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

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

3. 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.

4. Top Ranked hospitals have a sepsis reduction initiative

5. 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

6. 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

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

8. 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):

9. Scotland is using an Early Warning Score, an advanced sepsis screen, and a one hour bundle.

10. The entire country of Scotland uses an early warning score and sepsis management protocol to reduce their mortality ratio by almost 16%

11. North Shore University Hospital in Long Island Jewish system reduced ALOS and Mortality.

12. 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

13. * 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):

14. 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

15. 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
Date of download: 3/14/2016
Copyright © 2016 American Medical Association. All rights reserved.

16. 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
Table Title:
qSOFA = 2 or more:
RR > 22, SBP < 100, Altered Mental Status
Sequential [Sepsis-Related] Organ Failure Assessment Scorea
Date of download: 3/14/2016
Copyright © 2016 American Medical Association. All rights reserved.

17. From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
The task force maintains that standardization of definitions and clinical criteria is crucial in ensuring clear communication and a more accurate appreciation of the scale of the problem of sepsis.
An added challenge is that infection is seldom confirmed microbiologically when treatment is started; even when microbiological tests are completed, culture-positive “sepsis” is observed in only 30% to 40% of cases.
Thus, when sepsis epidemiology is assessed and reported, operationalization will necessarily involve proxies such as antibiotic commencement or a clinically determined probability of infection.
Future epidemiology studies should consider reporting the proportion of microbiology-positive sepsis.
JAMA. 2016;315(8): doi: /jama

18. 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

19. 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

20. 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

21. 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

22. 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)

23. Modified Early Warning Score (MEWS) Tool

24. 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

25. MEWS Scoring Algorithm
Uses vital signs to generate an acuity score
No process change or manual entry
An additional tool to help identify deterioration
MEWS Score is an acuity score that can be trended over time in the patient record to provide a picture of each patient’s acuity using the algorithm above.
The scores are the same for each unit and hospital however the clinical response can be customized.

26. Color Coded Scores
1-4
5-6 7+

27. Clinical Response to MEWS Scores (may vary by unit)

28. MEWS Tool Scores trend every 2 hours to monitor changes in MEWS
Scoring components detail each components score
Comment field to communicate with ARRT
Available on patient lists and services

29. Adult Inpatient
Code Sepsis Program

30. Inpatient Code Sepsis Process
Sepsis should be suspected anytime a patient with a known or suspected infection has new or worsening organ dysfunction  
Sepsis can subtle and inpatients that develop sepsis may have delayed recognition and treatment and may deteriorate rapidly  
Nurses and Physicians/Advanced Practice Provider teams should assess suspected sepsis patients immediately  
Use the “Sepsis Bundle” order set for initial treatment of sepsis patients – this includes the first hours of sepsis treatment – additional antibiotic doses and diagnostic studies should be ordered as needed

34. Code Sepsis in Pediatric and Adult Inpt Acute Care and Progressive Care Units

35. What about ICU settings?
“Sepsis Bundle” order set is available for use in Epic including STAT first dose antibiotics
Larger order sets are being developed for inpatient use
Adult and pediatric sepsis pharmacy pagers that ICU teams can page directly
Adult expert panel will be determining future use of SOFA scoring systems and screening tools
Current ICU’s piloting internal team “code sepsis” processes

36. + 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:
“Adult Sepsis Bundle” EPIC order set
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 Bundle” Epic Orders
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

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

39. Sepsis Training
Case Examples

40. Example Inpatient Sepsis Case - Surgical
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
POD#8 at 1500, pt. continues to be confused/somnolent
VS at  HR 113, RR 18, SBP 89, Temp 35.3
No rapid response called and pt. remains on the floor

41. Example Inpatient Sepsis Case - Surgical
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
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

