Standardized & Accelerated Care of
Septic Shock
Standard Rollout Process
Develop a Sepsis Alert Program to prioritize and mobilize sepsis response
quickly.
Prioritize into
strategic plan and
set date for
initiation of rollout
Identify
Stakeholders
Stakeholders
Meet with
Stakeholders
Perform
SWOT
Analysis
(
(
(
(
(
(
(
MUST HAVES
) Incorporate evidenced based practice
) Flow chart process
) Identify metrics for evaluation
) Identify who needs education on initiative
) Assign Accountability and clear timeline
) Develop plan for sustained success
) Identify Methods for content delivery (Figure 1)
Develop
Action Plan
Debrief
Communicate
Plan
Implement
Action Plan
2/8/2016 Page 1
Changes
Need to
Be
made?
Adjust
Action
Plan
(Figure 1)
MUST PICK AT LEAST 7
WAYS TO DELIVER
INFORMATION FOR AT
LEAST 7 DAYS
( ) Webinservice
( x) Leader rounding on
initiative
( x) Post metrics and
measurements
( ) Change of Shift Report
( ) Formal inservice to staff
( x ) E-Mail to Staff
( x) E-Mail to Physicians
( ) Add to Initial Competencies
( ) Add to Annual
Competencies
( x ) Cover in Staff Meetings
( ) Cover in Unit Board Meeting
( ) Send out in Friday
Communication from Manager
( x ) Post flyers on initiative on
unit
( x ) Recruit unit champions /
superusers from staff to
promote initiative
( ) Show video of role playing
best practice
©2009 Karin League & Brent Lemonds
Vanderbilt Medical Center
Background
Worldwide, 500,000 people die from sepsis annually (1). Sepsis conveys a mortality rate of 30-50% (1).
Mortality and morbidity are significantly decreased with early administration of appropriate antibiotics,
aggressive fluid resuscitation, and control of the source of infection (1,2,3), which requires coordination of
nursing and physician resources. Protocols for septic patients encourage efficiency and reduce delays in
care (1,2).
Currently, our Emergency Department (ED) does not have a protocol to address patients who are septic.
Unlike level 1 Traumas, in which every participant has a specific role and set of responsibilities and in
which there are specific decision points with defined outcomes, critically ill septic patients are often
treated with some variability. It is clear that early administration of antibiotics, aggressive fluid
resuscitation, central line placement, and source control improve patient outcomes (1,2,3), but achieving
these goals is extremely difficult without protocols in place to coordinate physician, nursing, and
respiratory care.
The goal of this protocol is to improve the efficiency and timeliness of care for patients who present to
the ED with sepsis by standardizing and streamlining their care. We have outlined recommendations for
evaluation and goals for treatment from a physician and nursing and respiratory therapy perspective. The
leadership of the MICU has agreed on this standard workup for septic patients and has pledged to
expedite the transfer of septic patients to the ICU. We expect that implementing an aggressive and
standardized care protocol for septic patients will improve patient morbidity and mortality, as it has at
other hospitals (1).
References:
1. Gao F, Melody T, Daniels D, et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on
hospital mortality in patients with severe sepsis: a prospective observational study. Critical Care 2005,
9:R764-R770.
2. Rivers E, Nguyen B, Havstad S, et al. Early goal directed therapy in the treatment of severe sepsis and
septic shock. NEJM 2001;345:1368-77.
3. Rivers E, Coba V, Visbal A, et al. Management of sepsis: Early Resuscitation. Clin Chest Med 29 (2008)
689–704.
2/8/2016 Page 2
STRENGTHS
1. The operations in the sepsis alerts will
be similar to Level 1 trauma, STEMI, and
stroke alert operations, which are already
well defined.
2. The ED and MICU already have a
history of collaboration and this initiative
has been produced by joint collaboration.
3. The IT system at Vanderbilt is state of
the art and can be used to reduce
variability in care and measure process
outcomes easily.
WEAKNESSES
1. The ED is frequently at overcapacity
stretching staff very thin and causing a
shortage in physical space for care.
2. We have a large number of faculty,
residents, and staff that will need training
and there is frequent turnover of residents
and staff.
OPPORTUNITIES
THREATS
1. The use of standardized sepsis bundles
is well established to improved morbidity
and mortality.
