03/03/2016

1. Sepsis Awareness Training NYS Office for People with Developmental Disabilities Clinical StaffEve Bankert MT (ASCP)Quality Improvement SpecialistSeptember 22, 2016 03/03/2016

2. Please complete the Pre Training Assessment questions prior to the start of the training session Thank you!

3. Why This is Important Sepsis: Emergency Video Available on Sepsis Alliance Website: http://www.sepsis.org About Sepsis Alliance Sepsis Alliance is the leading nonprofit patient advocacy organization in North America promoting awareness of sepsis. Sepsis Alliance's mission is to save lives by raising awareness of sepsis as a medical emergency. The organization hosts national and community events, distributes educational information, and promotes training and education of sepsis and its devastating effects. Sepsis Alliance also provides support by giving patients and family members information about sepsis and post sepsis syndrome. Sepsis Alliance, a 501(c)(3) charitable organization, is a GuideStar Gold Rated Charity.

5. What is Sepsis? • Sepsis is a life threatening condition that arises when the body’s response to an infection injures its own tissues and organs1 • If not treated promptly Sepsis can result in: • Organ Failure • Tissue Damage • Death 1. (Singer, et al. JAMA 2016;315(8) 801-810)

6. Who is at Risk for Sepsis? Anyone with an infection (anywhere in the body) • People 65 or older • Infants less than 1 year old • People with chronic illnesses: diabetes, cancer, AIDS • People with weakened immune systems • People recently hospitalized • People recovering from surgery

7. Early Recognition is Important Early detection and treatment is critical to: • Decrease morbidity and mortality related to Sepsis • Avoid long term health-related complications • Potentially avoiding sepsis-related hospitalizations Your prompt actions could save a life!

8. Public Awareness of Sepsis is Poor Sepsis is one of the most under recognized and misunderstood conditions by HCPs and the public The public needs an understandable definition of Sepsis • 54% of US adults have not heard of Sepsis1 HCPs need improved clinical prompts to facilitate earlier identification of Sepsis 1.http://www.sepsisalliance.org/news/2013/four_in_ten_adults_never_heard_of_sepsis

9. Early Signs of Sepsis Patients typically have more than oneof the following: Infection(confirmed or suspected) plus: • Fever or feeling very cold • Rapid heart rate • Rapid breathing • Shortness of breath • Confusion or difficult to arouse • Complaints of extreme pain • Pale/discolored skin

10. Other Early Signs May Include: Decreased blood pressure • (SBP <90mmHg, MAP <65 or SBP decrease>40mmHg) Altered mental status Decreased urine output / dark, concentrated urine • (<0.5 ml/kg per hour ) Abnormal lab tests • Increased lactate level >2mm/L • Increased creatinine >2mg/dL • Decreased platelet count <100,000 • Coagulation abnormalities INR> 1.5 or PTT >60 secs • Hyperglycemia in absence of diabetes >120mg/dL

11. Special Considerations for Elderly Urinary tract infection (UTI) is a common source of Sepsis • Elderly are more at risk for UTIs • Especially those with indwelling urinary catheters • Symptoms can differ from younger people • Confusion • Agitation • Poor motor skills or dizziness • Falling • Other behavioral changes UTIs in elderly are often mistaken for early dementia or Alzheimer's Disease (NIH)

12. Sobering Statistics Mortality rate for Severe Sepsis (term no longer used) is 29%1 which is greater than: • AMI (25%)2 • Stroke (23%)3 • Trauma (1.5%)4 18 million people die of Sepsis worldwide every year Sepsis is the leading cause of childhood deaths Sepsis is the most expensive condition treated in U.S. hospitals5 Sepsis kills 258,000 Americans annually6 Early diagnosis of Sepsis is often missed • Crit Care Med 2001 • JACC 1996 • American Heart Association. Heart Disease and Stroke Statistics- 2005 Update • National Highway Traffic Safety Administration. Traffic Safety Facts 2003 • AHRQ • CDC

