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Severe Sepsis Care Path: Phase I Implementation

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Jennifer Meecha

on 13 May 2016

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Transcript of Severe Sepsis Care Path: Phase I Implementation

Prepare contingency plan at beginning of shift

Prioritize bed for SEPSIS Admission
Decision Point: Remain on RNF or Transfer to ICU?
Inpatient Screening Key Points
Septic Shock = Severe Sepsis + EITHER an initial lactate level ≥ 4

OR

Persistent Hypotension (SBP <90 mm Hg or SBP decrease >40 mm Hg)
in the first hour after completion of adequate fluid resuscitation
(30 ml/kg of crystalloid fluids)


SIRS + Infection + Organ Dysfunction + Lactate ≥ 4 or Hypotension despite IVF resuscitation
Septic Shock
SIRS Criteria:

Temperature: > 38.3 C or < 36 C
Tachycardia: Heart Rate > 90
Tachypnea: Respiratory Rate > 20 or
PaCO2 < 32 mmHg
Leukocytosis / Leukopenia: WBC > 12,000 or < 4,000 or > 10% Bands

Your patient has SIRS if two or more of the above are present
Systemic Inflammatory Response Syndrome
Sepsis is a time sensitive disease process and once suspected, should be acted upon as quickly as possible

Increased mortality in septic patients if not properly treated
Sepsis…
Time = Survival

10th leading cause of death in the U.S.

Mortality from severe sepsis approaches 50%, mortality from septic shock is up to 80%

Early recognition of sepsis is of paramount importance in reducing mortality

Aggressive intervention in the early "golden hours" provides maximum benefit in terms of outcome
Background/Significance
Rex Surgical patients: Call the Surgicalist x2227

NC Heart and Vascular patients: Call the Cardiologist APP x3542

Internal Medicine patients: Call the Hospitalist (and notify the attending if non-hospitalist patient)

For patients who have a lactate ≥ 4 or who does not respond to 30 mL/kg fluid bolus, call the Intensivist x1535
Provider Call List for Sepsis Alert
Reassess and notify provider if repeat BP reveals persistent hypotension and/or if the repeat lactate ≥ 4.

Hypotension is defined as: SBP <90 or MAP <65



Or a drop in SBP of > 40mmHg from the last previously recorded SBP considered normal for that patient

3 Hour Bundle Cont.
If a patient screens positive for Severe Sepsis while in the ED, the ED RN follows nursing protocol to initiate the bundle elements.

When the patient transfers from the ED and is admitted as an inpatient, the Sepsis Screening Tool and Checklist will follow the patient to facilitate continuation of the bundle elements. The checklist also serves as a handoff communication tool.

At time of transfer, the ED RN will notify the CRT RN of the sepsis patient transfer so that CRT may assist with the severe sepsis protocol and complete their 4 hour assessment.
ED Process Key Points
Can be ANY organ system

CNS: Altered consciousness
Pulmonary
Hepatic
Metabolic
Cardiovascular: Tachycardia
Renal
Hematologic
Hypoxemia
PaO2/FiO2 <300
Acute respiratory failure as evidenced by new need for invasive or non-invasive mechanical ventilation
Oliguria
<0.5 ml/kg/hour for at least two hours despite adequate volume resuscitation
Creatinine >2
Coagulation abnormalities
INR >1.5 or aPTT> 60 sec
Thrombocytopenia
Platelet count < 100,000/ul
Hyperbilirubinemia
> 2 mg/dL
Hyperlactatemia
lactate>2 mmol/L
Severe Sepsis = Sepsis + End-Organ Dysfunction
Think:
Wind (respiratory)
Wound (wounds/devices)
Water (urinary)
Sepsis = SIRS + Source of Infection + Lactate >2

Can be suspected infection or documented infection
Can be any infection: Pneumonia, UTI, etc.
Think source of infection such as…lines, drains, wounds, urinary tract, respiratory
Sepsis
Severe Sepsis Mortality Reduction Program Goals
Go Live: July 2016
Sepsis Screening Tool
Sepsis Screening Process
Just Think
Sepsis = Infection
The Process
The Problem
The 3 Hour Bundle -
Severe Sepsis

