Our center uses BPA in ED to RN and Medical Staff (with differing thresholds).
In the ED, as triage is time-zero, we have paired RN response to SIRS criteria
driven BPA and "Signs and Symptoms" concerning for infection reported to
provider [provider name is required to satisfy BPA]. This response starts a
running clock apparent on unit dashboard as well as highlighting patient
(change in color). We have added a distinct order, "Begin Sepsis Protocol"
which is preselected in order set among as well as work-up labs.
The inpatient population is a bit more difficult as the transition between
sepsis and severe sepsis can be subjective among providers. We are educating to
initiate "Protocol" at the advent of sepsis, as the diagnosis of severe sepsis
may be applied retrospectively. Again, we have applied a SIRS driven BPA to
nursing staff who answer the question about Signs and Symptoms concerning for
infection with prompts for S/S as well as risk factors. If positive, this is
referred to a provider for discernment of sepsis. Order-set again includes
"Begin Sepsis Protocol" as a discrete order. For providers, we have built a
SepsisNote (Epic Smartphrase) that has drop downs and phrases to accurately
capture documentation and organ system failures to accurately support
diagnosis. We have also provided a "SepsisNegative" note, aiding in attribution
of SIRS criteria to other factors.
While this does not directly answer the question of when the last element
consistent with diagnosis of sepsis is met, the pairing of required information
in a time-stamped note will create a discrete time-stamp.
Best regards,
Brian
Brian Pratt, MS, RN, CNS, CCRN
Sepsis Coordinator
Department of Nursing Quality
Upstate University Hospital
Room 6553
750 E. Adams Street
Syracuse, NY 13021
315-464-1557 (Office)
315-729-4276 (Mobile)
Confidential - Not for Redisclosure Under Education Law, Sect 6527 and Public
Health Law 2805-M
>>> 09/18/15 4:39 PM >>>
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Today's Topics:
1. presentation (CARIANN M DAHLQUIST)
2. Re: Sepsis core measures (Gerard, Daniel)
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Message: 1
Date: Fri, 18 Sep 2015 14:40:31 -0500
From: "CARIANN M DAHLQUIST"
To:
Subject: [Sepsis Groups] presentation
Message-ID: <[email protected]>
Content-Type: text/plain; charset="us-ascii"
Hello everyone,
Just inquiring how other facilities are going about the severe sepsis
presentation timing. I have brought forth the criteria for presentation time
and many of my physicians are concerned with "how do we really know when the
clock starts." I have educated that all 3 criteria need to be within 6 hours of
each other, however I think they have a valid point, how are bedside nurses and
physicians supposed to know when their "time clock" started?
What type of tools are facilities implementing to help the staff with the
"clock" if any?
We do have EPIC as an EMR, has anyone tried any timers or countdowns on the
patient header to identify where your at in the bundle clock? Just a thought
Thank you greatly!
CariAnn
CariAnn Dahlquist RN
Quality Management
Altru Health System | Grand Forks, ND
701.780.5339 phone | 701.780.1942 fax | [email protected]
( mailto:[email protected])
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Message: 2
Date: Fri, 18 Sep 2015 15:18:58 +0000
From: "Gerard, Daniel"
To: "[email protected]"
Subject: Re: [Sepsis Groups] Sepsis core measures
Message-ID:
Content-Type: text/plain; charset="iso-8859-1"
One thing as far as I know that has changed with regards to definitions of
Severe Sepsis from Surviving Sepsis to CMS is, Surviving Sepsis recognized the
organ failure definition should be secondary to a sepsis insult. I may be wrong
but as I understand it a single "organ failure" number (could be an elevated
coag for a patient on an anticoagulant) would count this patient as severe
sepsis.
