UNC Hospitals Sepsis Mortality Reduction Initiative General CMS Compliant 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.

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

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

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

High Suspicion, Early Warning, and Rapid Response Teams Research shows that there are signs of deterioration for 6-8 hours before a significant event Although Modified Early Warning Scores (MEWS) may detect deteriorating patients, the most sensitive detection of patient deterioration is bedside nurse clinical assessment Empower the frontline team members to call for help Failure to Rescue is a national concern that affects all types of patients Early warning scores assist in detecting deteriorating or “sick” patients – not necessarily sepsis

MEWS Scoring Algorithm Uses vital signs to generate an acuity score No process change or manual entry An additional tool to help identify deterioration

Color Coded Scores

Clinical Response to MEWS Scores (may vary by unit)

Sepsis Bundle Order Set

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

This is our temporary solution for repeat lactate and needs improvement

Screening Tools/ Order Sets Real Time Sepsis Best Practice Alert ED ONLY – “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

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 Call a Code Sepsis in areas where rapid response teams are activated Empower bedside RNs and New Residents to Activate RRT