How Cookeville Regional
Medical Center Set Up a
Sepsis Program
Angela Craig APN,MS,CCNS
Clinical Nurse Specialist
Intensive Care Unit
Cookeville Regional Medical Center
acraig@crmchealth.org
© SepsisSolutionsInternational 2012
Cookeville Regional Medical Center
• 247 Bed Community Hospital (NonTeaching)
• Regional referral center in the heart of the
Upper Cumberland in middle Tennessee
CRMC Sepsis Initiative
• Go live ICU/CVICU ED and Rapid Response
September 2009
• Go live Hospital Wide October 2010
• Cost Savings per patient
• Mortality Decrease = Lives Saved!!!
Sepsis Disease Specific
Certification
CRMC March 2015
Shout out to Maury Regional as
well who certified this year
CRMC Sepsis Initiative
JAN
FEB
MAR
APR
MAY
JUN
JUL
Pre-Sepsis Data Obtained
23 Pts Mortality 70%
2009
AUG
SEP
OCT
NOV
DEC
September 2009
Go live for ICU, CVICU
and ED
Sep-Dec 2009
29 pts Mortality 49%
October 2010 – Hospital Go Live
2010
Jan-Mar 2010
39 Pts Mortality 31%
2011
Jan-Mar 2011
64 Pts Mortality 16%
2012
Jan-Mar 2012
67 Pts Mortality 17%
Apr-Jun 2010
33 Pts Mortality 33%
Apr-Jun 2011
67 Pts Mortality 17%
Apr-Jun 2012
67 Pts Mortality 17%
Jul-Sep 2010
47 Pts Mortality 15%
Jul-Sep 2011
66 Pts Mortality 25%
Jul-Sep 2012
67 Pts Mortality 17%
Oct-Dec 2010
49 pts Mortality 14%
Oct-Dec 2011
59 Pts Mortality 27%
Oct – Dec 2012
67 Pts Mortality 17%
4-Tier Process for
Severe Sepsis Program Implementation
Credit to Pat Posa and
Kathleen Vollman who
built this model and
have implemented this
successfully in over 50
health systems!!
Measuring
Success
Implementation of
the Sepsis Bundle
Early Screening with
Tools and Triggers
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
4-Tier Process for
Severe Sepsis Program Implementation
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
Organization Support
– Executive management at hospital actively supports
the Target Severe Sepsis Program
– Improving care of severe sepsis is aligned with hospital’s
current year goals
– Willingness to align resources with program
– Minimum .5 FTE for project management, data collection
& teachable moments
Adult Sepsis/Severe Sepsis/Septic Shock Program Charter CRMC
Problem Statement:
Severe sepsis and septic shock are major healthcare
problems, affecting millions of people around the world
each year, killing one in four (and often more), and increasing
in incidence (1–5). Similar to polytrauma, acute myocardial
infarction, or stroke, the speed and appropriateness of therapy
administered in the initial hours after severe sepsis develops
are likely to influence outcome. ("Surviving Sepsis Campaign: International Guidelines for
Mission:
CRMC aspires to be the leading Sepsis Treatment Center of the
Upper Cumberland Area. We will expect best outcomes for our septic
patients by utilizing national guidelines and evidence to treat them to
the best of our ability.
Management of Severe Sepsis and Septic Shock: 2012​" appeared in the February 2013 issues
of Critical Care Medicine and Intensive Care Medicine)
Team Members:
Facilitator of Team – Angela Craig APN/MS/CCNS
Physician Support: Dr. Sully Smith – ED, Dr. Pierce – Infectious Disease, Dr.
Carey – Hospitalist,
OB/Nursery , 4E, 4N/4W, Education, Nsg Admin, Pharmacy, Respiratory,
Lab, ICU, CVICU, 5E, 6E, 5N, 6N, In Pt Rehab, Surgery/PACU, Quality, ED,
Hospitalist, Auditor, Infection Prevention
Performance Measures:
•Measure 1: Decrease time to Central Venous Pressure (CVP) goal for septic shock patients in addition to increasing compliance with CVP monitoring.
•Measure 2: Decrease the time to SCVO2 goal for septic shock patients in addition to increasing compliance with SCVO2 monitoring.
•Measure 3: Decrease time to administration of antibiotics to within one hour of time zero.
•Measure 4: Improve the accuracy of initial screening and recognition of severe sepsis/septic shock.
Scope:
Severe sepsis/Septic Shock patients Housewide at CRMC
Target Population:
Adult
Goals/ Objectives:
•Become Disease Specific Certified from The Joint Commission
•Reduce Severe Sepsis Mortality
•Proper Placement of patients initially (Step-down for severe sepsis
and Critical Care for Septic Shock)
Business Case:
In comparison to other patients, severe sepsis patients have a higher mortality
rate, increased LOS, and an increased need for a ventilator
Milestones:
•ICU, CVICU, ED, Rapid Response Team – Sepsis go live Sept 2009
•Housewide sepsis go live – October 2010
•Working toward disease specific certification 2014
•Goal Certification 2015
2/15
Organization Support
– Understanding that this is a 2 to 3+ year program to
make this the standard of practice for this patient
population
– Existing culture that supports change
• Successfully implemented other major change
programs— e.g., vent bundle, tight glucose control,
CR-BSI
– Established team in place with ICU physician and
nurse champion, ED physician and nurse champion
that are recognized leaders in the hospital
The Team Is KEY!