Daniel Gerard RPh
Critical Care Pharmacist
McLaren Northern Michigan
231-487-4770
FAX: 231-487-4817
________________________________________
From: Sepsisgroups on behalf of [email protected]
Sent: Friday, September 18, 2015 11:10 AM
To: [email protected]
Subject: Sepsisgroups Digest, Vol 171, Issue 7
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Today's Topics:
1. Re: Sepsis Core Measures Follow-up (Barnes-Daly, Mary Ann)
2. Re: Sepsis Core Measure Follow Up (Townsend, Sean, M.D.)
----------------------------------------------------------------------
Message: 1
Date: Thu, 17 Sep 2015 20:17:16 -0700
From: "Barnes-Daly, Mary Ann"
To: "Townsend, Sean, M.D." , Ram Parekh
Cc: "Allen, Gilman B" ,
"[email protected]"
Subject: Re: [Sepsis Groups] Sepsis Core Measures Follow-up
Message-ID:
Content-Type: text/plain; charset="utf-8"
While I understand some of the frustration associated with the looming CMS Core
Measure reporting for sepsis, I am stumped by some of the sentiments in the
post by Dr. Parekh. The organ failures indicative of SEVERE SEPSIS have not
changed. Relying solely on lactate is not clinically sound. And to clarify, a
lactate level of > 2.0, not 4.0, is defined as severe sepsis and >/= 4.0 is
septic shock. We have all seen pts who, despite being very ill, have normal
lactate levels. Often it is a case of sequestered lactate when hypo-perfusion
is so profound that the levels don't even rise until wash-out is achieved by
reperfusion.
Second, I have listened to the arguments against "cook-book" medicine - and one
could argue that complying with a core measure is such a practice - however the
overwhelming evidence for the effectiveness of the sepsis bundles is still
ignored by a large number of clinicians - SHAME ON US that we need an agency
like CMS to force us to abandon 'practice-based evidence' apply sound
principles to the care of sepsis pts.
We have complied with similar guidelines for MI and stroke with good outcomes
for pts - why not for this disease process that carries such peril.
I think that the State of NY may have gone too far by creating laws around
sepsis care, however desperate times........children, nor anyone for that
matter, should die as a result of our ignorance nor our egos.
I will admit that this core measure is extremely complicated - as is the
disease.
The specifications describing Time-0 are very complicated - but the fact
remains that if we recognize severe sepsis early and treat the pt properly in a
timely fashion, it seems to me that the time requirements will be met.
I also had hoped for a step-wise approach to the measure that would begin with
the severe sepsis bundle and progress to shock care. But the fact is that
septic shock mortality is still unacceptably high - and often because of
delayed or omitted care.
I for one welcome the double-edged sword that is this measure. This is a wild
ride and I am glad to have a front row seat.
Namaste,
MARY ANN BARNES-DALY RN BSN CCRN DC? | Clinical Performance Improvement
Consultant
Sutter Health - Office of Patient Experience | 2200 River Plaza Drive,
Sacramento, CA 95833
Mobile 916.200.5604| Office 916.286.6717 | [email protected]
?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: Sepsisgroups [mailto:[email protected]] On
Behalf Of Townsend, Sean, M.D.
Sent: Tuesday, September 15, 2015 11:35 AM
To: Ram Parekh
Cc: Allen, Gilman B; [email protected]
Subject: Re: [Sepsis Groups] Sepsis Core Measures Follow-up
While I appreciate many points of view, I can't engage in a reasoned discussion
that brings out advantages and disadvantages to certain approaches if we must
toss terms such as insanity, imposition, nefarious, unacceptable, misuse, and
disastrous.
It would we useful, I think, to remember that such dialogue has been used since
the inception of the Surviving Sepsis Campaign's efforts to improve care 14
years ago, and the proof of the effect of such efforts is that mortality in
Rivers' control arm was 46% versus 18.8 in ProCESS.
Working together carefully and patiently is an important tenet of our
improvenent efforts.
As for the remarks below, I would simply note that the approach to antibiotics
is fully supported in the 2012 SSC Guidelines, and those were endorsed by the
infectious Disease Society of America. The standard of broad spectrum
antibiotics for a disease that carries lethal potential if you guess
incorrectly is not in dispute.
Finally, the definitions if severe sepsis and shock have not changed. How one
*measures* persistent hypotension after fluid administration is the issue. If
the author has a measurement strategy to propose, I am certain we can carry
this forward as a consideration.
On Sep 15, 2015, at 11:03 AM, Ram Parekh > wrote:
Thank you, Dr. Allen, for speaking up on this insanity that is being imposed on
hospitals and providers.
I'll add 2 more questions, and one comment.
