John Gasman, MD Alec Jamieson, RN, MSN Kim Clifforth, RN, BSN, MSN, CNS Thomas T. Lam, MD. June 18, 2013

Transcription

1 John Gasman, MD Alec Jamieson, RN, MSN Kim Clifforth, RN, BSN, MSN, CNS Thomas T. Lam, MD June 18, 2013

2 Objectives Acquire knowledge on defining sepsis, severe sepsis and septic shock Recognize SIRS criteria. Define sepsis as it relates to pathophysiological changes in patients Describe methods used to improve EGDT 6 Hour measures.

3 Leverage and Optimize KPHC Culture of Safety and Teamwork World Class Hospital Goal Drivers Focus Areas Do No Harm Prevent Infections Prevent Falls Prevent Pressure Ulcers Medication Safety Surgical Safety Perinatal Safety The Quality Leader Evidence Based Care Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Stroke Sepsis Perinatal Care Critical Care Delirium Management Patient Mobility Pediatrics Coordinated Care Palliative Care Life Care Planning Excellent Transitions 3

4 Sepsis A clinical syndrome Systemic inflammation due to infection A continuum: Sepsis > severe sepsis > shock 750,000 cases / year in U.S. Any age, race, gender, or ethic groups 200,000 fatalities Mortality rate is 40% or more for severe sepsis or septic shock.

5 Sepsis in Perspective - NCAL AMI Admissions AMI Mortality Sepsis Admissions Sepsis Mortality AMI mortality rate 4.7% Sepsis mortality rate 24%

6 How Big an Issue is Sepsis? 205,548 Adult Hospital Admissions 2007 KPNC Adult Hospital Stays, includes OB 24% of All Deaths 1,364 Deaths from Sepsis 2.7% of All Admissions 5,558 Sepsis Admissions 199,990 Other Admissions 4,302 Deaths from Everything Else Mortality Rate 25% A Big Issue: 1 in 4 deaths Eleven times the mortality rate Mortality Rate 2.2%

7 The Spectrum of Sepsis

8 Goals for Sepsis Care

9 Does Early Goal Directed Therapy Work? Mortality (16% absolute reduction) Organ dysfunction Need for vasopressors (15%) Sudden cardiopulmonary complications (100%) ICU LOS and Health Care Resources (20%) From Henry Ford Hospital, E. Rivers NEJM 2001: 345;

10 Treatment of Sepsis Supportive care Respiratory support Hemodynamic support Assure perfusion to vital organs Control the Septic Focus Obtain cultures Remove source and debride or drain Antibiotics Septic Exotica Corticosteroids

11 Prognostic Value of Elevated Lactate * Source: Gabriel Escobar, MD DOR

12 Impact of Elevated Lactate 2079 elevated lactates KPNC Q Results based on elevated lactate in ED for patients then admitted, not specific to sepsis 18 patients a day 1653 intermediate lactates (2-4) 426 high (>4) lactates 5 patients a day 10% mortality 32% mortality 165 deaths 136 deaths -1 in 10 dies- -1 in 3 dies- 55% of lactate-associated mortalities are in intermediate lactate group. This group accounts for over 10% of all hospital mortalities. The intermediate lactate mortality was more than double that of our AMI patients. High lactate mortality was 7X the AMI mortality rate.

13 Identify at triage if suspected infection and 2 SIRS criteria T < 96.8 (36.0) or > (38.0) HR > 90 RR > 20 WBC > 12K or < 4K or > 10% bands -OR- Altered LOC CBC, Lactate, BC Consider IV fluids and ABX EGDT Goals from Time Zero 1. Start Antibiotic 1 hr 2. First CVP or ScvO2 within 2 hrs 3. CVP 8-12 within 6 hrs 4. MAP 65 within 6 hrs 5. ScvO2 70 within 6 hrs 6. Repeat lactate < initial lactate within 3-12 hrs Suspected Sepsis Document SIRS SBP 90 w/transient improvement (2 hr) Time Zero (1 hr from Initial) Hypotension Document Septic Shock SBP 90? 20 ml/kg fluid bolus in 1 st hour YES SBP 90 (1 hr) Time Zero Document Septic Shock Time Zero = Sepsis Alert NO SBP > 90 Document SEPSIS < 2.0 Lactate high? 4 Time Zero Document Severe Sepsis EGDT Aggressive fluid resuscitation Within 1 hr: Start ABX Within 2 hrs: Measure CVP or ScvO2 Last Modified: 10/13/10 Quality Management S:\Quality\Sepsis\Work Flows\SEPSIS Algorithm Document Severe Sepsis *Repeat lactate in 3-6 hours