Can Be Major Barrier If Not Functioning Well
• Must have nurse and physician champions from ED
and ICU (need at least one physician at all
meetings)
• Must be linked in the organization’s quality or
operational structure
• Must meet at least 1-2 times per month
• Team members must be well educated on the
evidence and armed with tools and knowledge to
change behavior at the bedside
• MUST have bedside nurses on team—provide
reality check and best knowledge of barriers
Economic Implications of an Evidence-based
Sepsis Protocol
Objective
• To determine financial impact of a sepsis protocol
designed for use in the ED
Design
• Analysis of results from recent prospective study
comparing outcomes in patients with septic shock before
and after initiation of sepsis protocol
Setting
• Academic, tertiary care hospital in US
Subjects:
• Adults (n=120) who sequentially presented to ED with
septic shock, specifically:
•
ED = Emergency Department
Shorr AF et al. Crit Care Med. 2007;35:1257–1262.
Summary of Results
• Post-protocol, savings of ~$6,000/patient observed
• Translated into total cost difference of $573,000
between the two groups
• Post-protocol, ICU costs reduced by ~35% (p=0.026)
and ward costs fell by 30% (p=0.033)
• Protocol resulted in a reduction in overall hospital
LOS of 5 days (p=0.023)
• Pre-protocol, 28-day mortality rate was 48.3% vs.
30.0% following protocol initiation (p=0.040)
•
ICU, intensive care unit; LOS, length of stay
Shorr AF et al. Crit Care Med. 2007;35:1257–1262.
Tier I: Organizational Consensus
Milestones and Checklist
• Define Sepsis Program Goals
– Team Charter
Adult Sepsis/Severe Sepsis/Septic Shock Program Charter CRMC
Problem Statement:
Severe sepsis and septic shock are major healthcare
problems, affecting millions of people around the world
each year, killing one in four (and often more), and increasing
in incidence (1–5). Similar to polytrauma, acute myocardial
infarction, or stroke, the speed and appropriateness of therapy
administered in the initial hours after severe sepsis develops
are likely to influence outcome. ("Surviving Sepsis Campaign: International Guidelines for
Mission:
CRMC aspires to be the leading Sepsis Treatment Center of the
Upper Cumberland Area. We will expect best outcomes for our septic
patients by utilizing national guidelines and evidence to treat them to
the best of our ability.
Management of Severe Sepsis and Septic Shock: 2012​" appeared in the February 2013 issues
of Critical Care Medicine and Intensive Care Medicine)
Team Members:
Facilitator of Team – Angela Craig APN/MS/CCNS
Physician Support: Dr. Sully Smith – ED, Dr. Pierce – Infectious Disease, Dr.
Carey – Hospitalist,
OB/Nursery , 4E, 4N/4W, Education, Nsg Admin, Pharmacy, Respiratory,
Lab, ICU, CVICU, 5E, 6E, 5N, 6N, In Pt Rehab, Surgery/PACU, Quality, ED,
Hospitalist, Auditor, Infection Prevention
Performance Measures:
•Measure 1: Decrease time to Central Venous Pressure (CVP) goal for septic shock patients in addition to increasing compliance with CVP monitoring.
•Measure 2: Decrease the time to SCVO2 goal for septic shock patients in addition to increasing compliance with SCVO2 monitoring.
•Measure 3: Decrease time to administration of antibiotics to within one hour of time zero.
•Measure 4: Improve the accuracy of initial screening and recognition of severe sepsis/septic shock.
Scope:
Severe sepsis/Septic Shock patients Housewide at CRMC
Target Population:
Adult
Goals/ Objectives:
•Become Disease Specific Certified from The Joint Commission
•Reduce Severe Sepsis Mortality
•Proper Placement of patients initially (Step-down for severe sepsis
and Critical Care for Septic Shock)
Business Case:
In comparison to other patients, severe sepsis patients have a higher mortality
rate, increased LOS, and an increased need for a ventilator
Milestones:
•ICU, CVICU, ED, Rapid Response Team – Sepsis go live Sept 2009
•Housewide sepsis go live – October 2010
•Working toward disease specific certification 2014
•Goal Certification 2015
2/15
Tier I: Organizational Consensus
Milestones and Checklist
• Define Sepsis Program Goal
– Team Charter
• Collect Baseline Data
Baseline Data Collection Process
• Pick time period for medical record query
• Sample size: minimum of 20 pts per ICU
• Query strategies:
– ICD 9 codes: 785.52 and 995.92
– Patients in ICU on 1-2 antibiotics, ventilator,
vasopressor (review charts to see if meet criteria for
severe sepsis or septic shock before include in
outcome data or process data)
• Select Data Collection Elements
– Outcome
– Process
Tier I: Organizational Consensus
Milestones and Checklist
• Sepsis Goals aligned with organizational goals
• Develop sepsis team (do we have all the right
people here?) and schedule monthly (minimum)
meeting for at least 6 months
• Identify nursing and physician champions in ED and
ICU and ensure champions attend team meeting
• Begin to define action plan and timeline for program
development and implementation
Action Plan
Tier
Tier I: Organizational
consensus
Gap
Action Steps
Action Plan
Tier
Tier I: Organizational
consensus
Gap
Team not meeting
regularly anymore
Action Steps
Re-formulate a team
Meet with unit manager or
nursing director to talk
about a plan to reformulate the team
Second Tier: Implementation of Early
Screening Tools and Triggers
Early Screening with
Tools and Triggers
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
Severe Sepsis: Defining a Disease Continuum
Infection
SIRS
Adult Criteria
A clinical response arising from a
nonspecific insult, including ≥ 2
of the following:
Temperature:> 38°C(100.4) or
< 36°C (96.8)
Heart Rate: > 90 beats/min
Respiration: > 20/min
WBC count: > 12,000/mm3,
or < 4,000/mm3,
or > 10% immature
neutrophils
SIRS = Systemic Inflammatory Response Syndrome
Bone et al. Chest.1992;101:1644-1654.
