We see approximately 20% of our pts with severe sepsis being treated on general medsurg floors. these are typically patients with a single organ dysfunction (typically lactate 2-4 or a small Cr. elevation) who have rather rapid improvement in vital signs after fluids in the ED.
We see that approximately 15% of these patients end up requiring transfer to step down (more common) or ICU (less common) in the 48 hours after admission. The patients that do transfer have a mortality rate similar or slightly higher than patients initially admitted to a step down unit or ICU. We have to date been unable to determine which characteristics predict which patients will further deteriorate. Based on these observations we are trying to guarantee that such patients are admitted directly to at least a step down unit. We struggle with this because of space limitations, so this is an ongoing issue we are working on. Joe Joseph Clement RN, MS, CCNS Clinical Nurse Specialist San Francisco General Hospital phone: (415) 206-6174 pager: (415) 327-0220 [email protected] "Townsend, Sean, M.D." <[email protected]> Sent by: [email protected] 03/17/2013 09:37 AM To "'Doberenz, Doris'" <[email protected]>, "'[email protected]'" <'[email protected]'> cc Subject Re: [Sepsis Groups] Where Does Severe Sepsis Belong? Dear Doris, Questions about strategies to improve practice on the listserv are a good thing. Not having a strategy beyond everyone's best judgment is probably not the right answer on the exam. I'm sure you have great judgment, but we all know many colleagues who would benefit from some guidance on where to place patients. Judgment alone hasn't done much to get adherence to best therapies. In the world's best example, Intermountain Healthcare in Utah, adherence to bundled therapies is 85% or so. Their mortality rate for severe sepsis is less than 10%. The rest of us can't say either of those things. Their publication is in peer review and soon we'll all see clearly the power of their example. I just wanted to survey the crowd that has demonstrated interest in this subject for what they do so I can fix my own problems. Sean Sean R. Townsend, M.D. Vice President of Quality & Safety California Pacific Medical Center 2330 Clay Street, #301 San Francisco, CA 94115 email [email protected] office (415) 600-5770 fax (415) 600-1541 -----Original Message----- From: Doberenz, Doris [[email protected]] Sent: Sunday, March 17, 2013 08:44 AM Pacific Standard Time To: '[email protected]' Subject: Re: [Sepsis Groups] Where Does Severe Sepsis Belong? Why is so much written about this without much real content? How many more or less rhetoric questions with or without answers because our patients and their diseases and severity actually vary... OOOPS who'd have thought that!? For example 'where severe sepsis belongs' will depend on seeing the patient as a clinician in addition to certain quite clear severity criteria in their context and conjunction e.g. heart rate, blood pressure, resp rate, urine output, lab signs of organ failure, lactate, central venous sats if available), and to decide how severe the whole situation is and thus how much monitoring and support a specific patient in a specific situation and severity needs. How many more mails and how many more pages of guidelines and time and expense of development of these guidelines by experts do we need for this and how many not always sufficiently evidence based but dictatorial bundles, which then get overtaken by the scientific evidence (e.g APC, steroids)??? Back t o the shopfloor (and the floor or the ICU according to the real need) and back to basics, and back to applying good medicine and good science for each individual patient and his or her specific situation rather than being spoonfed and dictated bundle criteria from some "institute" without sufficient robust and durable scientific evidence... Doris Doberenz FRCA FFICM EDAIC EDA Consultant Intensive Care Unit and Anaesthetic Department Charing Cross Hospital Fulham Palace Rd London W6 8RF Tel 020 3311 1234 bleep 5742 Mobile 07855 754 160 -----Original Message----- From: [email protected] [ mailto:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: 15 March 2013 06:32 To: '[email protected]' Subject: [Sepsis Groups] Where Does Severe Sepsis Belong? It's been a long time since I've had to ask this question. I used to think I knew the answer. Here it is: do all patients who meet severe sepsis criteria need to be admitted to the ICU ? Examples: 1. Pneumonia, fever, tachycardia, INR 1.5. 2. Cellulitis, leukocytosis, fever, creatinine 2.0. 3. UTI, leukocytosis, fever, lactate 3.0. Where do people put these patients in reality? What mind of monitoring do they deserve? By prevailing bundles, each gets lactate checked, blood cultures, broad spectrum antibiotics. That's it. Good enough? Good enough for the floor? Need the ICU? Why? Sean Sean R. Townsend, M.D. Vice President of Quality & Safety California Pacific Medical Center 2330 Clay Street, #301 San Francisco, CA 94115 email [email protected] office (415) 600-5770 fax (415) 600-1541 _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org Imperial College Healthcare NHS Trust notice: The contents of this e-mail are confidential to the ordinary user of the e-mail address to which it is addressed and may also be privileged. If you are not the addressee of this e-mail you may not copy, forward, disclose or otherwise use it in any form whatsoever. If you have received this e-mail in error please telephone the Imperial College Healthcare NHS Trust on +44 (0)20 3311 3311 and ask for the person who sent you the email. Please also delete the message from your computer. [end] _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
_______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
