1. 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

2. 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

3. 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

4. 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, 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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
                                              >50% collapse                   6-10
                                              <50% collapse                    11-15
>2.5                                                  <50% collapse                   
>2.5                                                   No change                          >20
Sue Trikha RN,C CEN CPHQ Quality Dept
9/25/2015

14. 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

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

16. 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

17. 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

18. 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: Crit. Care Med 41:2,
Hotchkiss, R.S., Karl, LE (2003): The pathophysiology and treatment of sepsis, N. Engl J. Med, 348,
Sharma, S. (2007, April 4): Septic Shock, Retrieved from eMedicine Web site:
Specifications Manual for National Hospital Inpatient Quality Measures Discharges through SEP-1
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

19. 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