Sepsis Recognition & Response - Sepsis Pathway Education

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Sepsis Recognition & Response - Sepsis Pathway Education

Transcript of Sepsis Recognition & Response - Sepsis Pathway Education

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Sepsis Recognition & Response - Sepsis Pathway Education

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AcknowledgementThis module was developed based the following presentations:

Recognition and Management of Sepsis and the Sepsis Pathway by Trudy Perry -ICU Educator & Chris Henson-EducationCoordinator, Flinders Private Hospital 2020.

Sepsis Pathway Education - BPH Toolkit for All Clinical Staff – Brisbane Private Hospital

This module was collaboratively developed and reviewed by:

Asuman Salkaya Ashford Hospital CCU Clinical Educator

Christine Henson Flinders Private Hospital Education Coordinator

Kim Bailey The Memorial Hospital Staff Development Coordinator

Roselyn Brown Ashford Hospital Staff Development Coordinator

Trudy Perry Flinders Private Hospital ICU Clinical Educator

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ObjectivesThis module is intended for Healthscope clinical staff and will:

Define, outline, and explain sepsis.

Improve knowledge around the warning signs & symptoms of sepsis and septic shock.

Introduce the Sepsis Pathways (adult and paediatric) and provide guidance on their use.

Identify nursing considerations for care of the septic patient.

Provide guidance on interventions required for sepsis management and the urgent time frames theyshould be undertaken in.

Outline the important relationship between antibiotic therapy (choice of drug and timing) and pathologycollection.

Provide some strategies to help better prevent sepsis and septic shock.

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IntroductionSepsis is a public health issue that affects people world wide and it claims thousands of liveseach year.

Just like a heart attack or stroke sepsis is a medical emergency that must be managed quickly andefficiently to reduce or minimise the potential effects on the affected person. Patients with sepsisare high risk and may deteriorate rapidly. (1)

Sepsis is the body’s generalised inflammatory response to an infection and it can lead to shock,multiple organ failure and death. Early recognition and rapid initiation of treatment is essential toimprove survival. (1)

All clinicians need to be aware of how it can be identified early and the care that patients need tosurvive.

Therefore sepsis awareness, early identification, resuscitation and referral to specialist care willensure that all patients with sepsis receive treatment in a timely and appropriate manner. (1)

The incidence of sepsis is continually escalating, and this is leading to an increasing burden onnational health care expenditure.(1)

Click on the image above to watch a short video.

Required viewing (4.23 minutes)

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What is sepsis & septic shock?Sepsis

Sepsis is a life threatening state of clinical deterioration due to an infection.

It occurs when the immune system reacts to an infection and begins to damage host tissues. Without timely treatment, sepsis canrapidly lead to tissue damage, organ failure, and death.(1)

All clinicians should be aware of the signs and symptoms of sepsis, to immediately implement the sepsis pathway and ensureurgent clinical intervention.

Septic Shock

Septic shock is the most extreme end of the clinical spectrum of symptoms caused by sepsis. This is when the body’s reaction tothe infection is so severe that multiple organ failure and death can occur.

Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, and killing asmany as one in four (and often more) (1)

The mortality of septic shock is increased by 25+% when sepsis is not recognised & treated early

If sepsis treatment is delayed then the patient will proceed to septic shock.

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What causes sepsis?When pathogens get into a person’s body, they can cause an infection. If that infection isn’t

stopped, it can cause sepsis

Sepsis is the bodies immune system overreacting to infection

Common causes of sepsis are pneumonia, wound and urinary infections

An infection of unknown source can also lead to sepsis

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Signs and symptoms of sepsis & septic shockSigns & symptoms suggestive of Septic Shock in Adults• Infection confirmed or suspected plus:

• Systolic BP < 90 mmHg or Mean Arterial Pressure (MAP) < 60 mmHg

• Arterial or venous lactate > 4 mmol/L

• Base excess < -5.0

• Oliguria (urine output less than 0.5 mL/kg/hour

• Mottled or cold peripheries

• Capillary refill time > 3 seconds

• Purpuric rash

There are slight variations to Maternal,Paediatric and Newborn signs andsymptoms. Refer to separate sepsispathways for more information