Dellinger RP. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. CCM 2013;41(2):580-637
1. Measure Lactate POC
Super-users process in ED
RT processes for in-patients
2. Blood cultures prior to Antibiotics
Critical Response Team to draw
Lab on stand-by for backup
3. Crystalloid 30 mL/kg for
hypotension or lactate > 2 mmol/dL
4. Broad spectrum Antibiotics
Within 3 hours of time zero
Critical Response Team RN Will Lead
3 Hour Bundle
3 Hour Bundle

These tasks must be accomplished within 3 hours

We do not need to wait 3 hours in order to move on!

If patient condition warrants, proceed with the 6 Hour Bundle
The 6 Hour Bundle - Septic Shock
6 Hour Bundle
Dellinger RP. Surviving Sepsis Campaign:International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. CCM 2013;41(2):580-637

Initiate vasopressors if persistent hypotension after IV fluids

Provider Physical Exam

Repeat lactate drawn if initial lactate > 2
6 Hour Bundle
ICU Charge Nurse
Ensure handoff tool transferred with patient
Anticipate CVC and arterial line?
Facilitate 6 hour bundle elements
ICU Nurse
Bedside response to Sepsis Alert
Facilitate transfer process
Secure bed in ICU when transfer necessary
Ensure bed stat cleaned
Administrative Coordinator
The Roles
The Pharmacology
Dellinger RP et al. Crit Care Med 2013;41:580-637.
Initial resuscitation
Crystalloids (e.g. 0.9% NaCl, Lactated Ringer’s)

Vasopressors for refractory hypotension
Norepinephrine recommended first-line
Achievement of resuscitation goals within 6 hours

Antimicrobial therapy
Broad spectrum antimicrobial therapy directed at suspected source and suspected pathogen(s)

Administer effective IV antimicrobials within the first hour of recognition of severe sepsis/septic shock
Pharmacology of Severe Sepsis & Septic Shock
Dellinger RP et al. Crit Care Med 2013;41:580-637.
Attempt to obtain blood cultures before administration

Empiric antibiotic regimen depends on suspected source of infection and pathogen(s)

Piperacillin/tazobactam (Zosyn®) + Vancomycin usual empiric treatment
Broad-spectrum for initial coverage
Alternative and/or additional antibiotics such as fluoroquinolones, carbapenems or aminoglycosides may be used
Antimicrobial Therapy
Lexi-Comp OnlineTM , Lexi-DrugsTM , Hudson, Ohio: Lexi-Comp, Inc.; 9/22/2013
Broad-spectrum penicillin + beta-lactamase inhibitor
Covers Gram positive microbes, Gram negative microbes (including Pseudomonas spp.) and anaerobes

Dose 3.375g (if pt >40kg)

Infuse over 30 minutes

Monitor for signs of hypersensitivity if allergies unknown
Piperacillin/tazobactam (Zosyn®)
Lexi-Comp OnlineTM , Lexi-DrugsTM , Hudson, Ohio: Lexi-Comp, Inc.; 9/22/2013
Covers Gram(+) bacteria including MRSA

Weight-based dosing
Adults: <50kg 0.75g
50-74kg 1g
75-90kg 1.25g
>90kg 1.5g

Administer doses ≤1g over one hour, >1g over two hours
Risk of Red Man Syndrome with rapid infusion
Slow infusion further if reaction occurs, treat with steroids/antihistamines. Not a true allergy & may continue Vancomycin therapy
Vancomycin
Overgaard CB et al. Circulation 2008;118:1047-56.; Dellinger RP et al. Crit Care Med 2013;41:580-637.
First line therapy

Initiate in any patient with life-threatening or refractory hypotension
Titrate to keep MAP ≥65 mmHg
Starting dose 0.5-5mcg/min
Usual target dose 0.5-30mcg/min

