UNC Hospitals Sepsis Mortality Reduction Initiative Core Adult Patient Sepsis Training Slides Updated Code Sepsis

UNC’s Mortality Index is ranked 65 th out of 73 Academic Hospitals with 500 or more beds in 2014.

If UNC's performance was consistent with the UHC Top Ten, there would have been 218 fewer inpatient deaths in the last two years.

Top Ranked hospitals have a sepsis reduction initiative

Deaths at UNC with a Diagnosis Code of Sepsis July-September 2014 UnitDeaths MICU 44 SICU 8 CICU 6 NCCC 5 NSIU 5 PICU 5 BMTU 4 MPCU 2 8 BT 2 6 BT 2 TICU 2 ISCU 2 6 EST 1 3 WST 1 5 BT 1 4 ONC 1 Grand Total 91 67% of deaths in the MICU involved Sepsis

Sepsis is a VERY common cause of inpatient deaths Hospital Deaths in Patients with Sepsis from Two Independent Cohorts Liu et al JAMA May 18, 2014 All Sepsis 52% All Sepsis 45% National Sample data shows that coding doesn’t catch all sepsis cases, UNC rates are likely higher than reported.

Other Organizations with successful sepsis reduction programs Wake Forest Baptist Nation of Scotland Penn State Long Island Jewish Health System Many more

Time to Antibiotic Administration Is the Most Important Predictor of Survival in Septic Shock* *Kumar A et al : Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine 2006; 34(6): Wake Forest reduced their time to first antibiotic significantly.

Scotland is using an Early Warning Score, an advanced sepsis screen, and a one hour bundle.

The entire country of Scotland uses an early warning score and sepsis management protocol to reduce their mortality ratio by almost 16%

North Shore University Hospital in Long Island Jewish system reduced ALOS and Mortality.

MORTALITY REDUCTION STRATEGY Healthcare Acquired Conditions Appropriate Palliative Care Failure to Rescue SEPSIS Improve Early Warning Systems and Response Systems Implement Early Suspicion and Accurate Recognition Sepsis Implement Prompt and Accurate Sepsis First Hour Treatment Implement Antibiotic Stewardship in Sepsis Program

* Kumar A et al : Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine 2006; 34(6):

Sepsis Program Overview Triage and Screening System for rapid recognition Rapid treatment with antibiotics and fluid resuscitation, lactate, CBC, and blood cultures Each area will have representation on implementation teams Adaptation of best practices from centers of excellence

Complacency, Education & Trying Harder isn’t enough

3 Recent Large Randomized Control Trials: Although advanced severe sepsis therapies (such as central line placement, SVO2 goals, etc) did not show improved outcomes, all were randomized after early recognition and standard therapies including antibiotics and fluid resuscitation which are the goals of UNC Code Sepsis

Surviving Sepsis Campaign: Association Between Performance Metrics and Outcomes in a 7.5-Year Study – published on line Critical Care Medicine December 2014 Increased compliance with sepsis performance bundles was associated with a 25% relative risk reduction in mortality rate Every 10% increase in compliance and additional quarter of participation in the SSC initiative was associated with a significant decrease in the odds ratio for hospital mortality total hospital LOS 4.8 days shorter compared to pre- implementation group (p = 0.043) ICU LOS decreased 2.6 days shorter (p = 0.004)

Reliable Sepsis Recognition and Assessment Reliable Recognition and Assessment Reliable Care Delivery Education and Awareness Culture of Safety and Quality Improvement Patient and Family Centered Care Reliable Sepsis Screening Early Warning System + SIRS Ensure reliable communication SBAR Ensure timely rescue of deteriorating patient by competent team Involve patient and family advisors in design Primary Drivers Secondary Drivers

UNC Sepsis Implementation Goal: to reduce the raw mortality rate by 10% at UNC Hospitals by June 2016 when compared to 2013 baseline – Scope: Children’s Hospital, ED, ICU’s and all areas of ARRT activation – Phase I: Children’s Hospital implementation complete by June 30, 2015 – Phases II-IV: ED, Critical Care Units, Inpatient Units

