Think Sepsis…. A Multidisciplinary approach Keith Knepp, MD Tammy Duvendack, RN, PhD.

Think Sepsis….A Multidisciplinary approach

Keith Knepp, MDTammy Duvendack, RN, PhD

Methodist Medical Center of Illinois2011 Statistics:

•329 Licensed Beds•Annual Admissions: 17,388•ED admissions: 59,000•CMI= 1.27•11,0000 surgeries•Minor teaching residency program (Family Practice and Psychiatry)•Hospitalist , Intensivist, Palliative Care Services

Learning Objectives• Describe the concept of nurse to nurse consultation

as an integral component of early recognition and initial treatment of sepsis

• Discuss the use of specific order sets and algothrims for ED, clinical inpatient units, and critical care.

• Analyze patient outcomes realized at Methodist Medical Center based on the “think sepsis” campaign

• Identify education strategies for front line staff caring for high risk of sepsis

• Discuss strategies for physician engagement and education

Overview• Sepsis is MMCI’s Top mortality diagnosis.• 2004-2005 ICU CVICU Intensivists implemented order sets based on SCCM

standards.• 2006-2007 – Initiated quarterly mortality rate monitor• Mid 2008 - Evaluation of data demonstrated that over 80% of all sepsis

patients came through the ED. Baseline analysis of ED records using the IHI Think Sepsis standards demonstrated considerable variability in identification and intervention for patients that met Sepsis criteria.

• 2009 through present very stringent multi disciplinary review of all ED records using consistent guidelines. As a result, sepsis patient standards in the ED have been standardized and considerable improvement in their documented process of care.

• 2010 Added as indicator on Intensivist dashboard. • 2011 Committee restructured and assumed by Acute Care Interdisciplinary

committee

Outcomes• Initiated through Critical Care unit-based councils• Standardization of the sepsis definition (Think Sepsis)• ED composite care standards improved from 63% to 93%

measures include– Antibiotic w/I 3 hours– NS bolus of 1000 cc– BC prior to antibiotic

• As the diagnosis has been standardized the patient volume has increased

• Mortality rates have dropped• Use of comfort care/Palliative Care/Hospice has increased• Incorporation of “Think Sepsis” in UAT calls and orders

Purpose of the UATNurse-to-Nurse consult

• Worried about the patient• Acute change in HR <50, >100 or 20 beat

change• Acute change in systolic B/P <90 or >160 or a

20 mm change• Acute change in RR, <12 or >24/min• Acute change in O2 Sat requiring increasing

need for oxygen

More “activation triggers”

• Acute change in LOC, onset of lethargy, agitation, delusions

• Acute change in urinary output, <20 ml/hr• Acute change in temp, <97º or > 101º

Multi-disciplinary Team• CNS or Nursing Supervisor• ICU Nurse• Respiratory Therapist• Dial 122 and state Urgent Assessment Team

needed to room # (or location)• 3 types of UAT calls:

a) Adult UATb) Pediatric UATc) Non-Patient UAT

RCA Learning Points

• Majority of RCA’s participants note the UAT would have been a helpful resource– Most common reason cited for not using

• Unaware of• Forgot…..did not think of• Was getting orders from the MD so thought “ok”• To busy to call• Did not seek out teammates help to stop and “think”

outside of the problem

Action Plan• Increase use of UAT…UAT saves lives…the

outcome data is clear!• Follow up education

– Introduced into new nurse orientation– Annual Unit-Based Education Days (Use of SimMan)– Preventing a Crisis Sessions (Spring and Fall

reinforcing early recognition of Sepsis and oxygen management as a result of RCA trends

– Sharing of events to promote Organizational Learning during monthly Clinical Practice Council meetings

Early Warning SignsDocumented observations show 84% of patients have clinical deterioration or new complaints < 8hrs before they cardiac arrest70% of patients showed deterioration of either respiratory or mental function

17% of cardiac arrests occur in patients who were being cared for in an inappropriate clinical area.

