Exemplary Professional Practice CARE DELIVERY SYSTEM(S ... · Sepsis is a potentially...

EP5 ExB Advocate BroMenn Medical Center 1

Exemplary Professional Practice CARE DELIVERY SYSTEM(S)

EP5 - Nurses are involved in interprofessional collaborative practice within the care delivery system to ensure care coordination and continuity of care.

Example B: Provide one example, with supporting evidence, of nurses’ involvement in interprofessional collaborative practice that ensures care coordination and continuity of patient care.

Interprofessional Collaborative Practice

Sepsis is a potentially life-threatening complication of an infection. If sepsis progresses to septic shock, blood pressure drops dramatically, which may lead to death. Early treatment of sepsis, usually with antibiotics and large amounts of intravenous fluids, improves the chance for survival.

At Advocate BroMenn Medical Center (ABMC), the Critical Care Collaborative Practice Committee reviews sepsis data and is responsible for the sepsis treatment plan of care and order sets. The Sepsis Workgroup, who reports directly to the Critical Care Collaborative Practice Committee, is an interprofessional workgroup that meets monthly with the goal of improving the care delivered to sepsis patients. The workgroup is chaired by Donna Schweitzer, APN, CCNS, CCRN, Critical Care Clinical Nurse Specialist and is comprised of clinical nurses, interprofessional partners and ancillary care support providers who are directly involved in the day-to-day care of sepsis patients including pharmacy, laboratory, hospitalist, health information management (Exhibit EP5.B.1 Sepsis Workgroup Minutes April 2015). This interprofessional workgroup studies data, makes recommendations for changes and provides support to their peers on the unit. The workgroup ensures that patients with sepsis are quickly identified and receive excellent, evidence-based care.

Care Coordination and Continuity of Care

Interventions to identify and aggressively treat patients with suspected sepsis at ABMC were developed and have been in use since the first Surviving Sepsis Campaign guidelines were published by the Society of Critical Care Medicine in 2008. In 2014, the interprofessional Sepsis Workgroup was charged with reviewing ABMC’s current program, outcomes, care, and identifying opportunities for improvement.

The Surviving Sepsis Campaign identified core improvement interventions called “bundles”. A bundle is a selected set of elements of care that, when implemented as a group, have an effect on the outcomes beyond implementing the individual elements alone. There are two sepsis bundles – one to be completed in the first three hours (3 hour bundle) and one to be completed within six hours (6 hour bundle) of positive sepsis screening.


The 3 hour bundle consists of:

Measuring lactate level

Obtaining blood cultures prior to administration of antibiotics

Administering broad spectrum antibiotics

Administering 30 milligrams/kilogram of crystalloid intravenous fluids forhypotension or a lactate level of greater than or equal to 4 millimoles/liter

The 6 hour bundle consists of:

Administering vasopressors for hypotension that does not respond to fluidresuscitation

Reassessing persistent hypotension, as needed

Re-measuring lactate, if initial lactate is elevated

On April 2, 2015, the Sepsis Workgroup reviewed data on sepsis care and identified opportunities for improvement that included timing of antibiotic administration and completeness of nursing documentation. The workgroup concluded that Donna would present focused education including the importance of the 3 hour bundle elements to the Emergency Department (ED) Shared Governance Team (Exhibit EP5.B.1 Sepsis Workgroup Minutes April 2015).

The ED Shared Governance Team met on April 23, 2015 and May 28, 2015. Donna provided education on sepsis and the 3 and 6 hour bundles, as well as the proposed Sepsis Alert Policy revisions. At the conclusion of the two meetings, it was decided that a small group from the ED Shared Governance Team and the Sepsis Workgroup would meet to develop an algorithm that included the 3 hour bundle elements (Exhibit EP5.B.2 ED Shared Governance Minutes April and May 2015). This algorithm would clearly define the needed interventions and serve as a reminder to document specific elements of care.