14 EGDT Bundle for Severe Sepsis/Shock & 2013 Goals Diagnose Severe Sepsis or Septic Shock Central Line Placed 1 st CVP or SvcO2 MAP CVP ScvO 2 at Goal Repeat Lactate is Lower than First Lactate Screen all patients at risk ABX started IV Fluid Time Zero 1 hour 2 hours 6 hours Within 12 hours 2013 Goals: 90% 70% EGDT bundle: 50%

15

16 Summary Early Diagnosis with sepsis screening tools. Risk stratification with lactate level and follow up of lactate trends Document the Sepsis diagnosis. Early resuscitation improves mortality, confirmed by RCT. Use of a Sepsis Order Set for uniformity of basic care. Collaborative team effort.

17

18 Key Components to Success Appropriate education and Training Frontline staff engagement, ownership and involvement Transparency of data: collection and review Multidisciplinary collaboration Clearly delineated roles, responsibilities and processes Standardization of practices In Other Words Build a Solid Foundation on Which to Build a Sustainable and Reliable Practice!!

19 Where we were Mortality rate 19.5% Sepsis Summit Nov 2008

20 The beginning Why was mortality in this population so high? Several key issues identified: We cause it Increased mortality We underestimate it We under treat it

21 The Beginning cont. What did we need to do to address these problems? 1. Find (Name and Document) Sepsis 2. Stratify Risk 3. Reliable Care at All Levels of Risk

22 Time Pain* BP P R T GCS* MAP* FiO2/ CVP RASS* Intervention (EMV) Note actions taken in response to the findings on SpO2 mm/hg Score Score Character SCVO2 the left. TOTALS SITE GAUGE TYPE STARTED ABSORBED Team Training Abx in 1 hr CL in 2 hrs How?: #1- The Power of Teams Develop Teams Kaiser Foundation Hospital - San Jose Tools and Equipment EMERGENCY DEPARTMENT DRAFT ED NURSES FLOW SHEET Addressograph Date Pg of ADDRESSOGRAPH Room / Bed # EARLY GOAL DIRECTED THERAPY (EGDT) ED AND ICU ORDERSET Page 1 of 4 X Check box to activate an order Diagnosis of of Severe Severe Sepsis Sepsis or or Septic Septic Shock Shock Aggressive fluid fluid resuscitation Within Within 11 hr: hr: Start Start ABX ABX Within Within2 2 hrs: hrs: Central Central Line Line Placed Placed Adopt Algorithms CVP 8-12? MAP 65? ScvO2 70? 70 Lower Lactate <8-12 < 65 <70 E A R L Y G O A L 500 to 1000 ml Fluid boluses q 30 min Norepinephrine If Hct low, transfuse to 30 <70 Dobutamine D I R E C T E D T H E R A P Y Train Measure Lactates Lactates on ED Blood Cultures Sepsis Care Sepsis Implementation 55% DENOM 47% 44% 84% 37% 69% 91% 29% 85% 32% 77% 37% 99% 80% 36% 63% 66% 58% 56% 100% 0% 0% 0% Mark chart: Allergic to No Known Allergies Weight (kg) Height Check if applies: Pregnant Lactating ED ORDERS ICU ORDERS Administer oxygen titrate FiO2 to maintain SpO2 between 90-94%. Notify physician if patient requires over 50% FiO2 via face mask or more than 10% increase in 1 hour to achieve needed goal Continue Discontinue, RN (Date/Time) OUTPUT INTAKE PARENTERAL FLUIDS Time TYPE AMOUNT Time TYPE AMOUNT Time # Insert Foley catheter, RN (Date/Time) VITAL SIGNS Measure intake and output hourly, RN (Date/Time) Continue Discontinue Continue Discontinue Initals Signature/Title Initials Signature/Title Initials Signature/Title Record vital signs (heart rate, blood pressure, respiratory rate, SpO2) per unit standards and as needed, RN (Date/Time) Continue Discontinue Measure central venous pressure (CVP) every 30 minutes until goal has been achieved and for at least 2 hours after goal has been reached, then monitor per unit standards and as needed, RN (Date/Time) Continue Discontinue Monitor mixed venous oxygen saturation (ScvO2) continuously, RN (Date/Time) Continue Discontinue Collaborate! Collaborate! 22

