sepsis - college of medicine

SEPSISLeighton Smith MD

CMO Florida Hospital Fish Memorial

FLORIDA HOSPITAL FISH MEMORIAL

175 Bed Acute Care Hospital

No Obstetrics or Pediatric in patient beds

No Neurosurgery or Cardiac surgery

5000 ED visits per month

1000 bed Quaternary Hospital 35 miles away

Tertiary Hospital 35 miles in the other direction

Undergoing a 100 million dollar expansion

Adventist Health System

Cerner Electronic Medical Record

Standardized evidence based order sets called power plans

Many sets of data available through the electronic system

Examples: Mortality, bundle compliance, antibiograms etc.

44 campuses

in 10 states

More than 7,700

inpatient beds

From sole

community

providers to

large tertiary

facilities

17 long-term care

facilities in 6 states

1,997 beds

FIVE YEAR SEPSIS JOURNEY

Situation 5 years ago

The need to change

The milestones of progress

The surviving sepsis campaign

The 3 hour and six hour bundle

Sirs criteria sofa criteria

Results so far

Future challenges

Institute for Healthcare Improvement

2x2 Mortality Matrix

CONFIDENTIAL Patient Safety Work Product. Protected under the Patient Safety And Quality Improvement Act.

Do Not Disclose unless authorized by the FHFM PSES Advisory Committee.

2017 n = 160

ICU Admission

No ICU Admission

Comfort CareBox 10% (0)

Box 20% (0)

Non ComfortCare

Box 357.5% (92)

Box 442.5% (68)

2x2 Matrix for Mortalities in Box 3 & 4. To consider:

• Failure to Recognize (change in heart rate, respirations, etc.)

• Failure to Plan (diagnosis, treatment, calling rescue team, etc.

• Failure to Communicate (patient to staff, clinician to clinician,

etc.)

2x2 Morality Matrix

Move Your Dot Annual Trends

6.4% 5.1%

0.0% 0.0% 0.0%

10.4%14.1%

0.8% 0.0% 0.0%

45.1%

37.9%

67.0%

55.0%57.5%

38.2%

42.9%

32.0%

45.0%42.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

2013 2014 2015 2016 2017

2x2 Mortality MatrixGoal is Box 3 = >50% of mortalities with an initial level of care admission into the ICU

Box 1 Box 2 Box 3 Box 4 Goal

CONFIDENTIAL Patient Safety Work Product. Protected under the Patient Safety And Quality Improvement Act. Do Not Disclose

unless authorized by the FHFM PSES Advisory Committee.

Key Definitions of SEPSIS

SEPSIS Signs & Symptoms

SEPSIS: Systemic inflammation due to an infection.

The patient exhibits at least two of the following symptoms:

• Body temperature above 100.9 F (38.3 C) or below 96.8F (36 C)

• WBC greater than 12,000 or less than 4,000• Heart rate higher than 90 bpm• Respiratory rate higher than 20 breaths per

minute• AND

• Probable or confirmed infection

Severe SEPSIS Signs & Symptoms

SEVERE SEPSIS: The patient’s condition will be upgraded if they also exhibit at least one of the following signs and symptoms, which indicate an ORGAN may be failing

• Significantly decreased urine output• Abrupt change in mental status• Decrease in platelet count• Difficulty breathing as evidenced by need for

intubation or bipap• Hypotension• Increased Creatine• Elevated INR, or aPTT and not on blood thinners• Lactic acid > 2.0

SEPTIC SHOCK Signs & Symptoms

• SEPTIC SHOCK: Infection + SIRS+ organ dysfunction + hypotension despite fluid resuscitation

OR SEVERE SEPSIS and LA >=4.0• The Onset Of SEPTIC SHOCK is determined when a patient with suspected infection has:

• Two (2) SIRS Criteria:

• Temperature > 38.3 C/100.9 F or <35.6 C / 96.0 F

• HR >90 bpm

• RR > 20 breaths/per/min.

• WBC > 12,000 or < 4,000

• AND One (1) of the following:

• And 1 of the following

• Hypoperfusion: SBP < 90mm HG; MAP < 60 mmHg;

• After a 30mL/kg bolus has been administered

OR

• Serum lactate 4 mmol/L regardless of the BP

How is SEPTIC SHOCK Defined?

SEPTIC SHOCK is defined when:

Documentation by the MD/NP/PA of septic shock, or that septic shock is suspected

OR

Must be documentation of or criteria met for SEVERE SEPSIS

AND

Tissue hypoperfusion as evidenced by:

Persistent hypotension (2 or more consecutive values within an hour

after fluids are completed)

SBP <90 or MAP <65

OR

Lactate level is >=4 mmol/L

Cerner SEPSIS Alert

The computer/Cerner is constantly checking for SIRS or SEPSIS criteria

When a patient qualifies the alert will fire

You do not have to be in the patients chart for the alert to fire

Call the SEPSIS ALERT Code in your facility if the Alert indicates it’s

appropriate

What makes the SIRS & SEPSIS Alerts Fire within Cerner?