Sepsis
SIRS
with a
presumed or
confirmed
infectious
process
Severe Sepsis
Sepsis
with ≥1 sign of organ
dysfunction,
hypoperfusion or
hypotension.
Examples:
• Cardiovascular
(refractory hypotension)
• Renal
• Respiratory
• Hepatic
Shock
• Hematologic
• CNS
• Unexplained metabolic
acidosis
Signs & Symptoms of Sepsis
 Platelets
Chills
Alteration in LOC
Tachypnea
Unexplained metabolic
acidosis
Heart rate
Altered blood pressure
Levy M, et al. Crit Care Med 2003;31:1250-6.
 Bands
 Skin perfusion
 Urine output
Skin mottling
Poor capillary refill
Hyperglycemia
Purpura/petechia
Identifying Acute Organ Dysfunction
as a Marker of Severe Sepsis
Respiratory
Increased Oxygen
Requirements
Cardiovascular
Tachycardia
SBP<90mmHg
MAP < 70mmHg
(despite fluid)
Need for Vasopressors
Renal
Metabolic
Unexplained
metabolic acidosis
•Lactate > 1.5 times
upper normal
UO < 0.5 ml/kg per hr
(despite fluid)
Hematologic
Platelets
<80,000/mm3
Decline in platelet
count of 50% over 3
days
Why Do You Need to Have
a Screening Process?
• TIME IS TISSUE!!
– Similar to polytrauma, AMI, or stroke, the speed and
appropriateness of therapy administered in the initial
hours after severe sepsis develops are likely to
influence outcomes.1
• To screen effectively, it must be part of the nurses’ daily
routines— i.e., part of admission and shift assessment
• Must define a process for what to do with the results of
the screen
If you don’t screen you will miss patients
that may have benefited from the interventions.
1. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis
and septic shock: 2008. Crit Care Med. 2008;36:296-327.
Where do you screen patients for Severe
sepsis/ Septic Shock Currently?
A:
B:
C:
D.
Housewide, all floors do sepsis screening
Emergency Dept. Only
Critical Care Areas and Emergency Dept.
only
We have no formal screening process at
our hospital
Make Screening for Severe Sepsis
Process-Dependent
• Weave into fabric of current practice
• Assess for on a daily basis
• Identify strategies for initiation of therapy
response once patient is identified
Incorporate Screening and Early
Identification Throughout the Hospital
• Emergency Department
• ICUs
• Patient Care Units
• Rapid Response Team
ED
Screening
Tool
Rapid Response Team Tool
What About Automation for
Early Recognition?
• MICU, single center, 442 consecutive patients
who met modified SIRS
• Randomized to automated identification of
SIRS with notification to MD or usual care
• Measure impact on early antibiotics and
outcomes in patients with sepsis
• Results
– No difference in median time to antibiotic
– No difference in amount of fluid administered
– No diff in LOS or mortality
Hooper MH, et al. Crit Care Med. 2012;40
Screening: Barriers/Strategies
• Barriers
– Time for nurses to do it (perception vs. reality)
– Screening is not sensitive only for severe sepsis
– Positive screen is not a diagnosis of severe
sepsis
• Strategies
– Must assign responsibility and enforce
accountability
– Perform audits to measure compliance
and identify problems
– Round on unit and ask nurses how it is going
and discuss issues
Screening: Barriers/Strategies
• Lesson learned:
– Bedside nurse must do daily screening.
– Education/Simulation/Education
• Every 6 months
• Build into orientation
• Must be part of your documentation
structure
• Practice-Practice-Practice
www.ICU-USA/Pro
Is Sepsis Training part of your
Unit based or hospital based
orientation?
A:
B:
C:
D:
Yes, Unit Based Orientation
Yes, Hospital Based Orientation
Yes, Both Hospital and Unit Based
Orientation
No – This is an opportunity for my hospital
Nursing Care Essentials to Complement SSC
• Infection Prevention
–
–
–
–
Education: Multimodal/interactive
Accountability: Culture of patient safety
Surveillance: Continuous
Hand Hygiene: Alcohol based gel 1st, if soiled soap & H20
•
•
•
•
Prevention of VAP
Prevention of CR-BSI
Prevention of SSI
Prevention of UTI
– Source control (catheter removal, isolation etc.)
