ࡱ> Z\Y^_`abcdefghijklmnopqrst _ dbjbj Cbb@*rrtJTLXKKKKKKK$OQ"LQ@"LrrsLr8KK"GDJJDqfH&KL0LHfCRsCRLJJZCRLK"L"L%LCR 8: St. Lukes 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 reading the 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 to Jessica 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 L 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 Tool will be completed by the attending physician, resident, PA, or CRNP or 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 Tool includes: #3 answered Signature Date & Time Fax to 691-4055 and initials of the person faxing the form The original Evaluation for Severe Sepsis Screening Tool form 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  EMBED AcroExch.Document.7   Date:_________ Time:________ Unit:_______ Evaluation for Severe Sepsis Screening Tool Instructions: Use this tool to screen patients (e" 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 C (101.0 F) ( Tachypnea > 20 bpm ( Hypothermia < 36.0C (96.8F) ( 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 physicians 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) If SUSPICION of INFECTION (#1 & #2) is present and ORGAN DYSFUNCTION (#3) is present, the patient meets the criteria for SEVERE SEPSIS and 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. 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