2. Multiple organizations have published
on their implementation of sepsis bundles.
1. ED care is affected by the natural
variability in timing/acuity of patient
arrivals.
2. Healthcare providers are sometimes
reluctant to standardize patient care due to
a longstanding culture of provider
autonomy and individualization of patient
care.
2/8/2016 Page 3
Sepsis Alert Protocol, VUH Emergency Department
Potentially Unstable Septic Patient Identified
(Via EMS call or identified by Triage Nurse)
SIRS Criteria plus any of the following: Hypotension (SBP<100), Immunocompromised,
Institutionalized, Recent Surgery, Age > 70, Altered Mental Status
SIRS Criteria
> 2 of the following:
HR > 90
RR > 20
Temp > 100.4 or < 96.8
WBC < 4 or > 12
Resources Needed:
2 providers (nurse/paramedic)
Care partner
Resident physician
Attending physician if PGY1 resident
Primary survey - intubate if needed
Secondary survey including logroll
Establish appropriate intravascular access
(2 >18ga IV or central line)
Draw labs and blood cultures
Initial IVF Bolus – standard 2L NS
Foley catheterization if deemed necessary
Bedside urine dip
Portable CXR
Physician initiates Sepsis Alert (via LF)
Page to MICU team and MICU charge nurse
Transfer to MICU when bed available
Initiate goal directed therapy:
- complete antibiotics
- bolus to CVP 8-12mmHg
- transfuse to HCT > 30 if SvO2 < 70%
- levophed to keep MAP > 65
- dobutamine if SvO2 remains < 70%
2/8/2016 Page 4
Evaluate urine dipstick and CXR
Empiric antibiotics begun
CT scan if source unclear
Yes
Intubation, significant
lab abnormalities or
refractory
hypotension
No
Keep re-evaluating
Admit to appropriate unit
Complete antibiotics
Identify metrics for evaluation:
- time to antibiotics
- time to disposition
- time in ED bed
- ICU and hospital LOS
- mortality
Identify who needs education on initiative:
staff
leadership team
Nurse champions
Faculty
Residents
Assign accountability and clear timeline:
Action
Person Assigned
Timeline
Status
Develop & Implement
Faculty Education Plan
Ian Jones, Stephan Russ
Dec 09 / Jan 10
Faculty Meetings
Scheduled
Develop & Implement
Resident Education Plan
Jeremy Brywczynski,
Candace McNaughton
Dec 09
Scheduled
Develop & Implement
Nursing Education Plan
Kevin High, Jackie
Ashburn and more TBD
Create Sepsis Toolbox
Kevin High, Jackie
Ashburn and more TBD
Identify Nurse Champions
Nursing Leadership
Nov 09
Develop Sepsis VGR
Jones, Russ, Wrenn,
McNaughton Brywczynski
Oct 09
Completed
Implement Sepsis VGR
Asli Ozdas, Stephan Russ
Dec 09
Work Underway
Coordinate Sepsis Alerts
with LF
Kevin High
Dec 09
2/8/2016 Page 5
Action
Person Assigned
Timeline
Create Coordinated Vision
of Severe Sepsis Care
MICU/EM Faculty
Aug/Sept 09
Education of MICU staff
Art Wheeler, Todd Rice
Dec 09
Add a section on sepsis
alerts to the orientation
guide for rotation residents
McNaughton and ED
Chiefs
Dec 09
Status
Completed
Develop plan for sustained success: sustained success will be achieved through ongoing
leader rounding for outcomes, incorporation of education into orientation pathway, at least yearly
education to staff, sharing of outcomes data with staff linking them to the initiative.
Identify Methods of Content Delivery:
Physician Staff:
Faculty will be briefed in two consecutive faculty meetings and resident physicians will be given a onehour lecture during one of their regularly scheduled Tuesday conferences. The physician work force
will also receive and email with an explanation of the intended plan. The Chief residents will provide
yearly education of incoming interns as part of their regularly scheduled orientation, while the ED
Medical Director (Ian Jones) will include the sepsis alert protocol in the new faculty orientation. The
monthly M&M conference will serve as a method for reviewing an hurdles that might be incurred
during the implementation of the sepsis alert program.
Nursing/Paramedic/Ancillary Staff:
2/8/2016 Page 6