Sepsis Identification and Rescue. Stony Brook University Medical Center January 23, 2008

Transcription

1 Sepsis Identification and Rescue Stony Brook University Medical Center January 23, 2008

2 Stony Brook: AIM Stony Brook University Medical Center s s goal is to engage in the Surviving Sepsis Campaign via the Institute for Healthcare Improvement s s Critical Care Learning Collaborative to achieve a 25% reduction in severe sepsis mortality by May 2009.

3 IHI s Critical Care Collaboratives September present Daily goals Multidisciplinary rounding Reducing pneumonia from ventilators (VAP) Reducing bloodstream infections from central venous catheters November present Reducing Complications from Ventilators (continued) Reducing Complications from Central Lines (continued) Communication and Collaboration of a Multi- disciplinary team Improved Glucose Control Reducing Mortality due to Severe Sepsis

4 Surviving Severe Sepsis Mortality rates associated with sepsis 30-50% for severe sepsis 50-60% for septic shock Severe sepsis is the leading cause of death in the non-coronary ICU Sepsis kills approximately 1,400 people worldwide every day

5 Surviving Sepsis Campaign The Society of Critical Care Medicine, the European Society of Intensive Care Medicine and the International Sepsis Forum joined forces to develop the Surviving Sepsis Campaign The goal is to reduce global mortality from severe sepsis by 25% by 2009

6 Surviving Sepsis Campaign Severe Sepsis Screening Standardized Protocols Resuscitation Bundle (completed within 6 hrs of presentation) Management Bundle (completed within 24 hours of presentation) Compliance Monitoring

7 Bundle A grouping of best practices that have been individually proven to improve quality in an area of clinical practice. Made of simple, basic, tested and proven interventions that will improve patient outcomes. They are generally so basic that they have been abandoned or lost in the intensity of high-tech devices. Not based on individual perception or practice style. Institute For Healthcare Improvement

8 Severe Sepsis Screening Determines if patient meets severe sepsis criteria Completed upon admission, daily, and PRN Prompts initiation of serum lactate, blood culture and first dose of antibiotic

9 Early Goal-Directed Therapy Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock Early hemodynamic assessment on the basis of physical findings, vital signs, central venous pressure, and urinary output fails to detect persistent global tissue hypoxia A more definitive resuscitation strategy involves goal-oriented oriented manipulation of cardiac preload, afterload,, and contractility to achieve a balance between systemic oxygen delivery and oxygen demand Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine. November 8,

10 Resuscitation Bundle (within 6 hrs) 1. Serum Lactate Measured 2. Blood cultures obtained prior to antibiotic administration 3. From the time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non-ed ICU admissions

11 Resuscitation Bundle (cont d) 4. In the event of hypotension and/or lactate > 4 mmol/l (36 mg/dl): Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent) Apply vassopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg 5. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/l (36 mg/dl): The goal is central venous pressure (CVP) of > 8 mm Hg The goal is central venous oxygen saturation (ScvO2) of > 70%

12 Management Bundle (within 24 hrs) 1. Low-dose steroids administered for septic shock in accordance with a standardized ICU policy 2. Drotrecogin alfa (activated) in accordance with a standardized ICU policy 3. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/l) 4. Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients

13 Supportive and Adjunctive Therapies Results of the German Prevalence Study Courtesy of Konrad Reinhart Interview Audit % Low tidal ventilation 4 Glycaemic control 9 18 ScvO 2 Hydrocortisone septic shock IHI Critical Care Collaborative Meeting, San Diego November 2006

14

15 Model For Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements that we seek? aims measurements change principles Act Plan Study Do testing ideas before implementing change Institute For Healthcare Improvement, September 2004

16 Measures Sepsis mortality Sepsis resuscitation bundle compliance (first 4 elements) Sepsis resuscitation bundle compliance (all elements) Sepsis management bundle compliance Serum lactate order volume

17 Step One: ICU Testing and Spread Utilized preexisting ICU performance improvement teams to address sepsis bundle compliance and mortality Developed severe sepsis screening tool Screening of patients for severe sepsis upon admission, daily, and PRN Developed Severe Sepsis Order Set

18 Step One: ICU Testing and Spread (cont d) Modified the bundles and screening tool for pediatric use Developed antibiotic bundle (adult and pediatric) Lactate obtained by Respiratory Therapist on unit using radiometer

