Inpatient Code Sepsis March Update. Sarah Prebil

Transcription

1 Inpatient Code Sepsis March Update Sarah Prebil

2 3 hour bundle

3 Time is life Kumar et al. Crit Care Med 2006; 34:

4 But Sarah, why are you harassing us about sepsis?

5 Pilot Results 10 Code Sepsis pabents Trigger for code sepsis 7 with hypotension 3 with elevated lactate DisposiBon 5 transferred to the ICU 5 stayed on the floor AQending specialty 3 surgical 1 oncologic 6 hospitalist

6 Pilot Results Core Measures Lactate drawn Median Bme order to result - 40 minutes Broad spectrum anbbiobcs Median Bme from order to infuse - 27 minutes % broad spectrum given first: 90% IVF given % appropriate IVF given: Not hypotensive: 33% received 15 ml/kg within 3 hours Hypotensive: 0% received 30 ml/kg within 3 hours Blood cultures drawn prior to anbbiobcs % blood cultures drawn prior to anbbiobcs: 80%

7 Pilot Results PosiBve sepsis screen pabents: PaBents who meet sepsis screening criteria and have a possible source of infecbon who were idenbfied by bedside RN or rapid response RN (includes the 10 Code Sepsis pabents). Total pabents: 47 Sepsis present (includes sepsis, severe sepsis, & sepbc shock): 75% (35 of 47 pabents) RRT call data for E3000, E3100 and W3500 Increase in number of calls : 37à 45à 61 (Dec, Jan, Feb)- Total of for suspected sepsis : 37à 83à 54 (Dec, Jan, Feb)- Total of for suspected sepsis

8 Pilot Conclusions Early recognibon of sepsis is highly dependent on the bedside nurse The rapid response team RN is crucial in making this process run smoothly Pharmacy, lab, RN, MD and pabent placement all need to work together and communicate effecbvely in order for goals to be met. (This is essenbally what the Code Sepsis process facilitates)

9 The future of ANW sepsis work Short term ConBnue current process on pilot units Expand the screening process (bedside RN screen every 8 hours) to all Med/Surg units- - - Mid- April 2015 Allow RRT RN to use the sepsis part of the RRT order set and the code sepsis process throughout the hospital when a pabent has a posibve sepsis screen Mid- April 2015 Provide sepsis educabon for all inpabent nurses and providers in Quarter 2 Long term Convert bedside RN sepsis screening tool to electronic form in Excellian UBlize NICOM to assess fluid responsiveness Decrease mortality associated with sepsis

10 Abbott severe sepsis and septic shock mortality

11 Rapid response team order set Insert and maintain 2 peripheral IVs or 1 peripheral IV if patient already has central venous access (PICC, port or central line) RRT Document I&O upon completion of IV fluid bolus RRT Continuous Oximetry RRT Oxygen RRT CBC and Diff RRT Protime-INR RRT Comprehensive Metabolic Panel RRT Lactate RRT Blood Cultures RRT NaCl 0.9% IV infusion 1000 ml if hypotensive (SBP <90 or MAP <70) ONE TIME, STAT. RN to order when patient is hypotension plus NEW signs or symptoms of suspected infection -OR- Two or more other Sepsis Screening criteria plus NEW signs or symptoms of suspected infection ONE TIME, Routine. Document in the I&O Flowsheet upon completion of IV fluid bolus. Document the volume given and indicate infusion complete on the MAR. CONTINUOUS, STAT. RN to order if patient presents with two or more positive sepsis screening criteria plus new signs or symptoms of suspected infection. CONTINUOUS, RN to order if patient s oxygen saturation is less than 90%. ONE TIME, STAT. RN to order if patient presents with two or more positive sepsis screening criteria plus new signs or symptoms of suspected infection. ONE TIME, STAT. RN to order if patient presents with two or more positive sepsis screening criteria plus new signs or symptoms of suspected infection and none on record in the last 24 hours. ONE TIME, STAT. RN to order if patient presents with two or more positive sepsis screening criteria plus new signs or symptoms of suspected infection. ONE TIME, STAT. RN to order if patient presents with two or more positive sepsis screening criteria plus new signs or symptoms of suspected infection. CONDITIONAL PRN x 2, STAT. RN to release order if not drawn in last 24 hours and if patient presents with two or more positive sepsis screening criteria plus new signs or symptoms of suspected infection. ONE TIME, Intravenous, Dose: 15 ml/kg. RN to order if patient presents with two or more positive sepsis screening criteria plus new signs or symptoms of suspected infection AND hypotensive (SBP <90 or MAP <70). Infuse over minutes via two peripheral lines except with CHF/ CRF, then infuse over 60 minutes.