• Educated to recognize signs of severe sepsis & septic
shock
– Use of early warning system
– Use of screening tools for early recognition
Aitken LM, et al. Crit Care Med;2011;39;39:1800-1818
Nursing Care Essentials to Complement SSC
• Communications tools be used to improve communication (i.e. SBAR,
RSVP (reason, story, vital signs & plan)
• Initial resuscitation of patients be provided through the use of a rapid
response system
– Education
– Adequate resources
– Adequate nurse staffing levels
– Sepsis six should be promoted in non-critical care areas (care within 1st hour)
(protocol directed care)
•
•
•
•
•
•
Starting high oxygen flow
Obtaining blood cultures
Administering antibiotic therapy
Starting IV therapy
Obtaining lab work (hgb & lactate levels)
Measuring I & O
– Pre-mixed antibiotics for 1st dose
– Tracking systems & daily sepsis rounds
Aitken LM, et al. Crit Care Med;2011;39;39:1800-1818
Clinical Scenario I: Early
identification and intervention
• 88 year old, 51.6kg,white, female admit
from ED; resided in ECF
• History: CAD, COPD, dementia, Alzheimer
disease, depression, SVT
• Chief Complaint: rib pain, chest congestion
and SOB
• Awake, alert and oriented, slight combative
(history of combative behavior)
Clinical Scenario I: Early
Identification and Intervention
• Initial VS:
– Temp: 101.6 F
– RR: 31
– HR: 109, atrial fib with occasional SVT
– B/P: 79/51
– 2L of O2, O2 sat of 96%
• Does this patient screen positive for severe
sepsis?
Clinical Scenario II: Early
Identification and Intervention
• 62 yr. old male, 2 days post op s/p colectomy,
73kg, receiving antibiotics
• Vital signs: HR 120. RR 24, BP 80/40, temp:
102.2; urine output 100ml over last 4 hrs.
• Does patient screen positive for severe sepsis?
Clinical Scenario II: Early
identification and intervention
• 62 yr. old male, 2 days post op s/p colectomy,
73kg,receiving antibiotics
• Vital signs: HR 120. RR 24, BP 80/40, temp:
102.2; urine output 100ml over last 4 hrs.
• Screen patient for severe sepsis
Positive Screen for Severe Sepsis
SIRS: HR>90; RR>20; Temp> 100.4
Infection: on antibiotics
Organ dysfunction: BP 80/40
Tier II: Screening for Severe Sepsis
Milestones and Checklist
• Develop screening process for ED, rapid
response team and ICU (eventually
housewide)
• Develop audit process to evaluate compliance
and effectiveness
• Ensure screening process has clear “next
steps” defined for nursing staff
Screening Compliance Audit Tool
Pt. Account #
(enter #)
Screened
Y/N (circle)
Y
N
Patient
transferred to
appropriate
level of care
Y/N (circle)
(Severe Sepsis
Stepdown
Septic Shock
(ICU/CVICU)
Y
N
Unit:___________________________
Pt. Have known
suspected
infection
Y
N
Antibiotics hung
within 1 hour of
time zero?
Y
SIRS Present
 T ≥ 100.4 or
< 96.8
 HR > 90
RR >20 or
PACO2 <32
 WBC >12,000
<4,000 or
> 10% Bands
Screen done correctly
Y/N (circle)
Organ Dysfunction
 Respiratory (increased oxygen
requirements)
 Cardiovascular (SBP less than
90 or MAP less than 65 or on a
vasopressor)
 Renal (Urine output less than
05.ml/kg/hr., creatinine greater
than 2)
 Metabolic (Lactate greater than
or equal to 4mmoL/dl)
 Hematologic (Serum total
bilirubin greater than or equal
to 4mg/dl)
 Hepatic (Serum total bilirubin
greater than or equal to
4mg/dl)
 CNS (Altered consciousness –
unrelated to primary neuro
pathology)
If screen not done correctly, why?
N
Date:_________________________
Which labs
were sent?
(=obtained)
 Bld Cult x2
Bld Cult
CVAD >48 hr
 Lactic Acid
Was Central
Line Inserted?
