Sepsis: The New Core Measure Henry Mayo Newhall Hospital Nursing Education August 26, 2015 Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Sepsis is the #1 Cause of Inpatient Deaths* Acute Care Discharges: 11% of patients have a Sepsis DX Acute Care Deaths: 48% of patients have a Sepsis DX *Sean Townsend MD, VP Quality & Safety, California Pacific Medical Ctr Clinical Assistant Professor: University of California, San Francisco Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Surviving Sepsis Campaign (SSC) and CMS come together: SEP-1 3 Hr Bundle 6 Hr Bundle Severe Sepsis Septic Shock Time Zero Fluid Volume Status and Tissue Perfusion Repeat Volume Status and Tissue Perfusion Assessments (documented) Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Sepsis Quality Indicators CMS Requirement Internal Goal Sepsis-1 Blood Cultures prior to Antibiotic <3 Hours Sepsis-2 Antibiotics administered < 3 Hours from time zero Sepsis-3 Initial Lactate from presentation Sepsis-4 Adequate Fluids For Lactate >4 or Hypotension 30 ml/kg NS or LR Sepsis-5* Repeat Volume status and Tissue Perfusion assess <6 Hours for lactate >=4 or refractory hypotension 5a Focused Exam: cap refill, peripheral pulse, skin exam, cardio-pulmonary exam and Vital Signs < 6 hours All 5 elements must be documented by a MD/PA/NP 5b Any 2 of the 4: 1-CVP 2-CV02, 3-Cardiovascular U/S, 4-Passive Leg Raise or **Fluid Challenge Sepsis-6 Repeat Lactate <6 hours Sepsis-7 Vasopressors Initiated for refractory hypotension, not responding to fluids Hypotension Defined: - SBP<90 MAP<65 SBP decrease >40mmHg from pts baseline OR Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Definitions Tissue Perfusion SIRS - Systemic Inflammatory Response Syndrome Defined as two or more of the following variables: HR >90 Temp <96.8 or >101 Resp Rate>20 or PaCO2<32mmHg WBC<4,000 or >12,000 cells/mm3 or >10% immature neutrophils (Bands) Glucose >140mg/dL in the absence of DM or increased insulin demand Sepsis = SIRS + proven/suspected infection Pneumonia, UTI, Acute Abdominal Infection, Meningitis, Skin/Soft Tissue, Bone/Joint, Wound, Blood Stream catheter infection, Endocarditis, Implantable device infection Severe Sepsis = Sepsis + acute organ dysfunction Organ Dysfunction: Altered Mental Status Lactate above 2 mmol/L Creatinine >2.0mg/dL or urine output <0.5 mL/kg/hr for more than 2hrs Bilirubin > 2 mg/dL Platelet Count <100,000 INR >1.5 Acute Lung Injury with Pa02/Fi02 <250 in the absence of PNA as infection source Acute Lung Injury with Pa02/Fi02 <200 in the presence of PNA as infection source SBP<90 or decrease 40mmHg from patients baseline Mildly elevated Troponin Septic Shock = Severe Sepsis + refractory hypotension Hypotension that is not responsive to volume resuscitation and requires administration of vasopressors Lactate >4 Tissue Perfusion For the purpose of this concept analysis, tissue perfusion refers to the flow of blood through arteries and capillaries delivering nutrients and oxygen to cells and removing cellular waste products. Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Index of Suspicion Patients at increased risk for sepsis: Age extremes (<10y and >70y) Major surgery, trauma, burns Prior antibiotic treatment Prolonged or recent hospitalization Invasive procedures: (catheters, intravascular devices, prosthetic devices, Hemodialysis and Peritoneal dialysis catheters, Endotracheal tubes) Primary diseases: Liver cirrhosis, Alcoholism, DM, Cardiopulmonary diseases, Solid malignancy, Hematologic malignancy Immunosuppression: Neutropenia, Corticosteroid therapy, IV drug abuse, Complement deficiencies, Absence of the spleen Other factors such as childbirth, abortion and malnutrition Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Presentation of Severe Sepsis or Septic Shock - “Time Zero” When the Physician/PA/NP documents, “Severe Sepsis or Septic Shock” or.. When all criteria are met for Severe Sepsis within 6 hrs of each other or.. When all criteria are met for Septic Shock within 6 hrs of each other Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Where can Time Zero occur? Anywhere inside the hospital Pertains to any admitted inpatient, anytime during their hospital stay May be “present on admission” May occur 1-2 days into their inpatient stay May occur anytime up to 180 days (patients are excluded=>180 days) Patients admitted through the ED, OR, or Direct Admission from MD office ED DOU ICU M/S units Tele Units Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Sep-1: Definition of Time Zero Will always be when the chart annotation suggest signs and symptoms are all present May be nursing charting, lab flow sheets, physician documentation, anything with a time stamp Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Regardless of when Time Zero is…. If you give your patient a fluid bolus, Re-assess your patients response to the fluid bolus Using a Repeat Volume Status and Tissue Perfusion Assessment Document New Vital Signs: Temperature Heart Rate Resp rate Blood Pressure Cardiac Exam Respiratory Exam Capillary refill evaluation Peripheral pulse evaluation Skin examination If you Re-assess your patient, don’t forgot to document these elements prior to the fluid bolus, to see if they are better, worse, or the same Report your findings to the doctor,--depending on your findings after the fluid bolus new actions/orders may be indicated Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Repeat Volume Status and Tissue Perfusion Assessment The Focused Exam must be dated & timed: Vital Signs- Temp, HR, BP, RR Cardiopulmonary Exam Heart- “RRR”, “Irregular”, “S1, S2..murmur” or other language Lungs- “clear”, “crackles”, “diminished”, or other language Capillary Refill Evaluation “brisk”, “<2 seconds”, “>2 seconds”, or other language Peripheral Pulse evaluation Pulses 1+, 2+, absent, or other language Skin exam Mottled, Not Mottled, “Knee caps clear or mottled” etc… Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