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13 PaBent hypotensive or two or more other Sepsis Screening Criteria* present and not chronic? Yes Possible infecbon? Call a Rapid Response (RRT) INPATIENT Severe Sepsis and Sep2c Shock Protocol Begin STAT. Time is Life! Yes- (Posi've sepsis screen) RRT verifies posibve sepsis screen No No End End Allina Health- AbboQ Northwestern *Sepsis Screening Criteria: SBP < 90 or MAP < 70 Temp > F (38.3 C) or < 96.8 F (36 C) Heart rate > 90 bpm RR > 20/min or PaCO 2 < 32mmHg WBC > 12,000 or < 4,000 or > 10% bands Acutely altered mental status PaBent hypotensive (SBP <90 or MAP <70)? Yes RRT calls Code Sepsis (call pa2ent placement) RRT uses RAPID RESPONSE TEAM Order Set (posi2ve sepsis screen sec2on) Start IV fluids (IVF) bolus if hypotensive RRT calls hospitalist/ house officer at the 2me of code sepsis No RRT uses RAPID RESPONSE TEAM Order Set (posi2ve sepsis screen sec2on) RRT calls aqending Discuss possibility of calling a code sepsis prior to lactate result Lactate > 2.2 mmol/l Provider uses SEVERE SEPSIS/SEPTIC SHOCK RAPID RESUSCITATION Order Set Perform Rapid ResuscitaBon STAT: Give fluid bolus to reach 30 ml/kg cumulabve for suspected hypovolemia Order lactate and other labs if not already done Ensure two blood cultures drawn before administering anbbiobcs Administer broad spectrum anbbiobcs RRT or bedside RN calls aqending Yes RRT calls Code Sepsis (call pa2ent placement) Any of the following? SBP < 90 aqer IVF MAP < 70 aqer IVF Lactate 4 mmol/l No - Usual care Sepsis** Diagnose the Severity of Sepsis: **Sepsis (without evidence of hypotension or organ failure) TWO of the following with new signs or symptoms of suspected or known infecbon: Temp > F (38.3 C) or < 96.8 F (36 C) Heart rate > 90 bpm RR > 20/min or PaCO 2 < 32 mmhg WBC > 12,000 or < 4,000 or > 10% bands Acutely altered mental status ***Severe Sepsis Sepsis plus ONE or more NEW organ dysfuncbon criteria (signs must be separate from the primary site of infecbon and not known to be chronic): SpO2 < 90% on room air in the absence of pneumonia CreaBnine > 2 mg/dl or 50% rise from baseline and > 1.2; or UO < 0.5 ml/kg/hr for > 2 hours Lactate > 2.2 and < 4 mmol/l Bilirubin > 2 mg/dl Platelet count < 100,000 SBP < 90 or MAP < 70 ****Sep2c Shock Sepsis plus ONE of the following: SBP < 90 or MAP < 70 aqer adequate IV fluid resuscitabon with 30 ml/kg NaCl 0.9% (or equivalent fluids) Lactate 4 mmol/l

14 NICOM Setup NICOM SYSTEM NICOM SENSORS Four sensors placement: 2 sensors Rt. & Lt. supra- clavicular or upper back 2 sensors Rt. & Lt. flanks or lateral sub- costal region 14

15 NICOM Basics CARDIAC OUTPUT CARDIAC INDEX (CO) = the amount of blood pumped by a ventricle during one minute (4-8 L/min) (CI) Stroke Volume (SV) x Heart Rate (HR) adjusted for body size ( L/min/m 2 ) ü Stroke volume is the volume of blood ejected with each heart beat ( ml) ü Stroke volume index - adjusted for body size (33-47 ml/m 2 ) 15 Parker RB, Parker RB, Cavallari LH. Chapter 20. Systolic Heart Failure. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw- Hill; 2011.

16 Impact of Frank-Starling Curve ConBnuous hemodynamic monitoring allows fluid status to be opbmized by determining fluid responsiveness. Stroke Volume (ml) Fluid administra2on improves cardiac performance Fluid administra2on has no benefit Preload Ventricular End Diastolic Volume (ml) 16 BarreQ KE, Barman SM, Boitano S, Brooks HL. Chapter 30. The Heart as a Pump. In: BarreQ KE, Barman SM, Boitano S, Brooks HL, eds. Ganong's Review of Medical Physiology. 24th ed. New York: McGraw- Hill; 2012.

17 Comparison of Bioimpedance and Bioreactance Ventricular ouulow drives changes in Phase (Phase Shiq) of radiofrequency waves as they cross the chest Measuring the Phase Shiq enables exact calculabon of flow Bioimpedance CHANGE IN AMPLITUDE Bioimpedance is an older technology which measures voltage AMPLITUDE ΔP Bioreactance PHASE SHIFT = ΔP TIME High signal to noise rabo with bioreactance leads to greater accuracy and ability to provide precise informabon during challenging clinical applicabons 17 Keren H, et al. Am J Physiol Heart Circ Physiol. 2007;293(1):H583- H589.

18 Take home points Be in contact with the aqending sooner rather than later StarBng in mid- April The current process of screening pabents every 8 hours for sepsis will start on E4100, E4500 and W The rapid response nurses will be able to use the Code Sepsis process on any pabent in the enbre hospital Watch for more NICOM training in April

19 Questions? Please contact me with anything related to Code Sepsis! or use anwpaging.com