The Sepsis Continuum: Overcome Barriers and … Sepsis Continuum: Overcome Barriers and Create Momentum ... CPHQ, CCRN alumna • dcampbell@kyha ... The Sepsis Continuum: Overcome

The Sepsis Continuum: Overcome Barriers and Create

MomentumSeptember 7, 2017

11:00 am. – 12:15 p.m. CT

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WELCOME AND INTRODUCTIONSEmily Koebnick | Program Manager, HRET

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Today’s Agenda

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11:00-11:05 am Welcome and IntroductionsEmily Koebnick

Program Manager, HRET11:05- 11:10 am Data Updates

Mariana LesherData Analyst, HRET

11:10-11:25 am Fluid Resuscitation: Overcoming Physician ResistanceUnderstand the science behind the recommended fluid resuscitation in Septic Shock. Learn ways to best influence physicians who may be resistance to this recommendation.

Dr. Sean Townsend M.D.Dr. Steve Tremain M.D.

Improvement Advisor, Cynosure

11:25-11:35 am Nursing Empowerment to Accelerate Sepsis CareExplore strategies that enhance nursing practice and empower them to recognize and treat sepsis as a medical emergency.

Deborah Campbell, RNInfection Prevention Improvement Advisor,

Kentucky Hospital Association

Agenda

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11:35- 11:45 am Family and Patient Engagement and EducationDiscover creative ways of engaging families in sepsis awareness and educational opportunities for patients discharged with sepsis.

Brett Hartkopp BSN, RN, CPPSMarket Director Quality and Infection Prevention,

Wesley Medical Center

11:45-11:55 am Sepsis in Your Neighborhood Community awareness around sepsis is a necessary component for a sepsis program that spans the continuum, review ideas to improve this vital need.

Patricia StahuraECRI Institute

11:55-12:10 pm Let’s hear from YOU!Facilitated discussion to gather updates on your sepsis month activities.

Maryanne WhitneyDr. Steve Tremain

Improvement Advisors, Cynosure12:10-12:15 pm Bring it Home

Emily KoebnickProgram Manager, HRET

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WEBINAR PLATFORM QUICK REFERENCE

How Did You Hear About This Event?

A) HRET HIIN flyerB) HRET HIIN websiteC) HRET LISTSERV D) State hospital associationE) QIN-QIO F) Your organization/colleagueG) Other, please specify.

Sepsis Measurement

• HIIN Measures– Post-operative sepsis (AHRQ PSI-13)

• 2013¹: 4.19 per 1,000

• Sepsis Impact²- Most expensive reason for hospitalization- Patients stay in the hospital 75% longer1. http://www.qualityindicators.ahrq.gov/downloads/modules/psi/v60-ICD09/version_60_benchmark_tables_psi.pdf2. https://blogs.cdc.gov/safehealthcare/the-cost-of-sepsis/

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Post-operative sepsis (AHRQ PSI 13)

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Fluid Resuscitation in Sepsis

Why 30ml/kg Cyrstalloid is Reasonable

Sean R. Townsend, MDVice President Quality & SafetyCalifornia Pacific Medical Center

September 6, 2017

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Why Do All Severe Sepsis Patients Need Volume??

1. Vascular volume is lost into interstitial space do to diffuse capillary leaking from cytokine release

2. Both venous and arteriolar tone is reduced & blood volume occupies a larger intravascular space than normal

3. Many patients also have GI and Skin losses

Does Early Aggressive Therapy Make a

Difference?

From Am. College of Surgeons ATLS Manuel

Trauma Patients

Fluids Prevent Intubation

• From Rivers: % Ventilated patients

Hours after start of Therapy0-6 7-72 0-72

Standard Therapy 53.8% 16.8% 70.6%Early Goal Directed Therapy

53% 2.6% 55.6%P Value <.001 0.02

N Engl J Med 2001;345:1368-1377

Chronic coexisting conditions--CHF: Control 30.2%

EGDT 36.7%

FACT:

• One liter of normal saline adds 275 mlto the patient’s plasma volume

The PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock— A Patient-Level Meta-Analysis.

N Engl J Med 2017; 376:2223-2234.

• Subgroup analyses showed no benefit from EGDT for patients with “worse” shock (higher lactate, hypotension, predicted risk of death).

• EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics.

