Pearls from the Sepsis Learning Collaborative and other good stuff!

1. Pearls from the Sepsis Learning Collaborative and other good stuff! © Premier, Inc. 2010

2. Beyond the Surviving Sepsis Campaign

3. SepsisAlliance

4. Goal: Reduce morbidity and mortality due to sepsis through early identification and initial resuscitation of adults (age>17) presenting to the ED with suspected sepsis/SIRS/severe sepsis/septic shock. QUEST Learning Collaborative: Sepsis © Premier, Inc. 2010

5. Global Aims: 1) screening at triage 2) early serum lactate 3) blood cultures before antibiotics 4) initial fluid resuscitation QUEST Learning Collaborative: Sepsis

6. D S P A A P S D A A P P S S D D Repeated Use of the Rapid Cycle to Improve Early Identification at Triage Changes That Result in Improvement Examples of “small tests of change” DATA Cycle 1d: tool & process forms used on all patients Cycle 1c: tool & process revised and used on next 5 patients Cycle 1b: tool is used on 1 patient by 1 triage nurse Theories Ideas Cycle 1a: severe sepsis screening tool & proposed process developed by the team is reviewed by others © Premier, Inc. 2010

7. Sepsis Collaborative Comparative DataSepsis Mortality Rates N= 30 9

8. Sepsis Collaborative Comparative DataPercentage of Cases with at least 1 Serum Lactate in the ED or on 1st day of Stay: within 90 days of start of Collaborative N= 30 10

9. Example of a Collaborator’s Sepsis team: Clark Willis MD - Medical Director of ED, Chris Snyder - Hospitalist/CMIO, Mike Miller - Clinical PharmD, John Morcom - Director of Respiratory, Susan Castrignano - Director of ED, Jo-Ann Lewis - Infection Preventionist, Beth Prouse - Clinical Microbiologist, Marybeth Damico - Director of Critical Care, Susan Elerding - Clinical Performance Improvement, Donna Thompson - Director of Clinical Performance Improvement Not Pictured: Tanya Clifford - Clinical Specialist Critical Care , and Melissa Lehrer - Medical Records Coding

10. What our team did during the Collaborative Change Concept focus: Standardize and Use of Reminders Sepsis Alert and Code Sepsis protocols More decision support in electronic orders/Iforms Care Alert for all Lactic Acids >4 and concurrent reviews Case reviews/M&Ms Barrier/challenges Decision for ICU, Central lines, and CVP monitoring

11. ED Iform for Sepsis

12. Antibiotic Guidelines on ordering screen 14

13. Admit to ICU If not already complete upon arrival: 1.Obtain stat Sepsis lab panel (blood cultures X 2, sputum culture, urine culture, CBCD, Chem8, Mg+, CRP, hepatic profile, urinanalysis, PT, PTT, Lactic acid, ABG, venous O2 sat, C-diff, type and screen) 2. Obtain Central line, CVP, A-line and VAMP 3. Place SCD’s/Lovenox as ordered 4. Insulin and GI prophylaxis as ordered Repeat lactate 6 hours after first level Provide Fluid Bolus as ordered: 20-30 ml/kg NSS (usually equals about 1-1.5L) rapidly Administer Antibiotic within 1 hour of arrival Broad spectrum prior to narrow spectrum Monitor CVP: If CVP < 8mmHg give 500 cc NS every 15 minutes X 3. If CVP still < 8mmHg after above call MD and Consult Pharm D Xigris for APACHE >25 CVP ≥ 8 No yes Once CVP ≥ 8 obtain venous blood gas MAP ≤ 65 If MAP < 65 and CVP > 8 begin Norepinephrine drip at 4mcg/min. Titrate to Map >70-80. If rate is 8-10 mcg/min start hydrocortisone 50mg every 6 hours yes No Scvo2 < 70% yes If CVP >8 and MAP > 65 and Scvo2 <70% begin Dobutamine at 2.5Mcg/kg/min No After 2 hours If MAP< 65 and on >15mcg/min of Norepinephrine begin vasopressin at 2 units and hour CVP, SBP, MAP, SvO2 goals achieved. Re-evaluate to maintain goals If CVP >8, MAP > 65 and Scvo2 <70% remain: Transfuse 2 units of PRBC’s over 2 hours ED to ICU flow

14. Our “WOW” (words of wisdom to other teams undertaking early identification and initiation of therapy for Severe Sepsis in the ED) • Involve Physician leaders early in the process. • Plan frequent working sessions. • Pilot and provide education. • Monitor compliance to identify gaps and barriers.

15. Barriers/Solutions • Barrier • ED physicians not ready to embrace aspects of EGDT • Nurses see this as just another “add on” thing to do • Solution • Break it down into components • Tackle low risk aims first • Severe Sepsis kills…early recognition means early intervention & lives saved • Start with Triage and nurse-driven protocols focused on early identification SIRS/sepsis/severe sepsis • Use common sense – no you won’t screen everybody (but you will be surprised at the catches you’ll make now that you are “looking” for suspected severe sepsis!!

16. Barriers/Solutions • Barrier • Early serum lactates: • We don’t have in-house capability • We can’t afford POC testing • Sometimes we forget to obtain it; we forget to follow up on it • Our physicians are reluctant to: • Order a serum lactate • Act on the results • Solution • Serum lactates are a “must have” not a “would be nice to have” – think “biomarker” • If POC testing is too expensive, use your whole blood analyzer • Standardized protocols; if patient looks sick enough for a blood gas or blood culture – get a lactate at the same time • Add serum lactate to Critical Values P&P – if > 4.0 – start aspects of EGDT • “Hardwire” rechecking any elevated lactate in 6 hours • Add “Severe Sepsis Alert/Protocol” to RRT

17. Barriers/Solutions • Barrier • Blood Cultures & Timely Antibiotics • We lose time while deciding what antibiotics to order • This is just more busy work – we can’t handle this • Solution • Use your local antibiogram to guide you; have 2-3 empiric regimens – pick drugs that can be quickly administered; have you ID docs work w/ your clinical pharmacists. Build in process/ “alerts” for switch to most appropriate therapeutic regimen once lab results are available. • Build on current processes/work flow that works – if you can get these things done for Pneumonia – you can make it happened for Sever Sepsis

18. Barriers/Solutions • Barrier • We don’t/can’t place central lines in the ED because: • We don’t have monitoring technology • We don’t have physicians who are comfortable placing “neck lines • Our nurses can’t read a CVP • We’re too busy; takes it much time to find all the stuff • Solution • If it is not feasible, don’t waste time focusing on this aspect • If your physicians are capable of placing central lines – engage ICU nurses to proctor/precept ED nurses in central line placement support & • If not ED physicians, have Intensivists or Anesthesia place the line • Have a central line cart (standardized) ready to go; adhere to the central line bundle components (same care – everywhere!)

20. THANK YOU!!!! © Premier, Inc. 2010 22