13. Geographic Component “The Sepsis Belt” • Includes Southeastern and mid-Atlantic states: Mississippi, Alabama, Georgia, Tennessee, North Carolina, Virginia, Maryland, Delaware and New Jersey • Sepsis mortality rates in these states are two times higher than states outside the “Belt” • High obesity rates in these states • Obesity is a risk factor for sepsis • Sepsis Belt geographically mirrors the “Stroke Belt” Infection Control Today July 29, 2011

14. Hospitalizations for Sepsis Increasing • Increase in aging population (high risk group) • Increase in antibiotic resistant bacteria • Increase in people with immunocompromising conditions

15. Patients Hospitalized for Sepsis Are more severely ill than those hospitalized for other conditions Have considerably longer lengths of stay in the hospital than those hospitalized for other conditions Are more likely to die during hospitalization compared to those hospitalized for other conditions

16. MFFS Length of Stay Data Albany & Syracuse Hospital Referral Region CY 2015 Highest Mortality Rate Occurs Within first 5 Days of Hospital Stay “Sepsis strikes quickly, and earlier recognition and improved care management can reduce sepsis-related morbidity and mortalities.”(Castellanos-Ortega A et al, 2010).

17. Consumption of Healthcare Resources Sepsis: Most Expensive Condition Treated in U.S. Hospitals1 • $24 billion spent each year treating Sepsis in hospitals • In-hospital mortality rate eight times higher than other diagnoses Increased Length of Stay Costs Related to Long-term Impacts of Sepsis2 • Significant subsequent medical care and services • High re-hospitalization rate • Delayed return to work 1. AHRQ- Agency for Healthcare Research and Quality 2. Medicare Fee for Service Paid Claims Data

18. Albany & Syracuse Hospital Referral Region MFFS Readmission Trends CY 2014 Source: CMS Medicare FFS Paid Claims

19. Systemic Inflammatory Response Syndrome SIRS = Systemic Inflammatory Response Syndrome Old definition : SEPSIS = INFECTION + 2 OR MORE SIRS CRITERIA SIRS Criteria: • Fever >101°F • Hypothermia <96.8°F • Heart rate >90 beats/minute • Respiratory rate >20 breaths/minute • WBC >12 or <4 or >10% bands • Note: SIRS can exist without progressing to Sepsis

20. Progression of Sepsis If not treated promptly, Sepsis can progress! INFECTION + SIRS SEPSIS (old definition) SEPSIS + NEW ONSET ORGAN INJURY SEVERE SEPSIS (term no longer used) SEVERE SEPSIS + REFRACTORY HYPOTENSION OR TISSUE HYPOXIA (ELEVATED LACTATE) SEPTIC SHOCK

21. 2016 New Definitions for Sepsis and Septic Shock Third International Consensus Definitions for Sepsis and Septic Shock (Singer, et al. JAMA 2016;315(8) 801-810) Utilizes SOFA criteria: Sequential Organ Failure Assessment Score • SEPSIS: life threatening organ dysfunction caused by dysregulated host response to infection (organ dysfunction determined by SOFA scoring) • SEVERE SEPSIS: a definition no longer to be used • SEPTIC SHOCK: Sepsis plus: • Fluid-unresponsive hypotension • Need for vasopressors to keep MAP >65mmHg • Serum lactate > 2mmol/L New definitions do not use SIRS criteria: too many hospitalized patients have SIRS but no infection

22. 2016 New Definitions for Sepsis (cont.) qSOFA (quick SOFA) Criteria: • Better predictor of patient outcomes for non-hospital and non-ICU settings • Appropriate and easy to use in the outpatient setting • Altered mental status • Hypotension ( systolic <100mmHg) • Increased respiration rate (>22 breaths per minute) • 2 of the 3 criteria provides simple bedside criteria to identify adults with suspected infection who are likely to have poor outcomes

