Successful Processes for Detecting Sepsis and Initiating Protocols for p g Effective Management M-LiNk Sepsis Learning Series October 6, 2011
Mortality: Learning-in-Network y g M ‐ LiNk is peer ‐ based learning opportunity for hospitals to: 1. Identify best practices correlated with a reduction in mortality; 2. Adopt system supports used in high ‐ 2. Adopt system supports used in high reliability organizations; and 3 Implement protocols to identify and 3. Implement protocols to identify and differentially treat high ‐ risk patients.
M-LiNk Approach pp • Learning series with local/national expertise on g p interventions associated with best practice for reducing hospital mortality rates • MHA portal with tools & resources in key content areas • Virtual networking to foster inquiries, share resources, and promote learning across hospitals promote learning across hospitals • Individualized technical assistance to support implementation of selected interventions p • Communications via MHA’s website and Issues Briefs to present case studies and highlight lessons learned
M-LiNk Portfolio of Offerings g • Focus on Structures & Processes Focus on Structures & Processes • Spring-Summer 2011 • Outcome Drivers: Part 1 – Sepsis Outcome Drivers: Part 1 Sepsis • Fall 2011 • Outcome Drivers: Part 2 - Other Drivers • Winter 2012 e 0
M-LiNk Portfolio Foc s on O tcomes Part I SEPSIS Focus on Outcomes Part I: SEPSIS • Sep 8 th : Gain Full Value from Your Root Cause Analysis Investigations (Using Sepsis Case Study for Review) ( d f ) • Sep 21 st : Identification and Management of Severe Sepsis i th E in the Emergency Department D t t • Oct 6 th : Successful Processes for Detecting Sepsis and Initiating Protocols for Effective Management Initiating Protocols for Effective Management • Oct 13 th : Sepsis bundles: Implementation Strategies 10 th I • Nov 10 th : Implementing Systems and Clinical Processes for N l ti S t d Cli i l P f Managing Sepsis
Successful Processes for Detecting Sepsis & g Initiating Protocols for Effective Management featuring • Nathan I. Shapiro, MD, MPH, Vice Chairman of Research, Department of Emergency Medicine, Beth Israel Deaconess Medical Center Center • Christina Breault BS, CPHQ, QI Specialist & Outcomes Analyst, & Janet Liddell MSN/MBA, RN, Quality Improvement Coordinator, Quality and Patient Safety Department, Saints Medical Center • Erin M. Donovan, Director, Quality & Risk & Janyce Breton, RN, Nursing Informatics Specialist Lowell General Hospital Nursing Informatics Specialist, Lowell General Hospital • Geraldine McQuoid, RN, MA, MSN, Director of Hospital Education & Infection Control, Fairview Hospital
Beth Israel Deaconess Medical Center Reducing Sepsis Mortality Nathan I. Shapiro, MD, MPH, Vice Chairman of Research, Department of Emergency Medicine, B th I Beth Israel Deaconess Medical Center l D M di l C t
B th I Beth Israel Deaconess Medical Center l D M di l C t Improvements in Care: One hospital’s practical experience Nathan I. Shapiro, MD, MPH Department of Emergency Medicine Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA Boston, MA Disclosure: Speaker’s bureau of Eli Lilly. Research funding: Abbot Lifesciences, Biosite. if i i i
70 year old female, crushing CP 70 year old female, crushing CP y y , , g g
50 year old female rollover MVC 50 year old female, rollover MVC
70 y/o female cough, fever, 70 y/o female cough, fever, tachychardic, BP 88/50
In Your Busy Emergency In Your Busy Emergency In Your Busy Emergency In Your Busy Emergency Department….. Department….. • Patient #1: 70 y/o female, chest pain, Patient #1: 70 y/o female, chest pain, ST elevation MI (10% mortality) ST elevation MI (10% mortality) ( ( y) y) • Patient #2: 50 y/o female, MVC, Patient #2: 50 y/o female, MVC, hemodynamically stable (5% mortality) hemodynamically stable (5% mortality) hemodynamically stable (5% mortality) hemodynamically stable (5% mortality) • Patient #3: 70 year old female, cough, Patient #3: 70 year old female, cough, fever tachycardic obtunded BP=88/50 fever tachycardic obtunded BP=88/50 fever, tachycardic, obtunded, BP=88/50 fever, tachycardic, obtunded, BP=88/50 (30% mortality) (30% mortality)
28d In-hospital Mortality Rate 28d In-hospital Mortality Rate 35% 28.8% 30% 25% % Mortality 20% 15% 9.3% 9.3% 10% 5% 2.1% 1.3% 0% 0% No SIRS SIRS/Sepsis Severe Sepsis Septic Shock Sepsis Syndrome Shapiro et al. Annals of Emergency Medicine, 2006.
