By: Jordan Anderson RN, BSN, OCN Quality Care of the Oncology Patient at Risk for Infection & Sepsis Intervention By: Jordan Anderson RN, BSN, OCN

Not so fun FACT: Infection is the #1 Non-malignancy related cause of death in oncology patients according to the NCCN1... Mortality (from sepsis) is 30-40% higher for patients with cancer2 So what can we, as nurses, do to protect our patients the best we can? 1. NCCN Guidelines Version 2.2017 Prevention and Treatment of Cancer-Related Infections https://www.nccn.org/professionals/physician_gls/pdf/infections.pdf

1st step: know the risk factors Specifically in the oncology patient… -cancer itself is a risk factor -central venous catheter -immunosuppressant medications (including steroids) -periods of neutropenia -poor nutrition

Step 2: Assessment/Identification Most oncology patients have a depressed immune system due to cancer treatments, so often the earliest warning sign of infection is FEVER 3 most common sites of infection: blood, lungs, urine/bladder “Time Zero” – time a patient is first identified as likely having an infection At UWMC…new Sepsis Screening protocol At Evergreen, we use a MEWS (Modified Early Warning Score) “Bedside Sepsis Huddles”

https://s-media-cache-ak0. pinimg https://s-media-cache-ak0.pinimg.com/736x/e1/be/87/e1be87b1be9f84a516c36e8481b9ce25.jpg Febrile neutropenia: Automatically falls in Sepsis…because you have WBC <4k AND Fever, and a presumed infection, so we have already surpassed the first warning trigger of “SIRS” For the cancer patient, the LEAST accurate assessment is RR > 20 ??

Signs/Symptoms of New Onset Organ Dysfunction AMS Decreased urine output Cap refill >3seconds Mottling of the skin Weight gain > ~2kg/day

Labs to watch: – Bilirubin > 2 mg/dl – Creatinine > 2.0 mg/dl –  Glucose > 140 mg/dl in non-diabetics –  INR ≥ 1.5 –  Lactate > 2.0 mmol –  Platelets < 100,000/mm3 I’ve highlighted lactate…because lactate can be used as an early warning sign and trigger a provider to order interventions earlier on

Septic Shock when >4mm/dl Lactate levels are an early sign of decreased perfusion Normal Lactate is < 2 mm/dl Elevated lactate may precede other signs/symptoms Elevated lactate and hypotension are indicators of poor outcome3 3: Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.   Serum Lactate Septic Shock when >4mm/dl

Step 3: Intervention Surviving Sepsis Campaign4,5 National 3 hour goals: Draw serum lactate Draw blood cultures prior to administration of broad spectrum antibiotic Administer broad spectrum antibiotic* IV fluid bolus of a crystalloid of 30ml/kg/hr if hypotensive and serum lactate >4 IV bolus of 30ml/kg…take an average 70kg person, that’s ~2L Crystalloid Fluids: mimic concentration of plasma, NS and LR most common 4. Dellinger, R.P., Levy, M.M., Rhodes, A., Annane, D., Gerlach, H., Opal, S.M..... The Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. (2013). Surviving Sepsis Campaign: International Guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39, 165-228. 5. Press Ganey. (2015). SEP-1 Measure Inpatient Specifications Manual v5.1 June 1- December 31, 2016 Discharges. http://www.survivingsepsis.org/Bundles/Pages/default.aspx TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*: Measure lactate level Obtain blood cultures prior to administration of antibiotics Administer broad spectrum antibiotics Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L * “Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review. TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1. Re-measure lactate if initial lactate elevated.

Step 3: Intervention Continued… National 6 hour goals6: -use vasopressors for hypotension not responding to initial fluids and to maintain MAP ≥65 mm Hg -If MAP <65, or initial lactate >4, reassess tissue perfusion and document : -either a repeat focused exam OR 2 of the following: -CVP -ScvO2 -bedside cardiovascular ultrasound -passive leg raise or fluid challenge From Surviving Sepsis Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.   SvO2-central venous oxygen sats

Passive Leg Raise/Fluid Challenge

UWMC Early Sepsis Warning System UWMC is now using a new trigger in ORCA (our charting system) to alert the bedside RN when the computer has identified certain early warning signs of sepsis If NEW or WORSENING infection is suspected, it’s our goal to have bedside RN, charge RN, and provider do a bedside sepsis huddle within 30 minutes Looks at labs and most recently documented VS This will help facilitate establishing “time zero” and get the sepsis bundle ordered and interventions happening as soon as possible

Meeting standards of Core Quality Measures set by The Joint Commission Implications Patient Survival rates depend on timeliness of antibiotic administration (dropping nearly 8% for ever hour delayed)6 Hospital sepsis accounts for >$20billion (5.2% of hospital costs) in US in 20117 Meeting standards of Core Quality Measures set by The Joint Commission : Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.   Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.

Barriers8 According the the Core Quality Measures ALL interventions are to be taken within the specified time frames…but this is not always plausible for each individual patient Ex: a patient with severe CHF…probably won’t want to give 2-3L of fluid/hour… False positive and getting “trigger fatigue” from computer generated warning systems There is still some research and updates to be done *Documentation is key

Sepsis order “Bundles”…Can they be nurse driven/initiated? Brenda Shelton, DNP, RN, APRN-CNS, CCRN, AOCN® Clinical Nurse Specialist Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins -John’s Hopkins is initiating nurse driven order sets that nursing can initiate…provider has in notes “add _____ Abx on first fever spike” Right now at UW, there are “If/Then” orders when a patient spikes a new fever, to initiate blood cultures… lactate could be added on here so a nurse only accesses once instead of waiting for providers to add the lactate order, but maybe not within the nurses to scope to know how much/what kind of fluids to initiate and start infusing Picture from: https://imgflip.com/i/103vne

Nursing Interventions to Reduce Risk of Infection Hand Hygiene – nurse and patient! Oral care – prevent thrush and decrease instance/severity of mucositis Curos caps on central lines Daily CHG baths Assess skin / wounds thoroughly every shift Advocate for patients when you have a feeling something is off! -notify provider -initiate RRT if warranted Communication is Key…with providers…and pharmacy…make sure Abx are ordered STAT on first fever spike to get Abx hung ASAP. If not ordered STAT, how is pharmacy to know?

Early Detection Can Save Lives! Remember…for each hour antibiotics are delayed, patient mortality increases nearly 8%

References 1. National Comprehensive Cancer Network. (2017). Version 2.2017. Prevention and Treatment of Cancer Related Infections. NCCN Clinical Practice Guideline in Oncology. 2. Mokart, D., Saillard, C., Sannini, A., Chow-Chine, L., Brun, J.P., Faucher, M., Blache, J.L., Blaise, D., Leone, M. (2014). Neutropenic cancer patients with severe sepsis: need for antibiotics in the first hour. Intensive Care Med, 40 (8), 1173-1174. 3. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288. 4 . Dellinger, R.P., Levy, M.M., Rhodes, A., Annane, D., Gerlach, H., Opal, S.M..... The Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. (2013). Surviving Sepsis Campaign: International Guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39, 165-228. 5 . Press Ganey. (2015). SEP-1 Measure Inpatient Specifications Manual v5.1 June 1- December 31, 2016 Discharges. 6. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis- 3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287. 7. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288. 8. Shelton, B.K., Kane, J., Jones, R., & Weber, M. (2016). Abstract 27: Challenges in Implementing the Sepsis Core Measure in Oncology. Oncology Nursing Forum, 43(2)E82, 74.

THANK YOU! Questions? You can e-mail me at jordan17@uw.edu