Purpose - present the new bundles that will start with Oct 1 discharges Review documentation required Review changes at GCH Resident Education

Sepsis Overview Cost of sepsis care in the US ~$400 billion annually1 Mortality ranges from 16-49%2 One of top ten most common principal causes for hospitalizations2 Compliance with the 3- and 6- hour bundles decreases: mortality length of stay cost of care

Sepsis will become a Core Measure starting with October 1, 2015 discharges Compliance with the bundles will be tied to payment from CMS

GCH Sepsis Project team review our current processes and procedures identify barriers in processes goals of enhance nursing Sepsis screening/assessment improve compliance with Severe Sepsis/Septic Shock bundles standardize care for adult sepsis, severe sepsis and septic shock patients ultimately decrease Sepsis mortality Implemented a multidisciplinary in mid-July to

Identified definitions we will use (also used by CMS)

Surviving Sepsis Campaign revised 3-hour and 6-hour bundles AND if Septic Shock present: Received within three hours of presentation of Septic Shock: Resuscitation with 30 ml/kg crystalloid fluids AND if hypotension persists after fluid administration, received within six hours of presentation of septic shock: Vasopressors AND if hypotension persists after fluid administration OR initial lactate > 4 mmol/L: received within six hours of presentation of Septic Shock: Repeat volume status and tissue perfusion assessment consisting of either: A focused exam by physician including all of the following: Vital signs AND Cardiopulmonary exam AND Capillary refill evaluation AND Peripheral pulse evaluation AND Skin examination   OR Any two of the following four: Central venous pressure measurement Central venous oxygen measurement (ScvO2) Bedside cardiovascular ultrasound Passive leg raise by physician or fluid challenge given Received within three hours of presentation of Severe Sepsis: • Initial lactate level measurement • Blood cultures drawn prior to antibiotics • Broad spectrum or other antibiotics administered AND received within six hours of presentation of Severe Sepsis: • Repeat lactate level measurement only if initial lactate level is elevated > 2 Surviving Sepsis Campaign (SSC) revised 3-hour and 6-hour bundles in early 2015 based on new evidence from Promise, Arise, Process Investigative Trials Major changes: “presentation time” (the time the last sign of Severe Sepsis/Septic Shock is noted or last lab value was reported)– There can be a presentation time for severe sepsis and if a patient did not also present with septic shock at that time, there may be a different time of presentation of septic shock. It is important to document these times so treatment can be done in a timely manner. Remeasure Lactate within 6 hours if >2 Fluids after septic shock (minimal) and vasopressors if sustained hypotension If hypotension after fluids OR lactic acid >4 need to check volume status within 6 hours of septic shock –options: Focused exam by physician OR two of CVP, ScvO2, cardiovascular ultrasound, or passive leg raise or fluid challenge ((Central line and ScvO2 are not required now if other options are done to assess volume status) If initial Lactate > 4 this is considered Septic Shock (with SIRS + known or suspected infection), Severe Sepsis and Septic Shock bundles need to be implemented

Improvements to Processes at GCH Sepsis Policy and Procedure revised  Hospital-wide policy Lactate > 4 Critical Value Sepsis order sets Inpatient Nursing Sepsis Screening Assessment enhancement in EMR ED - upon triage and every 2 hours ICU and inpatient units - on admission and Q4H “New and Worsening conditions” added to when to call physician Inpatient will notify physician with + sepsis screen/ call RRT with + severe sepsis screen ICU nurse will notify ICU physician with + sepsis/severe sepsis screen Sepsis, Severe Sepsis and Septic Shock Bundle Checklist Here are some improvements to current processes and procedures that were/will be made: Sepsis Policy and Procedure is being revamped to standardize care –will become a Hospital-wide policy and includes all the new guidelines (OCT 6th to med exec) Sepsis order sets will become one order set (to standardize care) 2 antibiotics changes on the Sepsis order sets will be updated in accordance with CMS guidelines for initial antibiotics inpatient nursing assessment criteria and improved instruction of what to do with positive sepsis screen, and what to anticipate

Sepsis, Severe Sepsis and Septic Shock Bundle Checklist paper checklist on nursing units can be printed from Forms Fast and is printed with sepsis order set to be used by the doctor and nurse to document times the patient met criteria for Severe Sepsis/Septic Shock compliant with the 3 hour and 6 hour bundles to be a guide of what interventions are required for each bundle communication handoff tool Interventions can be documented on the checklist as it will be part of the permanent medical record This checklist does not replace an order for any of the interventions and any medications including fluids should still be ordered, documented on the MAR “Shock Index” added as indicator