23. Initial Treatment- Evidence Based Consistent with Surviving Sepsis Campaign1 Within 3 Hours of Presentation* • Measure blood lactate level • Obtain blood cultures (prior to giving antibiotics) • Administer broad-spectrum IV antibiotics • Administer 30ml/kg crystalloid for hypotension or lactate≥4mmol/L Recommended within 1st hour of recognition Within 6 Hours of Presentation of Septic Shock • Administer vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg • For persistent hypotension (MAP<65) or initial lactate ≥4mmol/L, reassess volume status and tissue perfusion • Repeat lactate level if initial level was elevated *Time of presentation is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all the elements of severe sepsis or septic shock ascertained through chart review 1. Surviving Sepsis Campaign Bundle revised 4/2015 by SSC Executive Committee

24. Every Minute Counts! TREAT SEPSIS AS A MEDICAL EMERGENCY ** NOTIFY PHYSICIAN ASAP IF RESIDENT EXHIBITS THE SIGNS OF SEPSIS** Sepsis is treatable and can be prevented from progressing to Septic Shock…BUT it must be suspected! Early, prompt recognition and treatment improves survival rates For every hour that appropriate treatment is delayed the risk of death increases by 7.6%1 1. Crit Care Med,2006; 34: 1589-96.

25. Post Sepsis Syndrome Affects up to 50% of sepsis survivors • Impaired cognitive function-especially among older patients • Mobility impairments (muscle weakness) • Amputations • Hallucinations • Loss of self-esteem • Increased dependency on others More than 1 in 5 who survive sepsis have a late death not explained by health status (i.e. underlying comorbidities) before sepsis1 Impact on Caregivers • Inadequate hospital discharge education on what to expect during recovery • Difficulty accessing follow-up community treatment • Cost • Disruption to their lives 1.BMJ 2016;353:i2375http://dx.doi.org/10.1136/bmj.i2375

26. New York State Regulations NY is the first state in the nation to enact Sepsis Regulations Requires every hospital to have protocols for: • Recognizing early signs of Sepsis • Identifying high risk patients • Early treatment measures • Staff training • Metric analysis as a driver of change Source: NYS Department of Health Sepsis Regulations Guidance Document 405.4 (a) (4). 2013

27. Home Health Specific Training Home Care Services Adult Sepsis Screening Tool

28. Home Care Association of NYS (HCA) Sepsis Tools Home Care Association of NYS Quality Committee • Review of Medicare fee for Service Readmission Diagnoses from IPRO showed Septicemia to be #1 diagnosis for 30-day all cause readmissions for NYS hospitals • Investigated at the national level and through the National Association of Home Care (NAHC) to see what resources and tools were available for home health setting related to sepsis – no resources found • Sepsis Work Group formed to develop a Sepsis Screening Tool for home health setting, led by: • Al Cardillo, Executive Vice President / HCA • Amy Bowerman RN , Director of Quality Improvement/Privacy Officer  Mohawk Valley Health Systems- Home Care Services / Director of Patient Services-Senior Network Health • Adult Sepsis Screening SBAR (Situation-Background-Assessment- Recommendations) Tool • Adult Sepsis Screen Flow Chart • Beta Tested by multiple home health providers with input from prominent physicians at the state and national level as well as with the National Sepsis Alliance • Work Group focusing efforts on pediatric version of tool for home care

29. Crosswalks to mandatory NYS Emergency Department Sepsis Protocol Already included in Vital Signs and Nursing Assessment • Key Factors for Success • Senior leadership support • Clinician’s solid understanding of signs and symptoms of sepsis • Agency resource for questions from the field

31. Key Points About the Sepsis Screening Tool Screening is completed at SOC, ROC & every visit The tool is not to be used as standing orders The interventions are recommended interventions and not a substitute for treatment or advice from a physician or healthcare provider If clinicians choose to order tests/interventions not listed on the tool, they need to document at bottom of the screen tool (or “refer to nurse note and document on nurse note the intervention that was ordered) Clinicians still need to send orders for signature