Standard concentration 8mg/250ml D5W

Higher doses may be needed based on response

Almost immediate onset, duration of action two minutes
Norepinephrine (Levophed®)
Lexi-Comp OnlineTM , King GuideTM , Hudson, Ohio: Lexi-Comp, Inc.; 9/22/2013
Pressors
Norepinephrine, epinephrine, dopamine all compatible with each other

Antibiotics
Zosyn® & vancomycin compatible with all pressors
Zosyn® & vancomycin compatible with eachother

Consider intraosseous line for central access if no other central line quickly available

MUST record when you administer medications and fluid boluses in real time!
Miscellaneous Administration Issues
Remember to think about Sepsis in the following way:

Systemic Inflammatory Response System (SIRS):
Temperature < 36 or > 38.3 C
Heart rate > 90 BPM
Tachypnea > 20
WBC count < 4,000 or > than 12,000

Two of the above + a source = SEPSIS
+ Organ Dysfunction = SEVERE SEPSIS
+ Refractory Hypotension = SEPTIC SHOCK
Clinical Application Quick Points
Earlier identification of patients with sepsis

Increased compliance with 3-hour and 6-hour sepsis bundles

Expedited screening for severe sepsis and septic shock

“Sepsis Alert” – Critical Response Team for assistance in management of sepsis patients

Be aware of the process in the ED and for inpatients.
The screening process identifies Septic patients and begins the care path.
Once the patient has screened positive for Severe Sepsis, the 3 Hour Bundle Begins
Ideally, the 6 hour bundle will take place entirely in the ICU
Fluids are generally given as a
Wide Open
Bolus
DO NOT include evidence of organ dysfunction that is considered chronic or secondary to medication (ex. ESRD with CR>2, patient on warfarin with INR >1.5). Lab values used to determine organ dysfunction must have been reported within the 6 hours preceding the onset of severe sepsis.
MAP = SBP + 2(DBP)
3

Starts in triage for ED patients

Inpatients are screened by the RN at the beginning of the shift, after vital signs have been obtained
Both ED and inpatient RNs will use the same bright green screening tool and checklist.

Once a patient screens positive for sepsis, it will follow the patient from unit to unit to ensure each element is completed at the expected time.
Inpatient RNs screen their patients at the beginning of their shift after vital signs have been completed, and when the patient condition changes.

If the sepsis screen is positive, they will CONSULT the CRT RN.

The CRT RN will screen for severe sepsis using the tool located on the flip-side of the Adult Sepsis Screening Tool and Checklist.

If the patient screens positive for Severe Sepsis, the CRT RN will initiate the Sepsis Alert Order Set and coordinate care.
Lactate level is <4

Adequate blood pressure response to fluid resuscitation
RNF
ICU
Lactate level is ≥ 4

Remains hypotensive despite adequate fluid resuscitation
If at any time the patient status rapidly deteriorates, the CRT will respond per protocol
CRT Follow-Up
Regardless if the patient remains on the RNF or is transferred to the ICU, the CRT RN will:

Perform a debrief with the RNF team
Debrief the ED team
Place an order for a 6 hour repeat lactate
Ensure a provider completes a bedside assessment within 6 hours
Complete 4-hour follow-up assessment
These tasks must be accomplished within 6 hours of septic shock diagnosis (and after 30 mL/kg bolus started)
Fluid Requirements
Specific 30 mL/kg crystalloid bolus required if severe sepsis with hypotension OR septic shock based on lactate ≥ 4

Bolus is given in large volumes (>100 mL) over a period of a few hours
Do not include fluids given as part of routine medication administration or standard maintenance rate
Vasopressor Requirements
Must be initiated within 6 hours of Septic Shock if persistent hypotension

Vasopressor to achieve MAP ≥ 65
Norepinephrine preferred
Approved Vasopressors:
Norepinephrine
Epinephrine
Phenylephrine
Dopamine
Vasopressin
Provider Exam Requirements
Must be completed within 6 hours for all patients with Septic Shock

Provider performs a volume status and tissue perfusion assessment
Must be documented anytime after initiation of the crystalloid start time
Can be performed using a central line, ultrasound, or a focused physical exam

