Our Journey on the Road to Surviving Sepsis Debbie Sober, RN, MSN Community Hospital of the Monterey Peninsula
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