The small group included three ED nurses (Sherri Pearson, BSN, RN, ED Charge Nurse; Jennifer Toohill, BSN, RN, CEN, ED Nurse Clinician III and Leslie Carter, BSN, RN, CEN, ED Nurse Clinician II-Weekender) and Donna from the Sepsis Workgroup. They created a double-sided tool using evidence-based references from the Surviving Sepsis Campaign. On one side was the Sepsis Screening and Response Process algorithm and the other a Severe Sepsis Patient Flow Sheet. The Sepsis Screening and Response Process algorithm outlined four specific steps to screen patients for sepsis and the bundle elements to care for a patient with a positive sepsis screen. The Severe Sepsis Patient Flow Sheet was developed to facilitate handover communication and care delivery between the various care team members and units. Communication between care providers and documentation of the completed interventions are critical to ensure that all interventions are completed within the three hour time frame. As the nurse initiates or completes interventions (such as collection of blood cultures), care is documented on the flow sheet clearly communicating the status of the bundled interventions. The tool provides the nurse with a reminder to document key interventions (such as the time of the fluid bolus completion) in the patient’s electronic medical record. The tool also facilitates effective handovers to new care team members


with clear communication of the intervention status (Exhibit EP5.B.3 Sepsis Screening Tool/Flow Sheet). The tool can be used in the ED, or on the inpatient unit. The tool was presented to the ED Shared Governance team on June 25, 2015.

Education on the new tool was provided to the ED nurses by Michael Mandrell, BS, BSN, RN, CCRN, CEN, CPEN, CPN, ED Nurse Educator, at the July 2015 ED Department meetings. Donna provided education to all inpatient units, Same Day Surgery and the Post Anesthesia Care Unit at annual Skills Days in August 2015.

If severe sepsis is identified using the Sepsis Screening and Response Process, a “Code Sepsis” is called to elicit the response of the Code Sepsis Team. The Code Sepsis Team is comprised of the Critical Care Charge Nurse, the Clinical Nurse Specialist (during daytime hours), a phlebotomist, a pharmacist, a respiratory therapist (as needed) and a chaplain. The Code Sepsis process, Sepsis Screening and Response Process, and the Severe Sepsis Patient Flow Sheet went into effect September 8, 2015.

Nursing involvement in this interprofessional, collaborative change led to improvements in the coordination and continuity of patient care. There is an increased awareness and recognition of sepsis, and increased safety for patients. Due to the process change and earlier recognition of sepsis, Critical Care Unit admissions for sepsis have increased ensuring that patients receive the appropriate level of care. The overall length of stay for sepsis patients has decreased due to earlier and more effective treatment (Exhibit EP5.B.4 Critical Care Newsletter Sepsis 2015 Year End Review)

8.2.16 jlm

SEPSIS WORKGROUP BroMenn

April 2, 2015

FACILITATOR: Donna Schweitzer, APN, CCNS

PRESENT: Donna Schweitzer, APN, CCNS; Angela Turner RN, 6W/Acute Rehab Manager; Theresa Bailey RN, MOSU/Peds/Infusion

Manager; Missy Hardesty RN, Critical Care Charge Nurse; Shelly Jimenez RN, CCU/CVCU Manager; Michael Mandrell RN,

ED Education; Justin Meyers RPH, Pharmacy; Laurel Mode RN, Quality/Infection Control; Kaci Lind Hospitalists Program

Manager; Janell Durdle Director Lab; Kristin Peterson RN manager PCU; Heather Segerstrom, Supervisor HIM Coding; Mary

Anne Kirchner, RN Clinical Documentation; Kate Cassell, Clinical Documentation; Dr. Anjum, Hospitalist.

TOPIC DISCUSSION ACTION

Wins/Safety/Made

a difference story Lab has moved! No lost specimens or results have occurred.

Meeting minutes Approved and accepted February 10, 2015 meeting minutes

March meeting was Sepsis Symposium at Lutheran General. 33 people from

BroMenn attended. We need to use the Nurse breakout session power point to

do a gap analysis to identify area to focus improvement strategies.

Today we will have

Documentation and Coding

talk with us regarding what

their role is, how nurses can

improve their documentation,

review the sepsis coding

processes currently in use.

Quality outcomes No data presented this meeting.

ED Case Review One page case review sent to ED, Critical Care, Pharmacy. We met our 3 hour bundle

goals for this patient and the patient did not require/qualify for the 6 hour bundle but a

couple of opportunities for improvement were identified.

Antibiotic time met 3 hour bundle but was not within the “start within 1 hour

from suspect sepsis”. Donna has talked with Justin Meyers and Jen Woodward

from pharmacy regarding having a small group meet to discuss the process andoptions to improve antibiotic administration time in ED.

Fluid administration was achieved within 3 hours but documentation needs to be

improved. Donna went to ED shared governance last week and discussed the

documentation issue.

Justin Meyers and Donna will

put a meeting together to

discuss the process and

options to improve antibiotic

administration time in ED.

