1. Assistant Clinical Professor
Sepsis Day 2016
Russell Kerbel MD MBA
Assistant Clinical Professor
Hospital Medicine
UCLA Health

2. In Last Years Episode…

3. New in 2016 for UCLA Sepsis: CMS: SEP-1 Bundle
New Sepsis Team Structure for UCLA Health
Sepsis 3.0 Guidelines
Early SEP-1 Data

4. Assistant Clinical Professor
Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment UCLA Sepsis Day 2016
Russell Kerbel MD MBA
Assistant Clinical Professor
Hospital Medicine
UCLA Health

5. Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment UCLA Sepsis Day 2016

6. Mission: “Deliver Leading-Edge Patient Care, Research and Education”
Sepsis Executive Committee
Sepsis Quality and ValU Teams
Sepsis Nursing Champions

7. Defining: SIRS, Sepsis, Severe Sepsis & Septic Shock
Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment
Defining: SIRS, Sepsis, Severe Sepsis & Septic Shock

8. Why initiate the bundle at Severe Sepsis?
The Sepsis Continuum
Why initiate the bundle at Severe Sepsis?

9. Wait…I thought SIRS & Severe Sepsis were obsolete?
Utilization of the SOFA and qSOFA Scores
Not recognized by CMS or ICD-10

10. Mean Arterial Pressure = Cardiac Output X Systemic Vascular Resistance
MAP = CO x SVR
Mean Arterial Pressure = Cardiac Output X Systemic Vascular Resistance
Why is does the SVR fall in Severe Sepsis?

11. Severe Sepsis and Septic Shock
Derek C. Angus, M.D., M.P.H., and Tom van der Poll, M.D., Ph.D.
N Engl J Med 2013; 369: August 29, 2013DOI: /NEJMra

12. Microcirculation Tissue Severe Sepsis and Septic Shock
Derek C. Angus, M.D., M.P.H., and Tom van der Poll, M.D., Ph.D.
N Engl J Med 2013; 369: August 29, 2013DOI: /NEJMra

13. Severe Sepsis (2 SIRS Criteria + Infection Source + Any One of these)
Vasodilation
SBP < 90 or MAP <65
SBP drop of greater than 40mmHg from last “normal” blood pressure
Tissue Hypoperfusion
Bilirubin > 2 mg/dL
Creatinine > 2 or Urine Output <0.5 mL/kf/hg for 2hrs
Lactate > 2 mmol/L
Coagulability Issues
INR 1.5 or aPTT > 60 seconds
Platelets < 100,000

14. The Sequential Organ Failure Assessment (SOFA)

15. Future Sepsis Physiology Research

16. Identify Clinical Deterioration
Creating a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment
Identify Clinical Deterioration

17. Doctor and Nurse Bedside Collaboration Rapid Response Team or A.C.T.
Clinical Deterioration
Call Primary Team?
Doctor and Nurse Bedside Collaboration
Clinical Stability
Call Primary Team?
Stable Vitals
Rapid Response Team or A.C.T.
SIRS / Sepsis
Severe Sepsis
Code Blue Team
Septic Shock
Time

18. How Can We Identify Patients on the Sepsis Continuum?
Current Methods:
Nurse Sepsis Screening Tool
Physician and RN Clinical Skills
Rapid Response Team at SM
Pilots Projects:
A.C.T. Pilot (8E and 8W at RR)
Clinical Triggers Pilots (4MN & 5MN at SM)
Clinical Surveillance Team (RR)
Sepsis ED RN Best Practice Alert (Planned for 2017)

19. The Severe Sepsis & Septic Shock Bundles
Creating a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment
The Severe Sepsis &
Septic Shock Bundles

21. Severe Sepsis Bundle Evidence?
Severe Sepsis Bundle Compliance Rates < 30% 4-6% Absolute Reduction in Mortality
Severe Sepsis Bundle Compliance Rates of 52% 20% Absolute Reduction in Mortality
Bundle Completion vs Non-Bundle Completion ~14% in Mortality Difference

