UNC Hospitals Sepsis Mortality Reduction Initiative Emergency Medicine Sepsis Training Updated Code 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.

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

Sepsis Program Overview Early suspicion followed by effective confirmation of sepsis by a clinician leading to clinically appropriate, evidence-based sepsis treatment Although screening tools (Epic BPA-Best Practice Alerts, qSOFA, SOFA, early warning systems) may be helpful in identifying at-risk patients, these tools are not diagnostic Evidence-based sepsis bundle therapies require clinician assessment for confirmation and orders Program focus includes early detection, standardized bundles, training in sepsis diagnosis and care, hands on practice/simulation, and antibiotic stewardship 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

Date of download: 3/14/2016 Copyright © 2016 American Medical Association. All rights reserved. From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama New Sepsis Definitions 2015

Date of download: 3/14/2016 Copyright © 2016 American Medical Association. All rights reserved. From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama Sequential [Sepsis-Related] Organ Failure Assessment Score a Table Title: qSOFA = 2 or more: RR > 22, SBP < 100, Altered Mental Status

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis- 3) The task force maintains that standardization of definitions and clinical criteria is crucial in ensuring clear communication and a more accurate appreciation of the scale of the problem of sepsis. An added challenge is that infection is seldom confirmed microbiologically when treatment is started; even when microbiological tests are completed, culture-positive “sepsis” is observed in only 30% to 40% of cases. Thus, when sepsis epidemiology is assessed and reported, operationalization will necessarily involve proxies such as antibiotic commencement or a clinically determined probability of infection. Future epidemiology studies should consider reporting the proportion of microbiology-positive sepsis. JAMA. 2016;315(8): doi: /jama

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis- 3) Neither qSOFA nor SOFA is intended to be a stand-alone definition of sepsis Failure to meet 2 or more qSOFA or SOFA criteria should NOT lead to a deferral of investigation or treatment of infection or to a delay in any other aspect of care deemed necessary by the practitioners qSOFA can be done promptly at the bedside and may prompt testing to identify biochemical organ dysfunction and enable subsequent SOFA scoring SIRS criteria may still remain useful for identification of infection Septic Sock = Sepsis and vasopressor therapy needed to elevate MAP > 65 mm Hg and Lactate > 2 despite adequate fluid resuscitation JAMA. 2016;315(8): doi: /jama

CMS Sepsis Core Measure – released October 2015 Pre-2016 sepsis definitions – severe sepsis and septic shock Early recognition, lactate, blood cultures, broad spectrum antibiotics, >30 mL/kg fluid resuscitation for shock CMS core measure reassessment including repeat lactate within 6 hours if initial lactate > 2 AND Repeat clinical exam documented in chart by provider including specific wording (e.g. cap refill, peripheral pulses) OR 2 of the following [EGDT] CVL placement measure CVP CVL placement SVO2 Passive Leg Raise Documented Cardiac Ultrasound Not targeted in protocols in UNC Sepsis Program – Protocol-driven EGDT no longer supported

UNC Health Care System FY 2017 Org Goal Improve CMS Core Measure Compliance by 20% Compared to Baseline FY 2016

Current Pilot Tools

Screening Tools/ Order Sets Real Time Sepsis Best Practice Alert – “Possible Sepsis Alert” stop and evaluate – Alerts RN with link to RN ED Sepsis Orders (blood cultures, labs, initial fluid if indicated) – Alerts MD with link to ED Provider Sepsis Order Set (antibiotics and fluid resuscitation, etc) – Not all patients with sepsis BPA have sepsis – need clinician order for sepsis bundle implementation

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

Sepsis Alert for Nursing – Evaluate for Sepsis “Treating Associated Infection” silences the Alert for that user for 96 hours “Treating Separate Illness” silences the alert for that user for 96 hours

Nursing Order Set

Sepsis Alert for Providers – Evaluate for Possible Sepsis “Treating Associated Infection” silences the Alert for that user for 96 hours “Treating Separate Illness” silences the alert for that user for 96 hours

Provider Order Set

Update June 2016 – there are 2 fluid bolus options based on provider clinical judgment: Choose either 1.fluid challenge with 1-2 liters over minutes each or 2.30 mL/kg NS bolus for SEPTIC SHOCK

Provider Order Set – Choose antibiotic based on source or unknown source

Sepsis BPA FAQ Q: If I acknowledge the alert, will it pop up for my co-workers? A: Yes, the alert will pop up for any user that has not acknowledged it while the patient meets the alert criteria. Q: If I choose “cancel” will the alert pop up again? A: Yes, as long as the patient meets the criteria. The alert will continue to pop up until it has been acknowledged using “Treating Associated Infection” or “Treating Separate Illness”. Q: How does Epic calculate the LOC component? A: Epic identifies “Drowsy”, “Somnolent”, and “comatose” in the triage navigator to populate LOC.

Q: If my patient’s condition improves, will the alert stop? A: Yes Q: Should I always utilize the order set when the alert pops up? A: No, the alert is designed to be sensitive rather than specific. Use your clinical judgment to determine whether or not the patient is showing signs and symptoms of sepsis.

If patient requires fluid bolus give rapidly – not on pump If patient in SEPTIC SHOCK, give at least 30 mL/kg fluid bolus

Take Away Points Assess possible sepsis patients early to determine if bundle is indicated – New or Worsening Organ Dysfunction and Known or Suspected Infection Use the Sepsis Bundle Order Sets Adult Septic Shock Patients Require 30 ml/kg fluid bolus minimum use actual weight Pediatric Septic Shock Patients often require > 60 ml/kg in first hour Obtain 2 nd Lactate – can order with first Use.SEPSISEXAM in any note document post fluid exam