23 How?: #2-The Power of Standardization

24 Kaiser Fresno s Process 1. Identify stake holders and Engage the Frontline staff: ED and CCU identified as primary stake holders. 2. Have the right tools and equipment ready to use 3. Adopt Algorithms and Have a Scripted Process 4. Develop and implement education and training 5. Implement EGDT 6. Measure 7. Process Improvement Collaborate!!: Interdisciplinary AND Interdepartmental

25 1. Identify your stake holders and Engage the Frontline staff ED and CCU identified as primary stake holders Develop teams Develop departmental champions and experts: involve them in process development, education and communication Share data and stories with frontline staff and solicit feedback

26 2. Have the right tools and equipment ready to use Ensure that ALL equipment and supplies are readily available and operational these are tools to help, not obstacles to overcome. Central line kits and sterile barriers SvO2 monitoring central line Ultrasound Machines and probe covers CVP transducers, pressure bags etc. Create a Sepsis Cart where all supplies and equipment are centrally located and easily accessed

27 3. Adopt Algorithms and Have a Scripted Process Provides clear and consistent communication as to process steps and outcome measures Provides for reliable execution Standardized ordersets used for ALL EGDT cases: ordersets follow the EGDT algorithms Fluid resuscitation Antibiotics Vasopressors Blood products

28 Identify at triage if suspected infection and 2 SIRS criteria T o < 96.8 (36.0) or > (38.0) HR > 90 SUSPECTED SEPSIS RR > 20 DOCUMENT SIRS WBC > 12K or < 4K or > 10% bands -OR- Altered LOC E A R L Y R E C O G N I T I O N CBC, Lactate, BC Consider IV fluids and ABX SBP 90? yes 20 ml/kg fluid bolus in 1 st hr SBP 90 no SBP >90 Document Septic Shock (Time Zero) Document Sepsis <2 Lactate high? 4 EGDT Aggressive fluid resuscitation Within 1 hr: Start ABX Within 2 hrs: Measure CVP or ScvO Document Severe Sepsis (Time Zero) Sepsis Resuscitation The Golden Hours Aggressive IV fluid resuscitation Early ABX Repeat lactate in 3-6 hrs Document Severe Sepsis CVP MAP 65? 65 ScvO2 70? 70 Repeat lactate 3-12 hrs < 8 < 65 <70 EGDT Goals from Time Zero 1. Start Antibiotic in 1 hr 2. First CVP or ScvO2 within 2 hrs 3. CVP 8-12 within 6 hrs 4. MAP 65 within 6 hrs 5. ScvO 2 70 within 6 hrs 6. Repeat lactate is lower than initial lactate w/in 3-12 hrs E A R L Y G O A L ml Fluid boluses q 30 min Norepinephrine If Hct low, transfuse to 30 <70 Dobutamine D I R E C T E D T H E R A P Y

29 4. Develop and Implement Education and Training Regional Education: November 2008 Sepsis Summit: Introduction to formalized EGDT process for all EDs and ICUs All 21 northern California Kaiser medical centers attended Data presented Tools presented Algorithms presented Goals set

30 Develop and Implement Education and Training Regional learning brought back to Fresno and local, Facility specific training and education was developed and implemented Focused on frontline staff learning algorithms, tools and goals Development of unit based teams with departmental champions and experts spearheading the educational efforts with frontline staff Small group in the moment hands-on training Staff engagement through direct involvement of implementation efforts

31 RN Education and Training: Round Two: November 2009 All RNs completed online training course on EGDT Comprehensive training for a small group of Super Users. 2-3 per shift Trained in tandem with CCU RNs (establish common understanding of workflows and roles and responsibilities-teamwork) Superusers became departmental champions and trained staff one on one: SIRS recognition, equipment setup and calibration, managing CVP and SCVO2.