(Critical Care
Only)
Y
N
Fluid bolus
(30ml/kg)
provided for
hypotension
Y/N (circle)
Y
N
If no how
much given
 500 mL
 1 liter

__________
Screened
positive for
severe
sepsis (Y/N)
(circle)
Y
N
Comments
 Pos feedback letter given
 Neg feedback letter given
 Other (Explain)
Screened
positive
for Septic
Shock
Y/N
(circle)
Y
N
Positive
Screenings
If screened
positive for
Septic Shock
in CVICU/ICU
was Septic
Shock Clinical
Pathway
(Form 1112PRN) started
Y
N
If screened
positive for
Severe Septic
or Septic
Shock (floors
other than
ICU/ED/
CVICU) was
Initial
Management
of Patient
with Severe
Sepsis (Form
1135-PRN)
completed
Y
N
Shift:_____________________
# Audits Completed ___________________ (Every shift checked considered an audit):
# Audit Screened (numerator = number of screenings completed, denominator = audits completed Example: 7 screenings done, 10 audits completed = 70% audits screened)
________________ %
# of Audits screened correctly? _______________ (numerator = number audits screened correctly, denominator = number audits completed ) ____________________ %
% of follow up on incorrect screens (numerator = number of audits followed up on, denominator = number of incorrect audits) _________________%
Action Plan
Tier
Tier I: Organizational
consensus
Tier II: Screening and
Early Identification
Gap
Action Steps
Team not meeting regularly
anymore
Re-formulate a team
Meet with unit manager or
nursing director to talk
about a plan to re-formulate
the team
Action Plan
Tier
Gap
Action Steps
Tier I: Organizational
consensus
Team not meeting regularly
anymore
Re-formulate a team
Meet with unit manager or
nursing director to talk
about a plan to re-formulate
the team
Tier II: Screening and
Early Identification
No formal process for
screening or follow
through
Start to develop screens
and implement for the ICU
and ED
Homeostasis Is Unbalanced in
Severe Sepsis
FIBRINOLYSIS
COAGULATION
INFLAMMATION
Homeostasis
Carvalho AC, Freeman NJ. J Crit Illness 1994;9:51-75.
Kidokoro A, et al. Shock 1996;5:223-8.
Vervloet MG, et al. Semin Thromb Hemost 1998;24:33-44.
Inflammation, Coagulation and
Impaired Fibrinolysis In Severe Sepsis
Endothelium
COAGULATION CASCADE
Tissue Factor
Factor VIIIa
IL-6
IL-1
TNF-α
Monocyte
PAI-1
Factor Va
Suppressed
fibrinolysis
THROMBIN
Neutrophil
Fibrin
IL-6
Fibrin clot
Tissue Factor
Inflammatory Response
to Infection
Thrombotic Response
to Infection
Adapted from Bernard GR, et al. N Engl J Med. 2001;344:699-709.
Fibrinolytic Response
to Infection
MICROCIRCULATION: SUBLINGUAL
BLOOD FLOW
Healthy Volunteer
• BP: 120/80 mm Hg
• SaO2: 98%
Septic Shock
Patient
Resuscitated with fluids
and dopamine
–
–
–
–
1. www.opsimaging.net. Accessed April 2004.
2. Spronk PE, et al. Lancet. 2002;360:1395-1396.
HR: 82 BPM
BP: 90/35 mmHg
SaO2: 98%
CVP: 25 mmHg
Pathophysiologic Characteristics
in Severe Sepsis
• Maldistribution of blood flow
• Imbalance of oxygen supply & demand
• Metabolic alterations & activation of the
stress response
Imbalance of Oxygen Supply &
Demand
SUPPLY
DEMAND
© Vollman
2001
OXYGEN SUPPLY/DEMAND
DYNAMICS
ScvO2
CVP,
CO, CI,
SV, SVI,
SVV
Optimize Cardiac
Performance
Fluid Bolus to define place on
curve:
•Record Stroke Volume (SV)
•Give 250-500 NS bolus over
10-15minutes
•Record SV
•If see greater than a 10%
increase in SV pt. is on steep
portion of curve and will still
respond to fluid
O2 Supply/Demand Compensatory
Mechanisms
 Improve pulmonary gas exchange
 Increase oxygen delivery
 Alter the distribution of blood flow
Monitoring Oxygen Dynamics
• Lactates within 3 hours, then if elevated
obtain another one prior to 6 hour mark,
every 6 hrs. until cleared
• Correlates with mortality;
• Expect clearance within 24 hours
• ScvO2
• Subclavian or IJ triple lumen
intermittent sampling or continuous
monitoring
• Baseline and then hourly till > 70%;
Cornerstones of Multidisciplinary
Management of Severe Sepsis/MODS
• Prevention
• Screening and Early Identification
• Early Intervention: Source control, Blood
cultures and broad spectrum antibiotics
– May want to protocolize lactic acid/blood
culture collection
• 3 Hour Bundle
• 6 Hour Bundle
Third Tier: Implementation of
Evidence-Based Sepsis Bundles
Implementation of
the Sepsis Bundle(s)
Early Screening with
Tools and Triggers
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
Tier III: Implementation of Sepsis Bundles
Milestones and Checklist
• Develop easy to use order sets (ED and ICU should be
the same), organized by bundle
• Order sets approved by appropriate medical and nursing
leadership/committees
• Assess physician/provider skill level with CVP insertion.
