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Presented by:
AQKC HAI LANEarly Detection Saves Lives –Think SEPSIS
Kelly Shipley ���� QI Director, ESRD Network 14Dr. Stephen Jones ���� Director, SERRI: Sepsis Early Recognition and Response InitiativeLevi Njord ���� Director, Infection Prevention and Epidemiology, DaVita Healthcare Partners
Objectives
� Sepsis definitions and epidemiology
� Early Goal Directed Therapy – special considerations for the ESRD patient
� Review sepsis incidence and mortality rates for the ESRD patient population
� Identify sepsis early recognition and prompt interventions
� Discuss sepsis screening tools for outpatient dialysis facilities and lessons learned
� Review HAI/Sepsis data collection, tracking, and reporting
2
Leighann Sauls, RN, CDN
Quality Improvement Director
Sheila McMaster, MSN, CNN,
CPHQ
Quality Improvement Director
Kelly Shipley, RHIA
Quality Improvement Director
3
JK
2
4
Speakers
Stephen L. Jones, M.D., M.S.H.I.,
Director, SERRI
Levi Njord, Director, Infectious
Disease Epidemiology, DaVita
Healthcare Partners
Texas Gulf Coast Sepsis NetworkTexas Gulf Coast Sepsis NetworkTexas Gulf Coast Sepsis Network
SSSSepsis: epsis: epsis: epsis: An Equal Opportunity KillerAn Equal Opportunity KillerAn Equal Opportunity KillerAn Equal Opportunity Killer
End Stage Renal Disease Network of TexasEnd Stage Renal Disease Network of TexasEnd Stage Renal Disease Network of TexasEnd Stage Renal Disease Network of Texas
Alliant Quality Kidney CollaborativeAlliant Quality Kidney CollaborativeAlliant Quality Kidney CollaborativeAlliant Quality Kidney Collaborative
SERRI: Sepsis Early Recognition And Response Initiative 5
Stephen L. Jones, M.D., M.S.H.I.
Program Director: SERRI
Chief Clinical Informatics Officer - Department of Surgery
Division Chief of Health Informatics – Center for Outcomes Research
Houston Methodist Hospital
Research Scientist and Assistant Member, The Methodist Hospital Research Institute
Assistant Professor of Medical Informatics in Surgery,
Weill Cornell Medical College of Cornell University
December 15, 2015
Texas Gulf Coast
Sepsis Network
The project described is supported by Funding
Opportunity Number 1C1CMS330975-01-00 from
the U.S. Department of Health and Human
Services, Centers for Medicare and Medicaid
Services. The contents of these slides are solely
the responsibility of the authors and do not
necessarily represent the official views of the U.S.
Department of Health and Human Services or any
of its agencies. The research presented here was
conducted by Houston Methodist. Findings might
or might not be consistent with or confirmed by
the independent evaluation contractor.
SERRI: Sepsis Early Recognition And Response Initiative 2
DisclaimerTexas Gulf Coast
Sepsis Network
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Texas Gulf Coast
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Objectives
SERRI: Sepsis Early Recognition And Response Initiative
� Outcomes Data HMH 2008 – Q1 2015
� Introduction
� Epidemiology
� Pathophysiology
� Clinical Presentation
� Early Goal Directed Therapy
Texas Gulf Coast
Sepsis Network
Texas Gulf Coast
Sepsis Network
Texas Gulf Coast
Sepsis NetworkHMH 2008-2015 Sepsis Mortality – TrendTexas Gulf Coast
Sepsis Network
6SERRI: Sepsis Early Recognition And Response Initiative
35.4%
18.2%
Jan
20
08
Jan
20
09
Jan
20
10
Jan
20
11
Jan
20
12
20
13
Ja
n
20
14
Ja
n
De
c2
01
5 J
an
Sepsis Mortality Rate Trend (Sepsis Mortality)
Data Source: HMH – MIDAS as of 07/08/2015 HMH - Service Line Analytics Dept. (Billy Askary)
16.4%
19.9%
15.0%
13.1%
16.8%
14.9%
18.7%
19.7%
17.8%
16.1%
15.1%
18.2%
Latest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality Rate
20
14
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n
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Ma
y
Sepsis Mortality Rate Trend (Sepsis Mortality)
Texas Gulf Coast
Sepsis NetworkWhat Can We do About Sepsis?
Sydney Harris, ©1970, The American Scientist
Texas Gulf Coast
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8SERRI: Sepsis Early Recognition And Response Initiative
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Texas Gulf Coast
Sepsis NetworkWhat is SERRI?