32 Implementing Our EGDT Treatment Algorithms

33 Early recognition Identify patients at risk for sepsis as early as possible How? Front line staff key to this effort Education and training as to SIRS and S/Sx Development and implementation of screening tool ALL patients screened upon presentation at triage/arrival Raised awareness Standardized process of assessment

34 Screening Tool

35 Risk Stratification: Lactates in the ED Relatively inexpensive ($ 1- $ 3) Available at the bedside in the ED Marker of tissue hypoxia Increased lactate in setting of infection is an indicator of increased mortality What do levels of > 2 or > 4 Mean?

36 What Does Elevated Lactate Mean? * Source: Gabriel Escobar, MD DOR

37 Identify at triage if suspected infection and 2 SIRS criteria T < 96.8 (36.0) or > (38.0) HR > 90 RR > 20 WBC > 12K or < 4K or > 10% bands -OR- Altered LOC CBC, Lactate, BC Consider IV fluids and ABX EGDT Goals from Time Zero 1. Start Antibiotic 1 hr 2. First CVP or ScvO2 within 2 hrs 3. CVP 8-12 within 6 hrs 4. MAP 65 within 6 hrs 5. ScvO2 70 within 6 hrs 6. Repeat lactate < initial lactate within 3-12 hrs Suspected Sepsis Document SIRS SBP 90 w/transient improvement (2 hr) Time Zero (1 hr from Initial) Hypotension Document Septic Shock SBP 90? 30 ml/kg fluid bolus in 1 st hour YES SBP 90 (1 hr) Time Zero Document Septic Shock Time Zero = Sepsis Alert NO SBP > 90 Document SEPSIS < 2.0 Lactate high? 4 Time Zero Document Severe Sepsis EGDT Aggressive fluid resuscitation Within 1 hr: Start ABX Within 2 hrs: Measure CVP or ScvO2 Last Modified: 10/13/10 Quality Management S:\Quality\Sepsis\Work Flows\SEPSIS Algorithm Document Severe Sepsis *Repeat lactate in 3-6 hours

38 Sepsis Alert! If: Lactate greater than 4 or refractory hypotension in the presence of 2 or more SIRS criteria and a suspected source of infection Call a Sepsis Alert! Overhead Alert in the ED Initiated by primary/charge RN after discussion with physician Mobilizes resources in the ED Raises awareness to all House supervisor alerted CCU alerted

39 Identify at triage if suspected infection and 2 SIRS criteria T o < 96.8 (36.0) or > (38.0) HR > 90 SUSPECTED SEPSIS RR > 20 DOCUMENT SIRS WBC > 12K or < 4K or > 10% bands -OR- Altered LOC E A R L Y R E C O G N I T I O N CBC, Lactate, BC Consider IV fluids and ABX SBP 90? yes 20 ml/kg fluid bolus in 1 st hr SBP 90 no SBP >90 Document Septic Shock (Time Zero) Document Sepsis <2 Lactate high? 4 EGDT Aggressive fluid resuscitation Within 1 hr: Start ABX Within 2 hrs: Measure CVP or ScvO Document Severe Sepsis (Time Zero) Sepsis Resuscitation The Golden Hours Aggressive IV fluid resuscitation Early ABX Repeat lactate in 3-6 hrs Document Severe Sepsis CVP MAP 65? 65 ScvO2 70? 70 Repeat lactate 3-12 hrs < 8 < 65 <70 EGDT Goals from Time Zero 1. Start Antibiotic in 1 hr 2. First CVP or ScvO2 within 2 hrs 3. CVP 8-12 within 6 hrs 4. MAP 65 within 6 hrs 5. ScvO 2 70 within 6 hrs 6. Repeat lactate is lower than initial lactate w/in 3-12 hrs E A R L Y G O A L ml Fluid boluses q 30 min Norepinephrine If Hct low, transfuse to 30 <70 Dobutamine D I R E C T E D T H E R A P Y

