1. Diagnosis and Management of Sepsis BMC Sepsis Mortality Reduction Initiative Intern Noon Conference 7.2.13 Karin Sloan, MD Director of Quality, Dept of Medicine for the Sepsis Mortality Reduction taskforce

2. Outline Sepsis: definitions Introduce BMC sepsis mortality reduction initiative – Rationale for sepsis work – Focus on hospital-acquired sepsis Stress 2 key areas: – Timely recognition of sepsis – Timely administration of broad-spectrum antibiotic Show SCM sepsis order set

4. Sepsis Sepsis: a dysregulated inflammatory response of the body to infection High mortality rate More common than MI and stroke Most common post-op complication Like MI and stroke, time to treatment saves lives

5. 2012 BMC Sepsis Patients Expired vs. Discharged 883 sepsis pts in 2012 141 sepsis deaths

6. What is SIRS? SIRS “Systemic Inflammatory Response Syndrome” Dysregulated inflammatory response Patients can have SIRS without infection – PE, acute blood loss, etc Sometimes when a patient has SIRS, it is not certain if they have infection

7. Sepsis: Infection plus some of: Temperature >38.3 or <36ºC Heart rate >90 beats/min or more than two standard deviations above the normal value for age Tachypnea, respiratory rate >20 breaths/min **Altered mental status Hyperglycemia in the absence of diabetes Leukocytosis (WBC count >12,000 microL –1 ), greater than 10 percent immature forms, or leukopenia (WBC count <4000 microL –1 ) Hypotension Hypoxemia Acute kidney injury Coagulation abnormalities Ileus Thrombocytopenia Hyperbilirubinemia Hyperlactatemia Red: 2/4 = SIRS criteria

8. Severe sepsis: sepsis + organ dysfunction

9. Definition: Septic Shock Severe sepsis plus hypotension not reversed with adequate fluid resuscitation (30ml/kg crystalloid) – SBP < 90 – MAP < 70 – SBP > 40 decrease from baseline Vasodilatory shock – Low SVR – BP = CO x SVR Multiple organ dysfunction syndrome (MODS)

10. SIRS  sepsis  MODS continuum If sepsis is possible, without alternative explanation, best to treat empirically – Document “SIRS; suspected sepsis or possible sepsis” Can reassess, narrow or discontinue antibiotics later

11. Sepsis Background Patients with positive blood cultures almost always have sepsis, severe sepsis, or septic shock Sepsis incidence is increased in older adults, and mortality is higher Mortality highest for unknown, GI, or pulmonary source – lower for urinary tract source

12. BMC is now in the top quartile of academic medical centers for inpatient mortality Slide showing mortality improvements… 12

13. But…our sepsis mortality lags behind. Why work on sepsis at BMC? – Volume of cases Top cause of excess deaths at 2013 mortality goal Of the 444 inpatient deaths in FY12, sepsis was coded in 31% – Opportunity for improvement Particularly in hospital-acquired sepsis (65 th percentile performance) – 20% of BMC sepsis cases Recognition Time to antibiotics

14. Aim Statement To improve BMC hospital-acquired sepsis mortality O/E from UHC 65 th percentile to 25 th percentile by July 2014. – Save 1 hospital-acquired sepsis life/month. – Mortality O/E = Outcome Measure Process Measures – Use of sepsis order set (Process) – % with STAT first antibiotic order (Process) – % of patients receiving broad spectrum abx within 60 mins (Process) – Time to broad spectrum abx (Process) – % of pts with 2 blood cxs before abx (Balancing)

15. Early Goal-Directed Therapy (EGDT) 30.5% mortality, vs standard therapy 46.5%

16. QI: The real-world challenge consistent use of Evidence Based Practice making a strong recommendation standard of care Administer abx within 1 st hour of recognition of severe sepsis or septic shock. (SSC guidelines: strong recommendation)

17. Time to Antibiotic and Choice of Antibiotic are key to saving sepsis lives Broad spectrum antibiotic or “anchor” antibiotic should always be administered first – Cefepime 1g, Cetriaxone 2g, or Levofloxacin 750mg Stocked in all Pyxis machines at BMC Vancomycin is not broad spectrum and can lead to delay in getting the most important antibiotic Anchor Antibiotic – Effective against rapidly lethal organisms Gram negative rods S. pneumoniae – Long half-life – Can be infused quickly – Low incidence of allergy – Must be premixed or easy-mix, and dosing must not be weight-based

18. Goal 1: Decrease time to antibiotics in BMC hospital-acquired sepsis patients PI group met Defined reason for action Mapped initial & target state – Current performance: mean time from antibiotic order to administration 200 minutes Goal: 60 minutes from order to administration Performed gap analysis Solution approach (to perform P-D-S-A) – Ordering – changing sepsis order set – RN/MD Education on importance of broad spectrum abx first and time to abx – Communication

19. Sepsis Order Set

20. Sepsis Order set

21. STAT and continuing dose antibiotic options

22. Lab, micro, radiology

23. Culture Orders

24. Nurses: Document Accurate “Administered At” Time in EMR If the “administered at” time is not changed, STAT orders will default to the order entry time.

