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

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
Triage and Screening System for rapid recognition
Rapid treatment with antibiotics and fluid resuscitation, lactate, CBC, and blood cultures
Each area will have representation on implementation teams
Adaptation of best practices from centers of excellence

15. 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

16. 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

17. 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)

18. Reliable Sepsis Recognition and Assessment
Primary Drivers
Secondary Drivers
Reliable Recognition and Assessment
Reliable Care Delivery
Education and Awareness
Culture of Safety and Quality Improvement
Patient and Family Centered Care
Reliable Sepsis Screening
Early Warning System + SIRS
Ensure reliable communication SBAR
Ensure timely rescue of deteriorating patient by competent team
Involve patient and family advisors in design

19. UNC Sepsis Implementation
Goal: to reduce the raw mortality rate by 10% at UNC Hospitals by June 2016 when compared to 2013 baseline
Scope: Children’s Hospital, ED, ICU’s and all areas of ARRT activation
Phase I: Children’s Hospital implementation complete by June 30, 2015
Phases II-IV: ED, Critical Care Units, Inpatient Units

20. Project Updates

21. UNC Children’s Hospital Working Timeline

22. UNC Hospitals Implementation Timeline
Children’s Hospital Go-Live

23. Early Warning Score Development
Modified Pediatric Early Warning Score
Children’s Hospital IP units – currently being modified
Modified Early Warning Score
Currently being tested on adult acute care units
EPIC 2014 tools
MEWS-ED
Currently being tested in general ED

24. UNC Adult Implementation Team Training Timeline
UNCMC Staff
Awareness of Sepsis Alert
Screening Areas
MEWS Scoring and clinical Response
Sepsis Experts
Advanced Sepsis screening and treatment
Phase II: August 2015
ED Care Team
Inpatient Care Areas
ED Paper Go-Live June 2015
Phase III: November 2015
All Medical Center staff
Phase I: March/April 2015
Air care
ED advanced care team
ARRT –primary and secondary
Hem/Onc Responders
ARRT will begin using the adult bundle when recognizing sepsis in consults or Rapid response calls, we don’t expect an increase in cases as the screening will not be in place yet. In the ED, the response teams will be delivering the bundle and training the attendings.
Once the ARRT is comfortable with the bundle and delivering it smoothly, the ARRT2 will be trained to respond to sepsis using the bundle.
The nurses on the floor and in the ED’s will be instructed on how to use the Modified Early Warning System and screening tools. This tool is still under development.
A general awareness campaign will be needed to inform all medical center employees of the response system.

25. Working Adult
Patient Bundle

26. + 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:
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 antibiotic algorithm
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

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

28. When in doubt… Think to yourself first, “This is sepsis!”
Then ask, “Why isn’t this sepsis?”
When no other reason found, then conclude, “Oh wait, it is sepsis.”

30. Placeholder Adult Patient Sepsis Antibiotic Guidelines

31. Sepsis Case Reviews

32. Inpatient Sepsis Case 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
* Pt would have had a MEWS score of 2 which may have prompted a physician notification of change and a rapid response consult
POD#8 at 1500, pt. continues to be confused/somnolent
VS at  HR 113, RR 18, SBP 89, Temp 35.3
MEWS score of 5 based on vitals and provider concern
* Pt would have had a MEWS score of 5 based on vitals and provider concern
* With the new screening tool, this may have triggered a rapid response, potential sepsis screening and Q 1 hr monitoring
No rapid response called and pt. remains on the floor

33. Inpatient Sepsis Case
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
Pt. weighed 81.6 kg
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

34. ED Sepsis Case
57 year old 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%

35. 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

36. 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

37. Placeholder Area Screening and Treatment Plan

38. Take Home Points
This new system is still in design and will be different in the coming months when we “go live”
Septic Shock may be more subtle than you think
Call sepsis team (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:

39. Communication Tools

40. Intranet Site Content: Background Resources Sepsis Toolkit FAQs
Resources>Performance Improvement and Patient Safety>Sepsis Program
Content:
Background
Resources
Sepsis Toolkit
FAQs
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