The Sepsis 3 Hour Bundle…Don’t WAIT!!

Obtain physician order for:

- Broad spectrum IV antibiotics AND

- Fluid bolus for initial hypotension (SBP <90,

MAP<65) or lactic acid >=4.0, administer 30

mL/kg crystalloid fluid

Example: Pt weighs 80 kg.

Goal fluids = 80kg x 30mL = 2400 mL

In the one hour post conclusion of IVF’s, document

two consecutive BP’s.BE A PATIENT ADVOCATE

if the physician does not order enough fluids –

call and make him/her aware of CMS Guidelines.

SEPSIS Cerner Alert

Criteria that caused the alert to fire

Patient Information

Link to the patient chart

*Clicking on the link will take

you into the patient’s chart

that the alert pertains to.

*You could be on one patients

chart when this alert fires for

another patient. Pay close

attention to the patient

information displayed within

the alert.

URGENT SECOND MARKER: 6 Hour

MUST BE completed within SIX HOURS of time of presentation:

Apply VASOPRESSORS (for hypotension that does not respond to initial fluid

resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg

If 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 accordingly

Re-measure LACTIC ACID LEVEL if initial lactate elevated

Leg raising

Passive leg raise or fluid challenge

Patient is seated at 45 degrees head up semi-recumbent position

Patient’s upper body is lowered to horizontal and legs passively raised to 45 degrees up

Maximal effect occurs at 30–90 seconds

Leg raising

Dynamic variables for assessing fluid responsiveness

Passive Leg Raise

10% increase in stroke volume on a cardiac output monitor reflects a positive test (9% increase in stroke volume has 86% sensitivity and 90% specificity) OR

10% increase in pulse pressure via an arterial line (79% sensitivity and 85% specificity)

CMS Approved

Monotherapy

Antibiotics

CMS Approved

Combination

Antibiotics

Vasopressor Use if indicated

Procalcitonin in Sepsis

Procalcitonin in Sepsis

Blinded, prospective multicenter observational clinical trial

Study group were consecutive patients meeting criteria for severe sepsis or

septic shock who were admitted to the ICU

Procalcitonin was collected within the first 12 hr. & measured daily over the

first 5 days

A procalcitonin decrease of more than 80% from baseline to day 4 was

associated with a two-fold lower mortality at 28 days as compared to those

without the decrease (20% vs 10%; p = 0.001)

Procalcitonin in Sepsis

Serum lactate is a biomarker commonly used to help guide response to

resuscitation measures

Procalcitonin (PCT) has been demonstrated to be helpful in antibiotic

stewardship decisions

Kinetics of PCT have also been shown to predict mortality and treatment

failure in sepsis

Procalcitonin Conclusions

Inability to decrease procalcitonin by more than 80% is a significant

independent predictor of mortality in sepsis

To simplify, in secondary analysis, if PCT increased from baseline to day 1

there was a three-fold higher mortality than if PCT decreased

May translate into better informed clinical decisions regarding intensification

of care or ICU discharge

Hydrocortisone, Vit C and Thiamine Rx for Sepsis

Hydrocortisone, Vit C and Thiamine for

Sepsis

Treatment Arm – 47 consecutive patients with severe sepsis (53%) and septic

shock (47%) January 2016 and July 2016 treated with of 1.5 g vitamin C IV

every 6 hours, hydrocortisone 50 mg IV every 6 hours, and thiamine 200

mg IV every 12 hours within 24 hours of admission to ICU

Thiamine inhibits oxalate production and has potential

benefits in septic shock

Hydrocortisone, Vit C and Thiamine for

Sepsis

Exclusions - < 18 years of age, pregnancy, limitations of care, and septic

patients with PCT < 2ng/ml

Threshold PCT of 2ng/ml to increase the certainty that the patients had

severe sepsis and were at risk of developing sepsis-related organ dysfunction

Hydrocortisone, Vit C and Thiamine for

Sepsis

The control group consisted of the same number of consecutive patients

admitted to the ICU between June 2015 and December 2015 using the same

inclusion and exclusion criteria as the treatment group, and were matched in

baseline characteristics

Hydrocortisone, Vit C and Thiamine for

Sepsis

Hospital mortality was 4 of 47 (8.5%) in those in the treatment arm

compared to 19 of 47 (40%) in the comparator group (p<.001)

Vasopressors were weaned off all treatment arm patients, usually in <24 hours

(vs. 4 days for the controls)

Renal function improved in all patients with acute kidney injury

CURRENT ACTION PLAN

Code sepsis in ED

Point of service lactate

Review of all fall outs

Feed back to providers with fall outs

Multidisciplinary group that meets every two weeks and reports to the

executives

Questions??