1. Denise Flook, RN, MPH, CIC Melissa Nalder, RN, BSN Mary Whitaker, RN, CIC

2. Sepsis was identified as a leading cause of mortalities in our facility. Sepsis mortality rates were within national benchmarks, but still higher than corporate goals. Every sepsis mortality was a person….someone’s loved one, friend. Chart reviews demonstrated inconsistent identification and treatment of sepsis. Why did we start a Sepsis Program?

3. Overall sepsis mortality rate for 1Q2014 was 31.7% Septic Shock mortality rate for 1Q2014 was 40.3% 3 hour bundle incomplete within 3 hours in 35% of patients. Sepsis Statistics

4. Convened a Sepsis Team and reviewed Surviving Sepsis Campaign best practices. Held education sessions for physicians and staff presented by the President Elect of Society of Critical Care Medicine. Developed posters for ED triage and nursing pods with SIRS criteria and the 3 and 6 hour bundles. Revamped our Sepsis Alert Team and gave clearly defined expectations of the roles for each team member. Developed evidence based order sets for the ED and inpatient areas. Developed antimicrobial algorithms for appropriate coverage based on suspected source of infection and local antibiogram. Provided education to our EMS partners to call Sepsis Alerts from the field as they do with STEMI and STROKE. Identified methods to incorporate our MEWS system in Sepsis early identification. What did we do?

5. ED Triage Poster

6. Sepsis Alert Poster

7. EMS Poster

8. Antimicrobial Coverage Algorithm Antibiotic Therapy Recommendations for severe sepsis/septic shock: administer first dose within 1 hour Pneumonia:  Rocephin (ceftriaxone) 1 gm IV every 24 hours AND Levaquin 750 mg IV every 24 hours  Rocephin (ceftriaxone) 1 gram IV every 24 hours and Azithromycin 500 mg IV every 24 hours  Clindamycin 600 mg IV every 8 hours (if aspiration pneumonia suspected)  Zosyn 3.375 Gm IV q 8 hours AND Levaquin 750 mg IV every 24 hrs (if pseudomonas risk) Risk for MRSA Add:  Vancomycin 1 gm IV every 12 hours  Vancomycin for pharmacy to dose  Vancomycin ____q ____hours  Zyvox 600 mg IV every 12 hours (Restricted to Infectious Disease & Intensivist Providers) Sepsis due to UTI: Gentamicin 5 mg/kg IV x 1 dose AND Choose One:  Rocephin (ceftriaxone) 1 gram IV every 24 hours  Cefepime (Maxipime) 1 gm IV every 6 hours Intra-abdominal sepsis/unknown source:  Zosyn (Pip/Tazo) 3.375 gms IV every 8 hours  Merrem 500 mg IV every 6 hours Skin and soft tissue infections:  Unasyn (ampicillin/sulbactam) 3 grams IV q 6 hours If patient is allergic to PCN, use:  Ancef (cefazolin) 2 gm IV q 8 hr If suspected abscess or risk for community acquired MRSA: Choose one:  Vancomycin 1 gm IV every 12 hours  Zyvox 600 mg IV every 12 hours (Restricted to Infectious Disease & Intensivist Providers) Recommendations based on SCCM, IDSA and SHEA Guidelines for Sepsis and local epidemiology and antibiogram

9. The recommendation is for routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy. Sepsis Screening is built into every nursing assessment in EMR including ED. FOR EVERY 1 HOUR IN DELAY THE RISK OF MORTALITY INCREASES BY 8%!!! Screening for Sepsis and Process Improvement

12. Since there were 2 or more “Y” to the queries in Tier 1 – the Nurse is automatically taken to Tier 2. These are only Y/N and the nurse has to answer them. The answers are not defaulted in Tiers 2 or 3. In Tier 2 – if either of the queries is answered “Y” – the Nurse is taken to Tier 3

17. Only 1 organ dysfunction in Tier 3 needs to be answered Y in order for a positive alert to be triggered

18. How did we implement this? Lots of education!!!! Focus on Sepsis in every meeting Engaged hospital leaders Demonstrated how sepsis is everyone’s responsibility Perseverance Chart reviews and using data to guide changes to the program Modeled the program after STEMI and STROKE programs Looked for barriers in compliance Got feedback from frontline staff during every step Did we mention perseverance??? Celebrated successes Reviewed every fallout and used missed opportunities as teachable moments Included physicians

19. Check and double check that your EMR works as intended Verify your data and coding iStat ABGs with Lactate are a key to success. However, unless Wi-Fi enabled, the results do not reflect the time the test was done. Engage the frontline staff in fixing the issues If you have a program that works well such as STEMI or STROKE, build on that for Sepsis. “Time is Tissue” is true for all three. This helps build in a sense of urgency. DO NOT GIVE UP!!!!!!!! You are very unlikely to get it right the first time. We sure didn’t. Celebrate successes and use your misses as teachable moments. Do not assume everyone knows what Sepsis is. You have to build accountability into the program. Use existing systems: MEWS, EMR, iStat Lessons Learned

20. Sepsis screening tool does not work in all situations. iStat has to be docked immediately to reflect accurate test time Physician buy in is tough to hard wire…we are working on it Non-present on admission sepsis alerts are not being called routinely We still have fall outs. We are not meeting the 3 hour bundle 100% of the time. Opportunities

21. Where are we now?

22. Success Story 89 year old male Past Medical History – Hypertension – COPD – Coronary Artery Disease – Chronic Kidney Disease – Hyperlipidemia – Recurrent Aspiration Recently discharged with pneumonia. Presented to ED at approximately 4am with fever >104, AMS, Cough Sepsis Alert called in triage. All 3 hour bundle elements started within 34 minutes. Admitted to ICU with Septic Shock, on Levophed After 3 days in ICU, transferred to Medical Unit. Discharged home on Day 8.

23. A Family’s Perspective

24. Questions