Sepsis in Adult Leukemia Patients
Susan Gaeta, MD
Assistant Professor
Department of Critical Care
November 4, 2010
Epidemiology in septic cancer patients
• 2.3% of all hospitalizations among cancer
patients (1,784,445) 79-01
• 100,000 cases of sepsis/year
• 10 times more vs. noncancer patients
• 30% of all hospitalized cancer death
Danai et al Chest 2006;129:14321440
Background: Sepsis at MDACC
• 2005 Sepsis Order Set is developed
• 2006 Review of Sepsis Order Set
– Minimal to zero use of Order Set
– 5 pages of Order Set plus 1 page of Algorithm
• Aug 2006 CS&E Project- Drs Chen and Malik
– Aim Statement:
• To increase by 50% the use of the Sepsis Protocol in the ICU by August 18, 2006.
– Interventions:
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•
•
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Separating the sepsis protocol into part I & II
Limiting each part to 2-3 pages each
Adding an order in part I that activates part II automatically
Intensive education of all parties involved
– Results:
• increased use of the protocol by 650% from April 2006 and 44% from April 2005
Post CS&E
• Sepsis Committee
– Sepsis Order Set Follow Up Data Collection
– Research: PDOL
– Prospective Sepsis Analysis at MDACC
• Lack of Data Collection Support/Personnel
• Revised Sepsis algorithm and order sets
approved Sept. 2009
• Sepsis Collaborative October 2009
– Mission to decrease mortality in cancer patients
attributed to Sepsis
– Multidisciplinary group
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•
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•
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Leukemia -MLP, nurses, CAD, Pharm-Ds, Physicians
ICU – MLP, Nurses, Pharm-Ds, Physicians
Performance improvement
EMR Development & Support
MERIT
Nursing Admin
Infectious Disease- Physicians
MDACC Sepsis Mortality estimates
• Inpatient mortality
• ICU mortality
In-Hospital Sepsis Mortality and LOS For ICU Patients
5 month data in 2004, 2005, 2006
Not full year
ICU Sepsis Patients
2004
2005
2006
Aug-Dec
Aug-Dec
Aug-Dec
10
9
12
32%
35%
41%
ICU Total LOS (Mean/Median)
4.0/2.0
4.2/2.1
4.5/2.1
ICU All cause mortality
10.40%
10.90%
11.20%
248
277
521
ICU Sepsis-related LOS Mean
ICU Sepsis related mortality
Total # of patients
Clinical Effectiveness
Initial Data: Admissions & Mortality
• Date Range: 1/1/2008 - 3/31/2009
• Patient Age: >= 18
At least 1
Sepsis DX
Any DX
Percent
IP
Admissions
IP
Deaths
Percent
Mortality
2,165
497
22.96
26,738
1,066
3.99
8.10
46.62
Initial Data: Top ICD-9 DX Codes
ICD-9
Diagnosis
790.7
BACTEREMIA
1,110
24.49
038.9
UNSPECIFIED SEPTICEMIA
1,041
22.96
995.92
SEVERE SEPSIS
537
11.85
785.52
SEPTIC SHOCK
530
11.69
995.91
SEPSIS
511
11.27
Others
All Other Sepsis DX
804
17.74
4,533
100.00
Total
Count Percent
CS& E projects
– Early goal directed in Emergency Department
• Decreased mortality
– Sepsis in Adult Leukemia Patients
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–
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–
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Ninotchka Brydges - Lead
Jeffery Bryan
Jan Garza
Sonia Mathews
Karen Plexman
Medical Emergency Rapid Intervention Team (MERIT)
Intervention Data
Thoracic Oncology
Bone Marrow Transplant
Sarcoma Oncology
8%
Phase 1 (Research)
4%
16%
Breast Oncology
4%
3%
3%
Lymphoma/Myeloma
17%
4%
Gastrointestinal Surgery
General Medicine
3%
3%
Genitourinary Oncology
Gynecology Surgery
35%
Leukemia
Background Data
Pareto Chart - Leukemia Patients Admitted to ICU by Type of Sepsis - AprAug 2009 (n=47)
Average LOS of Leukemia Patients Admitted to ICU by Type of Sepsis Apr-Aug 2009 (n=47)
20
15
47%
120%
100%
80%
60%
10
40%
5
20%
0
0%
% Occurrence
(Days)
Avg.
Cases
# of LOS
25
# of Cases
% Occurrence
1
Knowledge Assessment Baseline
15
Process Analysis Flow Chart
Education Interventions
• Leukemia nursing sepsis in-service from 3/31
to 4/13/2010 in G12 (Leukemia Unit)
• Certified Nursing Assistant (CNA) in-service on
vital sign recognition for SIRS
• Pre/Post Questionnaires
• Sepsis Pocket Cards/Sepsis Algorithm
• 0.75 CEU’s for the RN’s
Pre/ Post Sepsis Education Assessment Tool
• Case based studies to assess
leukemia nurse’s recognition
of SIRS, Sepsis, Severe Sepsis,
and Septic Shock
• Assessed leukemia nurse’s
awareness of MD Anderson
Sepsis Algorithm
Pocket Cards/ Sepsis Algorithm
• SIRS, Sepsis,
Severe Sepsis and
Septic Shock
recognition pocket
cards were
distributed after all
the in-services
were completed
• Sepsis Algorithm
posters were
placed in G12
Pocket Cards/ Sepsis Algorithm
Leukemia MERIT Call Sepsis Types 06/01/09 - 8/31/10 (N = 291)
30
25
# of Sepsis Calls
20
Septic Shock
15
Severe Sepsis
Sepsis
10
SIRS
Non-Sepsis
5
0
FINANCIAL IMPACT OF SIRS PATIENTS REMAINING ON LEUKEMIA UNIT VS. ICU FOR TREATMENT
Charge
Intensive Care
Unit
Leukemia Unit
Savings
(Avoidance Costs)
Room Charge *
$3,588
$1,650
$1,938
Nursing Care **
$1,388
$700
$688
Total Charges
$4,976
$2,608
$2,626
Total Annualized Charges ***
* Based on cost of bed occupancy only. No treatment, equipment.
** Based on hourly rate of nurse
*** Based on an average of 6 SIRS patients per month to ICU
$312,000
SUMMARY OF POSITIVE CHANGES RESULTING FROM SIRS RECOGNITION IN LEUKEMIA PATIENTS
Aim: Increase recognition by
leukemia nurses of symptoms of
SIRS and other stages of sepsis:
42% improvement
ICU LOS
Visual Controls
Average LOS for SIRS patients = 6.69
Laminated pocket reference of
days. Average LOS for all other
symptom recognition at each stage
sepsis = 8.29 days. A difference of
of sepsis
1.6 days!
Transferable
Nursing, certified nursing assistant
education has been deployed
throughout Leukemia service. So
far, 115 educated!
Awareness of physicians' sepsis
algorithm increased from 55% to
97%
Poster-sized Physicians' algorithm
for sepsis has been posted in
leukemia nursing units
Education is being extended in
stages throughout the institution.
Nurses received 0.75 CEUs for their
education.
Nurses' algorithm for sepsis
recognition has been drafted
Education information is being
incorporated in the new nurse
orientation packet.
Ongoing/Future Initiatives
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Validation of ICD 9 codes
Retrospective Chart Review
Nursing sepsis algorithm
Elevation in serum lactate and febrile
neutropenia is associated with dev. of septic
shock within 48 hours (Study at Univ. of Penn)
• A study is being conducted in the EC by Dr. Yeung. Micro
RNAs and cytokines in patients with sepsis and cancer
presenting for emergency center.
• Sepsis Team
Questions