1. Sepsis Updates Theresa Harris MSN, APRN, ACCNS-AG
Maury Regional Medical Center
Angela Craig APN,MS,CCNS
Cookeville Regional Medical Center
ICU CCNS

2. “Partnering to Heal” Video

3. Objectives
Define the 2015 process criteria used for sepsis as a core measure
Identify different methods for sepsis screening
Evaluate sepsis related practice in your unit
Identify opportunities to establish or improve your practice for your septic patients
The Objectives for this session are to:
Define the 2015 process criteria used for sepsis as a core measure
Identify different methods for sepsis screening
Evaluate sepsis related practice in your unit
Identify opportunities to establish or improve your practice for your septic patients

4. Text
THERESAHARRI247 to
22333
once to join

5. Identification of Sepsis Through Screening
1. Electronic Medical Record 2. Paper Screening 3. Automated Screening/MEWs System 4. Rapid Response Team
Here are a few methods that are being used to help with screening patients for sepsis.

6. CRMC Emergency Dept. EMR Screening Tool
Here is a snapshot of CRMCs ED screening Tool. This tool is built into their electronic medical record.

7. CRMC ED Screening Tool
This is CRMC’s ED paper version for reference and for downtime. Do NOT forget to keep paper copies updated so when there is down time you will be able to continue to screen. If you are really serious about this you need to have contingency plans for when the electronic version does not work.

8. MRMC ED Triage Screening
This is the Sepsis screen currently being used in the MRMC. Every patient that presents to our triage nurse is screened for sepsis. This is built off of the top section of our ED sepsis bundle. So for the ED record to populate a SEPSIS RISK alert – first, the nurse has to answer yes to clinical suspicion of infection.  If they answer yes to that question,  they must also answer yes to any of the other questions on the screening.  If they do AND any of the vital signs meet SIRS criteria then the computer flags the patient as a Sepsis Risk.
The area of opportunity we see is identification of those that are immunocompromised. We have to look beyond those who are obviously immunocompromised to those more obscured ones. Such as the very young or older, anyone with an auto immune disease.

9. MRMC ED Screening Tool
 This is MRMC ED Sepsis bundle. As you can see it works like any other algorithm.

10. CRMC INPATIENT SEPSIS SCREENING

11. There are several different screening protocols available
There are several different screening protocols available. CRMC uses an electronic screening House-wide. In the ED they use Medhost but it is electronic and then on the floors they use Paragon and this is a snapshot of how it flows.

12. This is an example of how CRMC has made our screening tool “educational”. We have incorporated definitions that the nurses can see when they are defining where the patient is at on the sepsis continuum.

13. MRMC CRITICAL CARE SEPSIS PROTOCOL
MRMC is currently working on a house wide sepsis screen. In the critical care unit we screen our patients during our daily multidisciplinary rounds.

14. This is MRMC current Sepsis Protocol used in our Critical Care Unit

15. Sepsis Teaching and survival skills are addressed every shift with our Septic patients

16. CRMC Rapid Response Team Protocol
This is just one example of how you can update your rapid response team tool to include a sepsis evaluation. This is CRMC’s Rapid Response Team Protocol.

17. MRMC CRITICAL ASSESSMENT TEAM PROTOCOLS
Sepsis treatment is as time sensitive as AMI and Stroke, however the symptoms are less clear and are often missed.
This is where our rapid response teams call can be used to facilitate rapid treatment for these pts. As you see we even have a section that simply states “Staff worried about pt”
MRMC is currently working on a Sepsis Specific Block to address the 3 hour Bundle for patients who develop Severe Sepsis or have progressed to it since admission.

