Maryanne Whitney RN MSN CNS Improvement Advisor, Cynosure Health HRET HEN AK Webinar

SUCCESS IN SEPSIS MORTALITY REDUCTION

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Got Sepsis? Now What?- Alerts & Bundles Maryanne Whitney RN, MS, CNS Improvement Advisor, Cynosure Health

• Reduce Sepsis Mortality by 40% by September 2016

AIM

SEVERE SEPSIS: A SIGNIFICANT HEALTHCARE CHALLENGE

• Hospitalizations have doubled 2000-2008 • Most costly reason for hospitalization in 2011

– 20 billion in aggregate hospital cost

• 1 out of 23 patients in hospital had septicemia • Major cause of morbidity and mortality worldwide

– Leading cause of death in non-coronary ICU

– 10th leading cause of death overall

• In the US, more than 700 patients die of severe sepsis daily (1.6 million new cases per year)

• 1 DEATH EVERY 2 MINUTES

The # 1 cause of inpatient death

The same pattern in every hospital

Severe Sepsis vs. Current Care Priorities

Care Priorities

U.S.

Incidence

# of Deaths

Mortality Rate

AMI (1) 900,000 225,000 25% Stroke (2) 700,000 163,500 23% Trauma (3)

(Motor Vehicle)

2.9 million (injuries)

42,643 1.5%

Severe Sepsis (4) 751,000 215,000 29%

• Early Recognition – ED – Inpt

• Change the Culture – Alerts

• Drive Treatment w/ Definitions – Standard & clear

• Make Early Treatment Easy – Automatic – Bundle interventions

• Leverage Technology – EMR – BPA- Best Practice Alerts

• Integrate the 2015 Surviving Sepsis Campaign changes

THE PIECES YOU NEED

SCREENING? HOW IS IT GOING?

QUESTIONS ABOUT SEPSIS-3

• New definitions: – Sepsis:a life-threatening organ dysfunction due to

a dysregulated host response to infection. – Septic shock: is defined as a subset of sepsis in

which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality.

• Absent from the new definitions is the term “severe sepsis” – a significant change from previous definitions. Sepsis has a mortality rate of 10 percent or higher, making the condition already severe.

JUST IN SEPSIS-3! NOW WHAT?

Reference: http://www.sccm.org/Research/Quality/Pages/Sepsis-Definitions.aspx

• quickSOFA, or qSOFA (Sequential (sepsis induced) Organ Failure Assessment)

• The qSOFA assessment directs physicians to look for these warning signs in patients: – An alteration in mental status – A decrease in systolic blood pressure of less than 100

mm Hg – A respiration rate greater than 22 breaths/min

NEW DIAGNOSTIC TRIGGERS

http://qsofa.org/

CREATE ACTION: ALERTS AND BUNDLE IMPLEMENTATION

Identify clear and concise action for positive sepsis screen Who does what? By when? Build in concurrent review

Time Sensitive Diseases Changing the Paradigm of Practice

Trauma Stroke AMI

Change Culture

Think SEPSIS!!!

Think Emergency!

• Mobilize resources – What are they?

• Mobilize experts – Who are they?

• Consensus in diagnosis – Allow for clinical

decisions – Time sensitive

• Create action – Antibiotics – Labs – Fluids

• RRT – Can they be involved?

• Highest Mortality – Sepsis diagnosed on the floors – Lactate >2 mmol/l but < 4 mmol/l

• Bundle Compliance – Worst on the floor

• Hospitals with RRT/Sepsis Alert as resource saves most lives

SEPSIS SURPRISES IN THE LITERATURE

What’s happening at your hospital??

– What happens when a pt

screens (+) for sepsis?

– Do you have an alert? Who responds? Who can initiate?

Bundles • EBP • Stronger • Less distraction • Clear action • Outcomes

EARLY GOAL DIRECTED THERAPY

Infection or

trauma

SIRS Systemic

Inflammatory Response Syndrome

Sepsis 2 or more

SIRS + Infection

Severe Sepsis

Sepsis + s/s of organ

dysfunction

Septic Shock

Refractory Hypotension +/or lactate

>= 4

DEFINITIONS DRIVE TREATMENT

Sepsis is a Continuum

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• Severe Sepsis: Sepsis-induced tissue hypo-perfusion or organ dysfunction

Neuro – decreased LOC CV- hypotension Respiratory- hypoxemia Renal- low UO Hematological-

Thrombocytopenia Metabolic- Elevated lactate

• Septic Shock: Hypotension that persists despite adequate fluid resuscitation

• SIRS: Systemic Inflammatory Response Syndrome

Temp<36 C or >38 C, Heart Rate >90/min, Respiratory Rate >20/min or

PaCO2 32mmHg, WBC <4,000 or >12,000 or 10%

bands.

• Sepsis: presence of infection (suspected or confirmed) with systemic manifestations of infection

Standard Definitions

• Measure lactate level • Obtain blood cultures prior to

administration of antibiotics • Administer broad spectrum antibiotics • Administer 30ml/kg crystalloid for

hypotension or lactate ≥4mmol/L

POSITIVE SEPSIS SCREEN 3HR BUNDLE (TO BE COMPLETED WITHIN 3 HOURS OF PRESENTATION)

Time Zero • Will always be when

chart annotations suggest all signs and symptoms are present

• May be documented in nursing or physician notes, lab flow sheets, anything with a time stamp

• Equals triage time if all signs & symptoms are present at triage

Time Zero

• 3 hour counter • 6 hour counter • Starts when all signs and

symptoms of Septic Shock are present

• 3 hour counter • Starts when all signs and

symptoms of Severe Sepsis are present

Severe Sepsis

Two Clocks Septic Shock

• Automatic – Order sets – Protocols for fluid, antibiotics and labs – Bundle blood cultures with lactate

MAKE EARLY EASY

• Use EMR for inpatient screening • Best Practice Alerts • Prompts for Interventions

– Contact MD or RRT (Rapid Response Team) • Request lactate because one has not been drawn in 4 hours • Request blood culture because they have not been drawn • N/A pt. does not have suspected or known infection

LEVERAGE TECHNOLOGY

Common Barrier is Communication:

Customize

Adapted from Ashkenas, 1995

SHARE INFORMATION

SHAPE BEHAVIOR

General Publications flyers newsletters videos articles posters

Personal Touch letters cards postcards

Interactive Activities telephone email visits seminars learning sets modeling

Face-to-face one-to-one mentoring seconding shadowing

Customize the WAY You Communicate

(C) 2001, Sarah W. Fraser

Public Events Road shows Fairs Conferences Exhibitions Mass meetings

Screen every patient in ED @ triage or evaluation.

Screen inpatients every shift.

Clear and consistent actions after a positive sepsis screen.

Administer antibiotics within an hour

Bundle blood cultures with lactate.

Outcomes will follow.

SO….PUTTING IT ALL TOGETHER

• Referral • ICU • Communication • 6 hour Bundle

– Apply vasopressors – Re-assess volume status and tissue perfusion and document

findings (new for 2015) – Re-measure lactate if initial lactate elevated.

6 HOUR BUNDLE CONSIDERATIONS

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Surviving Sepsis Campaign http://www.survivingsepsis.org • Guidelines • Bundles • Protocols & Checklist • Sample sepsis screen • Educational videos • ProCESS Investigators, Yealy DM, Kellum JA, Juang DT, et al. A randomized trial

of protocol-based care for early septic shock. N Engl J Med 2014; 370(18):1683-1693.

• The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371:1496-1506.

• Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015: DOI: 10.1056/NEJMoa1500896.

• Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-137

RESOURCES

mwhitney@cynosurehealth.org