in 2001, the european society of intensive care medicine (esicm), society of critical care medicine...
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Compliance with Severe Sepsis Protocol:Compliance with Severe Sepsis Protocol:Impact on Patient OutcomesImpact on Patient Outcomes
Lisa Hurst RN BSN CCRN and Kim Raines RN CCRNLisa Hurst RN BSN CCRN and Kim Raines RN CCRN
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In 2001, the European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), and the International Sepsis Forum (ISF) developed the Surviving Sepsis Campaign.
The purpose of this initiative was to improve diagnosis, management, and treatment of sepsis.
Background
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The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHITo be accomplished as soon as possible and
scored over first 6 hours:Serum lactate measuredBlood cultures obtained prior to antibiotics
administeredPerform imaging studies promptly to find
sourceAdministration of broad-spectrum antibiotics
within 1 hour of diagnosis of septic shock and severe sepsis without septic shock
Dellinger, 2008
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The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHI
For hypotension and/or lactate > 4 mmol/L:Deliver an initial minimum of 20 mL/kg of crystalloid
(or colloid equivalent)Apply vasopressors for hypotension not responding to
initial fluid resuscitation to maintain MAP > 65 mmHg. For persistent hypotension despite initial fluid
resuscitation (septic shock) and/or lactate > 4 mmol/L:Achieve CVP of 8-12 mmHg & MAP > 65 mmHg &
UO > 0.5mL/kg/hrAchieve ScVO₂ of > 70% or SvO2 > 65%.if ScVO₂ not > 70%, consider blood or dobutamine
Dellinger, 2008
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Purpose
The purpose of this study is to establish the current level of medical compliance with the Severe Sepsis Protocol at UPMC Hamot.
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SEVERE SEPSIS: DEFINING A DISEASE CONTINUUM
SIRS with a
presumed or confirmed
infectious process
SepsisSIRSInfection Severe Sepsis
Sepsiswith 1 sign of organ
dysfunction, hypoperfusion or
hypotension.
Examples:• Cardiovascular (refractory hypotension)
• Renal• Respiratory• Hepatic• Hematologic• CNS• Unexplained metabolic acidosis
Adult CriteriaA clinical response arising from a nonspecific insult, including ≥ 2
of the following:
Temperature:> 38°C or < 36°CHeart Rate: > 90 beats/minRespiration:> 20/minWBC count: > 12,000/mm3,
or < 4,000/mm3,or > 10% immature neutrophils
SIRS = Systemic Inflammatory Response SyndromeBone et al. Chest.1992;101:1644-1654.
Shock
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Methods: UPMC Hamot Institutional Review Board (IRB) approval obtained Retrospective chart review of 50 patients admitted during 2010 Diagnosis of severe sepsis or sepsis with organ dysfunction
Data collected: Age Length of stay Source of sepsis Mortality/functional status at admission and discharge
Time of: Admission ScVO₂ value ≥70% noted PreSep (ScVO₂) catheter insertion Initiation of severe sepsis order set First CCM order obtained after severe sepsis diagnosis Blood cultures, lactate, and antibiotics post sepsis diagnosis
Methods
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Findings
*Dx=diagnosis Cx=blood cultures Lact=lactate Abx=antibiotics
Recommended time: Blood cultures drawn, 1 hour Antibiotics administered, 1 hour Lactate levels drawn, 6 hours
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Findings
22 patients (44%) had CCM consult 9 patients (18%) placed on protocol 5 patients (10%) protocol + CCM consult 8 patients (16%) received PreSep (ScVO₂) catheter 6 patients (12%) received PreSep (ScVO₂)
+ CCM consult
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Findings
56% of patients discharged to SNIF/Rehab 22% of patients died 22% discharged home
78% of patients came from home; only 22% were able to return directly home due to change in functional status
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Discussion
Time to treatment longer than recommended
Important measures of sepsis diagnosis not available:• Lactate not drawn• ABG drawn without panel• Cultures not obtained
CCM management• Frequency of consult• Time to first order
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Regional transfers
Floor patients
Documentation
Sample Size
Limitations
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Recommendations
Sepsis Alert Teams
Screening Tools
Education• Regional facilities• Medical staff
Recommendations
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Consistent use of a standardized protocol “ensures implementation of evidence based guidelines, decreases variability in management among clinicians…and monitors quality of care” (Moore, 2009).
Conclusion
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Thank You!
Jean Bulmer and Debbie Hess, our Research Residency mentors
Diane Voelker and Linda Jeffrey, Library services
Becky Stokes, EBP expert and role model, our inspiration
Ginny DiGello and Matt Niles, for their support of the residency program
Our MICU Colleagues
Acknowledgements