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Sepsis Program______________________________________
St. Luke’s Cornwall HospitalNYSPFP Presentation
August 10,2016
The Healthcare Impact750,000 patients per year will develop sepsis in
the United States annually; approximately 500,000 will require medical care at the level
of an Intensive Care Unit (ICU).
The total hospital costs for sepsis patients are estimated to be 16.7 billion annually and this diagnosis accounts for a 28% mortality rate.
Early identification and treatment is critical for best outcomes for Sepsis.
The Sepsis Program at SLCH Our Journey
The Sepsis Program TeamFormed in 2012, the
SLCH Sepsis Team was comprised of the following disciplines:
Pharmacy Emergency MedicineCase Management Infection ControlNursing Leadership Infectious MedicineICU Intensivist Program Quality
Health Information Management ITLaboratory Respiratory
* The Team continues to meet monthly to review data & processes
Impetus for Our Team• Length of stay (LOS)- Data demonstrated that the average
LOS for patients with a diagnosis of sepsis was 2.4 days longer than the expected LOS
• NYS DOH Mandate- NYS required the implementation of a Sepsis Program in all hospitals by 12/31/2016; protocols were to be based on EBP standards
• Data Reporting- Measures to include adherence to protocols and time frames (bundles) and risk-adjusted mortality
• GNYHA STOP Sepsis Collaborative- Organizational decision to participate in this initiative to improve care in sepsis
Goals for the Sepsis Program
1. To reduce mortality in patient with severesepsis and septic shock by implementing aprotocol-based approach to identification/resuscitation
2. To enhance communication and patient flowbetween the ED and other areas of thehospital (i.e. ICU)
Early Goal-Directed Therapy
Activation of Sepsis Response
Suspected Sepsis?
For ED CODE SEPSIS
For IP Rapid Response SEPSIS
Any CODE SHOCK Scoop and Run to ICU
Modified Early Warning System (MEWS)Scoring Key 3 2 1 0 1 2 3
RespiratoryRate
< 8 9- 14 15- 20 21- 29 > 30
Heart Rate < 40 41- 50 51- 100 101- 110 110- 129 > 129
Systolic BP < 70 71- 80 81- 100 101- 199 > 200
LOC Non-responsive
Responds to pain
Respondsto voice
Alert New agitation/ confusion
Temperature 95 or less 95.1- 96.8 96.9-100.4
100.5-101.3
>101.3
Urine output for last 2
hours
< 10ml hour
< 30ml hour
<45ml hour
Systemic Inflammatory Response Syndrome (SIRS)
Systemic Inflammatory Response Syndrome (SIRS) – two or more criteria
Temperature < 96.8F- >100.4F Respiratory Rate > 20
Heart Rate > 90 Acute altered mental status
WBC >12 or < 4 Bands > 10%
Vital Signs every 4 hours (MEWS auto calculates, based on VS)
For all patients: MEWS < 2 = Continue to assess Q4H, reviewing vital signs and LOC
MEWS > 3 = RN to assess for:• Documented infection source• Potential new source
MEWS > 3 with NO infection or source?• Consider non-infectious causes (eg: AF/ AFL)• Continue to monitor Q4H with VS, LOC & UO
YES, infection or suspected source?• Evaluate for SIRS/ Sepsis (two or greater
criteria)
MEWS > 3 with NO criteria for SIRS/ Sepsis or other non-infectious cause?• Evaluate need for CBC-D, BMP and lactate if
labs > 6 hours old• Reassessment in 2 hrs with VS, LOC & UO
YES, 2 or more criteria for SIRS/ Sepsis?• Initiate Rapid Response Sepsis• Consider labs (lactate level)• For lactate > 4 repeat Q2H X3• Contact primary physician to implement the
Sepsis Adult Order set
After reassessment in 2 hrs:MEWS > 3 on next assessment?• Initiate Rapid Response Sepsis
• Fluid resuscitation, blood cultures and STATantibiotic given within 1 hour of lab value results
• CODE SHOCK initiated for hypotension that is refractory to fluid resuscitation (SBP <90)
• “Scoop and Run” transport to ICU
Emergency Department Triage• VS are entered into the ED Triage Sepsis Alert; a score > 3
triggers the RN to request a STAT evaluation by the EDprovider for possible Sepsis
• For cases of potential Sepsis, the Call Center will page aCODE SEPSIS overhead and Respiratory/ Radiology/ Labwill respond and begin the Early Goal-Directed Therapyand initiation of the ED Severe Sepsis/ Septic ShockAdult Order Set
• The ED Severe Sepsis/ Septic Shock Adult Order Setprovides pre-checked elements of care to expedite thebest practice interventions expeditiously
ED Severe Sepsis/Septic Shock Order Set
Rapid Response- Sepsis
•In the inpatient setting, a patient with a known orsuspected source and two or more criteria for SIRS,the RN will initiate a Rapid Response- Sepsis
•Responders will include a Critical Care RN, aRespiratory Therapist and a Laboratory Tech; aninitial Lactate- Sepsis will be drawn, per protocol
•The primary RN will notify the provider toimplement the Adult Sepsis Order Set and toconsider transfer to the ICU setting, if indicated
Severe Sepsis/ Septic Shock
Severe Sepsis is defined as the presence of sepsisand at least one clinical sign of multiple organdysfunction syndrome (MODS) and a lactate of > 4
(Note: 3.2 is considered a critical value)
Septic Shock is defined as Severe Sepsis withrefractory hypotension (SBP < 90 mmHg) and/orlactate > 4, despite appropriate fluid resuscitationof 30 mL/kg
Code ShockFor hypotension (SBP < 90 mmHg) that is
refractory to 30mL/kg fluid resuscitation and/or Lactate > 4, a CODE SHOCK will be initiated and
paged overhead by the Call Center.