Significant ↑ or ↓ in any VS OR trending of ↑ oxygen needs should trigger a call to either the provider or UAT.

2/18/12 2012. Duncan. K.D., C McMulan & B Mills. Early Warning Systems, Nursing 2012: Feb, 38-39

UAT Statistics

2/18/12

5

15

25

35

45

55

MMCI PI Monitor: Number of UAT Calls vs Code Blues (CPA) vs ARC Calls

2011-YTD 2012n

um

be

r

2008-1 family initiated UAT call and 1 pediatric UAT call 2009-3 family initiated calls and 1 pediatric UAT calls2010-1 family initiated call and 0 pediatric UAT calls2011-0 family initiated calls and 3 pediatric UAT calls

housewide educationon Preventing a Crisis Sept 2010 2/11 RNs getting

bedside report in ED

1/2012 ED staff to take vitals during bedside report.

2/18/12

Disposition of UAT patients Jan YTD 2012 2011

# of calls 39 39 450

Remained on Unit 28 28 250

Transferred to ICU/CVICU 7 7 147

Transferred to another unit 4 4 51

Died 0 0 2

ICU stay prior to UAT call 1 1 32

ED 24 hrs prior 9 9 74

Sedation 24 hrs prior 2 2 25

PACU 24 hrs prior 2 2 19

Glucose/Insulin given during event 2 2 14

Reversal Agent given during call 3 3 24

Resulted in ARC 1 1 24

Resulted in CPA 2 2 9

MMCI IP MORTALITY TRENDS

Mortality Trends by Year

Year MS DRG 870, 871, 872

Cases # pts Mortality %Mortality

Index

CY 2005 248 49 19.76% 0.97CY 2006 211 49 23.22% 0.99CY 2007 254 65 25.59% 1.21CY 2008 210 57 27.14% 1.19CY 2009 359 64 17.83% 1.00CY 2010 476 86 18.07% 1.06CY 2011 646 71 11.02% 0.86

MMCI IP SEPSIS MORTALITY TREND

Sepsis was identified in 2005 as a mortality driver. Several interventions have been placed since that time and although mortality dropped we were unable to sustain that gain. In 2011 that goal was achieved .

Jan-07

Mar-07

May-07

Jul-07

Sep-07

Nov-07Jan

-08

Mar-08

May-08

Jul-08

Sep-08

Nov-08Jan

-09

Mar-09

May-09

Jul-09

Sep-09

Nov-09Jan

-10

Mar-10

May-10

Jul-10

Sep-10

Nov-10Jan

-11

Mar-11

May-11

Jul-11

Sep-11

Nov-11Jan

-12-15%

-5%

5%

15%

25%

35%

45%

55%

43%

30%

21%

27%

13%

31%30%29%

20%20%

12%

22%24%21%

38%36%

29%32%

8%

38%

20%

47%

19%

37%

17%

26%

11%

24%27%26%

10%

21%20%18%

6%

14%

9%

29%

8%

33%

10%13%14%

19%21%

12%

18%

11%

21%

13%16%

10%7%5%

12%15%

6%7%4%

10%14%

10%

UCL

0.214CL

0.094

LCL-0.026

Sepsis Mortality CY 2007 thru Feb 2012

Month/Yr

Mor

talit

y %

Good

Premier Comparative Database

In 2011, MMCI has been able to sustain the drop in

sepsis mortality

Sepsis Driver DiagramPrimary drivers Secondary drivers

Identification from sx onset PhysicianNursing unit/locationPatient mental statusS/O awareness of pt conditionPatient signs/symptomsHistory of illness

Initiation of treatment Use of algorithmFluid resuscitationPhysicianNursing unit/locationATB timeLabs drawnCode status

Patient mental and health Patient from nursing home status at time of onset Patient from acute hospital

Patient mental statusSource of sepsisHx of illness

Sepsis Mortality

Physician Leadership

• Physician leadership provided by Chief Quality Officer, along with– Intensivists– ED physicians

• Literature review, protocol and order set development done with assistance of this group

Physician Education/Engagement• Sepsis Initiative rolled out to the following:• Acute Care Interdisciplinary Team

– Multidisciplinary Team with nursing and physician representation (Acute care medical director, hospitalist, residency faculty physician)

• ED Department Meetings• Quality and Safety Council – broad physician

representation– Reports to Medical Executive Committee

• Specific presentations to hospitalists, residents

Physician Concerns• Hard to accept this sepsis definition

– Most physicians trained that “sepsis” is what we now call septic shock or severe sepsis

– Sepsis definition of “SIRS with source of infection” is a much broader net.

