Diagnosis and Management of Sepsis
BMC Sepsis Mortality Reduction Initiative
Intern Noon Conference
7.2.13
Karin Sloan, MD
Director of Quality, Dept of Medicine
for the Sepsis Mortality Reduction taskforce
Outline
• Sepsis: definitions
• Introduce BMC sepsis mortality reduction
initiative
– Rationale for sepsis work
– Focus on hospital-acquired sepsis
• Stress 2 key areas:
– Timely recognition of sepsis
– Timely administration of broad-spectrum
antibiotic
• Show SCM sepsis order set
Sepsis
• Sepsis: a dysregulated inflammatory response
of the body to infection
• High mortality rate
• More common than MI and stroke
• Most common post-op complication
• Like MI and stroke, time to treatment saves
lives
2012 BMC Sepsis Patients Expired vs.
Discharged
883 sepsis pts in 2012
141 sepsis deaths
What is SIRS?
• SIRS “Systemic Inflammatory Response
Syndrome”
• Dysregulated inflammatory response
• Patients can have SIRS without infection
– PE, acute blood loss, etc
• Sometimes when a patient has SIRS, it is not
certain if they have infection
Sepsis: Infection plus some of:
• Temperature >38.3 or <36ºC
• Heart rate >90 beats/min or more than two standard deviations above the
normal value for age
• Tachypnea, respiratory rate >20 breaths/min
• **Altered mental status
• Hyperglycemia in the absence of diabetes
• Leukocytosis (WBC count >12,000 microL–1), greater than 10 percent
immature forms, or leukopenia (WBC count <4000 microL–1)
• Hypotension
• Hypoxemia
• Acute kidney injury
• Coagulation abnormalities
• Ileus
Red: 2/4 =
• Thrombocytopenia
SIRS criteria
• Hyperbilirubinemia
• Hyperlactatemia
Severe sepsis: sepsis + organ dysfunction
Definition: Septic Shock
• Severe sepsis plus hypotension not reversed with
adequate fluid resuscitation (30ml/kg crystalloid)
– SBP < 90
– MAP < 70
– SBP > 40 decrease from baseline
• Vasodilatory shock
– Low SVR
– BP = CO x SVR
• Multiple organ dysfunction syndrome (MODS)
SIRSsepsisMODS continuum
• If sepsis is possible, without alternative
explanation, best to treat empirically
– Document “SIRS; suspected sepsis or possible
sepsis”
• Can reassess, narrow or discontinue
antibiotics later
Sepsis Background
• Patients with positive blood cultures almost
always have sepsis, severe sepsis, or septic
shock
• Sepsis incidence is increased in older adults,
and mortality is higher
• Mortality highest for unknown, GI, or
pulmonary source
– lower for urinary tract source
BMC is now in the top quartile of academic medical centers
for inpatient mortality
•Slide showing mortality improvements…
12
But…our sepsis mortality lags behind.
• Why work on sepsis at BMC?
– Volume of cases
• Top cause of excess deaths at 2013 mortality goal
• Of the 444 inpatient deaths in FY12, sepsis was coded
in 31%
– Opportunity for improvement
• Particularly in hospital-acquired sepsis (65th percentile
performance)
– 20% of BMC sepsis cases
• Recognition
• Time to antibiotics
Aim Statement
• To improve BMC hospital-acquired sepsis mortality
O/E from UHC 65th percentile to 25th percentile by
July 2014.
– Save 1 hospital-acquired sepsis life/month.
– Mortality O/E = Outcome Measure
• Process Measures
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Use of sepsis order set (Process)
% with STAT first antibiotic order (Process)
% of patients receiving broad spectrum abx within 60 mins (Process)
Time to broad spectrum abx (Process)
% of pts with 2 blood cxs before abx (Balancing)
Early Goal-Directed Therapy (EGDT) 30.5% mortality,
vs standard therapy 46.5%
QI: The real-world challenge
• consistent use of Evidence Based Practice
• making a strong recommendation standard of
care
Administer abx within 1st hour of recognition of severe sepsis or
septic shock. (SSC guidelines: strong recommendation)
Time to Antibiotic and Choice of
Antibiotic are key to saving sepsis lives
• Broad spectrum antibiotic or “anchor” antibiotic should always be
administered first
– Cefepime 1g, Cetriaxone 2g, or Levofloxacin 750mg
• Stocked in all Pyxis machines at BMC
• Vancomycin is not broad spectrum and can lead to delay in getting the
most important antibiotic
• Anchor Antibiotic
– Effective against rapidly lethal organisms
• Gram negative rods
• S. pneumoniae
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–
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Long half-life
Can be infused quickly
Low incidence of allergy
Must be premixed or easy-mix, and dosing must not be weight-based
Goal 1: Decrease time to antibiotics in
BMC hospital-acquired sepsis patients
• PI group met
• Defined reason for action
• Mapped initial & target state
– Current performance: mean time from antibiotic order to
administration 200 minutes
• Goal: 60 minutes from order to administration
• Performed gap analysis
• Solution approach (to perform P-D-S-A)
– Ordering – changing sepsis order set
– RN/MD Education on importance of broad spectrum abx
first and time to abx
– Communication
Sepsis Order Set
Sepsis Order set
STAT and continuing dose antibiotic options
Lab, micro, radiology
Culture Orders
Nurses: Document Accurate “Administered At” Time in EMR
If the “administered at” time is not changed, STAT orders will default to the order entry time.
