1. Purpose - present the new bundles that will start with Oct 1 discharges
Review documentation required
Review changes at GCH
Resident Education

2. Sepsis Overview Cost of sepsis care in the US ~$400 billion annually1
Mortality ranges from 16-49%2
One of top ten most common principal causes for hospitalizations2
Compliance with the 3- and 6- hour bundles decreases:
mortality
length of stay
cost of care

3. Sepsis will become a Core Measure starting with October 1, 2015 discharges
Compliance with the bundles will be tied to payment from CMS

4. GCH Sepsis Project team
review our current processes and procedures
identify barriers in processes
goals of
enhance nursing Sepsis screening/assessment
improve compliance with Severe Sepsis/Septic Shock bundles
standardize care for adult sepsis, severe sepsis and septic shock patients
ultimately decrease Sepsis mortality
Implemented a multidisciplinary in mid-July to

5. Identified definitions we will use (also used by CMS)

6. Surviving Sepsis Campaign revised 3-hour and 6-hour bundles
AND if Septic Shock present:
Received within three hours of presentation of Septic Shock:
Resuscitation with 30 ml/kg crystalloid fluids
AND if hypotension persists after fluid administration, received within six hours of presentation of septic shock:
Vasopressors
AND if hypotension persists after fluid administration OR initial lactate > 4 mmol/L: received within six hours of presentation of Septic Shock:
Repeat volume status and tissue perfusion assessment consisting of either:
A focused exam by physician including all of the following:
Vital signs
AND Cardiopulmonary exam
AND Capillary refill evaluation
AND Peripheral pulse evaluation
AND Skin examination
OR Any two of the following four:
Central venous pressure measurement
Central venous oxygen measurement (ScvO2)
Bedside cardiovascular ultrasound
Passive leg raise by physician or fluid challenge given
Received within three hours of presentation of Severe Sepsis:
• Initial lactate level measurement
• Blood cultures drawn prior to antibiotics
• Broad spectrum or other antibiotics administered
AND received within six hours of presentation of Severe Sepsis:
• Repeat lactate level measurement only if initial lactate level is elevated > 2
Surviving Sepsis Campaign (SSC) revised 3-hour and 6-hour bundles in early 2015 based on new evidence from
Promise, Arise, Process Investigative Trials
Major changes:
“presentation time” (the time the last sign of Severe Sepsis/Septic Shock is noted or last lab value was reported)–
There can be a presentation time for severe sepsis and if a patient did not also present with septic shock at that time, there may be a different time of presentation of septic shock. It is important to document these times so treatment can be done in a timely manner.
Remeasure Lactate within 6 hours if >2
Fluids after septic shock (minimal) and vasopressors if sustained hypotension
If hypotension after fluids OR lactic acid >4 need to check volume status within 6 hours of septic shock –options:
Focused exam by physician
OR two of CVP, ScvO2, cardiovascular ultrasound, or passive leg raise or fluid challenge ((Central line and ScvO2 are not required now if other options are done to assess volume status)
If initial Lactate > 4 this is considered Septic Shock (with SIRS + known or suspected infection), Severe Sepsis and Septic Shock bundles need to be implemented

7. Improvements to Processes at GCH
Sepsis Policy and Procedure revised  Hospital-wide policy
Lactate > 4 Critical Value
Sepsis order sets
Inpatient Nursing Sepsis Screening Assessment enhancement in EMR
ED - upon triage and every 2 hours
ICU and inpatient units - on admission and Q4H
“New and Worsening conditions” added to when to call physician
Inpatient will notify physician with + sepsis screen/ call RRT with + severe sepsis screen
ICU nurse will notify ICU physician with + sepsis/severe sepsis screen
Sepsis, Severe Sepsis and Septic Shock Bundle Checklist
Here are some improvements to current processes and procedures that were/will be made:
Sepsis Policy and Procedure is being revamped to standardize care –will become a Hospital-wide policy and includes all the new guidelines (OCT 6th to med exec)
Sepsis order sets
will become one order set (to standardize care)
2 antibiotics changes on the Sepsis order sets will be updated in accordance with CMS guidelines for initial antibiotics
inpatient nursing assessment criteria and improved instruction of what to do with positive sepsis screen, and what to anticipate