Clinical Trial Cohort Intravenous Fluids

(milliliters)

Central Line Placement

Vasopressor Utilization

ProCESS

May 2014

EGDT 2805 +/- 1957 411/439 (93.6%) 241/439 (54.9%)

Usual Care 2279 +/- 1881 264/456 (57.9%) 201/456 (44.1%)

Δ 526ml 35.7% 10.8%

ARISE

October 2014

EGDT 1964+/-1415 714/793 (90%) 528/793 (66.6%)

Usual Care 1713+/-1401 494/798 (61.9%) 461/798 (57.8%)

Δ 251ml 28.1% 8.8%

ProMISE

May 2015

EGDT 2000 (1150-3000) 575/624 (92%) 332/623 (53.3%)

Usual Care 1784 (1075-2775) 318/625 (50.9%) 291/625 (46.6%)

Δ 216ml 41.1% 6.7%

Differences between treatment and control groupsin the ProCESS, ARISE, and ProMISE Trials:

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 EnglJ Med 2015: DOI: 10.1056/NEJMoa1500896.

MD Ability to Predict Hemodynamics

Survey administered pre-PA catheterization

Variable N measured % correct prediction of range of actual value

Wedge Pressure 102 30%Cardiac Output 97 51%SVR 88 44%R Atrial Pressure 98 55%

CCM 1984 Vol 12, No. 7 pp549-553

Can We Predict Mortality in Infected Patients?

Systolic BP ≥ 90 still have ↑ lactate and mortality

ICM 2007 Vol 33: 1892-1899

Lowest ED reading

Lathan HE, Bengston CD, Satterwhite, L et al. Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes.

Journal of Critical Care 42 (2017) 42-46.

Lathan HE, Bengston CD, Satterwhite, L et al. Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes.

Journal of Critical Care 42 (2017) 42-46.

Seymour CW, Gesten F, Prescott H et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis.

N Engl J Med 2017; 376:2235-2244. .

Seymour CW, Gesten F, Prescott H et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis.

N Engl J Med 2017; 376:2235-2244. .

Liu VX, Morehouse J, Marelich G et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate

Values. Am J Respir Crit Care Med Vol 193, Iss 11, pp 1264–1270.

Liu VX, Morehouse J, Marelich G et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate

Values. Am J Respir Crit Care Med Vol 193, Iss 11, pp 1264–1270.

Influencing Physician Practice

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Nurse Empowermentin Sepsis Improvement

Deborah R. Campbell, RN-BC, MSN, CPHQInfection Prevention Improvement Advisor

Kentucky Hospital Improvement Innovation Network

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Role of nurses in sepsis

• Is it only assessment/recognition?– Current literature search- Yes, BUT….

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Why?

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• Nurses are often the first healthcare providers to interact with and assess the patient who presents with sepsis.

Why?

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• Nursing is often a more stable, consistent group than physicians, e.g., residents and fellows rotations.

WHY?

• Nurses are almost always employees as opposed to medical providers who may be contract staff, locum tenens, etc.

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Where are you?

• Do your nurses have a sepsis screen?• Can the triage nurse (or first on the scene) call

a “code sepsis” if that is appropriate?• Can the nurse instigate a sepsis huddle?• Can the nurse initiate an order set/protocol?

– Draw blood cultures, lactates, etc.– Start an IV, fluid bolus

• Can the nurse mix antibiotics in urgent situations?

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Nurse Protocol for Antibiotics• If patient is assessed for sepsis and is deemed

high risk requiring early antibiotic intervention, a nurse will access the “PedsSepsis Kit” as follows:

• Select patient in pyxis machine*• Remove med → OVERRIDE → “Peds Sepsis Kit” • Administer medications selected by provider according to guidance• Complete the documentation at the bottom of this form.• Place unused antibiotics and Peds Sepsis sheet in return bin to pharmacy

for charging and restocking.• Obtain EPIC medication orders from provider to document the

administration of the antibiotics used via the sepsis kit. EPIC Pediatric Sepsis Order set can be used for this.

34Courtesy of Golisano Children’s Hospital

Nursing Pathway

• At any time • If YES to Question 1 AND • Hypotensive (SBP < 90 or MAP < 65)

OR • Lactate ≥4 • Activate a CODE SEPSIS • Then notify a provider immediately • Start pathway to right

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Overview

• There were great examples of nursing empowered protocols described on the ListServe.