See ED shared Governance

listed below.

Clinical

Documentation or

sepsis and Sepsis

Coding

At the sepsis symposium there was a presentation regarding documentation and

coding. At the symposium, Rebecca Hernandez presented that when the HIM/CDI

associates were reviewing the nursing documentation at her hospital, they noticed how

early signs of deterioration in septic patients were being missed, supporting the need to

Exhibit EP5.B.1 Advocate BroMenn Medical Center

have a system wide sepsis improvement project.

Today, we would like to learn: How does nursing documentation fit into the

assessment of/for sepsis? How does it lead you to or support a sepsis diagnosis?

What changes in nursing documentation are needed regarding sepsis? Kate

Cassell, and Mary Ann Kirchner described their CDI process: Every patient is looked

at every day. If the patient’s reason for admission has an infection component, they

look at labs, screen for sepsis, etc. They look at the nurses’ sepsis screen to compare,

look for labs, look at provider documentation to see if they are using “sepsis” or if they

need to query to ask the physician if the patient has sepsis and to document as such.

Sometimes they see the positive screen, the labs initiated but then do not see provider

documentation of the possible sepsis. They will query the physician for clarification.

They asked us: when the nurse does their sepsis screening are they just looking at

the most current labs and vitals or do they look back to see a lab from the past 12

hours? It looks like there are times when a variety of SIRS components are present

but not all at one time. The nurses present at the meeting state that they use the most

current information for the screening. Kate says she has seen labs that were done the

night before but not necessarily used with the morning screening.

Are the nurses aware of the vital signs the techs take and enter? A discussion of

this subject occurred at another meeting last hour. There is much variance in how vital

signs are obtained, documented, relayed to the nurse if out of normal range,

knowledge of ‘normal range’, etc. Another group may be looking into this.

They keep a spreadsheet of all queries and will begin sending the sepsis queries to be

shared with the sepsis group.

One concern noted is the documentation of many axillary temperatures. There does

not seem to be a trend. Could it be a documentation issue or an actual practice issue?

Provider documentation and coding: When documentation is unclear if sepsis was

present on admission, ruled in or out, treated, or resolved a query will be generated to

the provider. Documentation has to tell a story. If the story is unclear, a query will be

initiated for additional information. Nursing documentation is reviewed and if sepsis

is apparent, the provider will be queried if not adequately documented by provider.

Providers occasionally will write sepsis but it is not supported clinically so a query

will be initiated. If the attending and consultant do not agree, the attending’s

Managers request Mary Ann

notify them when an axillary

is documented so they can

follow up and assess if this is

a practice issue or a


documentation ‘wins’.

Elevated lactate: admit to ICU

There has been an increase in patient’s being moved to ICU for increased

monitoring. Hospitalists have been contacting Intensivist to discuss patient.

Dr. Anjum presented her difficulty with having a patient transferred to the ICU

from CVCU this morning. Sometimes nursing availability in the ICU due to

patients awaiting transfer out of the ICU can delay transfer to the ICU. CVCU

has the support to provide care while awaiting transfer.

Continue to monitor this

process.

Sepsis Core

Measures

CMS released the sepsis core measures this morning. Data collection will

begin in October 2015. This will be an “all or nothing” measure. We either get

all the bundle elements correct or we get no credit. More information for

abstracting will come out soon. Sepsis is included in this measure. There will

be several exclusions such as comfort care. Not sure how sepsis NOT present

on admission will be handled. Midas will be developing their process on how

to identify patients to be abstracted.

Physicians will need to be involved with developing a process to fulfill the

assessment and documentation needed.

Laurel will report updates at

the next meeting.

BroMenn Sepsis

Policy

Policy was revised by Donna Schweitzer, Theresa Bailey and Michael

Mandrell

Still have revisions needed.

Donna will get a group

together to review and revise

the policy.

ED shared

Governance

documentation

project

Often the care is provided in the ED but not documented thoroughly/accurately.

At April ED shared Governance, the case study was reviewed and

documentation OFI were discussed.

Donna will present education

at the next ED SG meeting

regarding 3Hour bundle

elements and their

importance. An ED

workgroup will be developed.

