Early Recognition and Management of Sepsis

ECF Program

Angela Craig APN,MS,CCNSClinical Nurse Specialist ICU

Sepsis Team FacilitatorCookeville Regional Medical Center

acraig@crmchealth.org

Early Recognition and Management of Sepsis

• Welcome• Review of Program Objectives

– Develop and implement a early recognition of sepsis process

– Standardize processes for treatment of patients with early sepsis

– Standardize processes for infection prevention of PNA, CAUTI and CLABSI

– Decrease rate of transfer to higher level facility – Decrease sepsis mortality rates

• Orientation to training materials

Introductions

• Share:– your name,– facility– your role in the facility– what work you have done so far on sepsis

Why sepsis? Why now?

• Faces of Sepsis https://www.youtube.com/watch?v=12Qbnn6XfH0

• Surviving sepsis campaign• Early identification and management of sepsis at

Cookeville Regional Medical Center our journey to early identification and reduction in mortality

Early Recognition and Management of SepsisOverview of Training Program

• You will have 6 Webexes to do with your team and there will be 6 “Help Session” Webexes to go over barriers and any questions you may have about the content you reviewed on your own with your team– Need to pick a time workable for you and your team– Walk through action plan to implement a sepsis early

identification and management program that includes a focus on infection prevention

• You will want to complete the Webex prior to the “Help Session Webex”

• Provide training and educational materials• Defined process and outcome measures to evaluate success of

the program

Roles and Responsibilities• Each facility must have a team identified to do this work

– Should include: medical director, DON, infection prevention nurse at a minimum

• Team work through action plan provided in specified timeframe

• Implement sepsis screening process• Implement early management of sepsis process• Educate staff on screening and management processes• Assess current infection prevention practices related to

PNA, UTI and CLABSI and identify on intervention to improve upon

• Collect defined process and outcome data

Pre-training assessment

• Complete assessment (you can access the pretest on the series webpage)

Use this tool with your staff to assess their knowledge pre and post education

SEPSIS and INFECTION PREVENTION and MANAGEMENT OBJECTIVES

• DEFINE THE SEPSIS CONTINUUM AND ITS IMPACT ON THE ELDER ADULT

• IDENTIFY THE EARLY SIGNS AND SYMPTOMS OF THE SEPSIS CONTINUUM

Sepsis: CDC Vital Signhttps://www.cdc.gov/vitalsigns/pdf/2016-08-vitalsigns.pdf

• 80% of sepsis begins outside the hospital• 7 out of 10 patients with sepsis had recently used health services or had

chronic dx requiring frequent care• 4 types of infections most connected to sepsis; lung, urinary tract, skin and gut• HCP: think sepsis & act fast

10http://www.cdc.gov/nchs/data/databriefs/db62.pdf

Common Causes of Hospitalization Adults aged 85 and over: U.S.

11

Levant S, Chari K, DeFrances CJ. Hospitalizations for patients aged 85 and over in the United States, 2000–2010.

NCHS data brief, no 182. Hyattsville, MD: National Center for Health Statistics. 2015.

Sepsis is #1 Cause of Inpatient Deaths

Sepsis Impact on Mortality in Hospitals

1 out of 2-3 Deaths r/t Sepsis, Most POAIn KPNC 2012 subset, patient meeting criteria for EGDT comprised 32.6 percent of sepsis deaths & patients with sepsis, normal BP & lactate < 4 comprised 55.9% of sepsis deaths

Liu V, et al. JAMA,2014:May 18th, online.

314

Chang DW; Tseng CH; Shapiro MF. Critical Care Medicine. 43(10):2085-93, 2015 Oct.

Proportion & Cost of Unplanned 30 day Readmissions after Sepsis (2013 Nationwide Readmission Database)

Mayr FB, et al. JAMA, 2017, Jan 22nd published online

Discharge Disposition After SepsisSepticemia or

sepsisOther

diagnoses

Disposition PercentRoutine 39 79Transfer to other short-term care facility

6 3

Transfer to long-term care institution

30 10

Died during the hospitalization

17 2

Other or not stated 8 6Total 100 100

16

1Difference is statistically significant at the 0.05 level. SOURCE: CDC/NCHS, National Hospital Discharge Survey, 2008.

