Transcript Sepsis, detailed slide set (.ppt)

SEPSIS
Core Measures
INTEGRIS Health
Objectives
 Provide an overview of core measures
 Review the continuum of SIRS, sepsis, severe
sepsis, and septic shock
 Describe the Sepsis Core Measures
 Review Cerner PowerPlan changes
 Review severe sepsis/septic shock antibiotic
updates
 Describe Sepsis Core Measure
inclusion/exclusion criteria
 Review Cerner SIRS and sepsis alerts
Core Measures Matter
• Implications
– Quality initiative
– Linked to reimbursement
– Publishable data
• Other Familiar Core Measures
– Pneumonia
– CHF
– AMI
Definitions
• SIRS
– Temperature > 38.3° C or < 36° C
– HR > 90
– RR > 20
– WBC > 12,000 or < 4,000 or >10% bands
• SEPSIS
– 2 or more SIRS + Suspected/Confirmed Infection
SIRS
Sepsis
Severe Sepsis
Septic Shock
Definitions
• SEVERE SEPSIS
– SEPSIS + End Organ Dysfunction
• SBP < 90 or MAP < 65 or in SBP by 40 mmHg from the last
previously recorded SBP considered normal for the patient
• Creatinine > 2 or Urine Output < 0.5 mL/kg/hour for 2 hours
• Bilirubin > 2mg/dL
• Platelet Count < 100,000
• INR > 1.5 or aPTT > 60 seconds
• Lactate > 2 mmol/L
• AMS
• Hypoxia
SIRS
Sepsis
Severe Sepsis
Septic Shock
Definitions
• SEPTIC SHOCK
– SEVERE SEPSIS + Tissue Hypoperfusion after
crystalloid fluid administration
• SBP < 90 or MAP <65 or in SBP by 40 mmHg from
the last previously recorded SBP considered normal for
the patient
• Lactate > 4 mmol/L
SIRS
Sepsis
Severe Sepsis
Septic Shock
Sepsis Core Measures
• Severe Sepsis Treatment
– Within 3 hours of presentation
• Initial lactate level
• Blood cultures drawn prior to antibiotics
• Broad spectrum antibiotics administered
– Within 6 hours of presentation
• Repeat lactate level measurement ONLY if initial lactate
is > 2 mmol/L
Sepsis Core Measures
• Severe Sepsis Presentation Time
– Time at which the last criterion was met to
establish the presence of severe sepsis
• Physician/APN/PA documentation of severe sepsis/
suspected severe sepsis
• ED triage time for patients who present to the ED with
severe sepsis
• Lab reports may be reviewed to establish time
• Vital sign records may be reviewed to establish time
Sepsis Core Measures
• Septic Shock Treatment
– Within 3 hours of presentation
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Initial lactate level
Blood cultures drawn prior to antibiotics
Broad spectrum antibiotics administered
30 mL/kg crystalloid fluid administration
– Within 6 hours of presentation IF hypotension
persists after fluid administration
• Initiate vasopressors
• Septic Shock volume status and tissue perfusion
re-evaluation
Sepsis Core Measures
• Septic Shock Re-evaluation
– Within 6 hours of presentation
IF hypotension persists after fluid administration
OR initial lactate > 4 mmol/L
• Repeat volume status and tissue perfusion assessment
consisting of either:
– Vital signs, cardiopulmonary exam, capillary refill evaluation,
peripheral pulse evaluation, AND skin examination
» Physician/APN/PA documentation
OR any two of the following:
– Central venous pressure measurement
» Can be documented by nursing
– Central venous oxygen measurement
» Can be documented by nursing
– Bedside cardiovascular ultrasound examination
» Physician/APN/PA documentation
– Passive leg raise or fluid challenge
» Physician/APN/PA documentation
Sepsis Core Measures
• Septic Shock Presentation Time
– Time at which the last sign of septic shock was
noted or the last laboratory value was reported
• Physician/APN/PA documentation of septic shock/
suspected septic shock
• ED triage time for patients who present to the ED with
septic shock
• Lab reports may be reviewed to establish time
• Vital sign records may be reviewed to establish time
ED General Medical
PowerPlan
ED General Medical Adult PowerPlan updated to include a new ED Sepsis Screening subphase
in the lab section
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ED Sepsis Screening subphase has tests pre-selected for rapid ordering
New communication order for “Draw and Hold” blood culture specimens
Facilities with Lactic Acid POC testing, the POC test will be preselected
Severe Sepsis/Septic Shock
PowerPlan
PROTOCOL Early Goal Directed Therapy (EGDT) subphase:
Fluid resuscitation order comment updated indicating bolus of 30 mL/kg for hypotension
within 3 hours of presentation and to include any previous bolus amounts given
Severe Sepsis/Septic Shock
Antibiotic Updates
New Subphase:
Chorioamnionitis
Update Abscess/Post-op wound infection:
Ceftriaxone replaces cefazolin
Severe Sepsis/Septic Shock
Antibiotic Updates
Update Cellulitis:
Cellulitis without MRSA risk: removed option for cefazolin monotherapy, leaving ampicillinsulbactam monotherapy