32. INTERACT Stop and Watch Tool Stop and Watch is a helpful tool to help identify changes in a patient’s condition that could be the early signs of Sepsis: • Seems different than usual • Talking or communicating lessthan usual • Overall needs more help than usual • Participating in activities less than usual • Ate less than usual (not because dislikes food) • No bowel movement in 3 days: or diarrhea • Drinking less than usual • Weight change • Agitated or nervous more than usual • Tired weak confused or drowsy • Change in skin color or condition • Help with walking, transferring or toileting more than usual • HTTP://INTERACT2.NET/

33. Skilled Nursing Specific Training Skilled Nursing Facility Care Pathway

35. Special Considerations for SNF Residents Urinary tract infection (UTI) is a common source of Sepsis • Elderly are more at risk for UTIs • Especially those with indwelling urinary catheters • Symptoms can differ from younger people • Confusion • Agitation • Poor motor skills or dizziness • Falling • Other behavioral changes UTIs in elderly are often mistaken for early dementia or Alzheimer's Disease (NIH)

36. How You Can Help Familiarize yourself with the early signs of Sepsis Know who is at risk for Sepsis Educate your friends, family and patients / caregivers about the signs & symptoms of Sepsis Be cognizant of Health Literacy and its implications: Explain information to patients in a manner they can understand Teach Back Method

37. Teach Back Method Studies have shown that patients forget 40-80% of the information they receive almost immediately after hearing it1 Teach Backis asking people to restate in their own words what has been presented to them How Teach Back can help ensure effective communication: • Helps gauge the need for re-explaining if necessary • Heightens engagement of your audience • Fosters trust between presenter and audience • Creates an opportunity for dialogue between you and the audience 1. N Engl J Med 2009; 360: 1418-1428

38. Talking with Residents, Patients & Families Start the discussion by asking if they have heard of Sepsis (If they have let them tell you what they know) Share key points about Sepsis: • The body’s over enthusiastic/often life threatening response to an infection anywhere (skin, urine, respiratory etc.) • Anyone with an infection may be at risk for developing sepsis • Early signs and symptoms; fever/feeling cold, sleepy/confused, short of breath, rapid heart rate, decreased /dark urine • Its important that you let your caregiver know if you experience any of the above • Sepsis is a medical emergency

39. Talking with Resident/Patients/Families Preventative Measures • Practice good hand hygiene • Try to avoid infections • Treat infections promptly • Get vaccinated! • Maintain good overall health Share & introduce the IPRO brochure “Sepsis: Every Minute Counts!”

40. Sepsis Awareness Saves Lives Treat Sepsis as a MEDICAL EMERGENCY If the patient exhibits the early signs of Sepsis notify Physician ASAP for medical attention EARLY PROMPT RECOGNITION & TREATMENT GREATLY IMPROVES SURVIVAL RATES

41. Resources: Surviving Sepsis Campaign: http://www.survivingsepsis.org/Pages/default.aspx Centers for Disease Control (CDC): http://www.cdc.gov/sepsis/clinicaltools/index.html Sepsis Alliance: http://www.sepsis.org/ Rory Staunton Foundation: https://rorystauntonfoundationforsepsis.org/ IPRO Sepsis Initiative http://stopsepsisnow.org

42. Questions Feedback Recommendations

43. Please complete Post Training Assessment questions and hand in to presenter at the end of training session Thank you! Please Fax to Eve at 518-426-3418

44. Eve Bankert, MT (ASCP) Quality Improvement Specialist (518) 320-3552 Eve.Bankert@area-I.hcqis.org Sara Butterfield, RN, BSN, CPHQ Senior Director (518) 320-3504 Sara.Butterfield@area-I.hcqis.org For more information IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.atlanticquality.org IPRO Sepsis Initiative http://stopsepsisnow.org This resource is not all inclusive and may not apply to all patients/residents and/or situations. It is intended for educational purposes only and as guidance to support investigation for performance improvement, not as a substitute for treatment or advice from a physician or healthcare provider. IPRO does not endorse any particular vendor or tools. This material was prepared by the Atlantic Quality Innovation Network/IPRO, the Medicare Quality Innovation Network Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.11SOW-AQINNY-TskSIP-Sepsis-16-07