It sounds like we have a consensus that severe sepsis patients do not need ICU when ‘intermediate care’, typically in the form of a step-down type unit, is available. The discussion then surrounds the choice of a ‘typical’ med-surg type unit vs. ICU. And in a nutshell, better safe than sorry. And this of course takes into account triage of critical care resources. It is not likely that there can ever be a ‘rule’ for this because each hospital has its own set of circumstances- I would suggest that you examine your mortality data for severe sepsis patients who go directly to ICU vs. ones who go to med-surg (not intermediate units) and then decompensate; this will inform your process improvements.
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]<mailto:[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 From: [email protected] [mailto:[email protected]] Sent: Friday, March 22, 2013 5:52 PM To: [email protected]; [email protected]; [email protected]; Daly, Mary Ann; Townsend, Sean, M.D. Subject: RE: [Sepsis Groups] Where Does Severe Sepsis Belong? We have developed a step-down unit that is designed to address the needs of patients who do not need ICU but need more than a normal med/surg/tele floor. In California, step-down staffing is 3:1 (compared to 2:1 or 1:1 in ICU). With this staffing, we can monitor the patient adequately to run the fluids, POC lactates, etc. We are able to transduce a line if necessary. At this time, we do not care for vented patients in this unit, although this staffing would allow chronic vent care (which I have done in other facilities). We have developed PCU Sepsis Orders which are similar to ICU orders but without invasive lines or titrating vasopressor drips. If they require that level of support, they need to be in ICU. Peggy Rice, RN, BSN, MBA Associate Chief Nursing Officer Good Samaritan Hospital 2425 Samaritan Drive San Jose, CA 95124 (408) 559-2329 (office) (408) 438-0986 (cell) (408) 559-2620 (fax) [email protected]<mailto:[email protected]> From: [email protected]<mailto:[email protected]> [mailto:[email protected]] On Behalf Of Juanita Fernandes Sent: Friday, March 22, 2013 6:14 AM To: Sienecki Peggy; '[email protected]'; Mary Ann Daly; Sean M.D. Townsend Subject: Re: [Sepsis Groups] Where Does Severe Sepsis Belong? I have to agree with Mary Ann. Our hospital tracks admissions that are transferred from an inpatient unit to the ICU within 24 hours of admission. The nurse to patient ratio on inpatient units does not always lend itself to frequent enough assessments to catch patients early on in the game. We try to advocate for the ICU if the patient is in severe sepsis. When we talk about being stabilized in the ED we are often giving a lot of fluids - something that the inpatient nurses do not have orders for and are not comfortable with. I have encouraged my ED staff to cut the patient's fluid back to the rate that has been ordered on the inpatient orders. If there is change in VS they then have something to go to the hospitalist with to support the need for ICU. Juanita Fernandes, RN, BSN, CEN Emergency Department Nurse Educator Concord Hospital 250 Pleasant Street Concord, New Hampshire 03301 (603) 227-7000 ext. 3138 Pager (603) 221-1104 >>> On 3/18/2013 at 12:19 PM, "Daly, Mary Ann" >>> <[email protected]<mailto:[email protected]>> wrote: 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]<mailto:[email protected]> Blackberry: 916.200.5604 Office: 916.614.6370 ý 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]> [mailto:[email protected]] On Behalf Of [email protected]<mailto:[email protected]> Sent: Friday, March 15, 2013 9:05 AM To: Townsend, Sean, M.D.; [email protected]<mailto:[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]> [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]<mailto:[email protected]> office (415) 600-5770 fax (415) 600-1541 _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
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