Future meetings Bi-weekly (twice a month)

Next meeting CR20 April 14, 2015 @ 1000

SEPSIS WORKGROUP BroMenn

April 2, 2015

FACILITATOR: Donna Schweitzer, APN, CCNS

PRESENT: Donna Schweitzer, APN, CCNS; Angela Turner RN, 6W/Acute Rehab Manager; Theresa Bailey RN, MOSU/Peds/Infusion

Manager; Missy Hardesty RN, Critical Care Charge Nurse; Shelly Jimenez RN, CCU/CVCU Manager; Michael Mandrell RN,

ED Education; Justin Meyers RPH, Pharmacy; Laurel Mode RN, Quality/Infection Control; Kaci Lind Hospitalists Program

Manager; Janell Durdle Director Lab; Kristin Peterson RN manager PCU; Heather Segerstrom, Supervisor HIM Coding; Mary

Anne Kirchner, RN Clinical Documentation; Kate Cassell, Clinical Documentation; Dr. Anjum, Hospitalist.


Wins/Safety/Made

a difference story Lab has moved! No lost specimens or results have occurred.

Meeting minutes Approved and accepted February 10, 2015 meeting minutes

March meeting was Sepsis Symposium at Lutheran General. 33 people from

BroMenn attended. We need to use the Nurse breakout session power point to

do a gap analysis to identify area to focus improvement strategies.

Today we will have

Documentation and Coding

talk with us regarding what

their role is, how nurses can

improve their documentation,

review the sepsis coding

processes currently in use.

Quality outcomes No data presented this meeting.

ED Case Review One page case review sent to ED, Critical Care, Pharmacy. We met our 3 hour bundle

goals for this patient and the patient did not require/qualify for the 6 hour bundle but a

couple of opportunities for improvement were identified.

Antibiotic time met 3 hour bundle but was not within the “start within 1 hour

from suspect sepsis”. Donna has talked with Justin Meyers and Jen Woodward

from pharmacy regarding having a small group meet to discuss the process andoptions to improve antibiotic administration time in ED.

Fluid administration was achieved within 3 hours but documentation needs to be

improved. Donna went to ED shared governance last week and discussed the


Justin Meyers and Donna will

put a meeting together to

discuss the process and

options to improve antibiotic

administration time in ED.

See ED shared Governance

listed below.

Clinical

Documentation or

sepsis and Sepsis

Coding

At the sepsis symposium there was a presentation regarding documentation and

coding. At the symposium, Rebecca Hernandez presented that when the HIM/CDI

associates were reviewing the nursing documentation at her hospital, they noticed how

early signs of deterioration in septic patients were being missed, supporting the need to


have a system wide sepsis improvement project.

Today, we would like to learn: How does nursing documentation fit into the

assessment of/for sepsis? How does it lead you to or support a sepsis diagnosis?

What changes in nursing documentation are needed regarding sepsis? Kate

Cassell, and Mary Ann Kirchner described their CDI process: Every patient is looked

at every day. If the patient’s reason for admission has an infection component, they

look at labs, screen for sepsis, etc. They look at the nurses’ sepsis screen to compare,

look for labs, look at provider documentation to see if they are using “sepsis” or if they

need to query to ask the physician if the patient has sepsis and to document as such.

Sometimes they see the positive screen, the labs initiated but then do not see provider

documentation of the possible sepsis. They will query the physician for clarification.

They asked us: when the nurse does their sepsis screening are they just looking at

the most current labs and vitals or do they look back to see a lab from the past 12

hours? It looks like there are times when a variety of SIRS components are present

but not all at one time. The nurses present at the meeting state that they use the most

current information for the screening. Kate says she has seen labs that were done the

night before but not necessarily used with the morning screening.

Are the nurses aware of the vital signs the techs take and enter? A discussion of

this subject occurred at another meeting last hour. There is much variance in how vital

signs are obtained, documented, relayed to the nurse if out of normal range,

knowledge of ‘normal range’, etc. Another group may be looking into this.

They keep a spreadsheet of all queries and will begin sending the sepsis queries to be

shared with the sepsis group.

One concern noted is the documentation of many axillary temperatures. There does

not seem to be a trend. Could it be a documentation issue or an actual practice issue?

Provider documentation and coding: When documentation is unclear if sepsis was

present on admission, ruled in or out, treated, or resolved a query will be generated to

the provider. Documentation has to tell a story. If the story is unclear, a query will be

initiated for additional information. Nursing documentation is reviewed and if sepsis

is apparent, the provider will be queried if not adequately documented by provider.

Providers occasionally will write sepsis but it is not supported clinically so a query

will be initiated. If the attending and consultant do not agree, the attending’s

Managers request Mary Ann

notify them when an axillary

is documented so they can

follow up and assess if this is

a practice issue or a


documentation ‘wins’.

