Code Sepsis: Current Evidence Based Guidelines and the CMS Sepsis Core Measure Adult Patients - Abbreviated Updated August 30, 2017

Sepsis definitions

2016 Sepsis-3 REDUNDANT RETIRED

Suggested Clinical Criteria for Sepsis (if in ICU?) JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288 Suggested Clinical Criteria for Sepsis (if in ICU?) Infection + 2 or more SOFA points (above baseline) Consider Sepsis outside ICU if Infection + 2 or more qSOFA points

So What is Sepsis Then? Sepsis (with organ dysfunction) – now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. This is a clinical diagnosis. Note that “Severe sepsis” (previously used for sepsis with organ dysfunction) is no longer recognized since it would be redundant. Septic Shock – a subset of Sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality. This is a clinical diagnosis. Sepsis (with organ dysfunction) and Septic Shock are medical emergencies and it is recommended that treatment and resuscitation begin immediately (Best Practice Statement).

Treatment Guidelines

Evidence Based Sepsis Treatment to Meet the CMS Sepsis Core Measure Patients > 18 Years of Age: Meeting the Measure is ALL OR NONE At UNC Hospitals target *FLAB in the first hour Sepsis (with organ dysfunction) and Treatment Suspected/documented infection and Life Threatening Organ Dysfunction (Creatinine >2, Lactate > 2, oliguria, new oxygen demand - respiratory distress/failure, AMS, SBP<90, RR>20) list is not all inclusive In first 3 hours: Lactate, Blood Cultures, broad spectrum Antibiotics In first 6 hours: repeat Lactate if initial > 2 Septic Shock and Treatment (Sepsis + SBP <90 not responsive to 30mL/kg IV fluid given + requires vasopressors for SBP <90 or MAP <65 + lactate >4) In first 3 hours: Lactate, Blood Cultures, broad spectrum Antibiotics, and Fluid resuscitation with 30 mL/kg crystalloid fluids In first 6 hours: repeat Lactate, complete .SEPSISEXAM, and start Norepinephrine if hypotension persists after 30 mL/kg Fluid resuscitation Renal Failure, Heart Failure, Liver Failure & Surgical patients are NOT exempt from this measure. VAD patients are exempt from IV Fluid measure ONLY *FLAB in the first hour – Give Fluids, Result Initial Lactate, Give Antibiotics after Drawing Blood Cultures **We realize that even though CMS requires 30mL/kg fluid resuscitation to meet measure that not all patients would tolerate this amount of fluid. The provider still directs the amount of fluid resuscitation given to their patients. Please document reasons to help the sepsis review team

Don’t set it and Forget it! Newest Evidence-Based Guidelines Published in 2017 Remember Septic Shock is a Clinical Diagnosis! Don’t set it and Forget it! Data Source: A Users Guide to the 2016 Surviving Sepsis Guidelines. Society of Critical care Medicine. March 2017 Volume 45 Number 3.

UNC Code Sepsis

MEWS Scoring Algorithm Uses vital signs to generate an acuity score No process change or manual entry An additional tool to help identify deterioration MEWS Score is an acuity score that can be trended over time in the patient record to provide a picture of each patient’s acuity using the algorithm above. The scores are the same for each unit and hospital however the clinical response can be customized.

Color Coded Scores 1-4 5-6 7+

Sepsis Bundle Order Set

Sepsis Bundle Order Set

.SEPSISEXAM must be completed no more than 6 hours after fluid resuscitation TIP: Do your exam and .SEPSISEXAM documentation right after fluids are administered - you don’t have to wait several hours!

Sepsis Alert for ED Providers – Evaluate for Possible Sepsis “Treating Associated Infection” silences the Alert for that user for 96 hours “Treating Separate Illness” silences the alert for that user for 96 hours

Sepsis Monitor This will show a continuum of patient care even if part of time period was in the Emergency Department

Sepsis Monitor This will show a continuum of patient care even if part of time period was in the Emergency Department

Take Home Points Suspect Sepsis Early Evaluate Patients Promptly Treat as a team event and if determine patient is septic treat as a “code sepsis” Empower nurses to call for help Use the Sepsis Bundle order sets Use .SEPSISEXAM Use your clinical judgment as you fluid resuscitate