Lynda Richardson, RN, BSN Sepsis/Septic Shock Abstractor. No disclosures

Size: px

Start display at page:

Download "Lynda Richardson, RN, BSN Sepsis/Septic Shock Abstractor. No disclosures"

August Day
8 years ago
Views:

1 Lynda Richardson, RN, BSN Sepsis/Septic Shock Abstractor No disclosures 1

2 2

3 3

4 Discuss data requirements -3 hour bundle -6 hour bundle Challenges and compliance issues Success 4

5 Based on the Surviving Sepsis Campaign guidelines Customized data entry tool in Midas Nurses screen every shift for sepsis and septic shock Only enter Septic Shock patients into our data base Excludes all patients transferred into our ICU as direct admits from outside facilities Other exclusions may occur (i.e. DKA, post CPR,refusal of central line by patient) Data is compiled on a monthly basis and shared with Sepsis team, directors and providers In process of transitioning over to Sep Measure Guidelines to include severe sepsis cases 5

6 6

7 Mandatory beginning October 1, 2015 Focus is on those patient with diagnosis of severe sepsis or septic shock Emphasis on early management (thus the time frames) Consistent with the surviving sepsis campaign guidelines/recommendations Purpose of this measure is to bring about reduction in overall organ failure, hospital mortality, length of stay, and cost of care All or None Bundle 7

sepsis campaign guidelines/recommendations Purpose of this measure is to bring about reduction

8 8

9 Includes: Inpatients age 18 and over with an ICD-10-CM Principal or other Diagnosis code of Sepsis, Severe Sepsis, or Septic Shock Excludes: Patients under the age of 18 Patients with LOS greater than 120 days Patients with a directive for comfort measures documented by provider within 3 hours of presentation of severe sepsis Patients with a directive for comfort measures documented by provider within 6 hours of presentation of septic shock Transfer in from another acute care facility Patients with severe sepsis who expire within 3 hours of presentation Patients with septic shock who expire within 6 hours of presentation Patient/caregiver refusal for care(blood draw, fluid administration or antibiotics)- must be documented by provider or have a witnessed consent form stating the refusal of care present in the medical record (this form can be witnessed by nurse or provider) Patients receiving IV antibiotics for more than 24 hours prior to presentation with severe sepsis 9

provider within 6 hours of presentation of septic shock Transfer in from another acute care facility Patients with severe sepsis who expire within 3 hours of presentation Patients with septic shock

10 3- hour bundle 6-hour bundle 10

11 3- hour bundle: 1. Initial lactate level 2. Broad spectrum antibiotic 3. Blood culture prior to antibiotics 4. 30ml/kg crystalloid fluid 6-hour bundle: 1. Repeat lactate level 2. Vasopressor if hypotension persist 3. Volume status and tissue perfusion reassessment if hypotension persist 11

30ml/kg crystalloid fluid 6-hour bundle: 1. Repeat lactate level 2.

12 1. Initial lactate level within 3 hours of presentation of severe sepsis 2. Broad spectrum antibiotic administration within 3 hours of presentation of severe sepsis 3. Blood cultures drawn prior to antibiotic administration 4. Repeat lactate level drawn within 6 hours ( if initial lactate is greater than 2) 12

severe sepsis 3. Blood cultures drawn prior to antibiotic administration 4.

13 1. Resuscitation with 30ml/kg crystalloid fluids within 3 hours of presentation of septic shock 2. Vasopressors within 6 hours of presentation of septic shock only if hypotension persists after fluid administration 3. Repeat volume status and tissue perfusion assessment within 6 hours of presentation of septic shock only if hypotension persists after fluid administration 13

Vasopressors within 6 hours of presentation of septic shock only if hypotension persists

14 14

15 2 step process: 1. Identify severe sepsis or septic shock 2. Decide date and time it occurred Need to get this right cause all other interventions hinges on this date and time # 1 challenge for me as an abstractor 15

16 All three of following criteria must be met within 6 hours of each other to ID severe sepsis: 1.Provider documentation of a suspected source of clinical infection. 2.Two or more SIRS criteria: Temp > 38.3 C (100.9 F) or < 36.0 C (96.8F) Heart Rate(pulse) > 90 Respiration > 20 WBC >12,000 or <4,000 or >10% bands 3.Organ dysfunction, evidenced by any one of the following: Systolic BP <90 or MAP <65, or a systolic blood pressure decrease of more than 40 points Creatinine >2.0, or urine output <0.5ml/kg/hr for 2 hours Bilirubin >2mg/dl Platelet count <100,000 INR >1.5 or a PTT > 60 sec. Lactate >2.0mmol/l 16

8F) Heart Rate(pulse) > 90 Respiration > 20 WBC >12,000 or <4,000 or >10% bands 3.

17 The criteria for determining if septic shock is present are as follows: 1.There must be documentation of severe sepsis present AND EITHER 2.Tissue hypo perfusion persists in the hour after crystalloid fluid administration, evidenced by either: Systolic BP <90 MAP <65 A decrease in systolic BP by >40 points OR 3.Lactate Level >=

Tissue hypo perfusion persists in the hour after crystalloid fluid administration,

18 CRMC: 1. Triage time if patient comes through ED or direct admit arrival time to critical care 2. If patient identified on unit= suspected or known infection, meets 2 or more SIRS =hypotension 1 hour after fluid bolus OR lactate > or equal to 4(whichever comes first) 3. Enter multiple episodes within same admission CMS: 1. Time at which the last sign of severe sepsis or septic shock noted or the last qualifying lab value was reported. 2. For patients who enter the ED with severe sepsis or septic shock, time zero will equal triage time. 3. Enter only the initial episode within same admission 18

4(whichever comes first) 3. Enter multiple episodes within same admission CMS: 1.