Elevated lactate: admit to ICU

There has been an increase in patient’s being moved to ICU for increased

monitoring. Hospitalists have been contacting Intensivist to discuss patient.

Dr. Anjum presented her difficulty with having a patient transferred to the ICU

from CVCU this morning. Sometimes nursing availability in the ICU due to

patients awaiting transfer out of the ICU can delay transfer to the ICU. CVCU

has the support to provide care while awaiting transfer.

Continue to monitor this

process.

Sepsis Core

Measures

CMS released the sepsis core measures this morning. Data collection will

begin in October 2015. This will be an “all or nothing” measure. We either get

all the bundle elements correct or we get no credit. More information for

abstracting will come out soon. Sepsis is included in this measure. There will

be several exclusions such as comfort care. Not sure how sepsis NOT present

on admission will be handled. Midas will be developing their process on how

to identify patients to be abstracted.

Physicians will need to be involved with developing a process to fulfill the

assessment and documentation needed.

Laurel will report updates at

the next meeting.

BroMenn Sepsis

Policy

Policy was revised by Donna Schweitzer, Theresa Bailey and Michael

Mandrell

Still have revisions needed.

Donna will get a group

together to review and revise

the policy.

ED shared

Governance

documentation

project

Often the care is provided in the ED but not documented thoroughly/accurately.

At April ED shared Governance, the case study was reviewed and

documentation OFI were discussed.

Donna will present education

at the next ED SG meeting

regarding 3Hour bundle

elements and their

importance. An ED

workgroup will be developed.

Future meetings Bi-weekly (twice a month)

Next meeting CR20 April 14, 2015 @ 1000

ED Shared Governance Council April 23, 2015

Heart Center

PRESENT: Aaron Barclay; Jen Klaus; Leslie Carter; Wade Walters; Penny Boser; Sherri Pearson; Julie Maxedon; Mike Kelly; Marilyn

Nelson; Michael Mandrell; Emily Ruedi; Tim Furman; Susan Elizarraras;


Review of Minutes Minutes will be filed on the G: drive.

Wins/Safety It is Associate Appreciation Week this week.

Lunch was provided for staff today.

So far we have had OB and Lab for Adopt-a-Department. If you

have any suggestions please let Emily R. know.

Emily Schieler and Leslie Carter have met with Chaplain

services and are working on their involvement with Code R

patients.

The shared governance sold 36 t-shirts. They will be arriving

soon.

Sepsis Sepsis in the ED:

What is Sepsis:

o A clinical syndrome that complicates severe

infection

o It is characterized by the cardinal signs of

inflammation (vasodilation, leukocyte

accumulation, increased microvascular

permeability) occurring in tissues that are remote

from the infection.

o Systemic inflammatory response syndrome

(SIRS) is an identical clinical syndrome that

Handout provided by Donna Schweitzer.

Donna is doing case reviews and providing

feedback.


ED Shared Governance Council

2

complicates a noninfectious insult (eg. Acute

pancreatitis, pulmonary contusion).

o Current theories about the onset and progression

of sepsis and SIRS focus on dysregulation of the

inflammatory response, including the possibility

that a massive and uncontrolled release of

proinflammatory mediators initiates a chain of

events that lead to widespread tissue injury.

o This response can lead to multiple organ

dysfunction syndrome (MODS), which is the

cause of the high mortality associated with these

syndromes.

When SIRS is present – Suspect Sepsis:

o SIRS was previously defined as two or more

abnormalities in temperature, heart rate,

respiration, or white blood cell count.

o In practice, its clinical definition and

pathophysiology are equivocal such that SIRS

and early sepsis cannot be readily distinguished.

o Thus, when SIRS is suspected it should prompt

an evaluation for a septic focus.

Positive severe sepsis screen:

o Many people have sepsis and we are good at

treating it with antibiotics and some IV sluids.

Perhaps admit to the floor, control temperature,

etc.

o Severe sepsis can be sneaky...…..many patients

can compensate to hide the obvious signs of

being “really sick”.

o SIRS findings may be modified by preexisting

disease or medications. As examples, older

patients, diabetic patients, and patients who take

beta-blockers may not exhibit an appropriate

tachycardia as blood pressure falls.

o In contrast, younger patients frequently develop a

severe and prolonged tachycardia and fail to

become hypotensive until acute decompensation


3

later occurs, often suddenly.

o Patients with chronic hypertension may develop

critical hypoperfusion at a higher blood pressure

than healthy patients (ie, relative hypotension).

