UNC Hospitals Sepsis Mortality
Reduction Initiative
Code Sepsis
Emergency Medicine Sepsis Training
Updated 7.29.16
Sepsis is a
VERY common cause of inpatient deaths
National Sample % Deaths
UNC % Deaths
Other
55%
All
Sepsis
45%
Sepsis POA
Documented
Sepsis
Documented
Other
Sepsis Documented
Other
48%
All
Sepsis
52%
Sepsis by
Review
Other
Source: UHC Data, 2013, excl NNB, Psych, Rehab
National Sample data shows that coding doesn’t catch all sepsis cases, UNC rates are
likely higher than reported.
Hospital Deaths in Patients with Sepsis from Two Independent Cohorts Liu et al JAMA May 18, 2014
MORTALITY REDUCTION STRATEGY
Healthcare
Acquired
Conditions
Failure to Rescue
Appropriate
Palliative Care
SEPSIS
Improve Early Warning Systems and Response Systems
Implement Early Suspicion and Accurate Recognition Sepsis
Implement Prompt and Accurate Sepsis First Hour Treatment
Implement Antibiotic Stewardship in Sepsis Program
Sepsis Program Overview
Early suspicion followed by effective confirmation of sepsis by
a clinician leading to clinically appropriate, evidence-based
sepsis treatment
• Although screening tools (Epic BPA-Best Practice Alerts,
qSOFA, SOFA, early warning systems) may be helpful in
identifying at-risk patients, these tools are not diagnostic
• Evidence-based sepsis bundle therapies require clinician
assessment for confirmation and orders
• Program focus includes early detection, standardized
bundles, training in sepsis diagnosis and care, hands on
practice/simulation, and antibiotic stewardship
• Adaptation of best practices from centers of excellence
Complacency, Education & Trying Harder isn’t enough
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
From: The Third International
Consensus Definitions for Sepsis and
Septic Shock (Sepsis-3)
JAMA. 2016;315(8):801-810.
doi:10.1001/jama.2016.0287
New Sepsis
Definitions 2015
Date of download: 3/14/2016
Copyright © 2016 American Medical
Association. All rights reserved.
From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
Table Title:
Sequential [Sepsis-Related] Organ Failure Assessment
Date of download: 3/14/2016
Scorea
Copyright © 2016 American Medical
Association. All rights reserved.
qSOFA = 2 or more:
RR > 22, SBP < 100, Altered
Mental Status
From: The Third International Consensus
Definitions for Sepsis and Septic Shock (Sepsis3)
• The task force maintains that standardization of definitions and
clinical criteria is crucial in ensuring clear communication and a more
accurate appreciation of the scale of the problem of sepsis.
• An added challenge is that infection is seldom confirmed
microbiologically when treatment is started; even when
microbiological tests are completed, culture-positive “sepsis” is
observed in only 30% to 40% of cases.
• Thus, when sepsis epidemiology is assessed and reported,
operationalization will necessarily involve proxies such as antibiotic
commencement or a clinically determined probability of infection.
• Future epidemiology studies should consider reporting the
proportion of microbiology-positive sepsis.
JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
From: The Third International Consensus
Definitions for Sepsis and Septic Shock (Sepsis3)
• Neither qSOFA nor SOFA is intended to be a stand-alone definition of
sepsis
• Failure to meet 2 or more qSOFA or SOFA criteria should NOT lead to
a deferral of investigation or treatment of infection or to a delay in
any other aspect of care deemed necessary by the practitioners
• qSOFA can be done promptly at the bedside and may prompt testing
to identify biochemical organ dysfunction and enable subsequent
SOFA scoring
• SIRS criteria may still remain useful for identification of infection
• Septic Sock = Sepsis and vasopressor therapy needed to elevate MAP
> 65 mm Hg and Lactate > 2 despite adequate fluid resuscitation
JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
CMS Sepsis Core Measure – released
October 2015
• Pre-2016 sepsis definitions – severe sepsis and septic shock
• Early recognition, lactate, blood cultures, broad spectrum
antibiotics, >30 mL/kg fluid resuscitation for shock
• CMS core measure reassessment including repeat lactate
within 6 hours if initial lactate > 2
AND
• Repeat clinical exam documented in chart by provider
including specific wording (e.g. cap refill, peripheral pulses)
•OR 2 of the following [EGDT]
•CVL placement measure CVP
•CVL placement SVO2
•Passive Leg Raise Documented
•Cardiac Ultrasound
Not targeted in
protocols in UNC
Sepsis Program –
Protocol-driven EGDT
no longer supported
•
UNC Health Care System FY 2017 Org
Goal
Improve CMS Core Measure Compliance by 20% Compared to
Baseline FY 2016
Current Pilot Tools
Screening Tools/ Order Sets
• Real Time Sepsis Best Practice Alert –
“Possible Sepsis Alert” stop and evaluate
– Alerts RN with link to RN ED Sepsis Orders (blood cultures,
labs, initial fluid if indicated)
– Alerts MD with link to ED Provider Sepsis Order Set
(antibiotics and fluid resuscitation, etc)
– Not all patients with sepsis BPA have sepsis – need
clinician order for sepsis bundle implementation
ADULT Sepsis HIGH RISK Patients
Immunocompromised
Burn Patients
Transplant (BMT or Solid Organ)
Diabetes
Cancer
Geriatric
Indwelling medical device
Recent surgery/invasive procedure
Congestive Heart Failure
Sepsis Alert for Nursing – Evaluate for 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
Nursing Order Set
Sepsis Alert for 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
Provider Order Set
Provider Order Set
Update June 2016 – there are 2 fluid bolus options based on
provider clinical judgment:
Choose either
1. fluid challenge with 1-2 liters over 20-30 minutes each or
2. 30 mL/kg NS bolus for SEPTIC SHOCK
Provider Order Set – Choose antibiotic
based on source or unknown source
Sepsis BPA FAQ
Q: If I acknowledge the alert, will it pop up for my co-workers?
A: Yes, the alert will pop up for any user that has not
acknowledged it while the patient meets the alert criteria.
Q: If I choose “cancel” will the alert pop up again?
A: Yes, as long as the patient meets the criteria. The alert will
continue to pop up until it has been acknowledged using
“Treating Associated Infection” or “Treating Separate Illness”.
Q: How does Epic calculate the LOC component?
A: Epic identifies “Drowsy”, “Somnolent”, and “comatose” in the
triage navigator to populate LOC.
Q: If my patient’s condition improves, will the alert stop?
A: Yes
Q: Should I always utilize the order set when the alert pops up?
A: No, the alert is designed to be sensitive rather than specific.
Use your clinical judgment to determine whether or not the
patient is showing signs and symptoms of sepsis.
If patient requires fluid bolus give rapidly – not on pump
If patient in SEPTIC SHOCK, give at least 30 mL/kg fluid bolus
Take Away Points
• Assess possible sepsis patients early to determine if bundle is
indicated – New or Worsening Organ Dysfunction and Known
or Suspected Infection
• Use the Sepsis Bundle Order Sets
• Adult Septic Shock Patients Require 30 ml/kg fluid bolus
minimum use actual weight
• Pediatric Septic Shock Patients often require > 60 ml/kg in
first hour
• Obtain 2nd Lactate – can order with first
• Use .SEPSISEXAM in any note document post fluid exam