8. Sepsis, Severe Sepsis and Septic Shock Bundle Checklist
paper checklist on nursing units
can be printed from Forms Fast and is printed with sepsis order set
to be used by the doctor and nurse to document times the patient met criteria for Severe Sepsis/Septic Shock
compliant with the 3 hour and 6 hour bundles
to be a guide of what interventions are required for each bundle
communication handoff tool
Interventions can be documented on the checklist as it will be part of the permanent medical record
This checklist does not replace an order for any of the interventions
and any medications including fluids should still be ordered, documented on the MAR
“Shock Index” added as indicator

9. Fluids 3-hour bundle Crystalloid- LR or 0.9% Normal Saline only
Volume - ordered and documented as 30ml/kg, or an amount > 30ml/kg
Timeframe - duration or rate at which to administer must also be ordered
New order set default to 2000mL/hr, or can be manually changed to adjust the rate
Minimum requirement- last liter must be delivered within 3 hours of septic shock   
Time frame- examples 2000ml per hour or 2000ml over 2 hours

10. Focused exam by physician: ALL of the following
vital signs including all of
temperature, heart rate, blood pressure, respiratory rate
cardiopulmonary exam assess both the heart and lungs-
typically documented as heart - ‘RRR’, ‘Irregular’, ‘S1,S2,S3,S4’
lungs - ‘clear’, ‘crackles’, ‘diminished’ or other language
capillary refill evaluation assess superficial circulatory status
document ‘capillary refill’, ‘nail bed refill’ ‘brisk’, ‘<2seconds’, ‘>2seconds’ or similar
peripheral pulse evaluation to assess circulatory status.
Document ‘pulses ‘1+,’ or ‘2+’ or absent, or other language.
Need to make reference to any of the following: Peripheral pulse(s), Radial pulse(s), Dorsalis pedis pulse(s), Posterior tibialis pulse(s) 
skin exam to assess superficial circulatory status
May include such terms as ‘flushed’, ‘mottled’, ‘not mottled’, ‘knee caps mottled’, pale’, ’pallor’, ‘pink’, ‘, ‘pale’, flushed’ or other language
Must include reference to color 
Document on Checklist, in EMR or Progress Note and perform all components of the focused exam within 6 hours of fluid resuscitation start time

11. Any two of the following
Central Venous Oxygen measurement
expressed as SvO2 or ScvO2 & needs to be obtained via blood gas currently.
CVP
Bedside cardio US
may be referred to as echocardiogram, trans-thoracic echo, trans-esophageal echo, IVC Ultrasound, 2D echo, cardiac echo, Doppler echocardiogram, echocardiogram with Doppler, esophageal Doppler monitoring or Doppler ultrasound of the heart
Does not necessarily have to be performed at bedside
Passive Leg Raise With the patient in a semi-recumbent position, both legs are raised to a 45 degree angle to evaluate the vital sign response to additional fluid load
documented as ‘passive leg raise ‘, ‘PLR’ with findings ‘positive’, ‘negative’, ‘fluid responsive’ or other language
OR Fluid challenge to assess responsiveness to fluids
Similar to crystalloid fluid administration but is done after the crystalloid fluid administration if the patient remains hypotensive.
Fluid challenge is a rapid infusion of 0.9% NS or LR
typically 500 mL in fifteen minutes or 1000 mL in 30 minutes
within 6 hours of fluid resusitation start time (with Septic Shock):
Document and perform Passive Leg Raise on the Checklist, in EMR or Progress Note

12. Documentation tips
Document time patient met criteria for Severe sepsis and septic shock on Checklist (if not done by nursing)
Document time of known of suspected infection
when documenting a suspected source of infection, document it “possible infection from xx”, “suspect infection from xx”, not “SIRS secondary to xx”
If your patient is in severe sepsis, document it.
When documenting severe sepsis, make a relationship statement between it and the end-organ dysfunction “Severe sepsis with acute respiratory failure”
If your patient is in septic shock, document it. “Hypotension” is not equivalent to shock.

13. References
1. Lopez-Bushnell K, Demaray W, Jaco C. Reducing sepsis mortality. Medsurg Nurs 2014 JanFeb;23(1): National Quality Institute. (2015). Implementation of Severe Sepsis and Septic Shock: Management Bundle Measure (NQF #0500). Retrieved from Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: Critical Care Medicine Feb;41(2): ( ) Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5 –year study. Intensive Care Med 2014; 40: ( Tseng, J and Nugent, K. (2015). Utility of the Shock Index in patients with sepsis. The American Journal of the Medical Sciences.349: Surviving Sepsis Campaign. (2015). Updated Bundles in Response to New Evidence. Retrieved from