1. Code Sepsis: Current Evidence Based Guidelines and the CMS Sepsis Core Measure Adult Patients Updated May 26, 2017

2. Objectives Understand history and current definitions of sepsis
Understand the history and current sepsis treatment guidelines
Understand the reporting and regulatory sepsis measures
Understand the current and evolving UNC Code Sepsis System

4. Sepsis definitions

5. ACCP/SCCM Consensus Conference 1991 (Sepsis-1)
Sepsis = Infection + two or more SIRS criteria
Severe Sepsis = Sepsis + Organ dysfunction or hypo-perfusion
Septic Shock = Severe sepsis with persistent hypotension despite adequate fluids

6. In 2001, more detailed categories added to help clinicians recognize sepsis
Levy MM, Fink MP, Marshall JC, et al. 2001CCM/ESICM/ACCP/ATS/SIS InternationalSepsis Definitions Conference.Crit Care Med 2003;31:

7. 172 ICUs in Australia and New Zealand
>100,000 patients retrospectively found from with SIRS and sepsis
SIRS missed 1 in 8 patients with sepsis!!
No transition point in mortality with “2 or more SIRS criteria”!!

8. 2016
Sepsis-3
REDUNDANT
RETIRED

9. JAMA. 2016;315(8): doi: /jama
Task Force made up of 19 Intensivists convened to update Sepsis Definitions, understanding there’s no validated diagnostic test (Gold Standard)
“The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection
Severe sepsis definition removed – redundant with the new sepsis definition

10. Suggested Clinical Criteria for Sepsis (if in ICU?)
JAMA. 2016;315(8): doi: /jama
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

11. CBC, CMP and ABG

12. REALLY SICK Taskforce wanted to predict: Increased mortality
JAMA. 2016;315(8): doi: /jama
Taskforce wanted to predict:
Increased mortality
Increased ICU length of stay
Many difficulties with these definitions including clinical usefulness, confusion and possible delay in care, qSOFA may be very sensitive but still need specificity testing
REALLY
SICK

13. So What is Sepsis Then?
Sepsis – 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 and Septic Shock are medical emergencies and it is recommended that treatment and resuscitation begin immediately (Best Practice Statement).

14. Treatment Guidelines

15. Many of the same investigators involved with
consensus definitions Sepsis 1
Initial Guidelines for Treatment of Sepsis Published 2004
Early Goal Directed Therapy with 3 and 6 Hour Bundles

16. Study
Year
Mortality Before (%)
Mortality After (%)
EGDT
46.5
30.5
Ani et al (Severe)
40.0
27.8
Kumar (Severe)
39.6
27.3
Kumar (Shock)
47.1
36.4
Mult Observational
40.3
27.6
ProCESS
18.9
19-20
ProMISE
25.6
24.6
ARISE
18.8
18.6

17. 3 Recent Large Randomized Control Trials:
Although advanced severe sepsis therapies (such as central line placement, SVO2 goals, etc) did not show improved outcomes, all were randomized after early recognition and standard therapies including antibiotics and fluid resuscitation which are the goals of UNC Code Sepsis

19. 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.

21. Fluid Management in Sepsis
Early fluid initiation improved outcomes
But fluid overload at day 3 with high mortality so need Negative fluid balance at day 3
Sepsis maintenance bundle?
Avoid third spacing
Initiation of appropriate vasopressors

22. CMS Sepsis Core Measure

23. January 2013
October 2014

24. Septic Shock and Treatment
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 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 >2)
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
*FLAB in the first hour – Give Fluids, Result Initial Lactate, Give Antibiotics after Drawing Blood Cultures

26. UNC Code Sepsis

28. 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.

29. Color Coded Scores
1-4
5-6 7+

31. Sepsis Bundle Order Set

32. Sepsis Bundle Order Set
New in March L will not have 2 doses and 30 mL/kg NS will be IV “Bolus” and can choose time in order details

34. “RUN THE FLUIDS WIDE OPEN!!”
We are actually asking the rapid nurses to pressure bag IV fluids in for severe shock (gets fluids in even quicker).

35. 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

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

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

38. Coming Soon qSOFA elements in ED Best Practice Alert
SOFA scoring for ICU’s
Antimicrobial Stewardship in Sepsis
Inpatient Expanded Sepsis Order Set including Maintenance Bundle Elements

39. Add Case Examples Contact the Sepsis Core Team if your need examples
Add Case Examples

40. Add current process and outcome measures
Contact the Sepsis Core Team if your need updated measures
Add current process and outcome measures

41. 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