2. In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed the Surviving Sepsis Campaign. The purpose of this initiative was to improve diagnosis, management, and treatment of sepsis. Background

3. The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHI To be accomplished as soon as possible and scored over first 6 hours:  Serum lactate measured  Blood cultures obtained prior to antibiotics administered  Perform imaging studies promptly to find source  Administration of broad-spectrum antibiotics within 1 hour of diagnosis of septic shock and severe sepsis without septic shock Dellinger, 2008

4. The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHI For hypotension and/or lactate > 4 mmol/L:  Deliver an initial minimum of 20 mL/kg of crystalloid (or colloid equivalent)  Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain MAP > 65 mmHg. For persistent hypotension despite initial fluid resuscitation (septic shock) and/or lactate > 4 mmol/L:  Achieve CVP of 8-12 mmHg & MAP > 65 mmHg & UO > 0.5mL/kg/hr  Achieve ScVO ₂ of > 70% or SvO2 > 65%.  if ScVO ₂ not > 70%, consider blood or dobutamine Dellinger, 2008

5. Purpose The purpose of this study is to establish the current level of medical compliance with the Severe Sepsis Protocol at UPMC Hamot.

7. Methods:  UPMC Hamot Institutional Review Board (IRB) approval obtained  Retrospective chart review of 50 patients admitted during 2010  Diagnosis of severe sepsis or sepsis with organ dysfunction Data collected:  Age  Length of stay  Source of sepsis  Mortality/functional status at admission and discharge Time of:  Admission  ScVO ₂ value ≥70% noted  PreSep (ScVO ₂ ) catheter insertion  Initiation of severe sepsis order set  First CCM order obtained after severe sepsis diagnosis  Blood cultures, lactate, and antibiotics post sepsis diagnosis Methods

8. Findings *Dx=diagnosis Cx=blood cultures Lact=lactate Abx=antibiotics Recommended time:  Blood cultures drawn, 1 hour  Antibiotics administered, 1 hour  Lactate levels drawn, 6 hours *Dx=diagnosis Cx=blood cultures Lact=lactate Abx=antibiotics Recommended time:  Blood cultures drawn, 1 hour  Antibiotics administered, 1 hour  Lactate levels drawn, 6 hours *Dx=diagnosis Cx=blood cultures Lact=lactate Abx=antibiotics  Recommended time:  Blood cultures drawn, 1 hour  Antibiotics administered, 1 hour  Lactate levels drawn, 6 hours

9. Findings  22 patients (44%) had CCM consult  9 patients (18%) placed on protocol  5 patients (10%) protocol + CCM consult  8 patients (16%) received PreSep (ScVO ₂ ) catheter  6 patients (12%) received PreSep (ScVO ₂ ) + CCM consult

10. Findings  56% of patients discharged to SNIF/Rehab  22% of patients died  22% discharged home  78% of patients came from home; only 22% were able to return directly home due to change in functional status

11. Discussion  Time to treatment longer than recommended  Important measures of sepsis diagnosis not available: Lactate not drawn ABG drawn without panel Cultures not obtained  CCM management Frequency of consult Time to first order

12.  Regional transfers  Floor patients  Documentation  Sample Size Limitations

13. Recommendations  Sepsis Alert Teams  Screening Tools  Education Regional facilities Medical staff Recommendations

14. Consistent use of a standardized protocol “ensures implementation of evidence based guidelines, decreases variability in management among clinicians…and monitors quality of care” (Moore, 2009). Conclusion

15. Thank You! Jean Bulmer and Debbie Hess, our Research Residency mentors Diane Voelker and Linda Jeffrey, Library services Becky Stokes, EBP expert and role model, our inspiration Ginny DiGello and Matt Niles, for their support of the residency program Our MICU Colleagues Acknowledgements