Project Updates

UNC Children’s Hospital Working Timeline

UNC Hospitals Implementation Timeline Children’s Hospital Go-Live

Early Warning Score Development Modified Pediatric Early Warning Score – Children’s Hospital IP units – currently being modified Modified Early Warning Score – Currently being tested on adult acute care units – EPIC 2014 tools Early warning scores assist in detecting deteriorating or “sick” patients – not necessarily sepsis

UNC Adult Implementation Team Training Timeline Phase II: August 2015 ED Care Team Inpatient Care Areas ED Go-Live June/July 2015 Phase III: November 2015 All Medical Center staff Phase I: March/April 2015 Air care ED advanced care team ARRT –primary and secondary Hem/Onc Responders

Working Adult Patient Bundle

Does patient have > 2 of the following: Respiratory Rate >20 + UNC Adult Early Sepsis Screen ADULT Sepsis Response Team Assess to confirm sepsis COMPLETE BUNDLE IN < 60 MINUTES & notify primary team: “Adult Sepsis Bundle” EPIC order set Then Trigger Sepsis Response - in design Suspected Infection Core Temp 38 (home temp also valid) WBC count 12 High Risk* (see next page) Heart Rate >90 Altered Mental State Measure Lactate Level Obtain Blood Culture (attempt 2 sets prior to antibiotic) Alert Pharmacy of sepsis for faster antibiotic delivery - use closed loop communication Initial dose of antibiotic (even if no blood culture is available) see “Adult Sepsis Bundle” Epic Orders Consider transfer to higher level care if inadequate response to fluid resuscitation or based on clinical status Fluid Resuscitation 30 ml/kg or 2L in the first hour

ADULT Sepsis HIGH RISK* Patients Immunocompromised Diabetes Indwelling medical device Transplant (BMT or Solid Organ) Recent surgery/invasive procedure Burn Patients Congestive Heart Failure Cancer Geriatric

EPIC Foundation Sepsis Alert Epic Sepsis Alert

When in doubt… Think to yourself first, “This is sepsis!” Then ask, “Why isn’t this sepsis?” When no other reason found, then conclude, “Oh wait, it is sepsis.”

Sepsis Training Case Examples

Example Inpatient Sepsis Case - Surgical Pt. admitted for a major surgical procedure Procedure goes well and pt. is able to transfer out of ICU to floor on POD#2 On POD#8 at 0900, nursing begins charting that pt. is confused/somnolent/hallucinating after having been alert and oriented for the six days prior. – VS at 0900 – HR 106, RR 18, SBP 107, Temp 36.9 POD#8 at 1500, pt. continues to be confused/somnolent – VS at HR 113, RR 18, SBP 89, Temp 35.3 No rapid response called and pt. remains on the floor

20 hrs later, at 1100 on POD#9, nurse charts that pt. was extremely confused and hallucinating – VS at 1100 – HR 120, RR 18, SBP 81, Temp 35.6 – No urine output since POD#8 at 2200 POD#9 MD note states that sepsis suspected – Blood culture ordered at 1210 – 2250ml of Albumin 5% given between 1225 and 1809 – Zosyn ordered and first dose given at 1326 – Vanc ordered and first dose given at 1830 First lactate not drawn until POD#10 at 1530 Pt. transferred to SICU at 1458 on POD#9 Pt. eventually passed away 1 month post procedure Example Inpatient Sepsis Case - Surgical

Pt. with history of cancer with mets to abdomen and brain presented as direct admit with confusion and fatigue – 1722 – HR 101, RR 22, BP 129/74, Temp 36.7, Sats 95% on RA, A&O x 4 – 1943 – HR 134, RR 24, BP 103/59 (pt. had excessive nose bleeding) – 2000 – Rapid response called due to nose bleed – 2152 – Rapid response ended and pt. remained on wards – 2202 – 1000 ml NS bolus given – 2258 – HR 105, RR 15, BP 129/92, Temp 36.8, Sats 93% on RA, A&O x 4 – 2347 – NS infusion at 100 ml/hr started Example Inpatient Sepsis Case - Medical