19 Will always be when the chart annotation suggests signs and symptoms are all present May be from nursing charting, lab flow sheets, physician documentation, anything with a time stamp Will = triage time if all signs and symptoms are present at triage *content used with permission 19

physician documentation, anything with a time stamp Will = triage time

20 Initial lactate in 3 hours Repeat lactate in 6 hours 20

21 Fluids began within 3 hours of presentation of s/s of septic shock (time zero) Only 0.9% NS and LR count No provision for reason not to give 30ml/kg of fluid 21

22 A. Focused exam documented by Provider which includes ALL the following: Vital signs(includes all: BP, Pulse, Resp., Temp) Cardiopulmonary exam (heart and lung) Capillary refill evaluation Peripheral pulse evaluation Skin examination OR 22

23 B. Any two of the following: Central venous pressure measurement Central venous oxygen measurement Bedside Cardiovascular Ultrasound Passive Leg Raise or Fluid Challenge 23

24 May be referred in alternative terms: PLR or leg raise Commonly noted as positive or negative Performed with patient in semi-recumbent position with both legs raised to a 45 degree angle Evaluates the patient vital sign response to additional fluid load 24

25 Time for repeat volume status and tissue perfusion assessment starts at the crystalloid fluid administration date and time and stops six hours after presentation of septic shock date and time Focus assessment must be documented by provider Can use consult notes, ED record, H/P, or progress notes Can be from multiple sources Cannot use nursing documentation 25

26 Midas live Identification of patients Communicating needs of patients to nursing/providers Time involved 26

27 27

28 Education of nursing in orientation/ongoing Educate providers- cheat sheets Educate patients- discharge instructions Education in community- prevalence and disease process (health fairs,etc) 28

29 Monthly Sepsis Meeting Nurse Managers/Administration Providers/Board members Detail Report of OFI s Drill Down to patient level Track LOS, Survival rate, and readmission rate 29

30 Indicator/Month Jan 26 Feb 25 March 20 1 st Q 71 Apr 11 May 18 Lactate drawn within 3 hrs of time zero 100% (26/26) 92% (23/25) 95% (19/20) 96% (68/71) 82% (9/11) 100% (18/18) Blood C/S drawn prior to antibiotics 88% (23/26) 92% (23/25) 95% (19/20) 92% (65/71) 100% 89% (16/18) Broad Spectrum antibiotic within 3 hrs of time zero 92% (24/26) 84% (21/25) 75% (15/20) 85% (60/71) 82% (9/11) 67% (12/18) Administer 30ml/kg crystalloid 65% (17/26) 60% (15/25) 80% (16/20) 68% (48/71) 73% (8/11) 72% (13/18) Administer 30ml/kg crystalloid within 3hrs of time zero 82% (14/17) 100% (15/15) 81% (13/16) 88% (42/48) 100% 8/8 100% (13/13) Central line placed 88% (23/26) 64% (16/25) 75% (15/20) 76% (54/71) 73% (8/11) 78% (14/18) Central line placed within 6 hrs of time zero 57% (13/23) 94% (15/16) 40% (6/15) 63% (34/54)) 63% (5/8) 43% (6/14) MAP goal met within 6 hrs of time zero 85% (22/26) 88% (22/25) 60% (12/20) 79% (56/71) 91% (10/11) 56% (10/18) CVP goal met within 6 hrs of time zero 15% (4/26) 8% (2/25) 10% (2/20) 11% (8/71) 9% (1/11) 0% (0/18) Scv02 goal met within 6 hrs of time zero 4% (1/26) 0% (0/25) 5% (1/20) 3% (2/71) 0% (0/11) 0% (0/18) Survival Rate 77% (20/26) 64% (16/25) 60% (12/20) 68% (48/71) 82% (9/11) 94% (17/18) Readmission Rate 3.8% (1/26) 4% (1/25) 10% (2/20) 5.6% (4/71) 9% (1/11) N/A (No readmits) 30

31 31

32 Seasoned abstractor/nurse Education on Sepsis Careful study of guidelines Stream line documentation as much as possible Inter-Rater Reliability Backup Abstractor 32

33 Breath Believe Begin Molly,

34 CMS: Specification Manual for National Hospital Inpatient Quality Measures Discharges 5.0a Dellinger et al, Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: Critical Care Medicine. 2013;41: Townsend, Sean R. MD(2015)Sep-1:First National Core Measure on Sepsis Care/New Bundles & CMS Core Measures to begin October 2015 (PowerPoint slides) hosted by CMS: Early Management Bundle, Severe Sepsis/Septic Shock. Retrieved from events/ Molly (2011). Molly s Dance Show Super Why Season 2, Episode 4, WTCE TV, 15 Sept. 34

35 35

Core Measures SEPSIS UPDATES

Patricia Walker, RN-BC, BSN Evidence Based Practice Manager Quality Management Services UCLA Health System, Ronald Reagan Medical Center Core Measures SEPSIS UPDATES Sepsis Core Measures Bundle Requirements