Create strategy to deal with gap in skill if present
– We have had classes for physicians for
hemodynamics and central line placement
• Define who will put in the CVP line for patients when the
come from the floor, especially on off shifts and
weekends
Tier III: Implementation of Sepsis Bundles
Milestones and Checklist
• Ability to get lactate results in 30 minutes or less
• Ability to get antibiotics administered within one hour of
diagnosis or first hypotensive episode
• Identify equipment needs and make capital requests
• Identify education needs
If lactate 2.1-3.9: target resuscitation to normalize the
lactate (2C)
Dellinger, etal, Critical Care Medicine, Feb 2013, Vol 41 Number 2
SSC Guidelines
A: Initial Resuscitation
Should be protocolized, quantitative resuscitation
of patients with sepsis induced hypoperfusion
(defined as hypotension persisting after initial
fluid challenge or blood lactate > 4mmol/L)
Goals during the first 6 hours of resuscitation:
• Central venous pressure: 8-12 mmHg
• Higher with altered ventricular compliance or
increased intrathoracic pressure
• Mean arterial Pressure (MAP) ≥ 65mmHg
• Urine Output ≥ 0.5mL/kg/hr
• Central Venous (superior vena cava) or mixed
venous oxygen saturation 70% or 65% respectively
(1C)
CRMC Septic Shock Clinical Pathway
SBAR Report Form
Antibiotic Challenges
• Appropriate selection – determined based
upon consensus guidelines and pathogen
sensitivity at your institution
• Timing issues
• How? Delivery time challenges of
antibiotics
• Possible solutions
Clinical Scenario II: Early
identification and Intervention
• 88 year old, 51.6kg,white, female admit
from ED; resided in ECF
• History: CAD, COPD, dementia, Alzheimer
disease, depression, SVT
• Chief Complaint: rib pain, chest congestion
and SOB
• Awake, alert and oriented, slight combative
(history of combative behavior)
The Rest of the Story
Clinical Scenario II : Early
Identification and Intervention-ER
• Labs:
– WBC: 11.5
– Hgb: 15.8
– Hct: 47.4
– BUN: 28 Creatinine:1.6
– Glucose:158
– BNP:78 (moderate CHF); troponin:0.03
– Lactic acid: 4.6
– U/A: positive for bacteria
– ScvO2: 49.1%
– Blood cultures X 2 drawn
Clinical Scenario II : Early
Identification and Intervention-ER
• CXR: RLL consolidation
• Additional Interventions:
– Broad spectrum antibiotics given within 3
hours of presentation
– Lactic acid >4mmol/L so CVP inserted
– Fluid resuscitation continued
– Foley inserted
• Received total of 3 Liters of NS during 3 hour ED
stay
• ED diagnosis: Severe Shock, Pneumonia , UTI,
CHF
• Transferred to MICU
Clinical Scenario II : Early Identification and
Intervention--MICU
• Additional Interventions: Day 1
– Continued fluid resuscitation—7 L
– Low dose vasopressor
– Low dose steroids
– Remained on 2 L nasal cannula
• Labs:
– ScvO2: 72.8 (after resuscitation)
– Lactic acid: 4 hours after ICU admission: 6.7
12 hours after ICU admission: 3.0
Clinical Scenario II : Early
Identification and Intervention
• Day 2:
– Vasopressor weaned off
– Lasix to assist with fluid mobilization
– Lactic acid: 3.0
• Day 3:
– Lactic acid: 1.2
– O2 sat 93% on room air
– Central line discontinued
• Transferred to intermediate care on Day 3
• Discharged from hospital on day 7
Tier III: Sepsis Bundle Implementation
Milestones and Checklist
• Identify resistance and barriers to bundle
implementation and develop solutions
• Define educational plan for all staff:
• Develop implementation plan
Action Plan
Tier
Gap
Action Steps
Tier I: Organizational
consensus
Team not meeting
regularly anymore
Re-formulate a team
Meet with unit manager or
nursing director to talk about a
plan to re-formulate the team
Tier II: Screening and Early
Identification
No formal process for
screening or follow
through
Start to develop screens and
implement for the ICU and ER
Tier III: Implementing the
Bundles
Action Plan
Tier
Gap
Action Steps
Tier I: Organizational
consensus
Team not meeting
regularly anymore
Re-formulate a team
Meet with unit manager or
nursing director to talk about a
plan to re-formulate the team
Tier II: Screening and Early
Identification
No formal process for
screening or follow
through
Start to develop screens and
implement for the ICU and ER
Tier III: Implementing the
Bundles
Getting lactate &
antibiotics in < 1hr
Getting the Central line
inserted
Lactate: explore point of
care & measurement from
the ABG machine
Antibiotic: Broad spectrum
in the Pyxis
Central Line: Around the
clock Power PICC team
Is it difficult to get a central line
placed in your institution
A:
B:
Yes
No
Implementation
• Hospital resources often focus on planning phase
and then back off after implementation.
• The implementation phase is the most critical.
• Frequent rounds by project champion
recommended on unit to support staff and
answer questions.
