Highmark Quality Blue Pay-For-Performance Program: SEPSIS

St. Luke’s University Health Network

2013 SEPSIS SCREENING

Highmark Quality Blue Pay-for-Performance Program: SEPSIS

0.5 CE/Credit

Directions for Completion

Before proceeding to the posttest, be sure you have read the 3 documents that follow this cover page:

Highmark Quality Blue Pay-for-Performance Program: SEPSIS SCREENING Education
Severe Sepsis Screening Flowchart
Evaluation for Severe Sepsis Screening Tool (“Screening Tool”)

Exit after readingthe 3 documents and complete the posttest which is final step of this education.

“Take Test” is a brief posttest measuring your knowledge of content.

Remember, no attendance record is needed.

Completion of the posttest will be sent electronically to your EduTracker record once a 100% is achieved.

Print the Certificate of Completion for your records if desired.

Comments, questions, or suggestions regarding the content

can be directed toJessica Heckenberger, Patient Care Manager, PPHP 7 (484-526-1741) or any member of the Highmark Sepsis Project Committee

Highmark Quality Blue Pay-for-Performance Program: SEPSIS SCREENING Education

What are we doing?

Measure:Implementation of the Sepsis Resuscitation and Sepsis Management Bundles in the Emergency Department, ICU and non-ICU settings for patients >16 years of age.
Intent: To promote rapid identification of patients admitted with or developing severe sepsis and/or septic shock and improve the quality of care provided by aligning treatment with evidence-based guidelines.
Outcome:Reduced morbidity and mortality due to severe sepsis and/or septic shock.

What is Sepsis?

Sepsis is the body's response to a localized (e.g. tooth abscess) or systemic infection (e.g. septicemia)
Sepsis is a medical emergency just like a heart attack or a stroke because there is an interruption of oxygen and nutrients to the tissues including the vital organs such as the brain, intestines, liver, kidneys and lungs.
Infections leading to sepsis can be community acquired or hospital acquired (nosocomial)
Hospital-acquired infections are generally more difficult to manage because:
The patient is often already sick
The infecting microorganism may be more dangerous
Resistance to common treatments due to the widespread use of antibiotics in hospitals
Sepsis is becoming more common as a result of:
Medical and technological advances associated with treatments
Increasing number of elderly or debilitated people
Patients with underlying diseases (e.g. cancer) requiring therapy
Widespread use of antibiotics which encourages growth of drug-resistant microorganisms

Who is at risk?

Everyone (infant to adult)is at potential risk
Sepsis is most likely to develop in people who:
Are very young or very old
Have a weakened/compromised immune system
Have wounds or injuries (e.g. burns, penetrating wounds, etc.)
Have certain addictive habits such as alcohol or drugs
Are receiving invasive treatments/medical care (e.g. IV fluids/access, urinary catheters, etc.)

Stages of Sepsis

Uncomplicated Sepsis, such as that caused by the flu and other viral infections, gastroenteritis, or dental abscesses, is very common.
Experienced by millions of people each year
Majority of these people will not need hospital treatment

Severe Sepsis arises when sepsis occurs in combination with problems in one or more of the vital organs, such as the heart, kidneys, lungs, or liver.
Are likely to be very ill and require admission
More likely to die (in 30-35 % of cases)

Septic Shock occurs when sepsis is complicated by low blood pressure that does not respond to fluid administration.
Leads to problems in one or more of the vital organs
The body does not receive enough oxygen to properly function and vasopressors are used to raise the blood pressure.
Patients are very ill and require rapid emergency medical care
Despite active treatment, the death rate is around 50%

Most Common Sources of Sepsis

An infection in any part of the body. The following regions are most common:
Lungs - usually associated with pneumonia
Abdomen (e.g. appendicitis, gallbladder infections, peritonitis)
Urinary Tract - particularly patients needing a urinary catheter
Skin (e.g. wounds, skin inflammations)
Bones (e.g. inflammation and infections of the bone, marrow, sinuses, etc.)
Central Nervous System (e.g. meningitis or encephalitis) or spinal cord
The source of the sepsis cannot be found in about 20% of cases

Highmark Sepsis Project Definitions

SEPSIS is defined as a documented or suspected infection with one or more of the following:
Hyperthermia >101.0 F
Hypothermia <96.8 F
Tachycardia >90b pm
Tachypnea >20bpm
Leukocytosis WBC count >12,000
Leukopenia WBC Count <4,000

SEVERE SEPSIS is defined as sepsis associated with organ dysfunction, hypoperfusion or hypotension.
Organ dysfunction variables:
Arterial hypoxemia (PaO2/FIO2 <300)
Acute oliguria (urine output <0.5 mL/kg or 45 mmol/L for at least 2 hours)
Creatinine (> 2.0 mg/dL)
Coagulation abnormalities (INR >1.5 or aPTT >60 secs)
Thrombocytopenia (platelet count <100,000 μL–1)
Hyperbilirubinemia (plasma total bilirubin > 2.0 mg/dL or 35 mmol/L)
Hemodynamic variables:
Arterial hypotension (SBP <90 mm Hg, MAP <70, or SBP decrease >40 mm Hg)
SEPTIC SHOCK is defined as acute circulatory failure unexplained by other causes.
Acute circulatory failure is defined as persistent arterial hypotension (SBP <90 mmHg,MAP)

How will we identify these patients?