0231 – HR 97, RR 16, BP 106/88, Temp – Rapid response called for AMS, decreased O2 sats, and RN/family worry HR 125, BP 129/92, Sats 84% on 2 L NC 0519 – Lactate drawn (10.3) Rapid response RN and primary team MD see patient – primary MD requests repeat Lactate (result – 11.3). Primary team attributed lactate to extensive cancer. No fluids given – HR 109, RR 14, BP 120/69, Temp 36.6, Sats 94% on 4 L NC 0626 – Rapid response ended 0850 – Blood culture from CVAD (port) drawn (later result - Oxacillin susceptible staph aureus) 0925 – Lactate drawn (20.0) 0950 – Blood culture peripheral drawn (result – no growth) 1100 – HR 149, BP 66/28, Sats 87% on 4 L NC (Note - no vitals between 0615 and 1100) 1100 – Code blue called, transferred to MICU, dies in ICU days later Example Inpatient Sepsis Case - Medical

Example ED Sepsis Case Patient with ESLD presented to the ED complaining of syncope Underwent paracentesis one month prior and was scheduled to have another paracentesis the day of the syncopal episode 0709 – ED triage 0718 – Pt. A&O x 4, HR 79, RR 18, BP 93/45, Temp 36.5, Sats 100% 0730 – 20 G PIV in left AC placed 0731 – Venous lactate drawn (3.9) 0810 – 500 ml given over 91 min. (stopped at 0941) 0819 – Resident note states low suspicion of infection due to “lack of fever and nontoxic appearance” 0920 – Blood culture drawn 1243 – HR 76, RR 21, Temp 36.9, Sats 100%

Example ED Sepsis Case 1536 – Paracentesis done in ED 1542 – Pt. remained A&O x 4, HR 80, RR 20, BP 72/ – 500 ml NS bolus given 1557 – Paracentesis results showed spontaneous bacterial peritonitis 1559 – BP 76/42 (MD note states that pt. reported her baseline SBP’s at ’s) 1626 – Cefotaxime ordered 1643 – 75 g 25% albumin started (stopped at 1855) 1645 – NS infusion started at 100 ml/hr 1646 – BP 77/40 according to nursing note 1749 – Cefotaxime started (stopped 1855) 1950 – HR 86, RR 17, BP 71/45, Sats 95% 2031 – 500 ml NS bolus given over 1 hr. 100 ml/hr NS infusion stopped – HR 80, RR 15, BP 72/46, Sats 98% 2055 – Pt. transferred to MPCU

Example ED Sepsis Case 2057 – RN paged MD that SBP’s remaining in the 70’s – 1000 ml NS bolus given over 35 min. (stopped at 2210) 2223 – RN paged MD that BP 74/49 after fluid bolus 2259 – 1000 ml NS bolus given over 56 min. (stopped at 2355) 2310 – RN paged MD that BP 69/33 with 2 nd 1000 ml fluid bolus running 2341 – Med I at bedside to eval for admission to MICU – Transferred to MICU 0103 – Norepi and vasopressin started 0106 – 1000 ml NS bolus started 0107 – 1000 ml NS bolus started 0253 – Arterial lactate drawn (2.2) Total of 3900 ml NS given in ED and MPCU prior to MICU transfer. Cefotaxime continued. Vanc ordered but then discontinued and never given. Pt. transferred back to MPCU after several ICU days and then discharged the following week

Take Home Points This new system is still in design and will be different in the coming months when we “go live” and improve on the system Just because a patient has a positive “screen” or BPA alert for sepsis, it does not mean that the primary team or ED/Rapid response team will diagnose and treat sepsis Septic Shock may be more subtle than you think Call sepsis team (RRT for inpatient units – triggered ED response in ED) for rapid IV access, fluid administration, antibiotic arrival, and lab studies – all bundle elements EPIC Order Set for initial bundle = “Adult Sepsis Bundle” – available mid June 2015 Patients can worsen rapidly If you want to help us in the development or have feedback please contact the Sepsis Program Team:

Public UNC Code Sepsis Website Resources>Performance Improvement and Patient Safety>Sepsis Program Content: Background Resources Sepsis Toolkit FAQs Need Help? Content: Background Resources Sepsis Toolkit FAQs Need Help? Or just Google “UNC Code Sepsis”