1. Central Venous Pressure measurement Repeat Volume Status and Tissue Perfusion Assessment Or any 2 of the following 4: 1. Central Venous Pressure measurement 2. Central Venous Oxygen Measurement 3. Bedside cardiovascular Ultrasound TTE (trans-thoracic echocardiogram) TEE (trans-esophageal echocardiogram) IVC US (Inferior Vena Cava Ultrasound) Esophageal Doppler monitoring 4. Passive Leg Raise or Fluid challenge Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Definition of Bedside Cardiovascular Ultrasound   1.) TTE (trans-thoracic echocardiogram) 2.) TEE (trans-esophageal echocardiogram) 3.) IVC US (Inferior Vena Cava Ultrasound) 4.) Esophageal Doppler monitoring For Physician Reference— The following is clinically necessary information but does not require documentation Definition:  Caval Index: IVC expiratory diameter - IVC inspiratory diameter, divided by the IVC expiratory diameter x 100 = caval index (%) The caval index is written as a percentage, where a number close to 100% is indicative of almost complete collapse (and therefore volume depletion), while a number close to 0% suggests minimal collapse (likely volume overload) Correlation between IVC size and CVP: Inferior Vena Cava Size (cm)       Respiratory Change        Central Venous Pressure (cm H20) <1.5                                                  Total collapse                     0-5 1.5-2.5                                              >50% collapse                   6-10 1.5-2.5                                              <50% collapse                    11-15 >2.5                                                  <50% collapse                    16-20 >2.5                                                   No change                          >20 Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Early Recognition and Rapid Treatment is KEY to success ICU and the ED have a “Cheetah Monitor” that will assess fluid responsiveness and help guide appropriate treatment for the Sepsis patient Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

How the Cheetah NICOM works Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Using the Stroke Volume Index Its better than a CVP reading By using this new technology, we can now answer the age old question: “Is my patient fluid responsive?” need more fluids,? less fluids? Non Invasive Cardiac Output Monitor “NICOM” Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Tissue Perfusion Assessment Look at your patient carefully and do A thorough assessment: Tissue Perfusion Assessment Fluid Volume Status Exam Then call on your team and jump into action. Swift and precise treatment is required Re-Assess the effects of your interventions. Is your patient the same, better or worse? Stay on the lookout Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

References Cajanap-Gantman, J. “Electronic Sepsis Alert” presentation for Adventist Health System at Patient Safety First Collaborative 7/24/2015 Dellinger, R.P., Levy, M.M., Rhodes, A., et al, Surviving Sepsis Campaign: International Guidelines for management of severe sepsis and septic shock: 2012. Crit. Care Med 41:2, 580-637 Hotchkiss, R.S., Karl, LE (2003): The pathophysiology and treatment of sepsis, N. Engl J. Med, 348, 138-150 Sharma, S. (2007, April 4): Septic Shock, Retrieved from eMedicine Web site: www.emedicine.com Specifications Manual for National Hospital Inpatient Quality Measures Discharges 10-01-15 through 06-30-16 SEP-1 https://www.qualitynet.org/ Townsend, S MD, VP Quality & Safety California Pacific Med Ctr, SEP-1: First National Core Measure on Sepsis Care. CMS Webinar 6/22/2015 Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015

Summary: Test Questions Name the elements of a Tissue Perfusion and Fluid Volume Status Exam: Define Tissue Perfusion: When should the septic patient be evaluated for fluid resuscitation? How much fluid is required for the septic patient? Define Hypotension The results of inadequate tissue perfusion are: Organ Dysfunction can manifest as: Sue Trikha RN,C CEN CPHQ Quality Dept 9/25/2015