SERRISERRISERRISERRI is a bedside nurse driven sepsis screening protocol that
focuses on:
� vital signs
� white blood cell count
� mental status changes
The values of these parameters are entered into a rigorously
validated algorithm that derives a score of the likelihood that a
patient has sepsis.
If the score is high enough, it triggers an evaluation by
second level responderssecond level responderssecond level responderssecond level responders with advanced training in the
recognition of sepsis.
SSSSepsis epsis epsis epsis EEEEarly arly arly arly RRRRecognition and ecognition and ecognition and ecognition and RRRResponseesponseesponseesponse IIIInitiativenitiativenitiativenitiative
SERRI: Sepsis Early Recognition And Response Initiative 10
Texas Gulf Coast
Sepsis Network
Texas Gulf Coast
Sepsis NetworkTexas Gulf Coast Sepsis Network
Acute CareAcute CareAcute CareAcute CareLong Term Long Term Long Term Long Term Acute CareAcute CareAcute CareAcute Care
Skilled NursingSkilled NursingSkilled NursingSkilled Nursing
� St. Joseph Regional Health Center
� HCA Bayshore & East Medical
� HCA Rio Grande Regional Hospital
� Houston Methodist Sugar Land Hospital
� Houston Methodist San Jacinto Hospital
� Houston Methodist Hospital
� Houston Methodist West Hospital
� Houston Methodist Willowbrook Hospital
� Kindred Hospital Medical Center
� Kindred Hospital Bay Area
� Select Specialty Medical Center
� Houston Methodist Hospital
� Houston Methodist San Jacinto
Hospital
� St. Joseph Manor
� Burleson St. Joseph Manor
SERRI: Sepsis Early Recognition And Response Initiative 11
Spanning the continuum of care
Additional sites participating in the Sepsis Screening:
� *Houston Methodist Sienna Emergency Center
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Severe Sepsis/Septic Shock Mortality by ICU
0%
10%
20%
30%
40%
Mo
rta
lity
2006 35% 21% 38%
2007 24% 24% 37%
SICU CVICU MICU
5
Texas Gulf Coast
Sepsis NetworkSSC Guidelines 2012
B. Screening for Sepsis and B. Screening for Sepsis and B. Screening for Sepsis and B. Screening for Sepsis and Performance Performance Performance Performance
ImprovementImprovementImprovementImprovement
1. We recommend 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
(grade 1C).
Rationale. Rationale. Rationale. Rationale. The early identification of sepsis and
implementation of early evidence-based therapies
have been documented to improve outcomes and
decrease sepsis-related mortality (15). Reducing the
time to diagnosis of severe sepsis is thought to be a
critical component of reducing mortality from sepsis-
related multiple organ dysfunction (35). Lack of early
recognition is a major obstacle to sepsis bundle
initiation. Sepsis screening tools have been developed
to monitor ICU patients (37–41), and their
implementation has been associated with decreased
sepsis-related mortality (15).
SERRI: Sepsis Early Recognition And Response Initiative 13
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SSC Guidelines 2012:
Updates for Emergency Physicians
SERRI: Sepsis Early Recognition And Response Initiative 14
Texas Gulf Coast
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Texas Gulf Coast
Sepsis NetworkSepsis: A Review of Recent Literature
Conclusion:
This meta-analysis, covering 1001 patients, across 9 studies, found that applying
an early quantitative resuscitation strategy to patients with sepsis imparts a
significant reduction in mortality.
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Texas Gulf Coast
Sepsis NetworkSepsis: A Review of Recent LiteratureTexas Gulf Coast
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Sepsis NetworkSepsis: ProCESS Trial
1. This RCT was for patients in early septic shock.
2. Majority of the centers participating in this trial were large academic tertiary care referral
centers.
3. This study does *notnotnotnot* address the extent to which any of these strategies offer
advantages where septic shock has not developed.
4. No one can say for sure what care these patients had prior to the recognition of septic
shock. This is going to be a huge source of variability.
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Texas Gulf Coast
Sepsis NetworkSepsis: ProCESS Trial
At least 1L of fluids administered over 30 mins *prior* to randomization.
(Antibiotic administration status prior to randomization is unclear. All patients
received antibiotics *early*.)
18% aggregate mortality rate.
Conclusions: Protocol-based resuscitation of patients in who septic shock was
diagnosed in the ED did not improve outcomes between the 3 arms of the study.
The conclusions found no benefit between the 3 different arms of the RCT for
patients already in septic shock when they were identified in the ED.
