Presented by: Laura Messineo System Manager eICU Operations

1. Presented by: Laura Messineo System Manager eICU Operations

2. Objectives Sepsis Facts Case Studies Early Goal Directed Therapy Presence Health’s Sepsis Initiative Final Words

3. Sepsis Facts

4. National Incidence of Sepsis Every year, severe sepsis strikes about 750,000 Americans1. Severe Sepsis kills 266,464 patients per year in the U.S. 50% of these deaths are preventable Sepsis kills someone in the United States every 2.5 minutes The rate of sepsis cases increases by 9% every year According to the CDC: Patients hospitalized for septicemia or sepsis were more than eight times as likely to die during their hospitalization.

6. Patients hospitalized for septicemia or sepsis were more severely ill than patients hospitalized for another diagnosis.

8. Sepsis is Costly Severe sepsis is estimated as 40% of all ICU expenditures1; $16.7B in the US alone.2 The ALOS is 19.6 days and costs $22,100 per case.2 The ICU patient with sepsis costs 6 X more than that care of a patient without sepsis.3

9. National Focus on Sepsis

10. Case Studies

11. Rory Staunton A Preventable Death, An Opportunity for Improvement • Critical sepsis diagnosis missed by healthcare providers, leading to 12-year-old Rory’s untimely death in New York

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13. Jennifer Ludwin: Septic Shock Survivor

14. Malia’s Story

15. The Great Unknown Sepsis Survivors • Number of Disabilities • Amputation • Thinking • Memory • Calculations • Post Traumatic Stress Disorder Many carry the scars of sepsis for the rest of their lives

16. Suspect Sepsis

18. Sepsis: Invasion of a normally sterile organ/system by bacteria What is Sepsis? INFECTION KIDNEY GI LUNG HEART C Difficile Urosepsis Pneumonia Endocarditis

19. Suspect Infection Pneumonia/empyema Urinary Tract Infection Acute Abdomen Infection Meningitis Acutely Altered Mental Status Chills with Rigor Skin /Soft Tissue Inflammation Bone/Joint Infection Wound Infection Blood Stream Catheter Infection Implantable Device Infection Endocarditis Other Infections

21. 2 SIRS Criteria Hyperthermia >38.3 C/ 101F Hypothermia <36 C/ 96.8 F Acutely Altered Mental Status Tachycardia >90bpm Tachypnea >20bpm Leukocytosis (WBC >12,000) Leukopenia (WBC <4,000) Bands ≥ 10% Hyperglycemia >140 ( in absence of diabetes)

22. HYPOPERFUSION - Lactate > 2 mg/dL CARDIOVASCULAR - SBP < 90 mmHg, MAP < 65 mmHg, or decrease SBP decrease 40 mmHg from normal RENAL - Acutely elevated serum creatinine, or urine output < 0.5 ml/kg/hr PULMONARY - Bilateral infiltrates with P/F ratio < 300 HEMATOLOGIC - Platelets < 100,000 or INR > 1.5 GASTROINTESTINAL - Total bilirubin > 2 mg/dL Is There Organ Dysfunction?

23. From Sepsis toSeptic Shock

24. SEVERE SEPSIS: Source of infection Two SIRS criteria One organ dysfunction SEPTIC SHOCK: Source of infection Two SIRS criteria Lactate > 4 mg/dl AND/OR Hypotension requiring pressors after adequate fluid resuscitation Severe Sepsis Definitions

25. Early Goal Directed Therapy

26. Time Sensitive Interventions ACUTE MYOCARDIAL INFARCTION: Time is Myocardium SEPSIS: The Three and Six Hour Bundle ACUTE STROKE: Time is Brain TRAUMA: “Golden Hour”

28. Rivers, et al; NEJM 2001 Early Goal Directed Therapy (EGDT) In The Treatment Of Severe Sepsis And Septic Shock

29. 3 Hour Bundle • Measure Lactate level • Obtain Blood Cultures • Administer Broad Spectrum Antibiotics • Administer 30ml/kg crystalloid for hypotension or lactate ≥4

30. 6 Hour Bundle • Apply Vasopressors (for hypotension unresponsive to fluid resuscitation) Maintain MAP≥65 mm Hg • Septic Shock patients with persistent hypotension despite fluid resuscitation • Measure Central Venous pressure (CVP) • Measure central venous oxygen saturation (Scvo2) • Remeasure lactate if initial lactate was elevated

31. Presence Health’s Sepsis Initiative

32. Sepsis Council Representation from all 12 ministries Sepsis Champions identified at each ministry Goals • Implement 2012 Surviving Sepsis Campaign Guidelines • Standardize order sets in Epic and Meditech • Standardize screening process • Standardize data collection and distribute monthly

33. Septic Shock Mortality Utilizing ICD 9 Codes

34. Potential Impact of EGDT for Sepsis – at PRESENCE Health 1Nguyen, HB et al. Critical Care Medicine. 2007; 35:1105-1112 2Angus, DC et al. Critical Care Medicine. 2001; 29:1303-1310

35. Mobile Simulation Lab

36. Closing Thoughts……

37. Suspect Sepsis Implement EGDT Decrease Disabilities SAVE LIVES!!!

38. Join Me……