The Intensivist or Hospitalist and the assigned ICU RN will respond to the
CODE SHOCK.
Code Shock• The ED physician notifies the primary provider of
the need to hospitalize the patient; the provider willaccept care and provide admission orders
• The ICU Intensivist (or Hospitalist during off hours)will respond to the CODE SHOCK and initiate theAdult Sepsis Order set to expedite care, if notalready in place
• A hand off will occur between the ED physician andIntensivist/ Hospitalist prior to a “Scoop and Run”approach to transferring the patient to the ICU
ICU Admission/ Transfer• The Scoop and Run process to the ICU includes a
targeted report from ED provider Intensivist• The ED RNICU RN handoff without delay in transport• Focus of care continues to be on the elements of the
three and six hour bundles; resuscitation is guided byinvasive or non-invasive methods:– CVP and ScvO2 monitoring via a central venous catheter OR– Monitoring of fluid status via an IVC ultrasound
• The Adult Sepsis Order Set and Nursing Sepsis/ RapidResponse documentation are guides to following thebest practice pathways
Adult Sepsis Order Set
Sepsis Documentation
Lactate- Sepsis• For Sepsis, a venous Lactate-Sepsis will be
drawn by Lab Staff, handed off to Respiratoryand resulted, using the Blood Gas Analyzer inthe ICU
• Subsequent lactate levels (Q2 hours X3 for atotal of four lactate levels) will be drawn by Labw/ hand off to Respiratory, using the sameprocess
Modified Early Warning System (MEWS)
The MEWS Scoring System is designed to identify patients who are at risk for sudden deterioration in condition. Key scoring features of the MEWS:
Respiratory rate Level of consciousnessHeart rate TemperatureSystolic BP Urine output for previous
two (2) hours
Scoring the MEWSPCA takes vital signs:
• Enters VS into the computerwithin one hour of obtaining
• PCA enters the T, BP, HR, RR andMeditech adds the vital signscore automatically
Note: Vital signs are obtained at:
0001 0800 1600
0400 1200 2000
RN reviews vital signs:• Enters the LOC and urine output
into the vital signs screen withinone hour of obtaining VS
• Obtains the two scores (LOC andUO) and adds them to the vitalsigns score
• RN arrives at the MEWS scoreand enters it into box
• A MEWS of > 3 w/ known sourceof infection and two SIRS criteriarequires a Rapid ResponseSepsis and call to provider
RN adds the LOC and UO, arrives at the MEWS Score and enters it into box
Scoring the MEWS
So… how are we doing with the Program?Glad you asked!The success of our program was largely due to thecollective efforts of the SLCH Sepsis Team and stafffrom ED, ICU, Medicine, Nursing, Pharmacy,Laboratory, Respiratory, Pharmacy, Quality, IT andothers.The Sepsis Program touched many areas of thehospital that are not involved in direct care but arecritical to our processes~ and share in the accolades.
Sepsis Management: 97th % in NYS
80
52
0
20
40
60
80
100
4/1/15-3/31/16
Three Hour Bundle
SLCH NYS Avg
72
32
0
20
40
60
80
100
4/1/15-3/31/16
Six Hour Bundle
SLCH NYS Avg
Source: NYSDOH Report (6/30/16)