6/4/2018 OVERLAKE HOSPITAL OB SEPSIS Pacific NW Regional Sepsis Conference ABOUT OVERLAKE > 349-bed, nonprofit regional medical center offering a full range of advanced medical services to the Puget Sound Region > Level III Trauma Center > Approximately 22,000 admissions/year > Over 45,000 ED visits/year > Around 3700 Births/year 2 1
6/4/2018 SPREADING EARLY RECOGNITION AND TREATMENT OF SEPSIS TO THE OB POPULATION Margie Bridges, DNP, RNC-OB, ARNP-BC Betsy Pesek, MN, BSN, RN, CPHQ Perinatal Clinical Nurse Specialist Quality Improvement Consultant Women and Infant's Services Quality Department 3 NOTHING TO DECLARE 4 2
6/4/2018 OBJECTIVES 1 . Recognize rational for including the OB population into Sepsis Quality Improvement work 2. Name 3 considerations that are unique to the perinatal population 3. Describe a step wise approach to incorporating inter- professional education on early recognition and management of maternal sepsis 5 TRENDS IN PREGNANCY RELATED MORTALITY IN THE U.S. (1987-2013) CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html 6 3
6/4/2018 MATERNAL MORTALITY U.S.A. VERSUS OTHER DEVELOPED COUNTRIES 7 SEPSIS IS THE 3 RD LEADING CAUSE OF MATERNAL DEATH CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html 8 4
6/4/2018 MATERNAL MORTALITY IN WA https://www.doh.wa.gov/Portals/1/Documents/Pubs/140-154-MMRReport.pdf 9 CASE FOR CHANGE > Severe Sepsis is the 3 rd leading cause of maternal death > Incidence of sepsis increasing over the years > Once Severe Sepsis and Septic Shock develops mortality approaches 60% > SEP-1 Core measure since 2015 How many of you have included OB in your work? 10 Critical Care Medicine.2013;41:945. Confidential: Protected Quality Improvement Document 5
6/4/2018 WHAT’S UNIQUE ABOUT OB? • Distraction • Typically Young & Healthy • Uncommon • Limited studies • TWO patients • SIRS criteria 11 UNIQUE OB PHYSIOLOGY • Normal OB physiology mimics SIRS: • WBC higher • HR increases • RR Increases • Effect of Labor • HR, RR: pain and pushing • Temp: dehydration, epidural • Hypotension with epidural • Altered mental status 12 6
6/4/2018 A STORY THAT MOTIVATES GROUP A SEPSIS CASE 16 year old Vacuum delivery 1 st degree laceration Postpartum Day 1 : WBC 16.4 T 36.2 BP 118/71 Pulse 115 3 hours later : . WBC=*1.7 repeat 1.6 T: 38.7 HR: 120-156 BP: 95/45- 76/34 RR: 40-47 Mother comments that this is not her typical response to pain or stress 13 OB CASE CONTINUED RRT Called Transferred to CCU Test & Treat: CT Scan, Pulmonary angiogram, Abdominal Ultrasound, Blood & Urine Cultures, IV Unasyn, clindamycin, Vancomycin, fluid volume resuscitation, vasopressor support, respiratory support with intubation • BP: 68/40 P: 160 Sa02 87% on 6L Lactate 2.8 • Increasing pulmonary edema/pleural effusions, decreased UO • Respiratory failure, tachycardia/Hypotension requiring vasopressors. Major Goals of sepsis management were met: She was treated emergently with fluid resuscitation, antibiotic administration …. What else? 14 7
6/4/2018 OB CASE CONTINUED Postpartum Day 3: To OR for Surgery: TAH, APPY, and Abdominal washout. Uterus was “mushy” tissue friable. 4 liters of purulent Ascites • Positive for GAS • Remained ventilated 9 days (ARDS) • Day 17: T: 36.5, BP: 127/75 P: 88 RR: 16 Sao2 100% RA Discharged: Ambulating, Eating and Breastfeeding! 15 QI IS A NEVER ENDING PROCESS Where we were, where we are, and where we’re headed • ED & CCU Inpatient OB population • MEWS to MEWT • GLOSS Study Global Maternal Sepsis Study 16 8
6/4/2018 THE SEPSIS TEAM Medical Medical Nurse Medical Director Director Managers Director ED CCU Quality CCU & ED Group Inpatient Group Hospitalist Health Nurse Health MD MD Urgent Care Manager ED & CCU Inpatient RN CCU, ED, Epic ASAP RNs Champions OB CNSs Epic Liaison Pharmacy Lab MI, VIR 17 TIMELINE Sepsis Committee ED workflow planned for Pharmacy &Director of IP Hospital–wide formed early Identification & develop Antibiotic list. ED Sepsis education Best practice review Treatment Sepsis Quicklist amended . Sep 2014 Spring 2014 Oct 1, 2015 RN Sepsis Champion Sepsis Order Set PHASE 2 Sepsis Checklist Mar ‘15 Sepsis Checklist BPA built & tested behind Inpatient Build, ED BPA in Production scenes; iStat training done Provider Education OB Checklist Dec 2015 Jan 2015 Mar – May ‘15 Mar 2016 RRT Protocols Mews for MEWT in OB Sepsis Checklist in EMR ED Fluid MEWT in EMR ALL RN Protocol Inpatient . Documentation Aug 2017 Oct 2016 March 2018 TBD 2018 Dec 2017 June 2018 18 9
