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Search and Rescue: The keys to Surviving Sepsis
July 22, 2008
Emmel B. Golden, Jr., MD, ICU Medical DirectorMelanie Polzin, RN, CCRN, ICU Head NurseMary Ann Northern, PI Specialist
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Baptist Memorial Hospital- Memphis
• 706 bed tertiary care hospital
• 38 bed general ICU- 28 medical -surgical; 10 neuro- Intensivist-led, open unit model
• 22 bed CVICU
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Our Team Members
ICU Medical Director Intensivists Nursing PI Specialist Clinical Pharmacist Respiratory Therapist Dietitian Staff Development
Physical Therapist Speech Therapist Infection Control Case Manager Staff Development Palliative Care nurse ED nurse Lab- medical
technologist
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Commitment to Improvement
Multidisciplinary team IHI Model for Improvement
Aim, Measures, Process Changes, PDSA cycles
Incorporating principles of reliability
Using data to drive improvements
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Six Years on the Path to Excellence
FY 2002- Present
40% reduction in ICU Length of Stay 39% reduction in ICU mortality 48% decrease in ventilator length of
stay 23% reduction in VAP rate 33% drop in BSI rate 50% reduction in Sepsis mortality rate
for protocol patients (40% in 2004 for all patients coded in severe
sepsis/septic shock. In 2007 mortality was reduced to 19% for protocol patients.)
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Establishing the Foundation: ICU Process Changes
2003- 2008 Intensivist coverage for nights and week-
ends Multidisciplinary rounds ICU Daily goal sheet/ Patient Plan of Care Pre-extubation worksheet Care bundles: Ventilator, Central Line, UTI Clinical Pharmacy rounds Glycemic control protocol and policy Medical Response Team
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More ICU Process Changes
Sepsis screening Severe Sepsis protocol order set, including
resuscitation and management bundles Active surveillance/screening for MRSA Flexible visitation Now testing a Sedation Protocol
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Sepsis: Getting Started
Severe Sepsis/Septic Shock ProtocolIncorporated resuscitation and management
bundles Start small- lactates ED & ICU Collaboration Relationships
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Early Identification is Key
Screening tools All ICU admissions & >3day LOS High risk units- critical care, stepdown,
oncology ED MRT calls Case management
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What we know about our Septic Patients
The ED is a high volume location for septic or potentially septic patients
78% start their hospital stay in the ED
High Risk Patients- Pneumonia, UTI, Devices
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Sepsis Bundle Implementation
Start with one patient, one MD, one nurse One-on-one with physicians Staff education Multidisciplinary involvement Spread ED/ICU collaboration for resuscitation
bundle Prioritizing ICU bed
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Sepsis Resuscitation Bundle
0
20
40
60
80
100
Month
% P
atie
nts
Serum lactateBlood CulturesAntibiotics
CVPFluids
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Sepsis Resuscitation Bundle Reliabilty
Resuscitation Bundle
0
10
20
30
40
50
60
70
80
90
100
38687.00 38718.00 38749.00 38777.00 38808.00 38838.00 38869.00 38899.00 38930.00 38961.00 38991.00 39022.00 39052.00 39083.00 39114.00 39142.00 39173.00
Serum lactate w ithin 6 Hrs Blood Culture before Antibiotics
Antibiotic Compliance Fluids and Vasopressors for hypotension or elevated lactate
CVP>=8mm Hg w ithin 6 Hrs for shock or elevated lactate ScvO2>=70% or SvO2>=65% w ithin 6 Hrs for shock or elevated lactate
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Sepsis Management Bundle
0
20
40
60
80
100
Month
% P
atie
nts
Low dose steroidsDrotrecogin alfa according to policy
Glucose control Inspiratory plateau pressure <30 cm H20
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Sepsis Mortality
37.5
66.67
100
16.67
0
12.5
0 0
17
0
10 11
30
15
25
1419
31
11
23 22
13
22 25
8.330
14.29
33
0 00
20
40
60
80
100
Sep-0
5
Jan-
06
Mar
-06
May
-06
July'
06
Sep'06
Nov'06
Jan'0
7
Mar
'07
May
'07
Jul'0
7
Sep'07
Nov'07
Jan'0
8
Mar
'08
Month
% P
atie
nts
2004 DRG data: 40% mortality Jan06- Apr08: 18% (264 protocol patients)
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Where are we after 2 ½ years?
Good news: For patients on the protocol, mortality is
consistently 20%- historical mortality 40% ED is now able to volume resuscitate patients Able to move patients quickly to ICU bed
Identified in ED Notified by ED
Nurses can execute the protocol Nurses have accepted the protocol
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Where are we after 2 ½ years?
Fall short: MDs- “culture eats protocol for breakfast” Patients not coming from the ED are less
likely to go on the protocol Capture rate for protocol is not 100% for
patients that meet criteria for protocol
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Questions?