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1. This RCT was for patients in early septic shock.
2. Conducted in 51 tertiary and non-tertiary care metropolitan and rural hospitals (most in
Australia or New Zealand, with 6 centers in Finland, Hong Kong and Ireland).
3. Study centers did not have sepsis-resuscitation protocols in place at time of site
selection.
4. Eligibility criteria included refractory hypotension (sbp < 90, MAP < 65 after 1L bolus.).
Sepsis: ARISE and ANCIZSTexas Gulf Coast
Sepsis Network
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5. The initiation of the first dose of antibiotics was mandated before randomization.
6. Primary outcome was death from any cause within 90 days after randomization.
19% aggregate mortality rate.
Conclusion:
EGDT vs. “Usual Care” did not reduce 90-day mortality, nor 28-day in-house mortality in
patients that presented to the ED in early septic shock.
Sepsis: ARISE and ANCIZSTexas Gulf Coast
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* Same inclusion criteria as ARIZE.
Randomization occurred *after* 1L fluid bolus and *after* administration of antimicrobial
drugs.
Conclusion:
On average, EGDT increased costs, and the probability that it was cost effective was below
20%.
Sepsis: ProMISe TrialTexas Gulf Coast
Sepsis Network
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Texas Gulf Coast
Sepsis NetworkProCESS, ProMISe & ARISE:
� Required monitoring of CVP and ScvO2 via a central venous line as part of EGDT does not confer survival benefit in all patients with septic shock in who have received timely antibiotics and fluid who have received timely antibiotics and fluid who have received timely antibiotics and fluid who have received timely antibiotics and fluid administrationadministrationadministrationadministration compared with controls.
Key Themes:
� Administration of appropriate antibiotics as soon as sepsis is suspected is *critical**critical**critical**critical*
� Initial fluid challenge (30 ML/KG in one hour) is essential.
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Excerpted from a presentation given by: Sean R. Townsend, MD, June 22, 2015 during a CMS sponsored webinar: pg
43 http://www.qualityreportingcenter.com/wp-content/uploads/2015/06/IQR-Sepsis_20150622_FINAL1s508.pdf
Texas Gulf Coast
Sepsis NetworkHMH 2008-2015 Sepsis Mortality – TrendTexas Gulf Coast
Sepsis Network
6SERRI: Sepsis Early Recognition And Response Initiative
35.4%
18.2%
Jan
20
08
Jan
20
09
Jan
20
10
Jan
20
11
Jan
20
12
20
13
Ja
n
20
14
Ja
n
De
c2
01
5 J
an
Sepsis Mortality Rate Trend (Sepsis Mortality)
Data Source: HMH – MIDAS as of 07/08/2015 HMH - Service Line Analytics Dept. (Billy Askary)
16.4%
19.9%
15.0%
13.1%
16.8%
14.9%
18.7%
19.7%
17.8%
16.1%
15.1%
18.2%
Latest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality RateLatest 12 Months sepsis Mortality Rate
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Ju
n
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Ma
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Sepsis Mortality Rate Trend (Sepsis Mortality)
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Sepsis NetworkSepsis is a BIG PROBLEM
� Sepsis is the leading cause of death in non coronary ICUs11
� There were 1.1 million cases of sepsis in 2008 and this number is projected to increase.2
� 11th leading cause of death in the United States overall3
� Nearly 1 out of every 23 patients in the hospital has septicemia51
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� Sepsis-related hospitalization has more than doubled from 2000 through 20086
Sepsis is a BIG PROBLEM: Texas Gulf Coast
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Texas Gulf Coast
Sepsis NetworkSepsis is a BIG PROBLEM
� Sepsis was the 6th most common principal reason
for hospitalization in the US in 2009
� Sepsis was the most expensive reason for
hospitalization in 2009 - totaling ~ $15.4 billion in
aggregate hospital costs
� Septic patients spent 75% more time in the hospital
and were 8 times as likely to die in the hospital as
patients with other diagnoses.7
� Sepsis associated mortality rate of > 30%.7
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26SERRI: Sepsis Early Recognition And Response Initiative
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Sepsis NetworkSepsis in real life
� CurrentlyCurrentlyCurrentlyCurrently, more Americans die from severe sepsis
than from breast cancer, lung cancer and stroke
combined.
� The number of sepsis associated deaths in the US is
comparable to the number of Acute Myocardial
Infarction associated deaths in the US.
� Sepsis mortality *has* decreased in the last 6-7
years.