Case review for n of 1 in May: admit 4/12, Hosp-acquired sepsis 4/15, died 5/8. Sepsis order set
used (old), ordered STAT, 2 blood cxs obtained, time to antibiotic reported as 81 min but upon
manual review – 39 mins! Currently validating. Pt was on M6E and treament initiated by
Medicine intern. Pt on M6E.
Met SIRS criteria 4/14 21:36, ordered for cefepime 4/15 at 02:21. Delay in recognition leading to
delay in treatment.
Show current performance data
Time from abx order to administration
Mean time to first antibiotic
Menino General Medical Services and ICU
Hospital Acquired Sepsis patients (ave n = 3.3)
X bar S Chart
700
600
400
300
200
196.4
100
8-2013
7-2013
6-2013
5-2013
4-2013
3-2013
2-2013
12-2012
11-2012
10-2012
9-2012
8-2012
7-2012
6-2012
0
5-2012
Minutes
500
Goal 2: Improve recognition of
hospital-acquired sepsis at BMC
• PI group met
• Defined reason for action, mapped initial & target
state, performed gap analysis, and solution approach
• Kirkpatrick, Walkey, et al 2013 ATS abstract: Review of 35
BMC patients from 2008-2010 who died of hospital-acquired
sepsis:
– 12 (34%) had a greater than 6 hour delay in recognition or treatment
of severe sepsis
– 7 patients with delay > 12 hours after the onset of severe sepsis
– Patients without tachycardia were statistically more likely to be
missed.
– Trend towards patients on nodal blockers being more likely to be
missed.
Recognition solutions to test
• Pilot on Menino 6W began end of April
– Education
– CNA  RN notification parameters
– RN paper screening tool
• v1: identified many patients already on abx
• v2: exclude patients on abx.
– Without prompts, difficult for nurses to remember to complete.
– Changing flowsheet visual cues
Nurses: “CALL DR”
• MD Notification – always text page
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Helps providers know the urgency of the page
Patient name
Patient location
RN name
Call back number
Concern (sepsis)
• If RN does not reach someone, they have been
instructed to go up the chain (call resident,
attending if no one can be reached)
Management of sepsis: CALL DR
Cultures x 2
Antibiotics
Lactate
Liter boluses
Define Source
Reassess
Cultures x 2
• Goal to draw 2 sets prior to antibiotic administration
• Do not delay antibiotics – most important sepsis goal is to
administer broad spectrum antibiotics within 60 minutes
– Draw blood cultures as soon as possible
– Have a charcoal additive to remove antibiotics, if drawn after antibiotic
administration
• 2 sets and 2 separate peripheral venipuncture sites (per BMC
policy 3.76)
• BC Bottles:
– Should be labeled with source (peripheral, central line, etc.)
– Are plastic and should be sent to the lab via P-tube
Antibiotics (Broad Spectrum in < 60 mins)
Lactate
• Measure of tissue hypoperfusion
• Stratify severity of sepsis, severe sepsis
• Follow value with resussitation, goal to
normalize
Liter boluses
• For severe sepsis: 30ml/kg bolus Normal
Saline or Lactated Ringers
– 70kg patient = 2L bolus
• Goals in first 6 hours (early goal-directed
therapy):
– CVP 8-12 mmHg
– MAP ≥ 65 mmHg
– UOP ≥ 0.5ml/kg/hr
– SVC sat ≥ 70%
Define Source
• As directed by patient signs and symptoms, in
addition to blood cultures, may order UA,
urine culture, CXR, imaging
Reassess
• Follow heart rate, blood pressure, urine
output, lactate to determine whether patient
is improving or worsening
• Consinder whether patient may need to be
transferred to IMCU or ICU
• Follow up cultures and narrow or discontinue
antibiotics if appropriate
In Summary…
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Have a heightened suspicion for sepsis
Respond to RN notification in a timely manner
Document SIRS and sepsis
Treat aggressively and empirically for possible sepsis
– Can always peel back later
• Use the SCM “sepsis order set” to initiate early goaldirected therapy
• Communicate that timely orders were placed
– Stress importance of broad spectrum within 60 minutes
• Notify the attending of a change in patient’s clinical
status
– Involve the MICU if necessary
Future Directions
• Nursing floor spread
• Spread to ICU, Surgical services, ultimately
medical specialty services
• Possible simulation teams training
• Feedback welcome on the sepsis initiative
overall
• Potential for resident involvement
Acknowledgements
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Steering Committee
Stephanie Martinez
Willie Baker
James Murphy
Kate Mandell
Tamar Barlam
Kevin Horbowicz
Jennifer Ellingwood
Jane Jansen
Patty Covelle
George Barth
Louise Vecchio
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Roshan Hussain
Paul Kelley
Tom Lau
Kevin Guy
Nahid Bhadelia
Morsal Tahouni
Jim Meisel
Jake Feldman
Allan Walkey
Don Johnstone and 6W staff
Ann Woolley, Stephanie Maximous,
Morgan Richards, Jeff Jenks
YOU!!
Surgery residents and PA
Eric Poon
Stan Hochberg
Laura Harrington