18. Screening Compliance Audit Tool
Pt. Account # (enter #)
Screened
Y/N (circle)
Y N
Pt. Have known suspected infection
SIRS Present
 T ≥ or
< 96.8
 HR > 90
RR >20 or
PACO2 <32
 WBC >12,000
<4,000 or
> 10% Bands
Organ Dysfunction
 Respiratory (increased oxygen requirements)
 Cardiovascular (SBP less than 90 or MAP less than 65 or on a vasopressor)
 Renal (Urine output less than 05.ml/kg/hr., creatinine greater than 2)
 Metabolic (Lactate greater than or equal to 4mmoL/dl)
 Hematologic (Serum total bilirubin greater than or equal to 4mg/dl)
 Hepatic (Serum total bilirubin greater than or equal to 4mg/dl)
 CNS (Altered consciousness – unrelated to primary neuro pathology)
Which labs were sent? (=obtained)
 Bld Cult x2
Bld Cult
CVAD >48 hr
 Lactic Acid
Fluid bolus (30ml/kg) provided for hypotension Y/N (circle)
If no how much given
 500 mL
 1 liter
 __________
Screened positive for severe sepsis (Y/N) (circle)
Screened positive for Septic Shock Y/N (circle)
Positive Screenings
If screened positive for Septic Shock in CVICU/ICU was Septic Shock Clinical Pathway (Form 1112-PRN) started
If screened positive for Severe Septic or Septic Shock (floors other than ICU/ED/
CVICU) was Initial Management of Patient with Severe Sepsis (Form 1135-PRN) completed
Patient transferred to appropriate level of care Y/N (circle)
(Severe Sepsis Stepdown Septic Shock (ICU/CVICU)
Antibiotics hung within 1 hour of time zero?
Screen done correctly
If screen not done correctly, why?
Was Central Line Inserted?
(Critical Care Only)
Y N
Comments
 Pos feedback letter given
 Neg feedback letter given
 Other (Explain)
This is a screening compliance audit tool that we use at CRMC. Each department is responsible for auditing each month and sending good notes or notes of opportunity to the person who was audited.
Unit:___________________________ Date:_________________________ Shift:_____________________
# Audits Completed ___________________ (Every shift checked considered an audit):
# Audit Screened (numerator = number of screenings completed, denominator = audits completed Example: 7 screenings done, 10 audits completed = 70% audits screened) ________________ %
# of Audits screened correctly? _______________ (numerator = number audits screened correctly, denominator = number audits completed ) ____________________ %
% of follow up on incorrect screens (numerator = number of audits followed up on, denominator = number of incorrect audits) _________________%

19. Success With The Bundles

20. Bundle Summary 3- hour bundle: Severe Sepsis
Initial lactate level (NP)
Blood culture prior to antibiotics (NP)
Broad spectrum antibiotic
30ml/kg crystalloid fluid
NP = Nursing Protocol
6-hour bundle:
Severe Sepsis
Repeat lactate level (NP) If initial LA>2.0
Septic Shock
Vasopressor if hypotension persist
Volume status and tissue perfusion reassessment if hypotension persist
Bundles per CMS
“time of presentation” is defined as the time of earliest chart annotation consistent with all elements severe sepsis or septic shock ascertained through chart review.

21. SURVIVING SEPSIS CAMPAIGN BUNDLES
Dellinger, etal, Critical Care Medicine, Feb 2013, Vol 41 Number 2

22. CRMC Physician Progress Note
Due to the requirements from CMS CRMC has developed a progress note that is TN orange. If a patient screens positive for severe sepsis or septic shock house wide this form is to be placed on the chart and the provider is to be notified. The form guides them for all that is required per CMS

23. CRMC Physician Progress Note
Here is the second page. As you can see the specific CMS assessment requirements Severe Sepsis and Septic Shock are addressed.

24. MRMC PHYSCIANS SEPSIS ORDERS
MRMC Severe Sepsis/Septic Shock paper order set is 8 pages long and this is what our electronic order set was derived from. I’ve condensed it to show the most pertinent and time sensitive aspects and Nursing Procedures

25. MRMC PHYSCIANS SEPSIS ORDERS
Labs, Imagining and Therapies.
An area of opportunity that has been identified is to include an assessment area for documentation of physician assessment requirements

26. MRMC Physicians SEPSIS ORDERS
Consults, Medications and Nursing procedures
Another area of opportunity is developing a Sepsis Core Measure Intervention where we can better track compliance of bundles.

27. MRMC 3 HOUR Bundle STATS
PERCENTAGE
TIME

28. MRMC 3 HOUR Bundle Lactate STATS
At MRMC we first started tracking our Septic patients from the ED in 2011.
This is a comparison of our results from 2011 to Now our 2015 data was a very small sample size of only 15 patients.
In 2015 Our ED LOS was a little 230 mins
We improved significantly on getting our initial Lactate within 47 mins
We’re still working on our Fluid resuscitation. Part of this was affected by the recommended increase from 20ml/kg to 30ml/kg. in In the 2015 pilot we 229 mins for the 30ml/kg
We are improving on our first antibiotic administration with that being at 114 mins
PERCENTAGE
TIME

29. MRMC 3 HOUR BUNDLE IVF STATS
PERCENTAGE
TIME

30. MRMC 3 HOUR BUNDLE ABX STATS
PERCENTAGE
TIME

31. MRMC 6 HOUR BUNDLE CVP STATS
These are the results from the same study on our 6hr bundle compliance.
In 2015 we were getting our second lactate measured on average of 343mins
We were also obtaining our goal MAP >/=65 with or without 293 mins
We still are having issues with obtaining our goal CVP though. Partly because of the many variables that can affect it. Therefore we have actually moved towards using flotrac monitoring for our fluid volume status
PERCENTAGE
TIME

32. MRMC 6 HOUR BUNDLE Lactate STATS
PERCENTAGE
TIME

33. MRMC 6 HOUR BUNDLE MAP STATS
TIME
PERCENTAGE

34. MRMC Sepsis Readmission Rates
Our readmission rates for sepsis dropped significantly from 2012 to 2015 and are within our goal