25. Case review for n of 1 in May: admit 4/12, Hosp-acquired sepsis 4/15, died 5/8. Sepsis order set used (old), ordered STAT, 2 blood cxs obtained, time to antibiotic reported as 81 min but upon manual review – 39 mins! Currently validating. Pt was on M6E and treament initiated by Medicine intern. Pt on M6E. Met SIRS criteria 4/14 21:36, ordered for cefepime 4/15 at 02:21. Delay in recognition leading to delay in treatment.

27. Show current performance data

28. Time from abx order to administration

29. Goal 2: Improve recognition of hospital-acquired sepsis at BMC PI group met Defined reason for action, mapped initial & target state, performed gap analysis, and solution approach Kirkpatrick, Walkey, et al 2013 ATS abstract: Review of 35 BMC patients from 2008-2010 who died of hospital-acquired sepsis: – 12 (34%) had a greater than 6 hour delay in recognition or treatment of severe sepsis – 7 patients with delay > 12 hours after the onset of severe sepsis – Patients without tachycardia were statistically more likely to be missed. – Trend towards patients on nodal blockers being more likely to be missed.

30. Recognition solutions to test Pilot on Menino 6W began end of April – Education – CNA  RN notification parameters – RN paper screening tool v1: identified many patients already on abx v2: exclude patients on abx. – Without prompts, difficult for nurses to remember to complete. – Changing flowsheet visual cues

34. MD Notification – always text page Helps providers know the urgency of the page Patient name Patient location RN name Call back number Concern (sepsis) If RN does not reach someone, they have been instructed to go up the chain (call resident, attending if no one can be reached) Nurses: “CALL DR”

35. Management of sepsis: CALL DR Cultures x 2 Antibiotics Lactate Liter boluses Define Source Reassess

36. Goal to draw 2 sets prior to antibiotic administration Do not delay antibiotics – most important sepsis goal is to administer broad spectrum antibiotics within 60 minutes – Draw blood cultures as soon as possible – Have a charcoal additive to remove antibiotics, if drawn after antibiotic administration 2 sets and 2 separate peripheral venipuncture sites (per BMC policy 3.76) BC Bottles: – Should be labeled with source (peripheral, central line, etc.) – Are plastic and should be sent to the lab via P-tube Cultures x 2 Antibiotics (Broad Spectrum in < 60 mins)

37. Lactate Measure of tissue hypoperfusion Stratify severity of sepsis, severe sepsis Follow value with resussitation, goal to normalize

38. Liter boluses For severe sepsis: 30ml/kg bolus Normal Saline or Lactated Ringers – 70kg patient = 2L bolus Goals in first 6 hours (early goal-directed therapy): – CVP 8-12 mmHg – MAP ≥ 65 mmHg – UOP ≥ 0.5ml/kg/hr – SVC sat ≥ 70%

39. Define Source As directed by patient signs and symptoms, in addition to blood cultures, may order UA, urine culture, CXR, imaging

40. Reassess Follow heart rate, blood pressure, urine output, lactate to determine whether patient is improving or worsening Consinder whether patient may need to be transferred to IMCU or ICU Follow up cultures and narrow or discontinue antibiotics if appropriate

41. In Summary… Have a heightened suspicion for sepsis Respond to RN notification in a timely manner Document SIRS and sepsis Treat aggressively and empirically for possible sepsis – Can always peel back later Use the SCM “sepsis order set” to initiate early goal- directed therapy Communicate that timely orders were placed – Stress importance of broad spectrum within 60 minutes Notify the attending of a change in patient’s clinical status – Involve the MICU if necessary

42. Future Directions Nursing floor spread Spread to ICU, Surgical services, ultimately medical specialty services Possible simulation teams training Feedback welcome on the sepsis initiative overall Potential for resident involvement

43. Acknowledgements Steering Committee Stephanie Martinez Willie Baker James Murphy Kate Mandell Tamar Barlam Kevin Horbowicz Jennifer Ellingwood Jane Jansen Patty Covelle George Barth Louise Vecchio Roshan Hussain Paul Kelley Tom Lau Kevin Guy Nahid Bhadelia Morsal Tahouni Jim Meisel Jake Feldman Allan Walkey Don Johnstone and 6W staff Ann Woolley, Stephanie Maximous, Morgan Richards, Jeff Jenks YOU!! Surgery residents and PA Eric Poon Stan Hochberg Laura Harrington