SEPSIS PHYSICIAN

EDUCATION

2017

Oct'15 Nov'15 Dec'15 Jan'16 Feb'16 Mar'16 Apr'16 May'16 Jun'16 Jul'16 Aug'16 Sept'16 Oct'16 Nov'16

% Compliance 42.8 0.3 0 21.4 6.7 22.2 36.4 23.1 53.3 40 42.9 27.3 46.2 42.9

50th percentile 31.7 31.7 31.7 37.5 37.5 37.5 41.2 41.2 41.2 36.7 36.7 36.7 36.7 36.7

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SEPSIS COMPLIANCE

% Compliance

50th percentile

Linear (% Compliance)

SEPSIS 3rd and 4th QTR 2016

Sampled Cases Data Algorithm End Value (Reasons for Failures)

Severe Sepsis Fail Septic Shock Fail

Initial Sepsis

Population

Cases Sampled (Cat B, D, E, X)

Excluded Cases

(Cat B)

Sepsis Passed (Cat E)

Sepsis Failed

(Cat D)

Antibiotic Admin

Initial Lactate Level

Blood Cultures

Repeat Lactate Level

Crystalloid Fluids

Vasopressor Admin

6 Hour Counter

Persistent Hypo

tension Other *

Incomplete Cases

(Cat X)

3rd Quarter 2016

Jul 24 24 9 6 9 1 3 0 0 3 0 1 1 0 0

Aug 22 22 8 6 8 1 2 2 0 2 0 1 0 0 0

Sep 22 22 11 3 8 0 0 3 2 3 0 0 0 0 0

Qtr. Total 68 68 28 15 25 2 5 5 2 8 0 2 1 0 0

4th Quarter 2016

Oct 22 22 9 6 7 0 2 0 2 2 1 0 0 0 0

Nov 26 26 7 6 8 1 1 0 3 1 0 0 2 0 5

Dec 30 30 9 8 12 0 1 2 3 4 1 0 1 0 1

Qtr. Total 78 78 25 20 27 1 4 2 8 7 2 0 3 0 6

Total for Selected Period

146 146 53 35 52 3 9 7 10 15 2 2 4 0 6

Where Are We Failing?

• Not starting the antibiotic timely or choosing the wrong

antibiotic or combination of antibiotics.

• Blood Cultures not ordered or obtained after the antibiotic is

administered.

• Not using the Sepsis order set**

– Not identifying septic patient

– Fluid bolus not appropriate amount for body weight

(<30ml/kg)

– Initial Lactate Level not ordered or not ordered in the 6

hours before or 3 hours after severe sepsis presentation

window.

– Repeat Lactate Level if > 2 not repeated or not repeated

within the 6 hour window of severe sepsis presentation.

– Wrong Lactate Acid ordered and it does not automatically

reflex if > 2.

Please use Sepsis Order Sets………

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SEPSIS This measure can and usually begins in the ED. However, the patient

may develop severe sepsis/septic shock as a inpatient or experience

more than one episode of severe sepsis/septic shock but we will

abstract the first episode.

All patients 18 years and older with an ICD 10 code of Sepsis will fall

into the measure. If criteria/documentation for severe sepsis/septic

shock are met it will stay in the measure for abstraction.

If the patient is to receive “comfort care” please dictate this in the

progress notes. If dictated prior to or within 3 hours of presentation of

severe sepsis and prior to or within 6 hours of septic shock it will

remove the patient from the measure.

The next slide will review the criteria for “severe sepsis” and “septic

shock”. Severe Sepsis components/criteria must be met within 6 hours

of each other. The date and time in which the last criteria for severe

sepsis is met (includes physician dictation of source of infection) is the

date and time that is used for presentation. This is the date and time

that the timed components of the measure must meet, 6 hours prior to

and 3 hours following severe sepsis presentation.

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SEVERE SEPSIS CRITERIA Documented source or suspected source of clinical infection (except viral and

fungal infections) by a physician/APN/PA. Documentation of signs and

symptoms is not acceptable for a suspected infection.