* First, NS and LR are ok, but Isolyte is unacceptable. How is this
possible? NS may cause harm, as you have already mentioned, and LR may affect
trending lactates particularly in shock states, yet those are the only CMS
sanctioned crystalloids, while balanced solutions like Isolyte or Plasmalyte do
not qualify.
* Secondly, on what evidentiary basis and by what rationale have the Severe
Sepsis and Septic Shock definitions been changed? Infection + 2+ SIRS + lactate
> 4mmol/L has been been the Severe Sepsis definition since the Rivers EGDT
trial and was also used in the RCT triumvirate of PROMISE, ARISE, and PROCESS.
Now, this Severe Sepsis criteria has been subsumed by the 'Septic Shock'
definition and the new Severe Sepsis definition includes a myriad of end organ
surrogates such as platelet count and bilirubin level. Again, on what
evidentiary basis are hospitals and providers being held to this arbitrary
definition? The best evidence we have to date uses the Rivers definition of
severe sepsis and septic shock, yet this has been scrapped in favor of a more
complicated and arbitrary definition. Adding complexity is not in the best
interest of patient care, if that is indeed the goal.
* And last, and most important, is the expectations involving broad spectrum
antibiotics. This is a more nefarious reincarnation of the disastrous
antibiotics for pneumonia CMS core measure. The effect this will have on
antibiotic overuse and misuse will be disastrous.
On Tue, Sep 15, 2015 at 12:25 PM, Allen, Gilman B > wrote:
Sean,
I attended your webinar on Sepsis Core measures last week and was left with a
number of concerning questions:
1. If we are using the logic that ?there is no evidence to show it doesn?t
hurt? to justify follow-up physical exam measures for evaluation of response to
resuscitation, then why does the same logic not apply to the use of Normsol and
other chloride-balanced crystalloids? I would argue that there is a growing
body of evidence that normal saline may indeed ?hurt? (JAMA.
2012;308(15):1566-1572.; Br J Surg 102 (1):24-36. Crit Care Med 2014;
42:1585?1591.
2. In defending the use of many of these unproven metrics of volume
responsiveness and distal perfusion, you described many of these measures as a
?proxy? measure of ?attentive evaluation? and intensive care. I full agree,
and practice this way. I believe these measures help represent a collective
epi-phenomenon of intensive and regimented care. Using the same reasoning, why
then is there no provision in any of this for providers to document their own
rationale for diverging from some of these restrictive mandates when judged to
be clinically justified. Is this not also a worthy ?proxy? of intensive and
attentive care?
3. When does the clock really start ticking? Our hospitals still don?t have a
solid and reliable answer to this question. Is it when the physician documents
their suspicion of sepsis, 3 hours after a fever and hypotension? When blood
cultures are first ordered one hour after the fever? Or when an MD orders
Tylenol, a CBC, lactate, and blood cultures on someone he/she suspects may be
either bleeding, in pain, or possibly infected post-Op? When do these types of
patients really ?declare? themselves septic.
The efforts to try to ?capture? every element of Goal-directed care in an
?all-or-none? pass/fail algorithm dooms itself from the beginning. Why didn?t
CMS just start off with the 3 hour bundle, monitor how others do with the 6
hour bundle, and try to figure out where (and why) their algorithm is
succeeding, or failing, to capture (and enforce) best practice?
I?ve augured to my group that there is absolutely no excuse for not getting
blood cultures, a lactate, and fluids on board within one hour of a high
suspicion of sepsis. This is a low bar we should all be meeting, but probably
aren?t. Why not simply start there, and work our way forward?
Gilman B. Allen, MD
Associate Professor
Department of Medicine
Director of Adult Critical Care Services University of Vermont / Fletcher Allen
Healthcare HSRF 220, 149 Beaumont Ave Burlington, VT 05405-0075 (802)656-9004
Fax: (802) 656-8926
[email protected]
_______________________________________________
Sepsisgroups mailing list
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------------------------------
Message: 2
Date: Thu, 17 Sep 2015 12:02:14 -0700
From: "Townsend, Sean, M.D."
To: "'Reynolds, Stuart'" ,
"[email protected]"
Subject: Re: [Sepsis Groups] Sepsis Core Measure Follow Up
Message-ID:
Content-Type: text/plain; charset="us-ascii"
In discussing this issue, I always start from the premise that you should never
do anything that you truly believe will cause actual harm to your patient,
regardless of the CMS core measure. That's just common sense. I typically
imagine this type of situation applying to a true reason not to resuscitate
with 30 mL/kg - critical aortic stenosis in a 90 year old frail female with
chronic renal failure and peripheral vascular disease. In that case, I'm
willing to fail the core measure and not worry too much.