• Defined resources for bedside nurse:
– Project champion has pager to be available 24/7
initially
– Clinical nurse champions identified on each ICU
unit , ED, and all Nsg Care Units to be resources
to bedside staff (these staff should be members of
the sepsis team/committee from the beginning)
Tier III: Develop and Implement the
Education Plan
– Content: (present to physicians, nurses, Pharmacy, and RTs)
•
•
•
•
•
Significance of problem
Sepsis continuum
Pathophysiology of severe sepsis
Prevention and management (share the evidence)
Case studies for staff to practice with bedside tools
– Methods:
• Self learning modules
• Classroom and/or small groups of staff on unit
• Web-based
– Ongoing:
•
•
•
•
build into orientation
monthly for residents
every 6 months for all staff
one-on–one during rounds
TIER III: Develop Implementation Plan
• Identify who will oversee the implementation and the
expectations of that person (sepsis nurse or program
coordinator)
• Define Critical Care/ED/Floor resources for staff that
they can call at any time for questions and assistance
– Example – OB Floor
TIER III: Develop Implementation Plan
• Create rounding schedule and process
– Should begin as daily in the ICU and ED
– Keep master list of all patients who go on the bundles
(and those who should have but didn’t if possible)
– Do real time interventions to ensure patients get the
evidence based practices
– Define follow up process for review and evaluate
missed opportunities
Fourth Tier:
Measuring Process & Outcome Changes
Use of evidence-based approach
Measuring
Success
Implementation of
the Sepsis Bundle
Early Screening with
Tools and Triggers
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
Tier IV: Measurement
Milestones and Checklist
• Define outcome and process data elements that
will be collected
• Develop and implement a data collection
process
• Revise and update goals and action plan as
needed
• Execute implementation plan
Data Collection
• Patient Log
– Define how will find all patients that receive the bundles
– Real time data collection is optimal—then used as
checklist to ensure patient receives all appropriate
interventions
• Outcome
– Mortality (ICU and Hosp)
– Hosp LOS
– Cost per case (total and direct)
• Process
– SSC database
– Data elements that measure implementation of
resuscitation and management bundle
CRMC Data Sample
CRMC
Septic Shock
Data
Post Sepsis Protocol
Group VIII
Oct-Dec 2012
(49 pts)
Post Sepsis Protocol
Group IX
Jan-Mar 2013
(65 pts)
Where Septic Shock Identified
ED
14%
ICU
82%
CVICU
4E
2%
5E
2%
6N
5N
4N
6E
Outside Facility
43%
55%
Yes
No
98%
2%
100%
Yes
No
100%
94%
6%
Yes
No
71%
29%
72%
28%
Yes
No
65%
35%
65%
35%
Yes
No
71%
29%
57%
43%
500mL
1 liter
2 liter
1.5 liter
44%
56%
38%
62%
Serum Lactate Drawn within 6 hr from time
zero
Blood cultures drawn times 2?
Were Bld Cultures drawn w/in 1 hr of time
zero?
Was 20mL per kg infused?
If No was bolus of any amount given?
If Yes How much given?
2%
CRMC Data Sample
Was patient hypotensive after
fluid bolus?
Yes
80%
No
20%
Not Documented
84%
16%
Pt received antibiotic within first
hour (added field)
Yes
No
60%
40%
57%
43%
Initial lactate > or equal to 4
Yes
No
31%
69%
54%
46%
CVP Placed?
Yes
49%
No
51%
Not Documented
61%
39%
Was patient on vasopressors > 6
hours?
Yes
No
68%
32%
71%
29%
Patient Expired? ***
Yes
No
33%
67%
18%
82%
Indicator/
Month
Jan
26
Feb
25
March
20
Lactate drawn
100%
within 3 hrs. of time (26/26)
zero
92%
(23/25)
Blood C/S drawn
prior to antibiotics
88%
(23/26)
Broad Spectrum
antibiotic within 3
hrs. of time zero
1st Q
71
Apr
11
May
18
95% (19/20) 96%
(68/71)
82%
(9/11)
100%
(18/18)
92%
(23/25)
95% (19/20) 92%
(65/71)
100%
89%
(16/18)
92%
(24/26)
84%
(21/25)
75%
(15/20)
85%
(60/71)
82%
(9/11)
67%
(12/18)
Administer 30ml/kg
crystalloid
65%
(17/26)
60%
(15/25)
80%
(16/20)
68%
(48/71)
73%
(8/11)
72%
(13/18)
Administer 30ml/kg
crystalloid within
3hrs of time zero
82%
(14/17)
100%
(15/15)
81%
(13/16)
88%
(42/48)
100%
8/8
100%
(13/13)
Central line placed
88%
(23/26)
64%
(16/25)
75%
(15/20)
76%
(54/71)
73%
(8/11)
78%
(14/18)
Central line placed
within 6 hrs. of time
zero
57%
(13/23)
94%
(15/16)
40% (6/15)
63%
(34/54))
63%
(5/8)
43%
(6/14)
MAP goal met
within 6 hrs. of time
zero
85%
(22/26)
88%
(22/25)
60%
(12/20)
79%
(56/71)
91%
(10/11)
56%
(10/18)
CVP goal met within 15%
6 hrs. of time zero
(4/26)
8%
(2/25)
10% (2/20)
11%
(8/71)
9%
(1/11)
0%
(0/18)
Scv02 goal met
within 6 hrs. of time
zero
4%
(1/26)
0%
(0/25)
5% (1/20)
3%
(2/71)
0%
(0/11)
0%
(0/18)
Survival Rate
77%
(20/26)
64%