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Texas Gulf Coast
Sepsis NetworkWho gets sepsis?
Sepsis can affect anyone at any age
Carol Decker, a 32 y/o pregnant
mom, survived sepsis secondary to
pneumonia. She subsequently lost
her sight and is now a triple
amputee. It took 12+ days for
health professionals to realize
she was septic.
Mariana Bridi da Costa, a 20 y/o
Brazilian model, died of sepsis
secondary to a UTI. She had
undergone amputations of both
hands, had part of her stomach and
both kidneys removed to stem the
disease before she died.
Jen Ludwin, a graduate student,
had sepsis due to a viral infection after
presenting with flu-like symptoms.
She was hospitalized for ~ 5 ½ months,
survived after undergoing 20+ major
surgeries, lost all of her fingers & had
bilateral BKAs.
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http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?pagewanted=all
12 year old boy scrapes his arm playing basketball, ~132 hours
later, he dies from septic shock (NYT, June 12, 2012)
Wednesday, March
28th, mid-afternoon
Thursday, March
29th, mid-
afternoon
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Texas Gulf Coast
Sepsis NetworkEpidemiology
� Incidence varies among racial groups, but appears highest among African-American males
� Incidence is greatest during the winter
� Respiratory source
� Patients over the age of 65 years account for almost 60% of severe sepsis cases
� Severity is increasing
� Urinary tract is the most common source of nosocomial infection
� GI or pulmonary infections have the highest mortality rate
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Preliminary Admit Sources of Sepsis
Associated Encounters
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Preliminary 3 Main Sub-cohorts of Sepsis
Associated Encounters
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Preliminary Stage of Sepsis Associated
Encounters Present on Admission
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Texas Gulf Coast
Sepsis NetworkWhich patients are at risk?
� Extended hospitalization
� In/from a nursing home
� Malnourished
� ICU stay
� Chronic diseases
� History of sepsis
� Transplant
� Immunosuppression
� Radiation/chemotherapy
� A central line / PICC
� A Foley catheter
� A dialysis catheter
� Drains
� Pressure/diabetic ulcers
� Prosthetic devices/implants
� Recent surgeries/procedures
� Dialysis
� Heart valve replacement
Texas Gulf Coast
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31SERRI: Sepsis Early Recognition And Response Initiative
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Sepsis NetworkWhich patients are at risk?
� Any implant or foreign body
� Any recent procedure (30 days)
� Any comorbidity (e.g. DM, HTN, ESRD)
� Immunocompromised for any reason
(e.g. Age, Medications, etc.)
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Risk Factors for Developing SepsisRisk Factors for Developing SepsisRisk Factors for Developing SepsisRisk Factors for Developing Sepsis� Age Age Age Age 60 years or 60 years or 60 years or 60 years or olderolderolderolder
� Need Need Need Need for Emergency for Emergency for Emergency for Emergency SurgerySurgerySurgerySurgery
� AnyAnyAnyAny Other health Other health Other health Other health problemsproblemsproblemsproblems
• e.ge.ge.ge.g. . . . Diabetes,Diabetes,Diabetes,Diabetes,
• High High High High blood pressureblood pressureblood pressureblood pressure
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Sepsis NetworkESRD and Sepsis:
There is very little published research focused on
septic patients with ESRD!
� Patients with ESRD on HD or PD are at *significantly
increased risk* for mortality from sepsis over the
general population: 100 – 300X!! (Sarnak, Jaber 2000)
� Over a 7 year study period, 11.7% of HD patients and
9.4% of PD patients had at least one episode of sepsis. (Powe, et. al. 1999)
� ESRD patients are *severely* under-resuscitated (Dagher, et. al. 2015)
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Sepsis NetworkESRD and Sepsis: The Bugs
� The most common sources of infection:
� HD Catheters
� Lower respiratory tract (Dagher, et. al. 2015)
� The most common bugs:
� Eschericia coli
� Staphylococcus coagulase negative. (Dagher, et. al. 2015)
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ESRD and Sepsis: The Mechanism of
of Susceptibility
� Polymorphonuclear (PMNL) cell function in
dialysis patients is impaired. (Vanholder, Ringoir, 1992, Rao et. al. 2004)
� Glycolysis in uremic patients is disturbed
� This disturbance is intensified during dialysis with
cuprophan (not observed with non-complement
activating dialyzers)
� Response is especially suppressed towards
Staphylococcus Aureus.
� Uremia impairs the PMNL
� Dialyzer membrane bio(in)compatibility
� Uremic anemia
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