That said, I would ask you to consider that we have EXACTLY ZERO evidence that
patients who receive the full 30ml/kg bolus suffer adverse consequences from
any large trial in septic shock patients.
Moreover, mechanical ventilation is not necessarily an adverse outcome. I have
facetiously said before, "I'd rather be intubated than dead." Sometimes
patients will need to be ventilated to restore adequate perfusion. If we do
not intubate in those cases we risk further organ failure due to hypoperfusion.
Fear of the ventilator is largely overblown, especially when VAP rates are
uniformly low across the country. Typically if I gave someone too much fluid
in the morning and they were intubated, I'd extubate in the afternoon with a
little furosemide.
Interesting data as far back as the Rivers trial suggest that patients who
received more fluids in the EGDT arm of his trial sustained a LOWER rate of
intubation than those who did not receive fluids EVEN WITH CONCOMMITANT CHF as
a diagnosis. In Rivers, 70.6% of patients were intubated by 72 hours, whereas
those who received EGDT and significantly more fluid 55.6% of patients were
intubated. These data were statistically significant and it should be noted
that 30.2% of controls had CHF and 36.7% in EGDT had CHF. So despite having
more CHF patients in the intervention group and receiving more fluids fewer
patients were intubated.
Why? The reason is that these patients are not presenting to you with their
co-morbidity of renal failure or CHF as their primary problem - they are
presenting with shock. Shock needs resuscitation.
Consider that the American College of Surgeons Trauma guidelines suggest that
Class III trauma patients have lost 1500-2000 mL of blood. This represents a
30-40% blood volume loss and results in symptoms we see in established septic
shock: pulse greater than 120, detectably low blood pressure and pulse
pressure, tachypnea 30-40 per minute and diminished urine output 5-15 mL/hour.
The fluid replacement rule in this circumstance in trauma is to administer both
crystalloid and fluid in a 3:1 ratio compared to the loss.
A Class II patient has lost 750-1500 mL or a 15-30% volume loss, blood pressure
may remain normal, pulse pressure is decreased, respiratory rate 20-30 and the
fluid replacement for those patients is crystalloid (no blood) in a 3:1 ratio.
Clearly the 3:1 ratio in trauma exceeds needs in septic shock because ongoing
losses are less rapid, however even with these degrees of quantifiable initial
volume loss (up to 2 liters in Class III patients), a 30 mL/kg bolus is
essentially just replacing the loss that produced the observable physiology in
an 70 kg patient.
Thus, in shock states, these rates of fluid resuscitation are not unusual and
correspond to signs and symptoms we see clinically with our "attentive
evaluation" of septic shock patients.
Finally, to make the final point, in the three most recent trials, again
patients with CHF and chronic renal failure were not excluded from enrollment
in the trials. If you look at the volume of fluid these patients received it
quickly reaches the 30mL/kg threshold and goes beyond.
In ProCESS the EGDT group received 2805 +/- 1957 mL, the usual care group
received 2279 +/- 1881 mL. In ARISE, EGDT received 1964 +/1 1415 mL, usual
care 1713 +/1 1401 mL. In ProMISE EGDT received 2000 mL average, usual care
1784 mL average.
In general, I usually present this information to others by saying, "first do
not harm, but think about whether the harm you are not doing is really there."
Second, decide if mechanical ventilation (if the evidence were wrong that rates
are lower with fluid resuscitation) is really that harmful. Third, remember
you are treating shock, comorbidities are secondary issues at best if
physiological parameters are as abnormal as we see in Class II and Class III
trauma patients. Lastly, in all the large trials patients tolerated these
fluid boluses.
From: Sepsisgroups [mailto:[email protected]] On
Behalf Of Reynolds, Stuart
Sent: Wednesday, September 16, 2015 4:20 PM
To: [email protected]
Subject: [Sepsis Groups] Sepsis Core Measure Follow Up
I agree with Dr Allen's comments below.