Septicemia in U.S. Hospitals, 2009 Anne Elixhauser, Ph.D., Bernard Friedman, Ph.D., Elizabeth Stranges, M.S. (Statistical Brief #122) (AHRQ) (Key point: Over half were over age of 65 years)

Impact on the Elderly• Age itself independent risk factor for death• More likely admitted to ICU• Highest mortality in the old elderly (85+)• Prolonged hospitalization

Post Sepsis Impact• Contributes to Cognitive decline • Contributes to Physical long term disabilities

(walking, ADLs, and IADLs)

Time Sensitive DiseasesChanging the Paradigm of Practice

Severe Sepsis: Defining a Disease Continuum

Known/Suspected Infection SIRS Sepsis Severe Sepsis

Adult CriteriaA clinical response arising from a nonspecific insult, including ≥ 2 of the following:Temperature: > 38°C or < 36°CHeart Rate: > 90 beats/minRespirations: > 20/minWBC count: > 12,000/mm3,

or < 4,000/mm3,or > 10% immature neutrophils

SIRS with a presumed or confirmed infectious process

Sepsis with ≥1 sign of organ dysfunction, hypoperfusion or hypotension.Examples:•Cardiovascular (refractoryhypotension)

•Renal•Respiratory•Hepatic•Hematologic•CNS•Unexplained metabolic acidosis

Shock

SIRS = Systemic Inflammatory Response SyndromeBone et al. Chest. 1992;101:1644-1654.

Sepsis Definitions

2017 Guideline Definitions• Sepsis: life-threatening organ dysfunction

caused by a dysregulated host response to infection

• Septic Shock: a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality

Definitions (used by CMS and coders)

• Infection• Sepsis: infection plus 2 or more SIRS• Severe Sepsis: infection plus 2 or more SIRS plus

new organ dysfunction • Septic Shock: severe sepsis with a lactic acid

greater than or equal to 4mmol/L OR continued hypotension (systolic BP<90 or 40mmHg decrease from their baseline) after initial fluid bolus (30ml/kg)

SIRSSystemic Not localizedInflammatory Body’s response to an

insult, Can arise from chemical, traumatic or infectious stimuli

Response Reaction to situationSyndrome A group of symptoms

that consistently occur together

Challenge with SIRS as Sepsis Criteria

• SIRS is non-specific – can be caused by ischemia, inflammation, trauma, infection

• SIRS is not always related to infection

SIRS CriteriaTemperature >100.4 or <96.8Heart Rate >90 beats per minuteRespiratory Rate > 20 breaths per min or PaCO2 <32White Blood Cell Count

>12,000, <4000, or >10% immature neutrophils = Bands

Known/Suspected infection PLUS 2 or more SIRS

Known/Suspected infection PLUS 2 or more SIRS plus organ dysfunction

Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis

Known/Suspected infection PLUS 2 or more SIRS plus organ dysfunction with a lactate > or = 4 OR hypotension after a fluid bolus (usually 30mL/kg)

Lactic Acid• A weak acid that is produced when body cells break

down glucose by anaerobic metabolism in order to produce energy

• It is produced by muscles during vigorous exercise and is one of the factors that contribute to cramp

• Also produced in body tissues when they receive insufficient oxygen due to impairment of their blood supply in a heart attack or shock

• May be a hypoxia indicator

Except on few occasions, the patient appears to die from the body's response to infection rather than from it."

Sir William Osler – 1904The Evolution of Modern Medicine

Homeostasis Is Unbalanced in Severe Sepsis

Coagulation

Inflammation

Fibrinolysis

Carvalho AC, Freeman NJ. J Crit Illness. 1994;9:51-75; Kidokoro A et al. Shock.1996;5:223-8; Vervloet MG et al. Semin Thromb Hemost. 1998;24:33-44.

Inflammation, Coagulation and Impaired Fibrinolysis In Severe Sepsis

Reprinted with permission from the National Initiative in Sepsis Education (NISE).

Microcirculation of Septic Patient:Othogonal Polarization Spectral Imaging

• BP: 120/80 Hg• SaO2: 98%

1. www.opsimaging.net. Accessed April 2004. 2. Spronk PE, Ince C, Gardien MJ, et al. Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet. 2002; 360:1395-1396.

Microcirculation of Septic Shock Patient: Othogonal Polarization Spectral Imaging

• Resuscitated with • fluids and dopamine

– HR: 82 BPM– BP: 90/35 mm Hg– SaO2: 98%– CVP: 25 mm Hg

1. www.opsimaging.net. Accessed April 2004. 2. Spronk PE, Ince C, Gardien MJ, et al. Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet. 2002; 360:1395-1396.

CORNERSTONES OF MULTIDISCIPLINARY MANAGEMENT OF SEVERE SEPSIS

• Prevention (talk about this at future meetings)• Screening and Early Identification• Early Intervention: Source control, Blood

cultures and broad spectrum antibiotics• Initial Resuscitation Bundle• Septic Shock Bundle– at the hospital

TO SAVE LIVES.....

Early identification

Early antibiotics

Early fluid resuscitation

SEP-1 SEP-1

TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION † :

1. Measure lactate level2. Obtain blood cultures prior to administration of antibiotics3. Administer broad spectrum antibiotics4. Administer 30ml/kg crystalloid for hypotension or lactate

≥4mmol/L

† “time of presentation” is defined as the time of earliest chart annotation consistent with all elements severe sepsis or septic shock ascertained through chart review.

