Mary Ann, The clinical decisions should be driven by the Severe sepsis screening tool, not just whether the patient looks good. Step down units in organizations that allow severe sepsis to be admitted to step-down usually have severe sepsis orders that trigger aggressive fluid management and transfer if the patient's lactate trends up or BP trends down. If the process is thought out and education is broad and accountability is established, severe sepsis can definitely be safely managed outside of the ICU. Many severe sepsis patient are admitted to the ICU based on what the organ failure is and ICU criteria. The early identification, early antibiotic, and monitoring for progression in patients without lactic acidosis or hypotension can be effectively achieved outside ICU. So case by case basis is not based on clinician opinion, but an established protocol/process determined by our sepsis team.
Patty -----Original Message----- From: [email protected] [mailto:[email protected]] On Behalf Of Daly, Mary Ann Sent: Monday, March 18, 2013 11:19 AM To: '[email protected]'; Townsend, Sean, M.D.; '[email protected]' Subject: Re: [Sepsis Groups] Where Does Severe Sepsis Belong? Since I have gotten some feedback regarding my post about our admission to ICU ratio to mortality I wanted to clarify. I wasn't suggesting that every patient in every hospital with severe sepsis requires an ICU admission. Just stating how our data supports this for our institutions (6 in all) Perhaps if we had more optimal care in other areas of the hospital the necessity would be less for ICU That said, I am reading many posts about 'good clinical medicine' and deciding the disposition of the patient on a case-by-case basis. This is akin to how we treated cardiac patients (and in some cases still do) i.e. deciding the extent of cardiac involvement based on 'how the patient looks'. The problem with placing patients who has responded to initial therapy on the floors - is the level of surveillance and the rapid response to timely assessments = all done more effectively in the ICU setting. I would rather admit a stable patient to ICU for 6-12 hours then transfer knowing that stability has been maintained then wait for a patient to decompensate on the floors (data shows patients are typically in organ failure for 12 hrs to 2-3 days before they are transferred) which confers an increased mortality risk. This is supported by the SSC data base for the US and Europe. Thanks, Mary Ann Daly, RN BSN CCRN DC Regional Clinical Initiative Lead-Sepsis and ICU Liberation (ABCDE) Gordon and Betty Moore Foundation Grant Sutter Health Sacramento Sierra Region E-mail: [email protected] Blackberry: 916.200.5604 Office: 916.614.6370 You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete. R. Buckminster Fuller -----Original Message----- From: [email protected] [mailto:[email protected]] On Behalf Of [email protected] Sent: Friday, March 15, 2013 9:05 AM To: Townsend, Sean, M.D.; [email protected] Subject: Re: [Sepsis Groups] Where Does Severe Sepsis Belong? Sean, My answer is NO...they do not all need ICU. I think it is very patient specific and determined by "how close to the edge" they are....for lack of a better way to say it right now. The numbers do not ALWAYS reflect the patient status....We put some on the medical unit that seem to be stable after ED treatment....sure, a tiny few may end up being RRT'ed later...but for the most part....those with SS that are admitted to the floor instead of ICU seem to be OK once they get the antibiotic and fluids in ED and stabilize rather quickly. I would never treat it as a black and white decision with strictly numbers and test results. One has to see the patient and know the patient...including co-morbidities and response to the treatment you have initiated already. Just my 2 cents. -----Original Message----- From: [email protected] [mailto:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: Friday, March 15, 2013 2:32 AM 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 _______________________________________________ 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 This message (including any attachments) is confidential and intended solely for the use of the individual or entity to whom it is addressed, and is protected by law. 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