40 ED to CCU Transition: Communication, communication, communication Fresno SEPSIS PATIENT HAND-OFF: Worksheet NOTE: This worksheet is not a part of the patient s medical record. SIRS Criteria Met (2 or more of following): Temp Greater than 38 or Less than 36 Tachycardia (or greater than 90/min) Tachypnea (or greater than 20/min) WBCs less than 4000 or greater than New Onset Altered Mental Status Sepsis Patient Hand-off: Sending RN to Receiving RN Key Information Sending RN Receiving RN TIME ZERO and reason (circle reason) Initial Lactate Level Was Lactate Level Intermediate?(2-3.9) What is BUN? ( Lactate + BUN = Mortality Risk) Repeat Lactate Level (if drawn) (Time, Value) Repeat Lactate Level Due (if not yet drawn) TIME Yes / No VALUE BP or Lactate Yes/No : Time Due: Blood Cultures/ UA Sent (Time, Yes / No) / Yes / No, Yes / No Expected/Confirmed Source of Sepsis Initial HR/BP/RR Current HR/BP/RR IV Fluids Given (Time, Med, Dose) Vasospressor(s) (Time, Med, Dose) Antibiotic Given (Time, Med, Dose) Source: Fluid: Med: Med: Central Line Placed & Cleared (Times, Yes / No) / Yes / No, Yes / No Vigileo Attached; In vivo Calibration Completed Yes / No Dose Initial CVP (Value) Current CVP (Value) Initial ScvO2 (Value) &/or Mixed Venous Blood Gas Current ScvO2 (Value)

41 Data collection and transparency Quality analysts abstracted all data Presented and reviewed data with ED and CCU Transparency key to success Learnings for improvement Results presented to frontline staff on regular basis: data presented as well as tangible aspect (lives saved)

42 Sharing The Data Dec EGDT Goals From Jun Jan - 13 Feb - 13 Mar - 13 Apr -13 May-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Time Zero Targets EGDT Composite has demonstrated an upward trend since November 2010 and started to drift in June & July Upward trend in August EGDT Cases Abx in 1 hour 90% 100% 100% 100% 100% 83% 100% 100% 100% 100% 100% 100% 100% 1 st CVP or ScvO2 within 2 hours of EGDT 70% 75% 50% 100% 67% 83% 100% 100% 100% 100% 75% 86% 100% Target CVP Achieved None 75% 100% 100% 86% 83% 50% 100% 100% 100% 80% 100% 100% Target MAP Achieved None 100% 100% 100% 100% 83% 100% 100% 100% 100% 80% 100% 100% Target ScvO2 Achieved None 75% 100% 100% 86% 83% 100% 100% 100% 75% 60% 86% 100% Improved Repeat Lactate for EGDT Patients None 100% 50% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 6 Hour Bundle 50% 75% 50% 100% 71.% 67% 50% 100% 100% 75% 40% 86% 100% EGDT Composite None 87.5% 83.3% 100% 90% 81% 91.7% 100% 100% 96% 82.8% 90% Mortality 12% 14.8% 4.2% 8.2% 7.7% 8.2% 11.5% 12.9% 14.5% 6.2% 8.2% 6.5% Diagnosis Rates per 1,000 Total Admits (exclude deliveries)

43 PI process Worked closely with quality analysts: collaborative and transparent Multi-disciplinary approach Small tests of change with rapid review Solicited feedback from staff Tracked all Correlated with results

44 How To Improve From Here Act Study Plan Do Review Each Case For early feedback For learning For redesign Aggressiveness of Fluid Resuscitation Handoffs- every minute matters Timing Documentation 44

45 Where we are now! Mortality Rate 9.6%!

46 What we have learned Build strong teams and have solid education and training in place Early recognition and Diagnosis of sepsis is key to success Risk stratify by lactate & follow trends- reevaluate. Document Sepsis diagnosis. Early resuscitation goals improve mortality- the Six Hour Bundle Use standardized processes. i.e. EGDT algorithms and EGDT order set Collaborative team efforts are essential to success

47