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Texas Gulf Coast
Sepsis NetworkTexas Gulf Coast Sepsis Network
Mortality Escalates along the Sepsis Continuum:
A Clear Trend ExistsTexas Gulf Coast
Sepsis Network
Sepsis Mortality Continuum
(%) M
ort
alit
y(%
) M
ort
alit
y(%
) M
ort
alit
y(%
) M
ort
alit
y
Sepsis CategorySepsis CategorySepsis CategorySepsis Category
Perhaps The BestPerhaps The BestPerhaps The BestPerhaps The Best
Opportunity for Opportunity for Opportunity for Opportunity for
Safe and Effective Safe and Effective Safe and Effective Safe and Effective
Intervention is Intervention is Intervention is Intervention is Here!Here!Here!Here!
40SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis Network
EARLY RECOGNITION
EARLY INTERVENTION
IMPROVED SURVIVALIMPROVED SURVIVALIMPROVED SURVIVALIMPROVED SURVIVAL
Texas Gulf Coast
Sepsis Network
35SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis NetworkTexas Gulf Coast Sepsis Network
Elevated Heart Rate
Hyperthermia/Hypothermia
Elevated/Low WBC Count
Elevated Respiratory Rate
Acute Change in Mental Status
Texas Gulf Coast
Sepsis Network
42SERRI: Sepsis Early Recognition And Response Initiative
These vital signs may seem easy to spot –
but are often overlooked!
Recognize the Signs of Sepsis
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Total Observations: 1,883,135
(%)
%RR = 18: 37.41
%RR = 19: 7.21
%RR = 20: 21.24
%RR 18 or 20 65.86
%RR Remainder: 41.35
Mild Tachypnea is an *Early* Sign
Texas Gulf Coast
Sepsis NetworkSepsis on a Continuum
SEPSIS SEVERE SEPSIS SEPTIC SHOCKSEPSIS SEVERE SEPSIS SEPTIC SHOCK
DEATH
DEATH
DEATH
DEATH
CLINICAL SIGNSCLINICAL SIGNSCLINICAL SIGNSCLINICAL SIGNS
NURSES’ ROLENURSES’ ROLENURSES’ ROLENURSES’ ROLE
• Tachycardia• Tachypnea• Confusion• Fever
• Recognition/Assessment• Call Response Team!• Oxygen• Fluid bolus
• Obtain cultures• Obtain other labs• Antibiotic administration• VS Monitoring• I&O Monitoring
• Decreased UOP• Hypotension• Elevated lactate• Organ dysfunction
• Refractory hypotension• On vasopressors• On inotropes• Mechanical ventilation
Texas Gulf Coast
Sepsis Network
44SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis NetworkSIRS
Systemic Inflammatory Response Syndrome
• Temperature• >100.9°F (38.3°C) (hyperthermia)• or <96.8°F (36°C) (hypothermia)
• Heart Rate - >90 bpm (tachycardia)
• Respiratory Rate - > 20 (tachypnea)
• WBC • > 12,000 µ/L (leukocytosis)
• or < 4,000 µ/L (leukopenia)
Texas Gulf Coast
Sepsis Network
45SERRI: Sepsis Early Recognition And Response Initiative
3
Texas Gulf Coast
Sepsis NetworkSepsis
2 or more SIRS
+
a suspected or confirmed
source of infection
=
SEPSISSEPSISSEPSISSEPSIS
Texas Gulf Coast
Sepsis Network
46SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis NetworkPathophysiology of Sepsis16
Intravascular inflammationIntravascular inflammationIntravascular inflammationIntravascular inflammation:
� Is uncontrolled, unregulated, and self-sustaining
� Causes blood to spread mediators usually confined to the interstitial space
Texas Gulf Coast
Sepsis Network
47SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis NetworkSevere Sepsis
Sepsis Sepsis Sepsis Sepsis
++++
organ dysfunction, organ dysfunction, organ dysfunction, organ dysfunction,
hypoperfusionhypoperfusionhypoperfusionhypoperfusion
or hypotensionor hypotensionor hypotensionor hypotension
=
Severe SepsisSevere SepsisSevere SepsisSevere Sepsis
Texas Gulf Coast
Sepsis Network
48SERRI: Sepsis Early Recognition And Response Initiative
4
Texas Gulf Coast
Sepsis NetworkSigns of Severe SepsisTexas Gulf Coast
Sepsis Network
49SERRI: Sepsis Early Recognition And Response Initiative
Organ Dysfunction VariablesOrgan Dysfunction VariablesOrgan Dysfunction VariablesOrgan Dysfunction Variables15151515
� Arterial hypoxemia
� Acute lung injury
� Acute oliguria� UOP < 0.5 mL/kg/hr for at least 2 hours despite fluid
resuscitation
� Coagulation abnormalities� Thrombocytopenia
� Hyperbilirubinemia� Ileus/hypoactive bowel sounds
Texas Gulf Coast
Sepsis NetworkSigns of Severe Sepsis (con’t)
Hemodynamic VariablesHemodynamic VariablesHemodynamic VariablesHemodynamic Variables15151515
� Sepsis-induced hypotension
� Mixed venous oxygen saturation < 70%
� Cardiac index < 3.5 L/min
Tissue Tissue Tissue Tissue Perfusion VariablesPerfusion VariablesPerfusion VariablesPerfusion Variables15151515
� Mottled skin or decreased capillary refill
� Elevated lactate > 4 mmol/L (you can have severe sepsis without elevated lactate)
Texas Gulf Coast
Sepsis Network
50SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis Network
• Tachypnea, tachycardia and changes in mental status are early signs of severe sepsis AND often precede both fever and hypotension
• Skin remains warm (in early shock stage) unless severely volume depleted, then skin can be cool and mottled(in late shock stage)
�Early recognition is the key to successful treatment and outcomes!