• Concerns about fluid management being too aggressive in some patients

• Still navigating these issues over time– Ongoing committee oversight– Peer review discussions

STAFF KNOWLEDGE RETENTION

ASSESSMENT 2012

• When using the Sepsis Algorithm, which two would be considered a positive screening (In Step 1)?

A. HR 110 and Temp 101 orally – HR > 90 & T > 100.4

B. WBC 10 and RR 30– WBC <4 & RR >20

C. WBC 3 and Temp 99 orally– WBC < 4 but no temp

D. Serum glucose120 in non-diabetic and HR 100 – HR > 90 but glucose not > 140 iUse I- clickers

You go down to ED to get your patient and receive the following report: B/P 88/50, HR 120 and irreg, T 96.5⁰, RR 28. What additional information do you need?

A. Time of last VSB. Was pt screened for sepsis? C. Meds/IV fluids given/Lab resultsD. Is this pt appropriate for admission to my

unit?E. All of the above

i

Your newly admitted pt was treated for sepsis in the ED. They received an ATB, an IV bolus & are now on standing orders of NS at 250cc/hr X 4. Because you don’t have any further IV orders and VS are stable, IV is changed to SL. 6 hrs later, the pt’s B/P is now 80/48. What happened?

A. Pt has a new problem, call the DrB. Pt didn’t receive enough fluid to correct hypovolemia

and is still septic, should have gotten orders for maintenance IV fluids

C. Hang another IV of NS and administer fluid bolus, consider calling UAT

D. B & CE. All of the above i

Preventing a Crisis Case Study

• 81 yo male presented to the ED with hyperkalemia, kidney failure, hyponatremia, dehydration, afib, and GI bleed

• C/O – abd pain and cramping

• Hx– recent ileostomy formation (1 month prior), HF,

Stroke, diverticulitis, & multiple hospitalizations for dehydration

• Admitted to an acute care unit

• Treated with Kayexalate• What’s concerning about this information?

– Does it meet the sepsis criteria?

1800 in ED

V/S 97.9 72 20 169/85 99% RALabs WBC

29.6K

8.1Na 123

Crt 2.9

Glucose 167

29.6

167

2.9

Recent surgery, abd pain, ????

Oh no!…

• Unfortunately this patient was not screened…

– Fluid resuscitation was not started– Antibiotic therapy was not started

• Where can you find the algorithm?– Care organizer – resources menu – sepsis

screening algorithm

1800In ED

97.9 72 20 169/85 99% RA

WBC 29.6

K 8.1

Na 123

Crt 2.9

Glucose 167

0510On floor

96.9 61 18 124/71 94% RA

WBC 23.6

K 7.5

Na 124

Crt 3.2

Glucose 156

• Urinalysis clear• What should concern you?• ↓ temp, K+ still ↑, Crt ↑ ing, ↑ Glucose

(not diabetic)

• Baseline on floor at 2200: HR 69, BP 164/93, Temp 98.9

• 2200 (day of admission) – 1600 (next day):– Patient appeared “OK” throughout the day, staff were in

contact with MD.– Sometimes gives us a false sense of security

• 1600 – Marked deterioration ↑ HR, RR, & O2 needs, and ↓

BP, weakness, difficult to understand, • 1700RR 32 – BP 122/76 – 83% (2L O2 placed )• 1730 RR 28 – BP 88/48 -- 89% (kept taking O2 off)

• Not screened for sepsis in ED or acute care unit.–what was the WBC in ED? –29.6

• Sepsis identified too late – treatment delayed• 1800- - RR 25 - BP 75/46 - Sats 67% on 10 L O2

pt transferred to the unit• 1827 – intubated• Next day …Made “comfort measures”• ICU Dx – septic shock, severe lactic acidosis, acute

tubular necrosis, respiratory failure.