(16/25)
60% (12/20) 68%
(48/71)
82%
(9/11)
94%
(17/18)
Readmission Rate
3.8%
(1/26)
4%
(1/25)
10%
(2/20)
9%
(1/11)
N/A
(No readmits)
5.6%
(4/71)
Goals 4-Tier Process for
Severe Sepsis Program Implementation
Tier 4 Complete by
October 2010 – Plan in
place
Tier 1 Complete by May 1st, 2009
Measuring
Success
Tier 2 Complete by
May 26th, 2010
Tier 3 Complete by
August 2010
Educate for 3 weeks
Implementation of
the Sepsis Bundle
Early Screening with
Tools and Triggers
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
Three Biggest Challenges
Challenge #1: Finding the Patients
Redefining what a ‘septic shock’ patient looks like
Before
Supine in bed
Ventilator
Fluids wide open
Increasing vasopressors
Minimally responsive
NOW
Sitting up in bed
Nasal cannula
IV boluses
Weaning vasopressors
Awake
“Don’t look sick enough to be in ICU or to have a central line”
Must correct this misperception
Additional Strategies: Finding
the Patient
•
•
•
•
•
•
Unit sepsis champions
Sepsis coordinator
ED and ICU rounding
RRT screen on every call
Prospective patient log
Discuss sepsis screen as part of
Multidisciplinary Rounds
• Reports
• Patients who screened positive
• Lactate
Finding the Patients:
Prospective Patient Log
Unit
Pt #
Point of
Entry
Date of
Septic
Shock Dx
Time of
Septic
Shock Dx
Data
Obtained
Data
Complete
Comments /
Follow-up
Sepsis Management: Challenges #2
Physician Buy-in
Strategies:
• Redefining what a ‘septic shock’ patient looks like
• Physician Champions-ED and ICU
• Part of sepsis team
• Follow up with physician when bundles not followed
• ED and ICU rounding
• Unit sepsis champions
• Sepsis coordinator
• Data--• Often and detailed
• Physician specific
• Administrative support
Challenges #3: Not Meeting 3hr and 6hr
goals
Focused Incremental Goals
– First hour of care
• Lactate, blood cultures, antibiotics and
30ml/kg fluid bolus
– Other goals within 6 hours
• CVP greater than or equal to 8mmHg
• MAP greater than or equal to 65mmHg
• ScvO2 greater than or equal to 70 %
Work on 3 hour Bundle First then the 6 hour Bundle
Communication
**Poor between
RN & MD
re:diagnosis. (2)
**RN not comfortable discussing
w/ MD
Policy
Nurse does not
know where to
look for
information
re:bundles
Poor between ER-ICU &
OR-ICU (2)
Environment
No ICU beds to
transfer patient to.
(4)
**Nurse/Patient
ratio 1:2 with high
acuity (10)
Staff overwhelmed
with other
initiatives.
Lack of guidance on MN &
Weekends (5)
**Signs go unrecognized (8)
No IV line holders at
head of bed
Delay in antibiotic
verification in
pharmacy. (4)
Unclear process (4)
**Unsure how to follow bundle (8)
-RN forgot to screen (2)
-Unsure how to measure CVP from PICC
(4)
**-No sense of urgency (6)
Order sets not being
used. (3)
Materials
Process
**-MD buy in (3)
-RN: lack of knowledge
-Reoccurrence goes unrecognized
-Lack of critical thinking/cant put it all
together (3)
-RN/MD refuses to follow bundles
People
goals not
achieved in
3hours or 6
hours
Sustaining and Improving:
Strategies
• Independent checks
– Checklists, pathway
– Multidisciplinary rounds
• Real time feedback and on-going education
– Unit rounds
– Unit champions
– Staff meetings
– Orientation---RN and residents
– Quarterly with current staff
Sustaining and Improving:
Strategies
• Creating sense of urgency
– ‘Code Sepsis’ or ‘Sepsis Alert’
– Staffing ratio for initial 6 hours of ICU or ED
care
– Clock on the door
– Protocol Watch
Keys to Success
• Team in place with key stakeholders overseeing
implementation
• Project coordinator with lead clinical staff on each unit
• Sepsis resource/coordinator rounds frequently on units
• Strong physician leadership on team
• Reminders to staff through use of bedside sepsis
tools/checklist
Keys to Success
• Empowerment of nursing staff to prevent errors
• Administrative support to help manage barriers
• Review data monthly to identify opportunities for
improvement
• Support from state-wide collaborative/surviving sepsis
campaign
EDUCATION, DATA, PROCESS, EDUCATION,
COMPLIANCE
The Nurses Role
• Early recognition of
patients with signs of
sepsis
• Early initiation of
evidence based practice
therapies appropriate for
your area of practice
(antibiotics, fluids/blood &
pressors)
• Swift disposition to care
areas where the rest of
the bundle can be started.
References:
– Dellinger et al, Surviving Sepsis Campaign:
International Guidelines for Management of
Severe Sepsis and Septic Shock: 2012.
Critical Care Medicine. 2013; 41:580-637.
– Vollman, Kathleen and Pat Posa – Critical
Care Solutions – developed the pyramid