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

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

7 of the Top Ten UHC hospitals in our cohort (AMC with 500+ beds) for sepsis mortality index are in the top ten for overall Mortality Index. 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 Unit Deaths MICU 44 SICU 8 CICU 6 NCCC 5 NSIU PICU BMTU 4 MPCU 2 8 BT 6 BT TICU ISCU 6 EST 1 3 WST 5 BT 4 ONC Grand Total 91 67% of deaths in the MICU involved Sepsis

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

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

Wake Forest reduced their time to first antibiotic significantly. 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): 1589-1596.

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 Failure to Rescue Appropriate Palliative Care 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): 1589-1596.

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 Survey of German ICUs reveals that practitioners feel that they adhere to guidelines better than they actually do. Need for multidisciplinary ownership and standardization. Spain educational program showed adherence was better after education but still not good and lapsed after 1 year

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 Primary Drivers Secondary Drivers 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

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 MEWS-ED Currently being tested in general ED

UNC Adult Implementation Team Training Timeline UNCMC Staff Awareness of Sepsis Alert Screening Areas MEWS Scoring and clinical Response Sepsis Experts Advanced Sepsis screening and treatment Phase II: August 2015 ED Care Team Inpatient Care Areas ED Paper Go-Live June 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 ARRT will begin using the adult bundle when recognizing sepsis in consults or Rapid response calls, we don’t expect an increase in cases as the screening will not be in place yet. In the ED, the response teams will be delivering the bundle and training the attendings. Once the ARRT is comfortable with the bundle and delivering it smoothly, the ARRT2 will be trained to respond to sepsis using the bundle. The nurses on the floor and in the ED’s will be instructed on how to use the Modified Early Warning System and screening tools. This tool is still under development. A general awareness campaign will be needed to inform all medical center employees of the response system.

Working Adult Patient Bundle

+ ADULT Sepsis Response Team UNC Adult Early Sepsis Screen Does patient have > 2 of the following: Assess to confirm sepsis Core Temp < 36 or > 38 (home temp also valid) COMPLETE BUNDLE IN < 60 MINUTES & notify primary team: Respiratory Rate >20 Alert Pharmacy of sepsis for faster antibiotic delivery - use closed loop communication Heart Rate >90 WBC count <4 or >12 Measure Lactate Level Altered Mental State Obtain Blood Culture (attempt 2 sets prior to antibiotic) Initial dose of antibiotic (even if no blood culture is available) see adult sepsis antibiotic algorithm High Risk* (see next page) + Detailed bundle items on separate more detailed team algorithms including what is included in the assess to confirm sepsis, bundle details about giving fluids and detected response to fluids, all done by area’s own response team members who will get advanced training in treating sepsis. Details for team: 1. confirm sepsis – use 2+ SIRS criteria plus suspected infection (Source:Healthcare Improvement Scotland). 2. Antibiotic Choices Algorithm (Source: UNC ID, treatment teams, and pharmacy) Fluid Resuscitation 30 ml/kg or 2L in the first hour Suspected Infection Consider transfer to higher level care if inadequate response to fluid resuscitation or based on clinical status Then Trigger Sepsis Response - in design Version 1: 3/17/15

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

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.”

Placeholder Adult Patient Sepsis Antibiotic Guidelines

Sepsis Case Reviews

Inpatient Sepsis Case 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 * Pt would have had a MEWS score of 2 which may have prompted a physician notification of change and a rapid response consult POD#8 at 1500, pt. continues to be confused/somnolent VS at 1500 -  HR 113, RR 18, SBP 89, Temp 35.3 MEWS score of 5 based on vitals and provider concern * Pt would have had a MEWS score of 5 based on vitals and provider concern * With the new screening tool, this may have triggered a rapid response, potential sepsis screening and Q 1 hr monitoring No rapid response called and pt. remains on the floor

Inpatient Sepsis Case 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 Pt. weighed 81.6 kg 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

ED Sepsis Case 57 year old 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%

ED Sepsis Case 1536 – Paracentesis done in ED 1542 – Pt. remained A&O x 4, HR 80, RR 20, BP 72/41 1548 – 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 90-100’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. 2052 – HR 80, RR 15, BP 72/46, Sats 98% 2055 – Pt. transferred to MPCU

ED Sepsis Case 2057 – RN paged MD that SBP’s remaining in the 70’s. 2135 – 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 2nd 1000 ml fluid bolus running 2341 – Med I at bedside to eval for admission to MICU -------------- 0026 – 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

Placeholder Area Screening and Treatment Plan

Take Home Points This new system is still in design and will be different in the coming months when we “go live” 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 Patients can worsen rapidly If you want to help us in the development or have feedback please contact the Sepsis Program Team: sepsisfeedbackunch@unchealth.unc.edu

Communication Tools

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