Lactate Testing – Lactate is not only for sepsis:

o An elevated serum lactate (eg, >2mmol/L) can be

a manifestation of organ hypoperfusion in the

presence or absence of hypotension and is an

important component of the initial evaluation.

o A serum lactate level > 4mmol/L is consistent

with, but not diagnostic of, severe sepsis.

o Additional laboratory studies that help

characterize the severity of sepsis include a low

platelet count, and elevated international

normalized ratio, creatinine, and bilirubin.

Reasons for Lactate to increase – Type A Lactic

Acidosis:

o Lactic acidosis was described and classified by

Cohen and Woods into 2 categories – Type A

lactic acidosis occurs with decreased tissue ATP

in the setting of poor tissue perfusion or

oxygenation.

o Overproduction: Circulatory, pulmonary, or

hemoglobin transfer disorders are commonly

responsible.

o Underutilization: Liver disease, gluconeogenesis

inhibition, thiamine deficiency, and uncoupled

oxidative phosphorylation.

Type B Lactic Acidosis:

o Type B lactic acidosis is classically defined as

when evidence of poor tissue perfusion or

oxygenation is absent. Type B is divided into 3

subtypes based on underlying etiology.

o Type B1 occurs in association with systemic

If patient has elevated lactate level assume there

is a sepsis situation.


4

disease such as renal and hepatic failure, diabetes,

and malignancy.

o Type B2 is caused by several classes of drugs and

toxins including biguanides, alcohols, iron,

isoniazid, and salicylates.

o Type B3 is due to inborn errors of metabolism.

o Lactic acid exists in 2 forms – the L-lactate and

D-lactate.

o L-lactate is the most commonly measured level,

as it is the only form produced in human

metabolism. Its excess represents increased

anaerobic metabolism due to tissue

hypoperfusion.

o D-lactate is a byproduct of bacterial metabolism

and may accumulate in patients with short-gut

syndrome or in those with a history of gastric

bypass or small-bowel resection.

o Elevated Lactate:

Indicates inadequate perfusion or

oxygenation due to some source.

In the picture of sepsis, could confirm

severe or (impending) shock.

Fluid bolus to increase perfusion is still

needed.

Fluid Administration:

o Perfusion and outcomes are often dependent on

the timely administration of IV fluid

o It can be time consuming

o Often need a second nurse to assist

o Goal is 30 ml/kg administered in first hour for

initial fluid challenge.

o Need at least 2 peripheral IV sites if not a central

line.

o Pressure bags are strongly encouraged.

o Placed pressure bags on each inpatient unit and

Problems areas have been identified in scanning

of IV bags and Antibiotics. Need to have a start

and stop time.


5

ER supply room.

o Sepsis patients often need 6 liters of fluid to “fill

their tank”.

o Can be pushback for administering that amount of

fluid in a short period of time.

o Staff and physician often reluctant to administer

“that amount of fluid” in a short-time.

o If the “glass is not full” – perfusion is inadequate

– organ damage occurs- won’t overflow (into the

lungs)

o Assess lungs every 500cc to assess for fluid

shifts.

Blood cultures and Antibiotic Administration:

o Blood cultures drawn before antibiotics

administered.

o Start intravenous antibiotic therapy within the

first hour of recognition of severe sepsis after

obtaining appropriate cultures for septic shock.

o Broad spectrum: include one or more agents

active against likely bacterial/fungal pathogens,

& with good penetration into presumed source.

o Reassess regimen daily to optimize efficacy,

prevent resistance, avoid toxicity & minimize

costs.

o Antibiotics to begin within 1 hour of diagnosis.

o Pharmacy is notified of the STAT orders to

facilitate the antibiotic getting to the floor

quickly.

Central line insertions:

o If patient is not responsive to IV fluid bolus, (the

initial fluid challenge of 30 ml/kg) then continue

to administer fluids.

o Vasopressors are often added at this point.

o Vasopressors should be administered through a

central line, not peripherally

o Guidelines state to measure SCVo2 to measure

perfusion (controversial)

Mortality increases 7-8% for every hour of

antibiotic delay in septic shock.


6

o Guidelines also state to measure CVP to ensure

adequate fluid resuscitation (controversial)

o Can occur in the ED or CCU. Physicians need to

talk to barter for the insertion location

o Central line insertion supplies bucket might help

facilitate the process.