6/4/2018 BUCKETS OF WORK Bedside RN Champions Paper Equipment Checklists Workflows: ED EMR TEAM CCU BPA Inpatient OB Policy Education Protocols Order Sets CCU ED Inpatient 19 THERE CAN BE ONLY ONE! General Population: Primary sources in ED: Pna, UTI, Abdominal & Wound/skin OB Population: CHORIOAMNIONITIS…. AND Endometritis, Wound, Pyelo, Pna, Necrotizing fasciitis CHORIO – AND SEPSIS > Providers & Nurses thinking chorio is different than sepsis > Not understanding Sepsis is a body’s adverse reaction to ANY infection > Providers and nurses thinking delivery is cure > Not thinking more than one infection can be occurring at same time 20 10
6/4/2018 OB WORKFLOW Any two SIRS/symptoms AND Suspected below infection? HR>110 Yes 1. Call Rapid Response Team RR>24 Any suspected or unless MD is Temp < 36 OR >38 Known infection? available for WBC > 14 OR <4 immediate Acute Change in Mental Status assessment and SBP <90 orders 2. RRT initiates Sepsis (nurse ANY ISOLATED TEMP of 39 0 Notify MD initiated Orders) No Continue to monitor patient Early intervention was implemented for all patients who screen positive for sepsis RN champions instrumental Perinatal staff educated on early recognition and management of maternal sepsis 21 AFTER OB SEPSIS PROTOCOL CASE G1P0, 37 weeks gestation, with uneventful pregnancy 0300: Admitted to L&D • WBC 10,000 1200 : Temp (38°C) Tylenol was administered and ….. • Maternal and fetal tachycardia • Shaking • Change in mental status • Increased pain • Temp spiked to 41.1 °C , RRT was called & Sepsis Bundle was initiated • C-Section because of fetal intolerance • NICU for chorioamnionitis. • Mother’s blood cultures positive for E. coli. • Mom & Baby discharged in stable condition 22 11
6/4/2018 CHALLENGES & SUCCESSES Challenges • Lactate isn’t B.S. • Paper checklist “ONE MORE THING!!” • Consistency in application • Creating a sustainable process Successes • Change in culture: OB Hospitalist 24/7 • Engaged, multidisciplinary team • Improved competence at bedside • Resource every where they can reach – EMR, Department Internet 23 NEXT STEPS > MEWT build in Epic > Checklist build in Epic > Once hardwired, monitor process 24 12
6/4/2018 OBJECTIVES 1 . The WHY?? Recognize rational for including the OB population in Sepsis Quality Improvement work 2. The WHAT? Name 3 considerations that are unique to the perinatal population 3. The HOW? Describe a step wise approach to incorporating inter-professional education on early recognition and management of maternal sepsis 25 QUESTIONS? For more information, contact: Betsy.Pesek@overlakehospital.org or Margie.Bridges@overlakehospital.org 26 Confidential: Protected Quality Improvement Document 13
6/4/2018 OB Sepsis References Acosta, C.D., & Knight, M. (2013). Sepsis and maternal mortality. Current Opinion Obstetrics and Gynecology,25 (2), 109-116. Doi: 10.1097/GCO.0b013e32835e0e82. Barton, J. & Sibai, B. (2012). Severe sepsis and septic shock in pregnancy. Obstetrics & Gynecology, 120 (3), 689-706. Doi:10.1097/ACOG.Ob013e318263a52d Bural, K., & Rich, D. (2014). Code sepsis: development of a sepsis protocol for the obstetric patient. Journal of Obstetric, Gynecologic & Neonatal Nursing , 43 (1). S13. CDC (2016). Inpatient care for septicemia or sepsis; a challenge for patients and Hospitals. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db62.htm CDC (2017). Pregnancy mortality surveillance system. Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html Downs, B. (2013). Development of a maternal sepsis tool …from scratch. Surviving Sepsis Campaign Webcast. Retrieved from http://www.survivingsepsis.org https://www.doh.wa.gov/Portals/1/Documents/Pubs/140-154-MMRReport.pdf World Health Organization (2017). Global Maternal Sepsis Study. Project brief. www.who.int/entity/reproductivehealth/projects/Project-brief-GLOSS.pdf?ua=1 27 14
Recommend
More recommend
