1. 1 Search and Rescue: The keys to Surviving Sepsis July 22, 2008 Emmel B. Golden, Jr., MD, ICU Medical Director Melanie Polzin, RN, CCRN, ICU Head Nurse Mary Ann Northern, PI Specialist

2. 2 Baptist Memorial Hospital- Memphis 706 bed tertiary care hospital 38 bed general ICU - 28 medical -surgical; 10 neuro - Intensivist-led, open unit model 22 bed CVICU

3. 3 Our Team Members ICU Medical Director Intensivists Nursing PI Specialist Clinical Pharmacist Respiratory Therapist Dietitian Staff Development Physical Therapist Speech Therapist Infection Control Case Manager Staff Development Palliative Care nurse ED nurse Lab- medical technologist

4. 4 Commitment to Improvement Multidisciplinary team IHI Model for Improvement Aim, Measures, Process Changes, PDSA cycles Incorporating principles of reliability Using data to drive improvements

5. 5 Six Years on the Path to Excellence FY 2002- Present 40% reduction in ICU Length of Stay 39% reduction in ICU mortality 48% decrease in ventilator length of stay 23% reduction in VAP rate 33% drop in BSI rate 50% reduction in Sepsis mortality rate for protocol patients (40% in 2004 for all patients coded in severe sepsis/septic shock. In 2007 mortality was reduced to 19% for protocol patients.)

6. 6 Establishing the Foundation: ICU Process Changes 2003- 2008 Intensivist coverage for nights and week-ends Multidisciplinary rounds ICU Daily goal sheet/ Patient Plan of Care Pre-extubation worksheet Care bundles: Ventilator, Central Line, UTI Clinical Pharmacy rounds Glycemic control protocol and policy Medical Response Team

7. 7 More ICU Process Changes Sepsis screening Severe Sepsis protocol order set, including resuscitation and management bundles Active surveillance/screening for MRSA Flexible visitation Now testing a Sedation Protocol

8. 8 Sepsis: Getting Started Severe Sepsis/Septic Shock Protocol Incorporated resuscitation and management bundles Start small- lactates ED & ICU Collaboration Relationships

9. 9 Early Identification is Key Screening tools All ICU admissions & >3day LOS High risk units- critical care, stepdown, oncology ED MRT calls Case management

10. 10 What we know about our Septic Patients The ED is a high volume location for septic or potentially septic patients 78% start their hospital stay in the ED High Risk Patients- Pneumonia, UTI, Devices

11. 11 Sepsis Bundle Implementation Start with one patient, one MD, one nurse One-on-one with physicians Staff education Multidisciplinary involvement Spread ED/ICU collaboration for resuscitation bundle Prioritizing ICU bed

12. 12 Sepsis Resuscitation Bundle Serum lactate Blood Cultures Antibiotics CVP Fluids

13. 13 Sepsis Resuscitation Bundle Reliabilty

14. 14 Sepsis Management Bundle Low dose steroids Drotrecogin alfa according to policy Glucose control Inspiratory plateau pressure <30 cm H20

15. 15 Sepsis Mortality 2004 DRG data: 40% mortality Jan06- Apr08: 18% (264 protocol patients)

16. 16 Where are we after 2 ½ years? Good news: For patients on the protocol, mortality is consistently 20%- historical mortality 40% ED is now able to volume resuscitate patients Able to move patients quickly to ICU bed Identified in ED Notified by ED Nurses can execute the protocol Nurses have accepted the protocol

17. 17 Where are we after 2 ½ years? Fall short: MDs- “culture eats protocol for breakfast” Patients not coming from the ED are less likely to go on the protocol Capture rate for protocol is not 100% for patients that meet criteria for protocol

18. 18 Questions?