Surviving Sepsis: Identification and Evidenced Based Management

Rosemarie Anglin, RN, MANancy Biddle, RN, MSN

Introduction

In an effort to decrease length of stay and

standardize care for adult sepsis patients, our

hospital formed a Sepsis Task Force to

determine how best to accomplish these goals.

The task force was made up of Critical Care

Physicians, Clinical Nurse Specialists,

Pharm D’s, Nursing Directors and a

Nursing Informaticist.

Who we are

Robert Wood Johnson University Hospital (RWJUH) is a 600-bed Academic Medical

Center and the principal hospital of UMDNJ-Robert Wood Johnson Medical School in

New Brunswick, NJ.

Its Centers of Excellence include Cardiovascular Care from

minimally invasive Heart Surgery to Transplantation, Cancer

Care, and Women’s and Children’s care including the

Bristol-Myers Squibb Children’s Hospital at Robert Wood

Johnson University Hospital.

The hospital is also a Level 1 Trauma Center and serves as a

national resource in its ground-breaking approaches to

emergency preparedness.

The hospital has earned Magnet recognition for Nursing

excellence from the American Nurses Credentialing Center

(ANCC) for the fourth straight time. RWJUH is one of only a

handful of organizations nationally to achieve this distinction.

Allscripts Software Solutions

RWJ is a TDS legacy client currently using Sunrise Acute Care and Sunrise Pharmacy 5.5 SP 1.

Went live with Sunrise Clinical Manager 3.0 in 2005.

With our licensed staff of providers, including private and university attendings, residents, APN’s, and PA’s we have attained 88% CPOE compliance.

Currently live with Orders, Results, Order Reconciliation, Nursing documentation, and are in the beginning stages of Physician documentation.

Defining SIRS/Sepsis*

SIRS

(Systemic Inflammatory

Response Syndrome)

2 or more of the following criteria:

Temperature > 100.4°F or < 96.8°F

HR > 90

RR > 20 or PaCO2 < 32

WBC > 12000 < 4000, or > 10% immature (band) forms

Sepsis Documented infection together with 2 or more SIRS criteria above.

Severe Sepsis Sepsis associated with organ dysfunction, hypoperfusion or

hypotension.

Septic ShockSepsis with refractory hypotension or hypoperfusion abnormalities

in spite of adequate fluid resuscitation.

*Townsend, S (et al) Implementing the Surviving Sepsis Campaign (2005)

Society of Critical Care Medicine

The Challenge

Our hospital had an increased length of stay

for sepsis patients as compared to other

members of the University Health System

Consortium (UHC)*.

*The University Health System Consortium is an alliance of 112

academic medical centers and 252 of their affiliated hospitals

representing approximately 90% of the nations non-profit academic

medical centers.

Our Response to the Challenge

A task force consisting of Physicians, Nurses,

Educators, Pharmacists, Case Managers and IT

Clinical Analysts was formed to develop a strategy to

impact length of stay in the adult patient population.

A two pronged approach was used:

First, by detecting and alerting for signs of

sepsis in the Adult Med-Surg patient.

Second, by developing a research based, best

practice protocol for care of the adult septic

patient.

Detecting Signs of Sepsis

The task force designed a process to alert the bedside nurse when clinical data that meets the criteria for Systemic Inflammatory Response Syndrome (SIRS)* and some elements of Organ Dysfunction are charted in the electronic health record (EHR).

To determine which of the criteria would be used to fire the alert, we took into consideration how often a specific data point would alert for conditions other than sepsis and excluded them. For example we do not alert for a creatinine greater than 2.0 since our hospital has a large number of renal patients.

*SIRS is defined as two or more of the following variables: Fever of more than 38 C or less than 36 C, Heart Rate of more than 90 beats per minute, Respiratory Rate of more than 20 breaths per minute or a PaCO2 level of less than 32 mm Hg, abnormal White Blood Cell count (>12,000/ul or < 4,000/ul or > 10% bands).