Signs & symptoms suggestive of Sepsis in Adults

New onset of:

• Temperature < 35.5C or > 38.5C +/- rigors (normal Temperature does notexclude sepsis)

• Respiratory rate ≤10 or ≥ 25 / minute &/or cough especially ifproductive

• Heart rate ≤50 or ≥ 120/minute

• Systolic BP < 100 mmHg

• Acute confusion or decreased level of consciousness (altered cognition)

• Hyperglycemia (blood glucose > 7.7 mmol/L in patient without diabetes)

• Oliguria (urine output less than 0.5 mL/kg/hour) or frequency / dysuria

• Discoloured skin e.g. purpura

• Muscle or abdominal pain

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Identifying an adult at risk

An easy way to remember the symptoms of sepsis is to thinkof the term “SEPSIS”

S shivering, fever, chills, tachycardia

E extreme pain

P pale sweaty, clammy skin or skin rash, passing little or no urine

S shortness of breath, hypoxemia, tachynoepic

I impending doom - “I feel like I might die” , “I feel very unwell”

S sleepy, confused, disorientated, or slurring of speech, skin mottled

Click on the image above to watch a short video. (6.32 minutes)

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Identifying a child at riskChildren with sepsis might experience one or more of the following symptoms:

• Fast breathing

• Convulsions or fits

• A rash that doesn’t fade when pressed

• Discoloured or blotchy skin, or skin that is very pale or bluish

• Not passing urine (or no wet nappies) for several hours

• Vomiting

• Not feeding or eating

• A high or very low temperature

• Sleeping, confused or irritable

• Pain or discomfort that doesn’t respond to ordinary pain relief like paracetamol.

Sepsis is a life-threatening emergency, with more than 50 per cent of sepsis-related deaths in childrenoccurring within 24 hours. If a child you are caring for experiences any of these symptoms, head straightto the nearest hospital emergency department and ask,

‘Could this be sepsis?’.

Click on the image above to watch a short video “Mia’s Story”. (3.18 minutes)

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Who is most at risk of sepsis?The most at risk patient groups are:• Children under 1 year old.

• Adults over 60 years old.

• People with no spleen.

• People with chronic diseases.

• People with weakened immune systems.

• People with invasive devices, particularly long term ones.

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Detecting Sepsis –Using the Sepsis Pathway

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Sepsis Recognition & Sepsis Pathway InitiationEARLY DETECTION IS THE KEY! – The Sepsis Pathway is designed to assist.When you perform observations, respond accordingly. Know sepsis signs & symptoms - initiate the sepsis pathway when:Your patient has new onset of the following signs and symptoms of infection:

- Fever or rigors - Line associated infection, redness, swelling or pain

- Dysuria or frequency - Abdominal pain, distension or peritonism

- Cough, sputum, breathlessness - Altered cognition

PLUS‒ 2 or more observations are in the Yellow Zone

‒ The patient is pregnant and any observations are in the Yellow Zone

‒ Any observations fall in the Red Zone

‒ Additional criteria for sepsis (listed on the sepsis pathway) are identified

‒ The clinician is concerned about the patient’s condition

• There is a very high level of risk of sepsis in neonates, which remains high for children up to one year old.

• Clinician concern warrants calling a MET. If the patient just isn’t right and you are worried about deterioration, trust your instincts. It could save a patient.

• Note that hypothermia and normothermia do not exclude sepsis.

• While there may be other potential causes of the symptoms, don’t make that decision alone.

Remember to document your response / actions to clinical changes / deterioration in the

“Interventions” box on the observation chart

NEVER DELAY ESCALATING TO A RAPID REPONSE.

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How do we detect Sepsis in adults?

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Take the time to review the Adult sepsispathway HMR 7.44

Click on the image to view a copy of the fulldocument. Document also attached toelearning launching page if it is unable to beopened via this link.