Provider Exam Option 1
Focused bedside exam documented by provider which include all 5 of the following
Vital Signs (BP, HR, RR, Temp)
Review/documentation by provider within the 6 hour window
Cardiopulmonary exam
Heart and lung
Capillary refill
Peripheral pulse evaluation
Skin examination
Must include reference to skin color
Provider Exam Option 2
Includes 2 of 4 advanced interventions within 6 hours after presentation of septic shock
Passive Leg Raise
Fluid Challenge
CVP
Goal 8-12 mm
Central Venous O2 measurement
Goal ≥ 70%
Cardiovascular Ultrasound
Measured after initiation of crystalloid infusion
Can be performed at bedside or imaging
Goal IVC 1.5 - 2.5 cm with inspiratory collapsibility < 50%
Performed after initiation of crystalloid infusion
MUST be performed by an MD/DO/PA/NP.
Commonly noted as positive or negative
Ideally performed with patient in semi-recumbent position, then place the patient in supine position with both legs raised to a 45 degree angle.
PLR evaluates the patient vital sign response (or other parameters such as increased stroke volume or pulse pressure) to additional fluid load, and is reversible with returning the patient to the original position. Maximal effect occurs at 30-90 seconds.
Typically this will be given AFTER the 30mL/kg fluids bolus.

Rapid infusion (500mL in 15 min or 1,000mL in 30 min) of crystalloids done to assess responsiveness to IV fluids.

Provider documentation should specifically state “fluid challenge” to differentiate this from the required 30mL/kg crystalloid bolus
The fluid administered as part of this challenge does NOT count toward the 30m/kg bolus.

ED Nurse
CRT Nurse
CNA
Bedside Nurse
Phlebotomy
VARN
Pharmacy
Respiratory Therapy
Charge Nurse
Provider
Triage: If adult BPA fires, notifies charge RN and initiates order set

Bedded patient:
If adult BPA fires, notifies provider and initiates order set
Notifies CRT RN before patient is transferred to inpatient bed
Good handoff to inpatient RN which includes progress with sepsis care bundle

Notified of admission by ED
Consulted by RN with positive Sepsis Screen
Complete Severe Sepsis Screen
If positive, activate Sepsis Alert
Begin Sepsis order set interventions
Complete 4 hour reassessment

Enter vital signs in real time
Notify primary RN of abnormal values
Sepsis Screen every shift after completion of vital signs or when patient condition changes
If positive screen, consult CRT RN
Ensure provider notified of positive Severe Sepsis screen
Be available to assist with bundle elements
Continue patient monitoring
Gathers emergency equipment
Backup for primary RN's patient assignment
Assist with transfer if applicable
Bedside response to Sepsis Alert
Transport and process POC lactate
Responds to Sepsis Alert
Make antibiotic recommendations
Facilitate antibiotic delivery to patient
On stand-by for lab draws
On stand-by for difficult access
Ensure sepsis order set initiated
Timely bedside assessment
6 hour septic shock assessment
Ensure completion of sepsis bundle and documentation
Sepsis Updates
Most recently, the 2016 Third International Consensus Definitions for Sepsis and Septic Shock defined sepsis as:

A life-threatening organ dysfunction due to a dysregulated host response to infection.
Definition Update
The qSOFA score (also known as quickSOFA) is a bedside prompt that may identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care unit (ICU)
It uses three criteria, assigning one point for low blood pressure (SBP≤100 mmHg), high respiratory rate (≥22 breaths per min), or altered mentation (Glasgow coma scale<15)
The score ranges from 0 to 3 points
The presence of 2 or more qSOFA points near the onset of infection was associated with a greater risk of death or prolonged intensive care unit stay
These are outcomes that are more common in infected patients who may be septic than those with uncomplicated infection
Based upon these findings, the Third International Consensus Definitions for Sepsis recommends qSOFA as a simple prompt to identify infected patients outside the ICU who are likely to be septic
qSOFA
Kumar et. al Critical Care Medicine 2006 34:1 589
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