Summer Gupta, MSN, RN Sepsis Coordinator UCLA Health 09/13/2016 CSI Case Study – Severe Sepsis/ Septic Shock Summer Gupta, MSN, RN Sepsis Coordinator UCLA Health 09/13/2016

Objectives Identify TOP for Severe Sepsis/Septic Shock Know how to activate the nurse driven protocol and notify provider Activate the bundle in a timely manner and anticipate order for abx and IVF bolus

What you already know… Continuum Bundle Elements Sepsis = 2 SIRS + Infection Severe Sepsis = Sepsis + New or Acute Organ Dysfunction Septic Shock = Severe Sepsis + Persistent Hypotention OR lactate ≥ 36 Bundle Elements Blood Cultures x 2 sets Lactate and Repeat Lactate IV Broad Spectrum Abx IVF Bolus Vasopressors Tissue Perfusion Assessment

Case Study 1 83-year-old female presents to ED 04/09 with c/o gradual onset of productive cough x 1 month. History of asthma and psoriasis. Associated symptoms included generalized weakness, decreased appetite, weight loss, SOB, dizziness, and jaundice. Initial Vital Signs T 36.6 BP 127/58 HR 90 RR 18

Case Study 1 Admit diagnosis by ED Provider – Acute renal failure, Acute jaundice Pt transferred to floor Blood cultures drawn while in ED = Negative 04/13, WBC noted to be 20.26 but no other SIRS present 04/15, WBC noted to be 20.65, HR 104, RR 24 RN Screen answered YES to Infection 04/15 BP previously normal dropped to 70/36 04/15 Severe Sepsis documentation by MD on 04/16

Sepsis Audit Tool

Sepsis Audit Tool

Sepsis Audit Tool

What is the Time of Presentation (TOP)? SIRS HR 104 @ 1317 RR 24 @ 1317 Infection RN Screen @ 0845 Organ Dysfunction BP 70/36 @ 1317

What would you do next? Implement the Nursing Protocol Call physician Draw blood cultures Draw initial lactate Anticipate repeat lactate Call physician Anticipate order for IV Broad Spectrum Abx Anticipate order for IVF Bolus 30ml/kg

Case Study 2 59-year-old male who presented to ED 07/23 with c/o gradual onset AMS per caregiver. History of metastatic breast cancer, obstructive jaundice, and ascites. Per EMS, pt was picked up for BP 60/30. Initial BG was 24. Pt given D50 and BG improved to 124. Pt remains unresponsive. Initial vital signs T unknown HR 78 RR 16 BP 90/60

Sepsis Audit Tool

Sepsis Audit Tool

What is the TOP? SIRS Infection Organ Dysfunction RR 24 @ 1045 Septic Shock documentation by ED Provider @ 1015 Organ Dysfunction BP 76/49 @ 1045

What would you do next? Implement the Nursing Protocol Call physician Draw blood cultures Draw initial lactate Anticipate repeat lactate Call physician Anticipate order for IV Broad Spectrum Abx Anticipate order for IVF Bolus 30ml/kg

Case Study 3 53-year-old female presents to ED 08/06 with c/o sudden onset fever. History of HTN, hyperlipidemia, and large B cell lymphoma. Last chemo 07/27. Pt was at clinic in the am for lab draw and was informed to come to ED for hemoglobin of 6. At this time, the fever was identified. Initial vital signs T 38.9 HR 118 RR 16 BP 104/66

Sepsis Audit Tool

Sepsis Audit Tool

What is the TOP SIRS Infection Organ Dysfunction HR 118 @ 1527 WBC 13.49 @ 1629 Infection RN Screen @1528 Organ Dysfunction Lactate 20 @ 1603

What would you do next? Implement the Nursing Protocol Call physician Draw blood cultures Draw initial lactate Draw repeat lactate Call physician Anticipate order for IV Broad Spectrum Abx

Questions? Summer Gupta, RN, MSN 424.259.8534 X 98534 Thank you Questions? Summer Gupta, RN, MSN 424.259.8534 X 98534