Link for Victorian Adult Sepsis Pathway

Recognising and responding quickly to altered/ abnormal observations, and consideringsepsis as an initial possible cause for thedeterioration is important in detecting sepsisearly.

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Sepsis pathway for obstetric patientsLook for the pregnant woman icon on theMaternal Sepsis Pathway HMR 7.45– NOTE different risk factors, signs &

symptoms

Click on the image to view a copy of thefull document. Document also attachedto elearning launching page if it is unableto be opened via this link.

Pregnancy adds another complexity whenassessing an unwell adult. The sepsis pathwayfor the maternal patient should be applied if thepatient is pregnant and their observations orpresenting condition raises concern aroundclinical deterioration and possible sepsis.

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Sepsis pathway for newbornsThe Newborn Sepsis Pathway HMR 7.46provides a clear list of the different signs &symptoms of sepsis in the newborn.

Look for the newborn baby icon on thenewborn form.

Click on the image to view a copy of the fulldocument. Document also attached toelearning launching page if it is unable to beopened via this link.

Newborns deteriorate very quickly so it isimportant not to delay the escalation ofconcerns around the baby’s clinicalcondition.

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How do we detect Sepsis in children?

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Look for the baby icon on the Paediatric SepsisPathway HMR 7.47

– NOTE different risk factors, signs &symptoms

Click on the image to view a copy of the fulldocument. Document also attached toelearning launching page if it is unable to beopened via this link.

Children deteriorate very quickly so it isimportant not to delay the escalation ofconcerns around a child’s clinical condition.

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Rapid Response

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Clinical ConsiderationsIf you are concerned always activate a MET call.

Stay with the patient. Assess your patient using the A - E approach

• Ensure the bedside folder & medical records are available – Observations charts, fluidbalance chart, & medication charts + case notes

• Commence sepsis pathway if not already in use (adult, maternal, newborn or paediatric)

• Airway - assess & maintain patent airway

• Breathing - administer O2 prn; aim SpO2 ≥95% (88-92% for COPD) be wary of infectious risksie COVID

• Circulation

• establish vascular access;

• assist with bloods / blood culture collection;

• commence fluid resuscitation as ordered;

• fluid status – strict monitoring + IDC

• administer antibiotics as a priority; that is within 60 mins of sepsis recognition in severesepsis / shock

Note: The A – E and A – G assessment approach areinterchangeable as they achieve the same outcome.

A – E : Airway, Breathing, Circulation (incl. fluid input &output), Disability (incl. Neurological disability, Diabetes /BGL level, Drugs , Documentation , Exposure.

A – G : Airway, Breathing, Circulation, Disability, Exposure,Fluids (input & output), Glucose

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Clinical Considerations• Disability – continue to assess level of consciousness - AVPU

• Diabetes - assess the blood glucose level

• Documentation / Drugs – check all charts, medication (consider sensitivities to current antibiotics, pathology results

• Exposure / Examine – measure / record body temperature & assess for potential sources of infection

• Abdominal distension (assess if within your scope to do so)

• Swollen and/or reddened joints

• Sputum production / characteristics

• Urinary frequency/odour /output

• Light sensitivity, headaches

• Inflamed wounds and/or cellulitis

• Phlebitis or localized erythema at invasive device insertion sites

• Reassess - Ongoing monitoring / reassessment documented

• Document all treatment plans & treatments initiated

• Communicate to effectively and comprehensively with the patient and all members of the clinical team

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Time is criticalAny actions taken or treatments ordered are time sensitive.

The Hour 1 – Bundle explains the time critical steps that must be taken inthe treatment of sepsis.

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Hour 1 –Bundle Step 1Measure blood lactate level early

An elevated Lactate tells us two things.• The tissues in the body are not getting enough oxygen• The body is working hard to compensate

Normal Lactate is 1mmol/L.

Lactate between 2-4mmol/L = 7% increase in mortality

Lactate > 4.5mmol/L = 27% mortality rate.

Any patient with Lactate >4 should be admitted to ICU for aggressive management regardless of BP unless treatment ceilings are in place.

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Click on image to view full size document.

Document also attached to elearninglaunching page if it is unable to be opened via this link.