Vasopressors:

o New guidelines state to use norepinephrine

(Levophed) as first line vasopressor

o Dopamine should only be used if there is

bradycardia.

o Additional vasopressor should be epinephrine

o Vasopressin can be added to increase MAP or to

help titrate off other pressors (should not be used

alone)

Central venous pressure (CVP)

o Many studies disputing the usefulness and

accuracy of the CVP

o Is most accurate when it is low

SCV02 Measurement:

o Factors that influence SCV02

Cardiac Output

Hemoglobin Levels

Oxygenation

o SCV02 indicates the balance between global

oxygen delivery and consumption

A low SCV02 indicates inadequate

oxygen delivery to tissues.

o To improve the SCV02, treatments include blood

administration and inotropic administration

Blood administration is controversial if

Hg is > 7.

Dobutamine is controversial with

possibility of hypotension and other side

effects.

o Monitoring SCV02 remains controversial and

cannot be looked at in isolation


7

Announcements

Provider documentation of responsiveness to fluid bolus

and treatment.

o This is in development.

o Physician communication will occur once

necessary documentation features are identified.

o This will be communicated to nurses also.

Sepsis Alert Process:

Alert Critical Care Charge Nurse, Clinical Coordinator,

Pharmacy.

Sepsis alert policy revision meeting will be April 29th.

Announcements:

Tele Psych

Meditech Upgrade – 5/16 – 5/17 2015

Associate Survey thur April 26th

Magnet Journey/Education

Critical Care Charge Nurse can help facilitate bed

placement and talking with intensivist.

Please come if available to help with the alert

process.

Extra staff will be available.

Next Meeting Date May 28, 2015 – 0730 - 0900 – CR # 5&6 Please plan to attend


8

ED Shared Governance Council May 28, 2015

CR #5 & 6

PRESENT: Aaron Barclay; Leslie Carter; Sherri Pearson; Michael Mandrell; Susan Elizarraras; Jennifer Toohill; Justin Eighner; Kathy

Brown; Mary Short;


Review of Minutes Motion to approve minutes from Kathy Brown and second by

Mary Short.

Minutes will be filed on the G: drive.

Wins/Safety Emily Ruedi has her CEN certification.

Patient Satisfaction scores are on the rise.

Sepsis Sepsis in the ED:

We will be going to a “Code Sepsis” called overhead.

Need to clarify the process until the “Code Sepsis”

overhead goes live.

Our Process: (New)

Patient presents with a + sepsis screen, no

hypotension, + SIRS -

o Due to infection? If no, then no sepsis screen

needed.

o If yes, then, order Triage Adult Sepsis order set

and alert staff.

o Need a way to communicate to

techs/nurse/charge nurse/triage nurse.

Handout provided by Donna Schweitzer.

The system has determined that triage time is

time “zero”.

The July staff meeting will have education on

sepsis vs. severe sepsis vs. septic shock.

Will need to educate staff on the importance and

time sensitive information.

If it is just +sepsis screen with no hypotension,

call tech and charge nurse/triage nurse to alert

them of + sepsis screen. Michael will work with

techs individually to alert them of the priority for


9

It was asked if the blood bank section on the tracker can be

changed to a + sepsis screen reminder.

Patient presents with, + sepsis screen, + SIRS due to

infection, with hypotension –

o Order the Triage Adult Sepsis order set, call a

“Code Sepsis” over our intercom only, to alert

staff and physicians.

o The Triage Adult Sepsis order set will also

prompt a hypotension order set, if nurse marks

patient is hypotensive that will be needed as well.

o The secretary will call switchboard and that will

alert ICU charge nurse, clinical coordinator,

Donna (if she is available) and pharmacy.

o The patient will need 2 IV sites, 30 ml/kg IV

fluids, a foley, lung assessment.

It was asked if all “Code Sepsis” patients will go to ICU.

Could we have an algorithm for this process.

The 3 hour bundle includes

o Lactate

o Broad Spectrum IV

o Blood Cultures X2 before antibiotics

o Antibiotics

If the rescreen prompts a + Severe Sepsis, will need to

call a “Code Sepsis” and get antibiotics and blood

cultures.

sepsis screen.

Michael will inquire with IS if this can be done.

Calling “Code Sepsis” will get you a tech, a

second RN, and a physician.

The switchboard will page the appropriate people

until it is decided when the switchboard will page

“Code Sepsis” overhead. Donna will notify

switchboard of our changes.