• Limitations:– EDs and ICUs tend to allow more interventions

initially by nurses than less high acuity areas – Continue to see limits on what nurses can do

based on criteria v. having to wait for a physician to arrive, assess and order interventions

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Summary–Processes which allow nurses to

perform to the limit of their scope of practice is optimal for early recognition and timely treatment.

• Questions?• Deb Campbell, RN-BC, MSN, CPHQ, CCRN alumna• [email protected]• 502-992-4383

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Patient & Family Engagementin Sepsis

Brett Hartkopp BSN, RN, CPPSMarket Director Quality & Infection Prevention

Wesley Medical Center

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• 859 Bed Hospital• Level 1 Trauma• Only PEDs Trauma in Kansas

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About us

• Education to patient and families during alert process

• Questions encouraged• Follow-up by sepsis coordinator when

inpatient• Education from sepsis coordinator during

discharge planning phase of hospitalization• Coordination with case management

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Discharge Opportunities

• Community Health Fairs

• Patient stories

• Survivor Videos

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Community Awareness

Sepsis in Your Neighborhood

Patricia Stahura RN,MSNSenior Analyst and Consultant

ECRI Institute

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About ECRI Institute

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Independent & Research Driven International Non-Profit with strict conflict of interest rules

Evidence Based Practice Center - Agency for Healthcare Research and Quality

Federally Certified Patient Safety Organization (PSO)

Clinical risk management provider to all HRSA federally funded health clinics

Patient safety and clinical quality resources to 1,000s of healthcare organizations for nearly 50 years

ACCME accredited CME provider

Nursing CEU provider in patient safety

400+ multidisciplinary staff

Sepsis in the United States

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• 80% sepsis cases start outside the hospital• 70% patients with sepsis were seen or had

chronic diseases requiring frequent medical care• One million discharges/year include sepsis

diagnosis• 62% sepsis patients are readmitted within 30

days

Source: CDC

Why Community Outreach?

• 1 billion ambulatory visits occur annually • More Hospitalists, less Attending Physicians• Less than half of US adults have heard of sepsis• September is Sepsis awareness monthSource: NCHS; CDC

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Community Outreach Plan

• What’s in it for me?• Community needs• Make contact• Schedule a meeting• Mobilize resources• Community Collaborative • Follow Up

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Healthcare Provider Awareness

• Primary Care Centers• Urgent Care Centers• Dialysis Centers• Geriatricians• Pediatricians• Obstetricians• Birthing Centers• Home Health Agencies• Pharmacy• Community Flu shot programs

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Public Awareness

• Schools• Churches• Group Homes• Clubs and community organizations• Athletic and fitness centers• Support Groups• Senior Centers• City Council

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Topics for Community Education

• Prevent infections• Get immunizations • Keep scrapes and wounds clean• Manage chronic conditions• Recognize signs of worsening condition• Seek medical care if not better or worse• Say “I am concerned about sepsis”

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Informational Resources• Press and Radio Release• Surviving Sepsis App• Fact sheets• Brochures• Articles• Infographics• Screening tools• Pocket cards• Algorithms

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References and ResourcesCDC Sepsishttps://www.cdc.gov/sepsis/basic/index.htmlNational Center for Health Statistics (NCHS). 2015. FastStats A to Z. Ambulatory Care, and Hospital Utilization.http://www.cdc.gov/nchs/fastatsSepsis Alliancehttps://www.sepsis.orgSurviving Sepsishttp://www.survivingsepsis.org/Bundles/Pages/default.aspxHRET HIIN http://www.hret-hiin.org/topics/sepsis.shtmlECRI Institutehttps://www.ecri.org/components/hrc/pages/RMRep1215_Focus.aspx

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Open the Lines• Let’s hear from you!

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BRING IT HOMEEmily Koebnick, Program Manager, HRET

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Sepsis Resources

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on the HRET HIIN website

Sepsis Resources – LISTSERV®

• Join the LISTSERV® – Ask questions– Share best practices, tools and resources– Learn from subject matter experts– Receive follow up from this event and notice of

future events

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Sepsis Awareness Month

• Please continue to send us your inspirational stories and photos!

• You can tweet with the hashtags #sepsisawareness or #whyimhiin and/or email us your information at [email protected]!

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HRET HIIN Sepsis SNAPJoin the HRET HIIN SNAP!Register for the information call on Monday, September 11 to learn more.

Thank You!

Find more information on our website: www.hret-hiin.org

Questions or Comments: [email protected]

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