24. High-Reliability Organizations
Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment
High-Reliability Organizations

25. The Granular Elements of a Highly Reliable Organization
(1)
(2)
(3)
(4)

26. Collective Drive: Sepsis Day! Preoccupation with Severe Sepsis Failure
Achieving Highly-Reliable Severe Sepsis Identification and Treatment at UCLA
(1)
No Sepsis Guidelines or Protocols
Sepsis Screenings and Bundles
Integrated Order Sets and Protocols
Backup and Redundant Systems
(2)
No way to measure errors
Event Reports & Severe Sepsis Dashboards
Severe Sepsis Process and Outcome Benchmarking
Continuous Real-Time Severe Sepsis Screenings
Individual Autonomy for Severe Sepsis
Sepsis Safety and Quality Teams
Centralized Severe Sepsis Control
Organizational Severe Sepsis Awareness
(3)
(4)
Trial and Error
Defining Roles In Severe Sepsis
Collective Drive: Sepsis Day!
Preoccupation with Severe Sepsis Failure

27. Continuing to Create a Highly-Reliable Academic Medical Center in Sepsis Identification and Treatment
You!

28. PLEASE EMAIL ME WITH IDEAS rkerbel@mednet.ucla.edu
Your Eyes
Your Clinical Skills
Your Innovations
PLEASE ME WITH IDEAS

29. Thank You
Questions?

30. Current RR SEP-1 Data

31. Current SM SEP-1 Data

32. December 2014: Case #1
85F Dementia, presents to ED with fever, WBC 21K, AKI, + supra-pubic tenderness, + UA. Documentation: # Severe Sepsis Secondary to Bacterial UTI with Acute Renal Failure: The pt received IVF, has been started on broad spectrum abx. The pt had a lactate drawn as well as two sets of blood cultures draw in the ED. Fallout: The Lactate was drawn 4:25 minutes BEFORE the Time of Presentation for Severe Sepsis

33. January 2015: Case #2
63F presents to the ED with leukocytosis, abdominal pain, transaminitis. Documentation: # Severe Sepsis: Possible intra-abdominal source, concern for cholangitis given nature of abdominal pain and lactate of 33 Fallout: No blood cultures, lactate (in window) or IVF bolus.

34. How could an Attending Hospitalist not know to draw a lactate?
Why would an Attending Hospitalist not draw Blood Cultures, Bolus IVF?

35. They Need More Education
Solution:
They Need More Education

36. Lots of Clinician Education
December 2014 – February 2015
Lectures regarding Sepsis Bundle to:
5 Nursing Groups on 4MN and 5MN
Family Medicine Residents
Hospitalists
Private Physicians
Nursing Leadership
Administration Leadership

37. Who was the Attending Hospitalist for Cases 1 & 2?
Dr. Russell Kerbel

38. Did my patients “Fall-Out” of the Sepsis Bundle on purpose?No
This is a Systems-Error

39. Where was the Systems-Error?

40. Lets use the Sepsis Bundle as an Example
50%
Overall Bundle Compliance

41. Looking Closer at October 2014
82% +
11% =
50%

42. Breaking Down the Inpatient Bundle:
The 4 Components:

43. 2 of 8 Rapid Responses were Called
October 2014 Sepsis Fallouts
1. Lactate Not Drawn
2. Abx Not Given
2 of 8 Rapid Responses were Called
3. Blood Cultures Not Taken
4. IVF Bolus

44. Will Fish Diagrams Solve the Problem?:
Lactate
Abx
Lactate
Real-Time
Severe Sepsis Recognition and Documentation is Not Occurring
Blood Cultures
Fluid Bolus

45. 4MN & 5MN Clinical Triggers Pilot
Clinical Deterioration
Primary Team Communication?
4MN & 5MN Clinical Triggers Pilot
Clinical Stability
Primary Team Communication?
Stable Vitals
Rapid Response Team
SIRS / Sepsis
Severe Sepsis
Code Blue Team
Septic Shock
Time