The mandated 30ml/kg IVF bolus may be harmful; if 20ml/kg or 10ml/kg is
sufficient to improve perfusion; particularly in patients with acute lung
injury, or those with underlying heart or kidney disease.
This reflex dosing takes away from the "attentive evaluation". It is this
"attentive evaluation" which requires incentive.
Many will need to practice down to these bundles and put their patient at risk
to meet the CMS Core requirements.
1. 3 hours to volume resuscitate
2. 6 hours to assess volume status (which is only required if on
vasopressors)
3. 6 hours to add vasopressors in the setting of fluid unresponsiveness
4. Normal Saline (pH 5.5, Cl 154) versus balanced salt solutions like
plasmalyte (pH 7.4, Cl 98)
Here's the irony:
* If one is responsive to the patient's needs and prescribes 20 ml/kg
in the setting of hypotension, because reassessment reveals improved perfusion
and reversal of hypotension, this attentiveness results in penalty. If one
however in unobservant, automatic and simply prescribes 30ml/kg IVF over 3
hours, starts norepinephrine within 6 hours (patient may have required at hour
1 or 2), and evaluates the patient within 6 hours - they've checked all the
boxes and have met criteria with respect to volume, vasopressor initiation and
clinical assessment.
* Don't forget a patient with SBP <90 mmHg whose response to a fluid
bolus of 20-30ml/kg over 30min resulted in SBP >90 would not have met
inclusion into the EGDT trial. Arise and Process also required fluid
unresponsiveness before being enrolled.
* It's the unresponsiveness to fluids that determined enrollment; as
determined by an "Attentive Evaluation" after a fluid bolus.
Sincerely,
Stuart F Reynolds, MD FRCPE FCCP
Director Critical Care Services
Clinical Professor Critical Care Medicine MUSC AHEC
[cid:[email protected]]
101 East Wood Street | Spartanburg, SC 29303
o: 864-560-6531
e: [email protected] | w: SpartanburgRegional.com
Sean,
I attended your webinar on Sepsis Core measures last week and was left with a
number of concerning questions:
1. If we are using the logic that "there is no evidence to show it doesn't
hurt" to justify follow-up physical exam measures for evaluation of response to
resuscitation, then why does the same logic not apply to the use of Normsol and
other chloride-balanced crystalloids? I would argue that there is a growing
body of evidence that normal saline may indeed "hurt" (JAMA.
2012;308(15):1566-1572.; Br J Surg 102 (1):24-36. Crit Care Med 2014;
42:1585-1591.
2. In defending the use of many of these unproven metrics of volume
responsiveness and distal perfusion, you described many of these measures as a
"proxy" measure of "attentive evaluation" and intensive care. I full agree,
and practice this way. I believe these measures help represent a collective
epi-phenomenon of intensive and regimented care. Using the same reasoning, why
then is there no provision in any of this for providers to document their own
rationale for diverging from some of these restrictive mandates when judged to
be clinically justified. Is this not also a worthy "proxy" of intensive and
attentive care?
3. When does the clock really start ticking? Our hospitals still don't have a
solid and reliable answer to this question. Is it when the physician documents
their suspicion of sepsis, 3 hours after a fever and hypotension? When blood
cultures are first ordered one hour after the fever? Or when an MD orders
Tylenol, a CBC, lactate, and blood cultures on someone he/she suspects may be
either bleeding, in pain, or possibly infected post-Op? When do these types of
patients really "declare" themselves septic.
The efforts to try to "capture" every element of Goal-directed care in an
"all-or-none" pass/fail algorithm dooms itself from the beginning. Why didn't
CMS just start off with the 3 hour bundle, monitor how others do with the 6
hour bundle, and try to figure out where (and why) their algorithm is
succeeding, or failing, to capture (and enforce) best practice?
I've augured to my group that there is absolutely no excuse for not getting
blood cultures, a lactate, and fluids on board within one hour of a high
suspicion of sepsis. This is a low bar we should all be meeting, but probably
aren't. Why not simply start there, and work our way forward?
Gilman B. Allen, MD
Associate Professor
Department of Medicine
Director of Adult Critical Care Services University of Vermont / Fletcher Allen
Healthcare HSRF 220, 149 Beaumont Ave Burlington, VT 05405-0075
(802)656-9004
Fax: (802) 656-8926
[email protected]
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