to Surviving Sepsis - Hospital Council...•Joined Beacon Collaborative – share improvement...
Transcript of to Surviving Sepsis - Hospital Council...•Joined Beacon Collaborative – share improvement...
Our Journey on the Road
to Surviving Sepsis
Debbie Sober, RN, MSN
Community Hospital of the Monterey
Peninsula
Community Hospital of
the Monterey Peninsula
• 205 bed acute care hospital
• 28 bed skilled nursing
• Primary Stroke Center
• TJC Diabetes Certification
• Bariatric Center Excellence
• Cardiac Surgery
• Electrophysiology
• Invasive/diagnostic cardiology
• Behavioral Health Services
• Comprehensive Cancer Center
• Interventional Radiology
• Hospice
• Outpatient Surgery Center
Objectives
• Discuss current state of sepsis
management at Community Hospital of
the Monterey Peninsula
• Discuss importance of a
multidisciplinary team to implement
early goal directed therapy on medical-
surgical units, emergency department
and the intensive care unit.
• Discuss importance of standardizing
order sets for the hospitalist,
emergency department and intensivist
using evidence from the Surviving
Sepsis Campaign
How the need was
identified
• Critical Care Work Group
– Multiple anecdotal case
reviews
• Identified knowledge deficit
among different staff and
physicians
– Rapid Response Team
Performance Improvement
Report
• Number of ICU transfers
• Number of RRT calls
How the need was
identified
• Critical Care Work Group asked
– for small subgroup to evaluate the
problems and provide solutions
– for a Grand Rounds on Managing
Sepsis
SURVIVING SEPSIS TEAM
First team meeting April 2011
Reviewed 2010 data to identify scope of problem
Admission Source # Patients % Column1
Total 497
Transfer to ICU # Patients % Average time to transfer
from Med-surg 63 5.2 days
from Main Pavilion 16 1.8 days
Total Transfer of all pop. 79 16% 4.5 days
Possible savings if no transfer to ICU* # Patients Days
from Med-surg ($3870/day) 63 400 $1,548,000
from Main Pavilion ($1407/day) 16 262 $368,634
Total 79 $1,916,634*Bed charges only, does not inc. supplies
Overall sepsis rate (admissions) 4.0%
Overall sepsis rate/ 1000 patient days 6.6
Total patient days 5300
Average LOS, days 10.6
Mortality 129 26.0%
Surviving Sepsis
Team
• Data revealed problem with
identifying “early sepsis”
• Inadequate fluid resuscitation
prior to starting Dopamine
• Resulting in transfer to ICU in
Septic Shock
“Intubation is not a failure"
-Dr Karim Tadlaoui,
Intensivist, CHOMP
SURVIVING SEPSIS TEAM
• Identified the evidence-based literature and adopted as standard of
care Institute for Healthcare Improvement Surviving Sepsis
Campaign (Early Goal Directed Therapy)
• Identified current state in the Emergency Department, Intensive Care
Unit and Nursing Units
• Identified desired workflow and targeted patient placement and
began development of refinement of order sets.
SURVIVING SEPSIS TEAM
Sepsis Guideline “unofficial” Update
Highlights
2012 SCCM Congress
• Will be published in June 2012
• Bundles include Initial and Septic
Shock Bundle (delete
Management bundle)
• Two blood cultures w/in 45
minutes prior to antibiotics
• Use crystolloids initial fluid
resusitation
• Add Albumin if needed
• Do not recommend use of
Hetastarch
• 30ml/kg fluids first 4-6 hours
Update (cont)
• Fluid challenges ok only if progress
being made
• MAP > 65
• Recommend Norepinephine as first
choice
• Then Epinephrine as second choice
• Dopamine only used on highly selected
patients (low cardiac output, etc.)