Texas Gulf Coast
Sepsis Network
51SERRI: Sepsis Early Recognition And Response Initiative
Signs of Severe Sepsis (con’t)
5
Texas Gulf Coast
Sepsis NetworkSeptic Shock
Sepsis Sepsis Sepsis Sepsis
++++
↓ ↓ ↓ ↓ BP after fluid resuscitation BP after fluid resuscitation BP after fluid resuscitation BP after fluid resuscitation
(refractory hypotension)(refractory hypotension)(refractory hypotension)(refractory hypotension)
&&&& perfusion perfusion perfusion perfusion abnormalities abnormalities abnormalities abnormalities
====
Septic ShockSeptic ShockSeptic ShockSeptic Shock
Texas Gulf Coast
Sepsis Network
52SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis NetworkEarly Goal Directed Therapy
• Fluid resuscitation
• NS or LR
• Blood products if Hgb ≤ 7 (goal is 7-9)
• Labs & Diagnostic Tests
• Pan Culture
• Blood cultures (X2), urine, sputum, wounds, etc.
as indicated
• Antibiotics
• Initiate within 1 hour of recognition of sepsisInitiate within 1 hour of recognition of sepsisInitiate within 1 hour of recognition of sepsisInitiate within 1 hour of recognition of sepsis
Texas Gulf Coast
Sepsis Network
53SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis Network
SERRI: Sepsis Early Recognition And Response Initiative 54
Lactic Acid
� � levels common in patients with severe sepsis or septic shock
� � levels may be either/or both metabolic failure or
tissue hypoperfusion
� In sepsis, early lactate clearance is associated with preserved organ function and improved survival –prolonged lactate clearance is associated with
worsened multi-organ dysfunction
Texas Gulf Coast
Sepsis Network
6
Texas Gulf Coast
Sepsis Network
Texas Gulf Coast
Sepsis NetworkHemodynamic Support & Antibiotics are *KEY*
Volume resuscitation and immediate antibiotic administration are the most important therapies:
Fluid volume significantly increases cardiac output and systemic oxygen delivery
• Fluids alone may be sufficient to reverse hypotension and restore hemodynamic stability
• Fluid requirements may be as much as 3-5 liters
• Fluid challenge should be titrated to BP, HR and CO
55SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis NetworkSource Control
Antimicrobials
� Source - bacterial, viral, fungal, or parasitic
Surgery
� Source control is imperative when possible.
Other
� Infected lines, catheters, & implants
Texas Gulf Coast
Sepsis Network
53SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis Network
� Acute myocardial infarction
� Acute pulmonary embolism
� Acute pancreatitis
� Acute GI bleed
� Adverse drug reactions
� Trauma
� Burns
Noninfectious Mimics of SepsisTexas Gulf Coast
Sepsis Network
57SERRI: Sepsis Early Recognition And Response Initiative
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Texas Gulf Coast
Sepsis Network
� HR < 100 bpm
� SBP > 90 mmHg or MAP > 70 mmHg
� RR < 20
� Temperature normalized
� Lactic acid < 1.5 mmol/L
� Urine output ≥ 0.5 ml/hr/kg
� Source control
� Return to baseline mentation
GoalsTexas Gulf Coast
Sepsis Network
55SERRI: Sepsis Early Recognition And Response Initiative
Texas Gulf Coast
Sepsis Network
The project described is supported by Funding Opportunity Number 1C1CMS330975-01-00 from
the U.S. Department of Health and Human
Services, Centers for Medicare and Medicaid Services. The contents of these slides are solely
the responsibility of the authors and do not
necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was
conducted by Houston Methodist. Findings might or might not be consistent with or confirmed by
the independent evaluation contractor.