19 Step Two: Emergency Department Involvement Formed a team in the emergency department to increase severe sepsis detection and decrease mortality Created fever panel Blood culture, Urine culture, U/A, Lactic acid, CBC with diff, Chem 8, APPT/PT, Chest-Xray (lateral/portable) Created rule out sepsis panel - Blood culture, Type and screen, EKG, Hepatic, Optional labs: Trop I, Arterial blood gas, Magnesium, Phosphate Developed severe sepsis screening into triage system Reviewed non compliant chart reviews at ED M&M meetings Developed and implemented emergency medicine/critical care flow sheets to increase documentation of resuscitation bundle elements

20 Stage Three: Created Sepsis Steering Committee Formed a Sepsis Steering Committee to monitor compliance and to develop house-wide policies and procedures related to the detection and treatment of severe sepsis Instituted an automatic call from the lab to the unit/department for a lactate critical value ( ( 4 mmol/l) Developed and monitored central line criteria for severely septic patients Developed blood collection stickers to increase documentation of blood collection date/time Developed and implemented standardized hospital-wide adult sepsis resuscitation order set (emergency department, critical care units and floor patients)

21 Stage Four: Roll-out out to the Floors Printed copies of the sepsis screening tool on the back of the rapid response team form to initiate sepsis screening during RRT calls Developed mechanisms for communicating progress (via data) back to the emergency department, critical care units, rapid response team and medical/surgical floors Storage of first dose antibiotics on Pyxis machines Communicating missed diagnosis of severe sepsis back to the RRT Steering Committee, Sepsis Steering Committee and medical/surgical service

22 Criteria for Central Line in Severe Sepsis Patients A central venous catheter capable of measuring ScvO2 is inserted in a severely septic patient in the first 6 hours after presentation n if one or more of the below conditions are met*: Patient exhibits persistent hypotension despite fluid resuscitation ion Patient requires vasopressor therapy for hypotension Inability to obtain adequate peripheral access in patient for fluid resuscitation, blood products, or medications. Contraindications to the above criteria include: Patient is at risk for bleeding Patient is too unstable/code imminent Patient has a high risk of developing pneumothorax Vascular access is not possible (e.g., bilateral clots) Insertion of line would not change the course of treatment Patient refuses to give consent * For massive fluid resuscitation consider cordis

23 Antibiotic Bundle Broad spectrum antibiotics are used in instances of empiric treatment. tment. Recommended broad spectrum antibiotics: Imipenem Pip/ tazo (zosyn) Cefepime/Flagyl Vancomycin may be used in addition to one of the above, in cases where clinical judgment suggests that gram positive bacteria (MRSA/enterococcus enterococcus) ) is likely Specific antibiotic choice should be based on probable/possible infection, known bacteria, and antibiotic susceptibility. Every patient should receive at least 2 sets of blood cultures prior p to antibiotic administration. Serum lactate should be obtained to detect severe sepsis.

24 Antibiotic Bundle Once the location/organism is identified, the narrowest antibiotic(s) should be chosen to replace the initial broad spectrum antibiotic. Decision for the narrowest antibiotic must be made no later than day 4 of administration. Documentation must be made regarding antibiotic continuation and/or a change in antibiotic no later than day 4 of administration. ion. Antibiotics to be avoided absent specific indications are: Vancomycin Clindamycin Linezolid Aminoglycosides Beta-lactamase lactamase-inducing cephalosporins * Minimal duration of total antibiotic administration should be used.

25

26

27

28

29

30

31

32 Lessons Learned Standardization of care aids in the reliability of the services provided to the patient Decreased variation in the delivery of care is associated with improved compliance and better outcomes Breaking down the bundles into smaller, attainable steps (first 4 resuscitation bundle elements) assists in achieving compliance Active participation from the emergency department is essential in order to be successful

33 Lessons Learned Concentrate on increased compliance for the severe sepsis cases identified by staff rather than increasing the number of detected sepsis cases Seek out your physician champion to engage in one small test of change Drill-downs are insightful Leadership support is key to successful hospital spread of initiatives Small tests of change are easier to accept rather than wide-spread change It s s best to test and modify protocols from other hospitals than it is to create protocols from scratch

34 Next Steps Increased oxygen saturation measurement and compliance with goal Increased central venous pressure measurement and compliance with goal Decreased time to central line insertion