• Vasopressin can be added to Norepi
but should not be used as initital
vasopressor
• Dobutamine after resuscitation with
signs hypoperfusion
More “unofficial”
updates
• Only use steroids if
vasopressors/fluids do not
restore hemodynamic stability
• 200mg IV daily
• No stim test recommended
• Suggest proning for severe
ARDS patients
• Do not recommend
neuromuscular blockades unless
severe ARDS <48 hours
• Keep blood glucose < 180
• Recommend CRRT rather then
intermittent hemodialysis
Rotoprone
SURVIVING SEPSIS TEAM
• Joined Beacon Collaborative – share improvement strategies and allow
comparison of performance
Participated in SimSuite Sepsis Quality Initiative Training
(Sponsored by Hospital Council and Anthem Blue Cross)
“The
Bus”
SURVIVING SEPSIS TEAM
NEXT STEPS
• Strategic Initiative -Team Charter developed, seek approval
• Implement Order Sets
• Education - Several Avenues
• Physicians – Targeted training: Central Line insert
• Staff – Critical Care Competency Camp, Education Fair
• All – Return of the bus; expand
• Focused monitoring and mentoring ongoing
Sepsis
April 2011
RN Education Fair
Objectives
• Identify clinical indicators (signs
and symptoms) of sepsis
• Verbalize difference between
warm and cold sepsis
• State the definition of SIRS,
sepsis, severe sepsis & septic
shock
• Verbalize treatment plans for
sepsis
SEPSIS = Systemic Inflammatory Response Syndrome + Infection
If patient has symptoms in all three categories below, suspect Severe Sepsis. Notify the
physician and consider calling the Rapid Response Team.
□ A. Suspected or Confirmed Infection Criteria
□ Positive culture
□ Diagnosis of pneumonia
□ Any condition with a known risk of associated infection
(immunosuppression, etc.)
□ Any suspected source of infection (PICC line, Foley, wound, etc.)
□ B. Systemic Inflammatory Response Syndrome (SIRS)
□ Altered mental status
□ Temp >100.4 F or < 96.8 F
□ HR > 90
□ RR > 20
□ WBC > 12,000 or < 4,000/mm³, or normal with more than 10 % bands
□ Hyperglycemia BG > 120 (in the absence of diabetes)
□ Significant edema or positive fluid balance (> 20ml/kg over 24 hrs)
□ C. Organ Dysfunction
□ Cardiovascular: SBP < 90 or decrease in SBP >40 mm Hg
□ Respiratory: O2 sats <93 % (in the absence of known CO2 retention) or if
ABG available - PaCO2 <32
□ Renal: Significant decrease in urine output in the absence of renal failure or
creatinine >2.0 mg/dL (normal U/O = 1ml/kg/hr, Sig decrease = < 0.5
ml/kg/hr for more than 2 hrs)
□ Hepatic: Total bilirubin > 2.0 mg/dL
□ Metabolic: lactate level > 4 or if ABG available pH < 7.30
□ Hematologic: Platelets < 100,000mm³ or INR > 1.5 or aPTT >60 secs
When communicating the physician, be sure to use SBAR technique.
Situation – What is the patient’s condition? Explain why you suspect sepsis.
Background – Diagnosis and relevant history (possible source of infection).
Assessment – Include vital signs, O2 sats, BG, LOC, I&Os and any significant
changes from baseline assessment.
Recommendation – Ask the physician to consider the following….
□ IV bolus for BP support and maintenance IVF
□ Oxygen to keep sats > 93%
□ ABGs
□ Transfer to a monitored bed or ICU if unstable or requires vasopressors.
□ Cultures – Blood / Urine / Sputum / Wound (if applicable)
- Cultures should always be obtained before administering antibiotics.
If patient has a PICC or CL obtain an order for one BC to be drawn from the line
and one drawn peripherally.
□ Antibiotics (broad-spectrum)
- Remember to report patient allergies to antibiotics and elevated creatinine
as this may change the dosage and frequency of the antibiotic ordered.
□ Diagnostic tests (Chest X-ray, EKG)
□ Labs – CBC, CMP, BNP, PT/INR, Lactate (elevated in patients at risk for septic
shock even before patient becomes hypotensive)
We still have a ways to go……
Only 24
patients
on ED
order
sets
What’s next…
• Finalize order sets
• Finalize algorithm and post on all
nursing units and ED
• Ongoing education- Hospitalists
• Ongoing education- Nursing
• Develop Sepsis Screening tool
integrated in computer
• Develop a report system to alert
RRT for at risk septic patients on
other units
• Daily review order set use
• Performance Improvement
• Immediate feedback to MD/RN
Thank you