Cellulitis prior /suspected MRSA: removed clindamycin monotherapy choice – replaced with
ceftriaxone option
Severe Sepsis/Septic Shock
Antibiotic Updates
Update Intra-abdominal:
meropenem replaces ciprofloxacin + metronidazole
Update Necrotizing Fasciitis:
Streptococcal: non-groin/perineal – penicillin continuous infusion or ampicillin replaced with ampicillin-sulbactam
Streptococcal: non-groin/perineal with penicillin allergy – replace vancomycin or cefazolin with ceftriaxone
Severe Sepsis/Septic Shock
Antibiotic Updates
Update Septic Joint:
ceftriaxone replaces cefazolin
Repeat Volume Status and Tissue
Perfusion Evaluation
Septic Shock Re-evaluation to be documented WITHIN 6 HOURS
of Septic Shock Presentation
IF hypotension persists after fluid administration
OR initial lactate > 4 mmol/L
AND CVP and ScvO2 NOT documented
• Providers to order new DOCUMENT Repeat Volume and Tissue Perfusion
Evaluation to open forms with required details
Repeat Volume Status and Tissue
Perfusion Evaluation
DOCUMENT Repeat Volume and Tissue Perfusion Evaluation detail
– Order selection opens forms for documentation
Option 1 - Any two of the following:
• Central Venous Pressure (CVP) measurement (can be documented by nursing)
• Central Venous Oxygen (ScvO2) measurement (can be documented by nursing)
• Bedside Cardiovascular Ultrasound (Physician/APN/PA documentation)
• Passive Leg Raise or Fluid Challenge (Physician/APN/PA documentation)
Option 2 - Exam consisting of all the following
• Vital signs, Cardiopulmonary, Capillary Refill, Peripheral Pulse, AND Skin
(Physician/APN/PA documentation)
Repeat Volume Status and Tissue
Perfusion Evaluation
When Bedside Cardiovascular Ultrasound is selected, the following form opens
for documentation during signing
Repeat Volume Status and Tissue
Perfusion Evaluation
When Fluid Challenge or Passive Leg Raise is selected, the following form opens
for documentation during signing
Fluid Challenge: Rapid infusion of 0.9% saline or LR - typically 500 mL in 15 minutes or 1,000 mL in 30 minutes
(done after the crystalloid fluid administration if patient remains hypotensive).
Passive Leg Raise: Patient in a semi-recumbent position, both legs are raised to a 45° angle
to evaluate the vital sign response to additional fluid load.
Repeat Volume Status and Tissue
Perfusion Evaluation
When Repeat Volume and Tissue Perfusion is selected, the following form opens
for documentation during signing
Inclusion Criteria
• Inclusion Criteria
– Discharges age > 18 years with a diagnosis code of
sepsis, severe sepsis, or septic shock
Exclusion Criteria
• Exclusion Criteria
– Directive for Comfort Care within 3 hours of presentation
of severe sepsis
– Directive for Comfort Care within 6 hours of presentation
of septic shock
– Administrative contraindication to care
• Patient or surrogate decision-maker declined consent for one of the following:
– Blood draw
– Fluid administration
– Antibiotic administration
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Hospital length of stay > 120 days
Transfer in from another acute care facility
Patients with severe sepsis who expire within 3 hours of presentation
Patients with septic shock who expire within 6 hours of presentation
Patients receiving IV antibiotics for more than 24 hours prior to
presentation of severe sepsis
Cerner ED SIRS Alert
• SIRS alert displays on ED Tracking Board
when the patient meets at least 3
of the below criteria
– Temperature > 38.3° C or < 36° C
– HR > 90
– RR > 20
– WBC > 12,000 or < 4,000 or >10% bands
– Blood glucose > 120 (no diagnosis of diabetes)
Cerner ED Sepsis Alert
• Sepsis alert displays on ED Tracking Board
when the patient meets at least 2 SIRS criteria
AND at least 1 criterion for organ dysfunction
• SBP < 90 or MAP < 65
• Elevated Creatinine: Greater than 0.5 from baseline for
this encounter unless End Stage Renal Failure is on the
diagnosis/problem list or an active order for
Recombinant Human Erythropoietin within the last 7
days
• Bilirubin > 2mg/dL
• Lactate > 2 mmol/L
Cerner Inpatient
SIRS/Sepsis Alerts
Inpatient SIRS/Sepsis Alerts:
• RN/LPN caring for patient receives SIRS or Sepsis
alert window detailing criteria met to trigger the alert
• Nursing performs patient assessment and physician
notification
• Early Warning Alerts Flowsheet available to review
data that triggered the alert
• Only applies to select patient locations
References
• Specifications Manual for National Hospital Inpatient Quality
Measures. Discharges 10-01-15 through 06-30-16. NQFEndorsed Voluntary Consensus Standards for Hospital Care.
Measure Set: Sepsis. Version 5.0a.
• Specifications Manual for National Hospital Inpatient Quality
Measures. Discharges 10-01-15 through 06-30-16.
Alphabetical Data Dictionary. Version 5.0a.