Townsend, S (et al) Implementing the Surviving Sepsis Campaign (2005)

Society of Critical Care Medicine

The Alerting Process

Using Sunrise Acute Care, we developed a Medical Logic Module (MLM) to look for the following clinical indicators:

Systolic Blood Pressure less than 90

Heart rate greater than 100

Temperature less than 96.8 or greater than 101

Respiratory rate greater than 24

If one of the above is charted, the MLM looks for one of these lab results posted within the last 24 hours:

WBC greater than 12,000/uL or less than 4000/uL

Lactate greater than 2.0 mmol/L

Bands greater than 10%

The MLM is triggered from the Vital Signs flowsheet. Any two of the indicators will trigger an alert.

This could be one vital sign and one lab or two vital signs.

Alerting Process: MLM Alert

This alert fires to the user when saving the vital sign flowsheet data. The user

must acknowledge the alert.

Alerting Process: Sepsis Screen Order

The MLM then automatically enters the order “Sepsis Screening Required”. The

nurse is alerted to the order by a red flag in the Check Orders column of her Patient

List.

Alerting Process: Worklist Task

The Nursing Worklist Manager is the place where nurses document

medications and nursing interventions. The Sepsis Screening order

creates a STAT task for the nurse to document on the Worklist.

Alerting Process: Screening Tool

Documentation of the task on the work list is accomplished by completing the questions on

the task below. A positive sepsis screen requires the nurse to notify the MD to do a bedside

evaluation.

Alerting Process: Follow up Task

A follow up task is created to document the name of the MD who evaluated the pt

and the outcome of the evaluation.

Evidence Based Protocol

Based on the Surviving Sepsis Campaign, the Task force

developed a protocol to guide the care of adult patients who

screened positive for sepsis.

The protocol is divided into two phases:

The first six hours of treatment after sepsis identified.

The treatment after the first six hours, through out

hospitalization.

The protocol includes medications, nursing interventions,

assessments, diagnostic testing, consults and patient

education.

Sepsis Protocol

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Protocol Order Sets

Order sets for each phase of care were developed to facilitate implementation of the written protocol.

Protocol recommendations range from general: ‘Initiate appropriate antibiotics’. To specific: ‘Vital Signs q 15 min until stable’.

The order sets include the specific orders when appropriate , but also give the prescriber the necessary options to meet the general recommendations.

Protocol Order Sets

Protocol Order Sets (con‟t)

The Order Set expands on the recommendation „Begin Appropriate Antibiotics‟.

Order Set Detail with Recommendations

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Clinical Analytics

When designing alerts and order sets, consider the option to run

reports based on charted data.

The order „Protocol Patient Sepsis‟ was created and defaulted

in the order set. It is used to easily identify patients who have

been diagnosed with sepsis. We run reports and/or create

specialty patient lists from this order.

A weekly report is also run from the MLM. It lists the patients who

screened positive for sepsis and is automatically emailed to the

Sepsis Task Force leaders and the Health Information

Management staff who are involved with chart coding.

Outcomes

To date, we have decreased our length of

stay for sepsis patients by 2.1 days.

In the last 6 months, an average of 13

patients per week are screened positive for

sepsis and evaluated.

Conclusions

Clinical Decision Support can be used to alert nursing and

clinical staff to changes in patient condition that might otherwise

be missed.

This was our first attempt at alerting for complex combinations of

clinical data, we are optimistic about the role clinical decision

support plays at the bedside.

The Nurse Informaticist, as part of the interdisciplinary team,

plays an essential role in developing an EHR that is not only a

repository for patient data but is a tool that can be used to

positively effect patient safety and outcomes. The unique

combination of clinical nursing and workflow experience, along

with the technical knowledge of EHRs and how they can be

used to assist the clinician at the bedside.

Lessons Learned

Reassessment of the process and interpretation of data is essential after implementation.

End users may find a way to circumvent the designed workflow. Evaluation of the documentation will help determine if revisions are needed to ensure correct use.

Unexpected scenarios in the workflow will occur and alerts will need to be revised to accommodate them.

We still have a large number of pts who meet the screening criteria but do not screen positive for sepsis.

The Code

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Final Review/Q&A

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Any Questions?