AND

2 or more SIRS criteria

• Temp > 38.3˚C (100.9) or < 36˚C (98.6)

• Heart Rate > 90min

• Respiratory Rate > 20min

• WBC > 12,000 or < 4,000 or 10% Bands

AND

Organ Dysfunction (any one) (Except if documented normal for patient, from

acute condition that is not infection, from chronic conditions or medications.)

• Systolic BP < 90, or mean arterial pressure <65, or a decrease in SBP by

40mmHg from baseline with physician/APN/PA documentation that the decrease

is related to infection, severe sepsis or septic shock and not other causes.

• Acute Respiratory Failure evidenced by a new need for invasive or non-invasive

ventilation. ET/Tracheostomy Tube, BIPAP or CPAP.

• Creatinine > 2.0, or urine output < 0.5ml/kg/hour for 2 hours

• Total Bilirubin > 2 mg/dl

• Platelet count < 100,000

• INR > 1.5 or PTT > 60 sec

• Lactate > 2 mmol/l

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SEPTIC SHOCK CRITERIA

There must be documentation of Severe Sepsis present.

AND

Hypotension persists in the hour after the conclusion of the

30ml/kg crystalloid fluid administration: As evidence by 2 or

more consecutive BP readings:

Systolic BP < 90, OR

Mean Arterial Pressure < 65 OR

Decrease in SBP by > 40 mmHg from the last recorded

SBP considered normal for given patient WITH

physician/APN/PA documentation that the decrease

is related to infection, severe sepsis or septic shock and

not other causes.

OR

Tissue hypo-perfusion is present as evidenced by:

-Initial Lactate level is = or > 4mmol/l

Physician/APN/PA documentation/dictation of Septic Shock. 7

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The date and time in which the last criterion was met within 6 hours of

each other to establish the presence of severe sepsis will be the “start”

date and time.

If criteria for severe sepsis is not met but there is physician dictation

of Severe Sepsis then that dictation time will be the date and time of

Severe Sepsis present.

If criteria for severe sepsis are met after physician/APN/PA

documentation of septic shock, the date and time of documentation of

Septic Shock will be used as presentation time.

If criteria for severe sepsis are not documented and there is not

physician/APN/PA documentation of severe sepsis, but there is

physician/APN/PA documentation of septic shock, the earliest time

septic shock was documented will be the sepsis presentation time.

If the clinical criteria was met or there is physician/APN/PA

documentation of severe sepsis but within 6 hours there is additional

physician/APN/PA documentation indicating that the patient does not

have severe sepsis then disregard the previous documentation/criteria.

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Should occur within 3 hours of presentation of Severe Sepsis:

Assess measurement of lactate (6 hours prior to until 3 hours after).

Obtain Blood Cultures (48 hours prior to until 3 hours after).

Unless there is a documented delay as to why the blood cultures were not

obtained timely. Surgical patients receiving prophylactic antibiotic prior to

severe sepsis/septic shock presentation, patient was treated for another type of

infection prior to severe sepsis/septic shock presentation, lab unavailable to draw

cultures within 45 mins or longer)

Administer Broad Spectrum Antibiotics: Correct single dose or combination

doses of approved antibiotics. (Administered 24 hours prior to or within 3 hours

after presentation date and time.)

Make sure the first ordered antibiotic is administered promptly. If not

administered prior to presentation time, the first antibiotic has to be started

within 3 hours of presentation time. If a combination of IV antibiotics are

prescribed they must also be given within 3 hours of presentation time. Please

refer to the next two slides for recommended antibiotic monotherapy and/or

combinations of antibiotic therapy.

Antibiotic Monotherapy Table

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ertapenem ceftriaxone ampicillin/sulbactam

Invanz® Rocephin® Unasyn

meropenem ceftaroline fosamil piperacillin/tazobactam

Merrem® Teflaro® Zosyn®

cefotaxime levofloxacin

Claforan® Levaquin®

ceftazidime amoxicillin/clavulanate

Fortaz® Augmentin®

Combination Antibiotic Table (Choose one from each column)

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Column A Column B

aminoglycoside (gentamicin or tobramycin)

cephalosporin (1st & 2nd Gen) OR

OR clindamycin IV OR

aztreonam daptomycin OR

OR glycopeptide (vancomycin) OR

ciprofloxacin linezolid OR

macrolide OR

penicillin

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Should occur within 6 hours of presentation of Severe Sepsis:

Repeat lactate measurement if >2

Please use the Sepsis Order Set .