35. MRMC Sepsis Mortality Rates
We had an increase in mortality in 2013 but have improved to be right at our goal

36. CRMC Data

37. CRMC Data

38. CRMC Data

39. CRMC Data

40. CRMC Data

41. Nursing Protocols to Help Compliance
Development of a TEAM devoted to SEPSIS
Protocol for rapid treatment of SEPSIS
Areas to focus on Sepsis recognition are the ED and the inpatient floors where it’s frequently less clear of a presentation and often unrecognized
We need a paradigm shift to SCREEN all patients at least daily,
the recommendation though is every 8hrs.
This is where nurses can have the most influence! It is often the bedside clinician, the nurse, that recognizes sepsis.
This is where it’s essential that hospitals have protocols in place to address this. Nurses shouldn’t have anything slowing them down in terms of treatment.

42. CRMC Critical care standing orders
As you can see we allow our nurses to draw an SCVO2 if the patient has a non-continuous catheter and we give them the tools to do this per protocol. We also allow them to go ahead and connect CVP monitoring and hemodynamic monitoring as long as the line exists. We can help with compliance with Nsg protocols.

43. MRMC CRITICAL CARE NURSE DRIVEN PROTOCOLS
Progressive Upright Mobility
SAT/SBT
K+, MG++, Phos. Repletion
Proning Protocol
Glucostabilizer
At MRMC all of our pts with central lines do get CVP monitoring. We’re fortunate that we have an intensivist 24/7 on our unit. We have a very close professional relationship with them and practice as a team.

44. 2016 New Definitions

45.   

47. Reimbursement UTI UTI with medical complication/comorbidities
Appropriate documentation
A patient that comes in with sepsis and has a UTI but no medical complication/comorbidities (respiratory failure or shock) the relative weight of reimbursement is
If that same patient has or develops a major medical complications/comorbidities (respiratory failure or shock) it changes the reimbursement to This can be a difference of approximately $4000 in reimbursement.
Supporting documentation of sepsis with MCC makes a huge difference in severity of illness, risk adjustment and reimbursement.
Severe sepsis changes the severity of illness and is reflected in the core measures. This is the transition from being septic with a source (UTI) to having organ dysfunction (AMS, Resp Failure) Severe Sepsis, to Septic shock (hypotension and altered hemodynamics despite fluid resuscitation and an elevated serum lactate >2mmol/L)

48. CASE STUDY 2 Clocks ••Time Zero
Will always be when the chart annotation suggests signs and symptoms are all present •
May be derived from nursing charting, lab flow sheets, physician documentation, anything with a time stamp
Will = triage time if all signs and symptoms are present at triage
Severe Sepsis: Three Hour and Six Hour Counters
Septic Shock: Three Hour and Six Hour Counters
Clinical Example follows
2 Clocks

49. A patient developed severe sepsis at 3 p. m
A patient developed severe sepsis at 3 p.m. but did not become hypotensive and fail to respond to fluids until 5 p.m.
when Does the “shock clock” start?

50. When does the six hour window to complete the physical exam requirement begin at 5 p.m. with the shock clock or at
3 p.m. when severe sepsis was first noted?

51. Initial lactate level measurement Antibiotic Administration
The severe sepsis clock would start with the presentation of severe sepsis (3 p.m.) and the septic shock clock would start with presentation of septic shock (5 p.m.)
The presentation of severe sepsis at 3 p.m. will trigger the following counters with the start time being 3 p.m. :
"Sepsis Three Hour Counter" would require the following be completed by 6 p.m.:
Initial lactate level measurement
Antibiotic Administration
Blood Cultures prior to antibiotics
"Sepsis Six Hour Counter" would require the following be completed by 9 p.m.:
Repeat lactate if initial lactate is >2
Severe Sepsis Clock starts with the presentation of severe sepsis 3pm
The Septic Shock Clock starts with the presentation of septic 5pm
The Severe Sepsis Clocks starting at 3pm will trigger the 3hr measures to completed by 6pm and the 6hr measure of repeat Lactate to be completed by 9pm

52. Resuscitation with 30 mL/kg of crystalloid fluids
The presentation of Septic Shock at 5 p.m. will trigger the following counters with the start time being at 5 p.m. :
“Shock Three Hour Counter" would require the following be completed by 8 p.m. :
Resuscitation with 30 mL/kg of crystalloid fluids
"Shock Six Hour Counter," ONLY if hypotension persists, would require the following be completed by 11 p.m. :
Vasopressor administration
Repeating the volume status and tissue perfusion assessment
The Septic Shock Clock started at 5pm will trigger the 3hr Septic Shock measure of fluid resuscitation by 8pm and
the 6hr measure of adding vasopressors for refractory hypotension and repeating volume status and tissue perfusion assessment by 11 pm

53. Are you ready for SEPSIS?
Thank You!

54. Questions

55. Theresa Harris tharris@mauryregional.com and
Angela Craig