SEP-1 SEP-1

TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:

5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg

6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to table 1.

7. Re-measure lactate if initial lactate elevated.

SEP-1 SEP-1

TABLE 1DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE

PERFUSION WITH:

Either • Repeat focused exam(after initial fluid resuscitation) by

licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse and skin findings.

Or two of the following:• Measure CVP • Measure ScvO2• Bedside cardiovascular ultrasound• Dynamic assessment of fluid responsiveness with passive

leg raise or fluid challenge

3 hour Bundle 1 hour Bundle

• Evidence Shows the 3 hour bundle should be completed in 1 hour

The Surviving Sepsis Campaign Bundle: 2018 update

Authors: Mitchell M. Levy, Laura E. Evans, Andrew Rhodes

Hour-1 Surviving Sepsis Campaign Bundle of Care

Intensive Care Med, May 2018

Severe Sepsis Screening Tool

Screening• When do you screen?

– Upon admission, daily, with condition change or stop and watch alert or if receiving antibiotics

• First step: Does the patient have a known or suspected infection?

Screening• Second Step: Does the patient have signs of

systemic inflammatory response syndrome (SIRS)?

Screening• Third Step: Does the patient have any new organ

dysfunction in an organ system distant from site of infection?

Screening

• If screens positive for severe sepsis, then follow the SBAR at bottom of tool

• Link with current process

• Educate CNAs

Clinical Scenario 1: Early identification and intervention

• 88 year old, 51.6kg,white, female admit from ED; resided in ECF

• History: CAD, COPD, dementia, Alzheimer disease, depression, SVT

• Chief Complaint: rib pain, chest congestion and SOB

• Awake, alert and oriented, slight combative (history of combative behavior)

Clinical Scenario 1: Early identification and intervention

• Initial VS:– Temp: 101.6 F– RR: 31– HR: 109, atrial fib with occasional SVT– B/P: 79/51– 2L of O2, O2 sat of 96%

• Does this patient screen positive for severe sepsis?

Positive Screen for severe sepsis:SIRS: HR >90; RR> 20; Temp > 38Organ dysfunction: SBP<90mmHg

WHAT ARE THE NEXT STEPS?Call physician—follow SBARExpected orders:

Give fluid bolus of 30ml/kg bolusLabs drawn(lactate, CBC, ABG)

Severe Sepsis Screening Tool

Upper Cumberland Coalition

April 2017 – June 2017We had 147 patients that were discharged with a sepsis diagnosis and readmitted (both inpatient and observation included in this number)

April 2017- June 2017 Data40.8% (60 pts) Were readmitted from

Home28.6% (42 pts) Were readmitted from

Home Health27.9% (41 pts) Were readmitted from

Skilled Nursing Facilities2.7% (4pts) Were readmitted from our

Rehab Facility6.8% (10pts) Of the re-admits expired

Signature Putnam’sSepsis Screening Tool

Discharge Data From Signature Putnam Nursing home

Sepsis Early Identification Action PlanStep Who? When? Status

1. Get team together to create early identification process

2. Develop screening tool/process

3.Get medical staff support for screening and early intervention

4. Develop and implement educational plan for sepsis and screening

5. Develop patient & family education process and tools

6. Evaluate screening: define outcome and process metrics

Education for staff• Tools and materials:

– This presentation which is downloadable from the website

– Videos from MPRO : https://www.youtube.com/playlist?list=PL5ITOxWOe7JoWfbVblphE1rOOh1uCavBA

Your homework related to education (item 4 on action plan):

• Define content for your staff education and whom will provide education

• Develop implementation plan for the program

RESOURCES

New jersey Sepsis Learning-Action Collaborative

www.njha.com/sepsis

Surviving Sepsis Campaign

http://www.survivingsepsis.org/Pages/default.aspx

Centers for Disease Control and Prevention – Sepsis

http://www.cdc.gov/sepsis/index.html

Centers for Disease Control and Prevention – Nursing Homes and Assisted Living Resources

http://www.cdc.gov/longtermcare/

Minnesota Hospital Association “Seeing Sepsis Long Term Care Resources”

http://www.mnhospitals.org/patient-safety/current-safety-quality-initiatives/severe-sepsis-and-septic-shock

American Hospital Association’s Health Research and Educational Trust “Sepsis Resources”

http://www.hret-hen.org/index.php?option=com_phocadownload&view=category&id=370&Itemid=369

Homework

• Complete 1-4 on action plan

• Screen 10 patients using the screening tool

• Come prepared to share what you have done during the Round Robin at the next meeting

QUESTIONS???