SERRI: Sepsis Early Recognition And Response Initiative 2
DisclaimerTexas Gulf Coast
Sepsis Network
60
8
Texas Gulf Coast
Sepsis NetworkReferences1. Sands KE, Bates DW, Lanken PN et al. Epidemiology of sepsis syndrome in 8 academic medical centers. Academic Medical Center Consortium Sepsis Project Working Group.
JAMA 1997; 278: 234-240
2. Angus DC et al. Epidemiology of Severe Sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29: 1303-1310.
3. CDC FastStats: Leading Causes of Death: http://www.cdc.gov/nchs/fastats/lcod.htm4. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med. 2004
Jun ;32(6):1254-9
5. Elixhauser A, Friedman B, Stranges E. Septicemia in U.S. Hospitals, 2009. HCUP Statistical Brief #118 [Internet]. 2011 Jul [cited 2011 Jul 20]; Available from: http://www.hcup-
us.ahrq.gov/reports/statbriefs/sb118.pdf6. Hall M, Williams S, DeFrances C, Golosinsky A. Inpatient care for septicemia or sepsis: A challenge for patients and hospitals [Internet]. 2011 Jun [cited 2011 Jun 30];Available
from: http://www.cdc.gov/nchs/data/databriefs/db62.pdf
7. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The
ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992 Jun;101(6):1644-1655.8. Rivers E, et. al. EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK, N Engl J Med, Vol. 345, No. 19, pgs. 1368 – 1377.
9. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit.Care.Med 2004;32:1254-9.
PMID 1518750210. Critical Care Workforce Partnership Position Statement: The Aging of the U.S. Population and Increased Need for Critical Care Services, Amer.Assoc.Critical.Care.Nurses, et. al.,
November. 2001.11. Donchin Y, Gopher D, et. al. A look into the nature and causes of human errors in the intensive care unit. Crit.Care.Med 1995; 23:294-300.12. Dellinger RP, et. al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004 Vol. 32, No. 3, pgs. 858-873.13. Surviving Sepsis Campaign website: (http://www.survivingsepsis.org/aboutcampaign)14. Neviere, R. Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis. In: P. E. Parsons & G. Finlay (Eds), UpToDate. Retrieved from:
http://www.uptodate.com/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis?detectedLanguage=en&source=search_result&search=sepsis&selectedTitle=1%7E150&provider=noProvider
15. Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. (2003). Intensive Care Medicine, 29:530-538
16. McCance, K.L. & Huether, S.E. (2006). Pathophysiology: The Biologic Basis for Disease in Adults and Children (5th ed.). St. Louis, MO. Elsevier Mosby.
17. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000;58(4):1758-1764.
doi:10.1111/j.1523-1755.2000.00337.x.18. Powe NR, Jaar B, Furth SL, Hermann J, Briggs W. Septicemia in dialysis patients: Incidence, risk factors, and prognosis. Kidney Int. 1999;55(3):1081-1090. doi:10.1046/j.1523-
1755.1999.0550031081.x.
19. Abou Dagher G, Harmouche E, Jabbour E, Bachir R, Zebian D, Bou Chebl R. Sepsis in hemodialysis patients. BMC Emerg Med. 2015;15. doi:10.1186/s12873-015-0057-y.
20. Vanholder R, Ringoir S. Polymorphonuclear cell function and infection in dialysis. Kidney Int Suppl. 1992;38:S91-S95.21. Rao M, Guo D, Jaber BL, et al. Dialyzer membrane type and reuse practice influence polymorphonuclear leukocyte function in hemodialysis patients. Kidney Int.
2004;65(2):682-691. doi:10.1111/j.1523-1755.2004.00429.x.
SERRI: Sepsis Early Recognition And Response Initiative 61
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements::::• Sepsis Nurse Practitioner Team at Houston Methodist Hospital • Supported in part by a training fellowship from the Keck Center for Interdisciplinary Bioscience
Training of the Gulf Coast Consortia (NLM Grant No. 5T15LM007093).