Will automatically re-order lactate level if >2.

Fluid Resuscitation (30ml/kg) (0.9% Normal Saline or Lactated Ringers given

for hypotension or lactate level >= 4). Total volume infused must be at least

30ml/kg which should be specified in the physician order. (Within 3 hours of

Septic Shock Presentation)

The Sepsis Order Set will calculate this for you.

If hypotension is still present after completion of at least 30ml/kg fluid boluses

as evidence by documentation of 2 or more consecutive SBP readings < 90,

Mean arterial pressure < 65, or a decrease in SBP by > 40 mmHg from the last

previously recorded SBP and physician/APN/PA documentation that is it from

infection, severe sepsis or septic shock not other causes, in the hour following

the conclusion of the boluses or initial lactate >=4.

Add:

Vasopressor administration, Reassessment of Volume Status, Tissue Reprofusio

Vasopressors (IV or Intraosseous): Norepinephrine (Levophed), Epinephrine

(Adrenalin), Phenylephrine (Neosynephrine), (Vazculep), Dopamine (Inotropin),

Vasopressin (Pitressin)

If Vasopressors needed (hypotension persists) should be received within 6 hours

of Septic Shock presentation.

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Repeat volume status and tissue perfusion assessment (for chart abstraction the

dictation must be in the time window beginning at the fluid administration date/time

and ending 6 hours after presentation of septic shock date and time to pass the

measure) consisting of either:

A focused exam by the MD/PA/APN including date and time dictated, including:

Vital Signs Assessment (temp, pulse, resp, BP)

AND Cardiopulmonary Exam-notes must include both heart and lung assessment.

AND Capillary Refill Evaluation (capillary refill, nail bed refill, etc.)

AND Peripheral Pulse Evaluation (radial, brachial, dorsalis pedis, femoral, etc.)

AND Skin Examination (reference to color, flushed, mottled, pale, etc.)

New for Jan 1, 2017 discharges:

Documentation indicating Physician/APN/PA has performed, or attested to

performing a physical examination, perfusion (re-perfusion) assessment, or sepsis

(severe sepsis or septic shock) focused exam is acceptable.

Documentation indicating Physician/APN/PA has reviewed, performed, or attested to

reviewing or performing a Vital Sign Assessment, Cardiopulmonary Exam, Capillary

Refill Exam, Peripheral Pulse Evaluation, and a Skin Examination is acceptable.

(Without documentation of the specific components.)

OR Any 2 of the following with date and time dictated:

CVP measurement (CVP or RAP right atrial pressure must be documented that

reading was obtained by a central venous catheter.) Measurements from a PICC

line are acceptable.

Central venous oxygen measurement (Sv02 or Scv02 obtained by central

venous catheter.)

Bedside cardiovascular ultrasound (actual performance of test). May be

performed in a location other than the bedside such as imaging department or

ultrasound department.

Passive leg raise or Fluid Challenge (noted to be positive or negative). With the

patient in a semi-recumbent position both legs are raised to a 45 degree angle

and v/s response is evaluated.

A Fluid Challenge is the rapid infusion of crystalloid fluid volumes between

500 mls to 1000 mls over 15-20 mins and is done to assess the responsiveness

to fluids. (Starts at the completion of the crystalloid fluid administration and

stops 6 hours after the presentation of septic shock date and time.

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References

• The Specification Manual for National Hospital

Inpatient Quality Measures. (2017)Version 5.2

(for discharges 1/01/2017-12-31-2017)

Retrieved from: http://www.qualitynet.org.

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QUESTIONS?

Please contact one of the Quality Improvement

Specialists:

Deborah Priebe ext. 5286

Pam Wise ext. 5288

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