42. Example Inpatient Sepsis Case - Medical
Pt. with history of cancer with mets to abdomen and brain presented as direct admit with confusion and fatigue
1722 – HR 101, RR 22, BP 129/74, Temp 36.7, Sats 95% on RA, A&O x 4
1943 – HR 134, RR 24, BP 103/59 (pt. had excessive nose bleeding)
2000 – Rapid response called due to nose bleed
2152 – Rapid response ended and pt. remained on wards
2202 – 1000 ml NS bolus given
2258 – HR 105, RR 15, BP 129/92, Temp 36.8, Sats 93% on RA, A&O x 4
2347 – NS infusion at 100 ml/hr started

43. Example Inpatient Sepsis Case - Medical
0231 – HR 97, RR 16, BP 106/88, Temp 36.8
0512 – Rapid response called for AMS, decreased O2 sats, and RN/family worry
HR 125, BP 129/92, Sats 84% on 2 L NC
0519 – Lactate drawn (10.3)
Rapid response RN and primary team MD see patient – primary MD requests repeat Lactate (result – 11.3). Primary team attributed lactate to extensive cancer. No fluids given.
0615 – HR 109, RR 14, BP 120/69, Temp 36.6, Sats 94% on 4 L NC
0626 – Rapid response ended
0850 – Blood culture from CVAD (port) drawn (later result - Oxacillin susceptible staph aureus)
0925 – Lactate drawn (20.0)
0950 – Blood culture peripheral drawn (result – no growth)
1100 – HR 149, BP 66/28, Sats 87% on 4 L NC (Note - no vitals between 0615 and 1100)
1100 – Code blue called, transferred to MICU, dies in ICU days later

44. Example ED Sepsis Case
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%

45. Example 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 ’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 ml/hr NS infusion stopped.
2052 – HR 80, RR 15, BP 72/46, Sats 98%
2055 – Pt. transferred to MPCU

46. Example 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

47. Adult ED Patient Code Sepsis Program

48. Emergency Department Screening Tools/ Order Sets
Real Time Sepsis Best Practice Alert – “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

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

51. Sepsis Alert for ED Nursing – Evaluate for Sepsis
“Treating Associated Infection” silences the Alert for that user for 96 hours
“Treating Separate Illness” silences the alert for that user for 96 hours

52. ED Nursing Order Set

53. Sepsis Alert for ED Providers – Evaluate for Possible Sepsis
“Treating Associated Infection” silences the Alert for that user for 96 hours
“Treating Separate Illness” silences the alert for that user for 96 hours

54. ED Provider Order Set

55. ED Provider Order Set

56. ED Provider Order Set

57. FAQ
Q: If I acknowledge the alert, will it pop up for my co-workers? A: Yes, the alert will pop up for any user that has not acknowledged it while the patient meets the alert criteria. Q: If I choose “cancel” will the alert pop up again? A: Yes, as long as the patient meets the criteria. The alert will continue to pop up until it has been acknowledged using “Treating Associated Infection” or “Treating Separate Illness”. Q: How does Epic calculate the LOC component? A: Epic identifies “Drowsy”, “Somnolent”, and “comatose” in the triage navigator to populate LOC.

58. Q: If my patient’s condition improves, will the alert stop
Q: If my patient’s condition improves, will the alert stop? A: Yes Q: Should I always utilize the order set when the alert pops up? A: No, the alert is designed to be sensitive rather than specific. Use your clinical judgment to determine whether or not the patient is showing signs and symptoms of sepsis.

59. Important Reminders

60. If patient requires fluid bolus give rapidly – not on pump If patient in septic shock, give at least 30 mL/kg fluid bolus

61. Reassessment Patients with sepsis can progress to shock rapidly
Reassess patients with documented repeat exam within the first few hours of sepsis development
Repeat lactate within 4 hours of the first lactate if septic patient’s initial lactate is >2

62. Take Home Points
This new system is an iterative process and will be different in the coming months
Septic Shock may be more subtle than you think
Process is a team event (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:

63. Public UNC Code Sepsis Website
Resources>Performance Improvement and Patient Safety>Sepsis Program
Content:
Background
Resources
Sepsis Toolkit
FAQs
Need Help?
Or just Google “UNC Code Sepsis”