Click on image to view video on serum lactate.

(6.19 minutes)

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Hour 1 –Bundle Step 2Collection of Blood Cultures

• Blood cultures are ideally collected before the administration of any antibiotics.This is vital for diagnosis and to target antibiotic therapy choices.

• HOWEVER in patients with severe sepsis / septic shock, if difficulty inobtaining blood cultures DO NOT DELAY antibiotic administration

• Ensure empiric antibiotics are commenced within 60 mins of sepsisrecognition as per pathway (the earlier the better); within 2 hours in patientwith sepsis

Ensure there are no delays transportation of blood gas sample to ICU / pathologyservice

• All pathology collections are urgent

• Communicate urgent nature of bloods when contacting pathology courier

• Confirm collection of samples

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Hour 1 –Bundle Step 3Early administration of one or more antimicrobials

One or more antimicrobials should be commenced immediately.

Many distractions with an acutely ill patient can delay administration of antibiotics / antifungals/ antivirals

Use of a sepsis pathway assists in achieving time critical targets

These tips will assist with early antimicrobial administration• Ensure there is access to an adequate supply of antimicrobials (e.g. after hours drug

cupboard on site)• Contact the Infectious Diseases Consultant for advice on antibiotic choice• Utilise STAT orders• Prescription of antimicrobials should fit local colonisation patterns & should enable

administration via an IV push• Efficient sequencing of antimicrobials must be planned– consider simultaneous

delivery via multiple vascular access• Consider intraosseous administration for first dose of antimicrobials if IV access is

problematic

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Hour 1 –Bundle Step 4Commence IV fluid administration early

Restoration of adequate perfusion pressure to the vital organs is essential.

Ensure IV fluids are commenced early, to maintain Blood Pressure, and all prescribed medications must be given in a timely manner.

Fluid administration beyond initial resuscitation should be carefully monitored to ensure that the patient remains fluid responsive.

Close, frequent monitoring and documentation of fluid input and output is critical to ensure effective management of fluid balance.

Click on image to view a video on IV fluid administration in sepsis

(4.27 minutes)

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Hour 1 –Bundle Step 5Consider the need for VasopressorsRestoration of adequate perfusion pressure to the vital organs is essential.

Vasopressors should be started within the first hour to achieve MAP of ≥ 65 mm Hg if initial fluid resuscitation is not adequate.

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Other essential care and management• Use the Sepsis Pathway to guide the resuscitation and ongoing management of the septic person.

• Closely monitor for & report any changes in condition.

• Consider upward transfer if the patient’s condition warrants higher levers of assessment or treatment.

• Communicate clearly and frequently to the patient and the care management team, to ensure all personsinvolved are well informed and up to date with the current situation and treatment plan

• Document, report, debriefClick on image to view AdultSepsis Pathway

Link for Victorian Sepsis Pathway.

Document also attached toelearning launching page if it isunable to be opened via this link.

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Top 5 Barriers to Treatment• Delay in Recognition of sepsis

• Poor communication regarding changes to the patient condition

• Delay in, or failure to measure lactate level

• Delayed or no antibiotic administration

• Inadequate fluid resuscitation

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What other barriers to early sepsis recognition and antimicrobial administration / sepsis treatment can you foresee?

Share your concerns with your manager so strategies can be initiated to prevent or manage these barriers.

View this video to understand why earlyrecognition & management to sepsis is soimportant and to appreciate the impact it canhave when this does not occur. Julie Moretti spentmany weeks within ACHA wards as a result ofsepsis.

Click on the above image to view the video.(1.47 minutes)

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Risk Management and Sepsis Prevention

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How do we prevent Sepsis?We prevent sepsis by preventing infection

• Hand Hygiene, general hygiene and environmental cleaning

• Vaccinations

• Following guidelines for procedures – strict aseptic technique, “scrubthe hub”, best practice guidelines

• Safe childbirth

• Accurate observation, assessment, documentation and handover ofclinical signs and symptoms

• Observe, assess, document and handover findings on every invasivedevice, every shift. Consider IV site selection and length of timedevice is inserted.