Hospitals will implement a severe sepsis screening tool to screen patients for severe sepsis in the Emergency Department, non-ICU and ICU locations
The screening tool will: enhance rapid identification of severe sepsis and identify the need to implement the bundle (antibiotics) in order to improve morbidity and mortality related to sepsis

What else do I need to know?The Process

A report will be available on the common drive every day by 9:00 am
It is the responsibility of the CC or charge nurse to review the report for potential sepsis indicators and discuss with the RN
The Evaluation for Severe Sepsis Screening Tool is implemented as appropriate
If “Yes” to both question #1 & #2 contact* attending physician, resident, PA, or CRNP and notify of Suspicion of Infection
Obtain order for labs and draw STAT (if ordered)
When lab results return, notify* physician, resident, PA, or CRNP of results

*Communication with the attending, resident, PA, or CRNP is vital to improve patient outcomes

Inability to rapidly notify attending should be escalated to the Rapid Response Team in the presence of indicators

The Evaluation for Severe Sepsis Screening Toolwill be completed by the attending physician, resident, PA, or CRNPor the Rapid Response Team leader in the event a Sepsis Alert is indicated (lab results and “Yes” to question #3)
If the physician, PA, or CRNP concludes a “Sepsis Alert” is indicated, the Hospital Operator is notified of the Sepsis Alert
When Sepsis Alert is called, an automatic page goes to the Pharmacist to notify of need for antibiotic
RN administers antibiotic in time frame required (within 3 hours in the ED and within 1 hour in critical care or acute care/med surg)
Completion of the Evaluation for Severe Sepsis Screening Toolincludes:
#3 answered
Signature
Date & Time
Fax to 691-4055 and initials of the person faxing the form
The original Evaluation for Severe Sepsis Screening Toolform is placed in the front of the chart

Please note: the Evaluation for Severe Sepsis Screening Tool is on purple paper

The RN, CC, or charge nurse records appropriate information on the Tracking Tool in the Charge Binder

Date:______Time:______Unit:______

Evaluation for Severe Sepsis Screening Tool

Instructions: Use this tool to screen patients (≥ 16 years of age) for potential severe sepsis in the following areas: Emergency Department, Critical Care, and Acute Care

1. Is the patient’s history suggestive of a new infection?** Yes No

 Pneumonia, empyema Bone/joint infection  Implantable device infection

 Urinary tract infection Wound infection  Other

 Acute abdominal infection Bloodstream catheter infection

 Meningitis Endocarditis

 Skin/soft tissue infection

2. Are any TWO of following signs & symptoms of infection both PRESENT AND NEW to the

patient?** Yes No

Note: laboratory values may have been obtained for inpatients but may not be available for outpatients.

 Hyperthermia > 38.3 ºC (101.0 ºF)  Tachypnea > 20 bpm

 Hypothermia < 36.0ºC (96.8ºF)  Leukocytosis (WBC count > 12,000 IJL – 1)

 Tachycardia > 90 bpm  Leukopenia (WBC count < 4000 IJL – 1)

**If the answer is yes to both questions 1 & 2, SUSPICION of INFECTION is present.

Notify the Physician / PA-C / CRNP
The following lab work is indicated and will need an order to obtain:

STAT lactic acid, blood cultures, CBC with differential, basic chemistry labs, bilirubin

At the physician’s discretion, obtain: UA, chest x-ray, amylase, lipase, ABG, CRP, CT scan

3. Are any of the following organ dysfunction criteria present at a site remote from the site of

the infection that ARE NOT considered to be chronic conditions? Yes No

 Acutely altered mental status

 SBP < 90 mmHg or MAP < 65 mmHg

 SBP decrease > 40 mmHg from baseline

 Bilateral pulmonary infiltrates with a new (or increased) oxygen requirement to maintain SpO2 > 90%

 Bilateral pulmonary infiltrates with PaO2/FiO2 ratio < 300

 Creatinine > 2.0 mg/dl (176.8 mmol/L)

 Urine Output < 0.5 ml/kg/hour for > 2 hours

 Bilirubin > 2 mg/dl (34.2 mmol/L)

 Platelet count < 100,000

 Coagulopathy (INR > 1.5 or aPTT > 60 secs)

 Lactate > 4 mmol/L (18.0 mg/dl)

IfSUSPICION of INFECTION (#1 & #2) is presentandORGAN DYSFUNCTION (#3) is present, the patient meets the criteriaforSEVERE SEPSISand should be entered into the Severe Sepsis Protocol. NOTE: Antibiotic must be infused within 3 hours for ED and 1 hour for non-ED patients.

Signature (Physician/PA-C/CRNP)______

 Patient is already receiving antibiotics  Severe Sepsis has been identified  YES  NO

Date: ______Time severe sepsis recognized: ______Form faxed by (initials): ______

***MUST Fax to Laura Kohler at x691- 4055(SLB)***

For questions or concerns please contact the Critical Care Attending / PA-C / CRNP

This document is NOT part of the permanent medical record