Texas Gulf Coast
Sepsis Network
Texas Gulf Coast Sepsis Network
AQKC HAI LAN Webinar –
Sepsis
Levi Njord,Director, Infection Prevention & Epidemiology
Texas Gulf Coast
Sepsis Network
Summary
• ESRD surveillance in the United States
• National incidence of sepsis
• Surveillance & treatment obstacles
• Strategies to improve surveillance &
treatment
• Opportunities ahead
9
Texas Gulf Coast
Sepsis Network
The “Dialysis Event”
• Positive blood culture
• IV abx start
• PRS at vascular access
• Fever
• Chills
• Hypotension
• Other
Texas Gulf Coast
Sepsis Network
Patient-Months
• Number of:
– Unique patients
– Treating on the first
two treatment days
of the month
– Grouped by vascular
access
Texas Gulf Coast
Sepsis Network
Methods of surveillanceMethod Strengths Limitations
Centrally identified / Centrally reported
• Standardized application of rules
• Limited burden on facilities
• Highly auditable
• Less facility engagement with surveillance data
• Requires advanced technical support
Centrally identified / Facility reported
• Standardized application of rules
• Highly auditable
• Clerical burden on facilities
• Opportunity for data entry error
• Requires moderate technical support
Facility identified / Facility Reported
• Easiest to implement• Most like CDC-defined
process
• Highly burdensomefor facilities
• Large variance in rule application
• Difficult to audit
Ideally surveillance would be standardized, accurate, fair, useful and not burdensome to facilities
10
Texas Gulf Coast
Sepsis Network
Bloodstream Infection Rate
����������� ������
Σ������ � ������������∗ 100
• BSI rates can be calculated monthly, quarterly, or annually• BSI rates can be grouped by vascular access type
• Requires that blood cultures were drawn and/or recorded• IV abx & PRS have no bearing on current BSI rates
• Blood cultures are grouped by the NHSN 21 day rule
Texas Gulf Coast
Sepsis NetworkStandardized Infection Ratio
Steps to calculate SIR
1) Obtain the national reference
stratified BSI rates
2) Divide the rates by 100 to get the
rate per 1 patient month (basic rate)
3) Multiply the basic rate by facility’s
census stratified by access type to
obtain the “expected” number of
infections
4) Obtain the facility’s observed
infections for the year stratified by
access type
5) Sum the expected number of
infections
6) Sum the observed number of
infections
7) Divide the sum of observed
infections by the sum of expected
infections to obtain the SIR
National Rate Rate
CVC 2.16
AVF 0.26
AVG 0.39
Other 0.67
National Rate Rate
CVC 0.0216
AVF 0.0026
AVG 0.0039
Other 0.0067
NationalRate
Rate
Annual
Census
Expected BSI
CVC 0.0216 240 5.184
AVF 0.0026 840 2.184
AVG 0.0039 120 0.468
Other 0.0067 60 0.402
NationalRate
Observed BSI
CVC 3
AVF 2
AVG 1
Other 0
1 2
3 4
# / 100
X
X
X
X
=
=
=
=
56
National RateObserve
d BSIExpected
BSI
CVC 3 5.184
AVF 2 2.184
AVG 1 0.468
Other 0 0.402
TOTAL 6 8.238
Observed 6
Expected 8.238
SIR 0.73
7
Texas Gulf Coast
Sepsis Network
How are we doing?
11
Texas Gulf Coast
Sepsis Network
Obstacles
• Early and standard identification of sepsis
– Sign-based identification
– Cases identified outside the clinic
• Obtaining blood culture results
– Drawing blood cultures when indicated
– Obtaining externally resulted results
• Antibiotic stewardship
Texas Gulf Coast
Sepsis Network
Strategies to improve identification
• Standardized and clear “sign definitions”
– Fever, Chills, Hypotension
– Altered mental status, pain, etc.
– Consider the vascular access
• Clinical algorithms
Texas Gulf Coast
Sepsis Network
Strategies to obtain results
• Blood Culture “Rate”
���� �����������
��������������������� �!���
• Structured follow-up with each hospitalization
or missed treatment
• Health Information Exchanges
1. Blood culture results can be negative or positive2. Signs of sepsis include fever, chills, hypotension
12
Texas Gulf Coast
Sepsis Network
Opportunities ahead
• Promising new technologies
– Surveillance
– Prevention
• Collaboration between stakeholders
– Dialysis providers, regulators, public health,
ESRD networks/QIOs, academia, etc.
AQKC Contact Information and
Sepsis Resources� How to get help
– Sepsis Resources http://www.aqkc.org/content/healthcare-associated-infections
– AQKC website (www.aqkc.org)
– Network contacts• ESRD Network 8 - [email protected]• (Alabama, Mississippi, Tennessee)
• ESRD Network 14 - [email protected]
(Texas)
– Please take a moment to complete the poll questions at the end of the webinar
DO NOT email patient-specific information
(name, DOB, SSN, etc.) to the Network office!