What could have been done better?

• High Potassium• No telemetry• No IV fluids• No cultures• No sepsis screening• Proper pt placement on admission• Face-to-face report

Use the sepsis algorithm: Allows us to:

ID sepsis earlier & get order from MD for ATB & fluids

Call MD and ask to implement sepsis orders for labs (procalcitonin and lactic acid) and fluids.

Transfer to higher level of care if necessaryIf response if negative and you believe patient

meets criteria. . . . . . . . . . . Call the UAT!!!

• Sepsis Orders (to be used if the patient has screened positive for sepsis and is not currently under active treatment for sepsis)

• The nurse is to initiate orders 1 through 4:

• Activate the urgent assessment team• Complete the screening algorithm for organ dysfunction• Initiate the following if they have not been done in the last 4 hours:

– CBC– CMP– Serum lactate– Serum procalcitonin– UA– Blood culture x2– Urine culture

• Start second IV (if patient has only 1 IV site) • IV fluids: Ask MD for fluid bolus of at least 500ml NS

Chain of Command?• Staff was in contact with MD throughout the day

but at times was difficult to contact.

• What do you do when this happens?• Initiate the chain of command

• How do you do this?• Find your lead/supervisor/manager and state “I need to

activate the chain of command for…”

• Remember…if the plan doesn’t feel right, you can’t get in touch with the MD, or if you have a fast decline don’t hesitate to initiate the chain of command or call a UAT.

Procalcitonin (PCT)• Rises in response to a pro-

inflammatory stimulus, especially of bacterial origin

• Produced mainly by the cells of the lung and the intestine

• In septic conditions, increased PCT levels can be observed 3-6 hours after infectious challenge

• PCT blood levels may rise to 100 ng/ml

• PCT results can help reduce unnecessary antibiotic use : starts to fall with effective ATBs

WBC

What do you think is the primary problem?

•78 y/o male with dyspnea/cough•BP 89/51•HR 110•RR 14•Temp 99.2 oral•WBC 4.2•SpO2 96 on 3 l/np•Weight 122 lb (55 kg), baseline is 127 lb

a. HF exacerbationb. Dehydrationc. Sepsisd. B and Ce. All of the above

2/18/12

i

After 500 ml normal saline bolus.What should be next?

•BP 90/56–Pt’s Normal BP = 143/76

•HR 98–Pt’s normal HR = 65

•RR 20•Temp 99.2 oral•SpO2 96 on 3 l/np•Weight 55 kg

2/18/12

a. Pt is septic and dehydrated, give another 500ml bolus to = 20 ml/kg, then IV at 100 ml/hr

b. Pt is septic and dehydrated with HF/kidney insufficiency, hold additional bolus and start IV at 100ml/hr

c. Patient is septic, start inotropes (dopamine) to increase BP

i

2/18/12

After 1500 mL bolus, based on the vital signs, what is the appropriate unit for this patient?

• BP 90/56– Pt’s Normal BP = 143/76

• HR 98– Pt’s normal HR = 65

• RR 20• Temp 99.2 oral• SpO2 96 on 3 l/np• Weight 55 kg

a. 5C since the patient is HF

b. 7 Ham since the patient is septic

c. ICU

i

Is your unit appropriate?• What questions would you ask

before bringing this patient to your unit?

– Did patient meet Sepsis criteria?– Were the fluid and antibiotics given?– When was the last set of vitals taken?– IF still abnormal, were they seen and

patient okay’d for admission to selected floor by the ED physician

• Above and beyond the “SHARE” form….

Future Opportunities

• Nursing Home outreach education• ????

Questions?