The Impact of Organ Failure on 28day The Impact of Organ Failure on 28day Mortality Mortality Mortality Mortality 60% 53.0% 50% 50% 40% lity % 30% 30% 26.0% 26 0% Mortal 20% 13.0% 10% 5.9% 1.0% 0% 0 0 1 1 2 2 3 3 4 or more 4 or more Number of Organ Failures Shapiro et al. Annals of Emergency Medicine. 2006.
Therapy Therapy “Over 13,000 patients have been enrolled in 23 multi-center, placebo-controlled, clinical trials……results have been generally disappointing with some spectacular failures” From “Clinical Trials for Severe Sepsis. From Clinical Trials for Severe Sepsis. Past Failures and Future Hopes, 1999 Opal et al. Infectious Disease Clinics of North Opal et al. Infectious Disease Clinics of North America. 1999:13:2.
Proven Therapies in Sepsis p p • Activated Protein C (6% absolute mortality reduction) – Bernard et.al. NEJM. March 8, 2001:344:10:699-709 • Early Goal Directed Therapy (16%) – Rivers et al NEJM: 354 (19): November 8,2001 Ri l NEJM 354 (19) N b 8 2001 • Steroids in adrenal suppression (10%) – Annane et al. JAMA 288(7), August 21, 2002 Annane et al. JAMA 288(7), August 21, 2002 • Intensive Insulin Therapy in ICU (3%) – Van Den Berghe et al. NEJM 345(19), NOV 8, 2001 • Early,Appropriate Antibiotics (10-40%) – Numerous (no randomized trials)
• Early, protocolized resuscitation to targeted physiologic endpoints physiologic endpoints • Facilitates early, aggressive resuscitation Rivers, Nguyen et al NEJM: 354 (19): November 8,2001 i l ( ) b
T he he MUST MUST P P rotocol he he rotocol rotocol rotocol Multiple Urgent Sepsis Therapies Multiple Urgent Sepsis Therapies l l l l S S h h Shapiro et al. “A Blueprint for a Sepsis Protocol.” Academic Emergency Medicine : April 2005:12:4:352 ‐ 359. Shapiro et al. “The implementation and Outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol.” Crit Care p g p p ( ) p Med : 2006:4:1025 ‐ 1032
“6 Step” Program 6 Step Program 1) Admission 1) Admission 2) Collaboration 3) O 3) Organization i ti 4) Education 5) Implementation 6) Evaluation 6) Evaluation
Step 1: Admission Step 1: Admission • Admit you have a problem
Step 2: Form a Leadership Team Step 2: Form a Leadership Team • Emergency Medicine Emergency Medicine –Physicians and Nurses • Medical Intensive Care M di l I t i C –Physicians and Nurses • Surgical Intensive Care –Physicians and Nurses Physicians and Nurses • Others
Step 3: Organization Step 3: Organization • Protocol handbook Protocol handbook • Protocol quick guide • Bedside posters B d id t • Nursing flow sheet
How do I identify patients? How do I identify patients? Create Screening Points Create Screening Points 1. Initial encounter in the ED (Bl (Blood culture = lactate) d lt l t t ) 2. Upon ICU admission (Evaluation Sheet)
Is Lactate a Useful Screen? Is Lactate a Useful Screen? 35.0% 28.4% 30.0% 25.0% 22.4% 20.0% Any Death 15.0% Death <=3 days 9.0% 9 0% 10.0% 4.9% 4.5% 5.0% 1.5% 0.0% 0-2.4 2.5-3.9 >4.0 •1316 admitted ED patients, 109/1316 (8.3%) deaths p , ( ) Shapiro et al, Annals of Emergency Medicine May 2005.
Lactate Shock Shock O l Only 27% 32% Shock Only 41% 116 patients enrolled
Identify patient Identify patient Activate Sepsis Activate Sepsis Team Team O2 & O2 & Early Early Rapid central venous Rapid central venous Antibiotics Antibiotics ventilatory ventilatory access access (with continuous ScvO2 (with continuous ScvO2 (with continuous ScvO2 (with continuous ScvO2 support prn support prn t monitoring) monitoring)
< 8 < 8 - 12 12 500 cc 500 cc 00 00 CVP CVP crystalloid bolus crystalloid bolus ? ≥ 8 - 12 < 65 < 65 Norepi is Norepi is Norepi is Norepi is MAP MAP MAP MAP Pressors. Pressors. preferred. preferred. ? ≥ 65 < 30% Transfuse. Transfuse. < 70% < 70% ScVO ScVO ScVO ScVO 2 Hct Hct H t H t ? ? Dobutamine Dobutamine ≥ 30% ≥ 70%
ICU ICU Admission Admission Intensive Intensive Prevent Prevent Start activated activated Start insulin insulin for for Excessive Excessive protein C protein C protein C protein C ACTH ti ACTH stim ACTH ti ACTH stim Euglycemia? Euglycemia? Inspiratory Inspiratory if criteria met. if criteria met. test. Steroids test. Steroids Plateau Plateau if criteria if criteria Pressures Pressures met? met? met? met?
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