Be sure to enter patients’ weight into computer.

Donna will clarify with Stephanie and Shelly.

Sherri, Jennifer T., and Leslie will work on the

Algorithm.

Update There will be some salary changes for the clinical nursing staff.


10

Last year we were about 3 – 4% higher for new grad

starting salary.

Due to some changes at OSF we are now about 7 – 8 %

behind.

The executive team did some research and our starting

new grad salary will be increased

This means that all clinical RN salaries will increase with

the cap increasing as well.

Look for more information in the next few weeks.

As a result of the executive teams’ findings the PEP test

will no longer be required and Vice presidents and above

will not be receiving raises this year.

More information to come.

Next Meeting Date June 25, 2015 – 1730 - 1900 – Heart Center Please plan to attend

SEPSIS 2015 Year End Review

Sepsis may be present in approximately 1 in 10 patients but it accounts for almost 50 percent of all U.S. hospital deaths (Budryk,

2014). Patients with sepsis have better recovery and outcomes when hospitalized in medical centers who have an organized plan

for recognizing and treating sepsis. Data received from the Advocate Clinical Effectiveness Sepsis Workgroup (ACESW) show positive

results from the sepsis care provided here at BroMenn. Graph 1 shows the increase in number of sepsis patients identified in a time

range in 2015 compared to the same time range in 2014. These numbers are cumulative but show a steady increase.

BroMenn’s sepsis case abstractions often show there were patients who were initially treated for sepsis in the ED, admitted to the

general medical or intermediate care floor where the patient’s condition deteriorated. This deterioration may not be noticed until

the next set of Q4H vital signs are taken. With deterioration in condition, the floor staff often has difficulty providing aggressive

treatment in a timely manner in addition to facilitating a transfer to the ICU. Often, these patients would require a couple or several

day ICU stay. It was felt that if the patient could be monitored closer, the deterioration could be detected sooner and, if needed,

treatment provided more aggressively, to give the patient the best change to recover with better outcomes. In discussions with

Intensivists, the plan was made to admit the severe sepsis patient to the ICU for a period of hours to provide closer monitoring and

timely aggressive treatment if needed. After several hours of monitoring and stability, the patient could then be moved to the

general or intermediate floor in a more stable condition. This plan would increase the number of “stable” patients admitted to the

ICU but their length of stay (LOS) would be shorter and the patient would be more stable when transferred to the general or

intermediate floor. This should result in a shorter hospital stay and decrease in hospital costs for the patient and the hospital. A

study published in CHEST in October 2015, showed that lowering the threshold for admitting sepsis patients to the ICU from the

emergency department lowers the length of ICU stays, transfers from intermediate floors to ICU and mortality (Bird, 2015). Our

data from the ACESW show we have increased the number of patients admitted to the ICU for sepsis (Graph 2) and the ALOS of

these sepsis patients is less than the ALOS of the same time range in 2014 (Graph 3). Thank you for the great attention you give to

detecting and treating sepsis patients!!!!

Bird, J. (2015). Emergency room – ICU collaboration key to better sepsis outcomes. Retrieved from

http://www.fiercehealthcare.com/node/148576/print

Budryk, Z. (2014). Sepsis contributes to half of hospital deaths. Retrieved from

http://www.fiercehealthcare.com/story/sepsis-contributes-half-hospital-deaths/2014-05-19

Graph 1Change in Volume for All Sepsis Patients

Jan to current month2015 vs Jan to current month 2014

March 64

May 100

June 114

July 121

August 125

September 122

0

20

40

60

80

100

120

140

March May June July August September

Change in Volume for All Sepsis Patients Jan to current month2015 vs Jan to current month 2014

Graph 2Change in ICU days for Hospital All Sepsis Patients


March 18

May 53

June 68

July 32

August 45

September 43

0

10

20

30

40

50

60

70

80


Change in ICU days for All Sepsis Patients Jan to current month2015 vs Jan to current month 2014

Graph 3 Change in ICU ALOS for all sepsis patients


March -0.35

May -0.2

June -0.15

July -0.27

August -0.2

September -0.17

-0.4

-0.35

-0.3

-0.25

-0.2

-0.15

-0.1

-0.05

0


Change in ICU ALOS for All sepsis patients Jan to current month2015 vs Jan to current month 2014


http://www.fiercehealthcare.com/node/148576/print

http://www.fiercehealthcare.com/story/sepsis-contributes-half-hospital-deaths/2014-05-19

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