• Raising awareness – World Sepsis Day is September 13th.

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ConclusionSepsis is a leading cause of death or life long disability.

Clear guidance on identification and evidence-based interventions are available to support effective and safe sepsis management.

With the help of simple tools, such as the sepsis pathways, and robust escalation systems, it is possible for all staff to intervene early to prevent harm and significantly reduce mortality.

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Resources & ReferencesArticles

1. Clinical Excellence Commission – Sepsis Toolkit, Inpatient Program Implementation Guide 2014

2. Breen, S.J & Rees, S. (2018). Barriers to implementing the Sepsis Six guidelines in an acute hospital setting. British Journal of Nursing, 27(9): 473-478.

3. Dellinger, R.P., Schorr, C.A. & Levy, M.M. (2017). A users’ guide to the 2016 Surviving Sepsis Guidelines. Intensive Care Med, 43:299-303.

4. Gul, F., Arslantas, M.K., Cinel, I. & Kumar, A. (2017). Changing definitions of Sepsis. Turkish Journal of Anaesthesiology and Reanimation, 45:129-138.

5. Levy, M.M., Evans, L.E. & Rhodes, A. (2018). The Surviving sepsis campaign bundle: 2018 update. Intensive Care Med, 44:925-928.

6. Marik, P.E. & Taeb, A.M. (2017). SIRS, qSOFA and new sepsis definition. Journal of Thoracic Disease, 9(4):943-945.

7. McClelland, H. & Moxon, A. (2014). Early Identification and Treatment of Sepsis. Nursing Times, 110(4): 14-17.

8. Rhodes, A., Evans, L.E., Alhazzani, W., Levy, M.M., Antonelli, M. & Ferrer, R. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Medicine, 43: 304-377.

9. Seymour, C.W., Liu, V.X., Iwashyna, T.J., Brunkhorst, F.M., Rea, T.D., Scherag, A., et al. (2016). Assessment of Clinical Criteria for Sepsis for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Journal of the American Medical Association, 315(8): 762-774.

10. Singer, M., Deutschman, C S., Seymour, C W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Journal of the American Medical Association, 315(8): 801-810.

Online Resources

11. Australian Sepsis Network – Recognising Sepsis: https://www.australiansepsisnetwork.net.au/healthcare-providers/recognising-sepsis , sighted on 17/07/2020

12. World Sepsis Day: https://www.worldsepsisday.org/sepsis , sighted on 17/07/2020

13. Australian Commission Deteriorating Patient Guide: https://www.safetyandquality.gov.au/our-work/recognising-and-responding-deterioration/recognising-and-responding-physiological-deterioration/guide-implementation-national-consensus-statement/observation-and-response-charts , sighted on 17/07/2020

14. NSW Sepsis Toolkit : http://cec.health.nsw.gov.au/keep-patients-safe/Sepsis/sepsis-tools , sighted on 17/07/2020

15. Victorian Sepsis Toolkit : https://www.bettercare.vic.gov.au/our-work/innovation-fund/scaling-projects/sepsis-scaling , sighted on 17/07/2020

16. Australian Commission Sepsis Report : https://www.safetyandquality.gov.au/publications-and-resources/resource-library/epidemiology-sepsis-australian-public-hospitals , sighted on 17/07/2020

17. Australian Commission Recognising and responding to Sepsis : https://www.safetyandquality.gov.au/our-work/recognising-and-responding-deterioration , sighted on 17/07/2020

18. Australian Therapeutic Guidelines – Sepsis Management: https://tgldcdp.tg.org.au/viewTopic?topicfile=sepsis-principles-managing , sighted on 17/07/2020

Policy

19. HCP 8.45 Clinical Deterioration, Recognising and Responding to

20. BPH 2.0 BPH Rapid Response System policy

Textbooks

21. Greenwood, M. & Juers, A. (2019). Multiple organ dysfunction syndrome. In Aitken, L., Marshall, A. & Chaboyer, W. Critical Care Nursing 4th ed., Elsevier Australia, 759-780.

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