Sepsis Webinar Success with Sepsis– Septic shock: is defined as a subset of sepsis in which...
Transcript of Sepsis Webinar Success with Sepsis– Septic shock: is defined as a subset of sepsis in which...
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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
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• Reduce Sepsis Mortality by 40% by September 2016
AIM
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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
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The # 1 cause of inpatient death
The same pattern in every hospital
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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%
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• 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
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SCREENING? HOW IS IT GOING?
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QUESTIONS ABOUT SEPSIS-3
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• 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
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• 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/
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CREATE ACTION: ALERTS AND BUNDLE IMPLEMENTATION
Identify clear and concise action for positive sepsis screen Who does what? By when? Build in concurrent review
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Time Sensitive Diseases Changing the Paradigm of Practice
Trauma Stroke AMI
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Change Culture
Think SEPSIS!!!
Think Emergency!
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• 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?
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• 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
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What’s happening at your hospital??
– What happens when a pt
screens (+) for sepsis?
– Do you have an alert? Who responds? Who can initiate?
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Bundles • EBP • Stronger • Less distraction • Clear action • Outcomes
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EARLY GOAL DIRECTED THERAPY
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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
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• 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)
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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
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• 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
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• Automatic – Order sets – Protocols for fluid, antibiotics and labs – Bundle blood cultures with lactate
MAKE EARLY EASY
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• 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
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Common Barrier is Communication:
Customize
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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
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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
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• 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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31
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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