Fluids 3-hour bundle Crystalloid- LR or 0.9% Normal Saline only Volume - ordered and documented as 30ml/kg, or an amount > 30ml/kg Timeframe - duration or rate at which to administer must also be ordered New order set default to 2000mL/hr, or can be manually changed to adjust the rate Minimum requirement- last liter must be delivered within 3 hours of septic shock      Time frame- examples 2000ml per hour or 2000ml over 2 hours

Focused exam by physician: ALL of the following vital signs including all of temperature, heart rate, blood pressure, respiratory rate cardiopulmonary exam assess both the heart and lungs- typically documented as heart - ‘RRR’, ‘Irregular’, ‘S1,S2,S3,S4’ lungs - ‘clear’, ‘crackles’, ‘diminished’ or other language capillary refill evaluation assess superficial circulatory status document ‘capillary refill’, ‘nail bed refill’ ‘brisk’, ‘<2seconds’, ‘>2seconds’ or similar peripheral pulse evaluation to assess circulatory status. Document ‘pulses ‘1+,’ or ‘2+’ or absent, or other language. Need to make reference to any of the following: Peripheral pulse(s), Radial pulse(s), Dorsalis pedis pulse(s), Posterior tibialis pulse(s)  skin exam to assess superficial circulatory status May include such terms as ‘flushed’, ‘mottled’, ‘not mottled’, ‘knee caps mottled’, pale’, ’pallor’, ‘pink’, ‘, ‘pale’, flushed’ or other language Must include reference to color  Document on Checklist, in EMR or Progress Note and perform all components of the focused exam within 6 hours of fluid resuscitation start time

Any two of the following Central Venous Oxygen measurement expressed as SvO2 or ScvO2 & needs to be obtained via blood gas currently. CVP Bedside cardio US may be referred to as echocardiogram, trans-thoracic echo, trans-esophageal echo, IVC Ultrasound, 2D echo, cardiac echo, Doppler echocardiogram, echocardiogram with Doppler, esophageal Doppler monitoring or Doppler ultrasound of the heart Does not necessarily have to be performed at bedside Passive Leg Raise With the patient in a semi-recumbent position, both legs are raised to a 45 degree angle to evaluate the vital sign response to additional fluid load documented as ‘passive leg raise ‘, ‘PLR’ with findings ‘positive’, ‘negative’, ‘fluid responsive’ or other language OR Fluid challenge to assess responsiveness to fluids Similar to crystalloid fluid administration but is done after the crystalloid fluid administration if the patient remains hypotensive. Fluid challenge is a rapid infusion of 0.9% NS or LR typically 500 mL in fifteen minutes or 1000 mL in 30 minutes within 6 hours of fluid resusitation start time (with Septic Shock): Document and perform Passive Leg Raise on the Checklist, in EMR or Progress Note

Documentation tips Document time patient met criteria for Severe sepsis and septic shock on Checklist (if not done by nursing) Document time of known of suspected infection when documenting a suspected source of infection, document it “possible infection from xx”, “suspect infection from xx”, not “SIRS secondary to xx” If your patient is in severe sepsis, document it. When documenting severe sepsis, make a relationship statement between it and the end-organ dysfunction “Severe sepsis with acute respiratory failure” If your patient is in septic shock, document it. “Hypotension” is not equivalent to shock.

References 1. Lopez-Bushnell K, Demaray W, Jaco C. Reducing sepsis mortality. Medsurg Nurs 2014 JanFeb;23(1):9-14. 2. National Quality Institute. (2015). Implementation of Severe Sepsis and Septic Shock: Management Bundle Measure (NQF #0500). Retrieved from http://www.hqinstitute.org/post/implementation-severe-sepsis-and-septic-shock-management-bundle-measure-nqf-0500 Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine. 2013 Feb;41(2):580-637. (http://www.sccm.org/Documents/SSC-Guidelines.pdf ) Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5 –year study. Intensive Care Med 2014; 40: 1623-1633. (http://www.ncbi.nlm.nih.gov/pubmed/2527022) Tseng, J and Nugent, K. (2015). Utility of the Shock Index in patients with sepsis. The American Journal of the Medical Sciences.349: 531-535. Surviving Sepsis Campaign. (2015). Updated Bundles in Response to New Evidence. Retrieved from http://www.survivingsepsis.org/Bundles/Pages/default.aspx