Sepsis/ SIRS Clinical Decision Support Alerting

Cyndi Barbour, RN NEC November 17, 2014

Objectives

• At the conclusion of this presentation, nurse executive leaders will: • Recognize how implementation of SIRS/ Sepsis Clinical

Decision Support (CDS) alert can improve patient outcomes

• Begin to identify what operational changes may need to be implemented to support care processes to address and manage the CDS alert

• Patient care nurse • Charge Nurse • CRT

• Support the plan to educate nurses to management of the alert

Sepsis

“Sepsis is a life threatening condition that occurs when the body responds to an infection in a manner that injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure, and death, especially if it is not recognized and treated promptly. Sepsis remains the primary cause of death from infection despite medical advances that include vaccines, antibiotics, and acute care; millions of people around the world die of sepsis each year” (Buck, 2014, p.124).

SIRS

• Systemic Inflammatory Response Syndrome- “A physiological response to a nonspecific insult of either infectious or noninfectious origin” (Burdette, 2010). • Can be caused by ischemia, inflammation, trauma,

infection, or several insults combined. • Not always related to infection • Defined by changes in physiological variables

Early Identification of Sepsis

• Ascension VCO (value creation opportunity)- • Improve stats for early identification • Increase compliance with 3 & 6 hour care bundles • Improve clinical care : SAVE LIVES • Decrease length of stay • Improve documentation of care • Increase revenue

• Seton goals: • Reduce Harm Across the Board • Reduce Serious Safety Events

Smart Interventions: Clinical Decision Support

St. John Sepsis agent • Proactive risk identification • System gathers patient data,

discerns patterns • Alert fires when system finds

• Two signs of systemic inflammatory response syndrome

• One sign of organ dysfunction

• Reduced mortality for severe sepsis and septic shock from 33% to a single-digit percentage

• Reduced LOS of sepsis patients from 16.5 to

13.6 days • Sepsis Mortality rate dropped 17% • LOS reduction combined with appropriate

coding saved $ 2M

Systemic inflammatory response in presence of infection • Affects nearly 750,000

Americans each year • Each case extends the

patient’s average length of stay by an average of 11 days, at an additional cost of $43,000

Diagnosis and treatment in the first “golden 6 hours” can save lives

Sepsis

Healthe Intent: Sepsis Agent

Cerner Millennium

Healthe Intent Cloud Services

Alerting Service

Concept Recognition

PowerChart

Cerner Crawler

Healthe Intent

Chart Search

Sepsis Agent (DAAKO

S)

HR RR Temp BP Labs Status Etc.

Temp (SNOMED 386725007) RR (SNOMED 86290005) WBC (Loinc 26464-8) Etc.

Alert, Action

Presenter

Presentation Notes

SIRS alert when 3 SIRS criteria met SEPSIS alert when 2 SIRS plus organ dysfunction

Clinical Reference Ranges

Overview of ED Workflow

• Patient presents to ED • Triage Nurse triages patient: collects and

documents VS (HR, RR, BP, temp). • ED Physician may order labs, lactate • Algorithm runs, if criteria met>>

• Icons display on ED tracking board • SIRS – alerts RN • Sepsis– alerts RN and Physician

• RN notifies provider and documents on Clinical Event Form

• RN completes the task

Overview of inpatient care workflow

• Patient is receiving care in an inpatient care unit • Care team documents vital signs (HR, RR, BP,

temp) • Lab values may already be present on the chart • Algorithm runs, if criteria met

• SIRS and Sepsis ccons display on Care COMPASS & PAL • Tasks and Orders display • SIRS – alerts any nurse with relationship to patient • Sepsis– alerts any nurse with relationship to patient • Rules to prevent alert from firing again in 24/ 48 hours

from ED • Rules to prevent from firing when patient transferred

from PACU

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Overview of inpatient care workflow

• RN assesses patient • RN notifies CN

• If infection is suspected, RN notifies provider, may call CRT

• RN. CN & CRT may initiate • RN completes the task by documenting on Clinical

Event Form • Process aligns with critical thinking through a Pre-

Arrest protocol or change in patient in condition

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Example of CDS Alert

Flowsheet view

• Can see history of the alert and what data values triggered it

• Menu item

Flowsheets

How often will these alerts occur?

• Algorithm has been running without alerting since June 2014.

• Not going to see in WH, IMC or ICU or DCMC • Will see in the acute care units • Had alert been viewable to nurses, would have

revealed: • 88 times for SIRS (3 criteria) • 2 times for SIRS (4 criteria) • 74 times for Sepsis (SIRS + organ dysfunction) • October 29- November 12 • All adult hospitals

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SIRS

17

0

2

4

6

8

10

12

14

3 SIRS criteria found

3 SHC

3 SWC

3S SMC

3W SMC

4 SHC

4 SWC

4N SMC

4N SNW

4S SNW

5 SWC

5N SMC

5S SMC

6N SMC

7E BH

7N SMC

7W BH

8E BH

8W BH

9E BH

9W BH

IMCU SHL

Med/Surg SHL

Sepsis

18

0

1

2

3

4

5

6

7

8

9

10

SIRS criteria met and Organ dysfunction criteria met

3 SHC

3 SWC

3S SMC

3W SMC

4 SHC

4 SWC

4E CDU BH

4N SMC

4N SNW

4S SNW

5 SWC

5N SMC

5S SMC

6N SMC

6S SMC

7E BH

7N SMC

7W BH

Education Plan

By Dec. 9, 2014 • Nurses and CRT responders are to take the

Seton Learning Central (SLC) module: seton.gradepoint.com 02NEN-CompAcuteSIRS-Sepsis • User Guides and Tips and Tricks posted on

COMPASS Clinician Sharepoint Site

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References

• Buck, K. M. (2014). Developing an Early Sepsis Alert Program. Journal of nursing care quality, 29(2), 124-132. doi: 10.1097/NCQ.0b013e3182a98182

• Burdette, S. D., Parilo, M. A., Kaplan, L. J., & Bailey, H. (2010). Systemic inflammatory response syndrome. Medscape, eMedicine.

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