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- 2. Purpose Develop an evidenced based protocol that will allow rapid identification of sepsis and to educate and empower nurses to use the protocol to manage patients with severe sepsis
- 3. Background Sepsis is a complex condition that is often life-threatening. It is characterized by hematological disorders and a pronounced inflammatory response to an infection or injury. Sepsis accounts for 215, 00 deaths in the United States each year at a cost of more than $16 billion. Septic shock remains the most frequent cause of death in non-cardiac ICU’s 0 50 100 150 200 250 Thousandsofdeaths/year Cause of death Picard, O'Donoghue, Young-Kershaw, & Russell, 2006
- 4. Methods Identification of patient’s with suspected infection Patients > 18 yrs. Within one hour of admission Level 1 emergency room
- 5. Inclusion Criteria Patients > 18yrs or older with signs/symptoms of infection Meets two or more of the following for systemic inflammatory response syndrome: Temperature > 100.4 F or < 96.8 F Heart rate > 90 beats/min Respirations > 32.min or Paco2 <32 mm Hg White blood count > 12,000 cells/mm3 or < 4,000 cells/mm3
- 6. Protocol Central line insertion with continuous Scvo2 monitoring Broad Spectrum ABX CVP <8-12 500 mL NS bolus Repeated q 20-30min until CVP >8 mm Hg Monitor lungs sounds for tolerance of boluses MAP <65 Initiate Norepinephrine drip Titrate for a MAP > 65 mm Hg Scvo2 < 70% Hematocrit < 30% Tranfuse 1 unit PRBC Repeat Hgb and Scv02 2hrs after blood transfusion > 30% Initiate dobutamine drip Titrate every 1 hr for Scvo2 > 70% Supplemental oxygen or mechanical ventilation
- 7. Results 300 patients >18yrs 24 months of data collection by trained nurses Serum lactate
- 8. Educating Staff In service programs Grand rounds Poster size sepsis protocol 24hr on call nurse
- 9. Outcomes-Success Goals of therapy will be met within 12hrs Central Venous Pressure (CVP) 8-12 mm Hg Mean Arterial Pressure (MAP) 65-90 mm Hg Mixed Venous Oxyhemoglobin (Scvo2) 70%-80% Hematocrit > 30% Serum lactate < 4mmol
- 10. Barriers Educating a large staff working various shifts. Transferring patients treated by using the protocol in a timely manner. Expediting placement of central venous catheters. Equipment issues.
- 11. Summary Will obtaining serum lactate levels immediately on emergency department (ED) patients, age 18 and older, meeting certain sepsis high-risk prognostic criteria, reduce mortality due to immediate treatment interventions.
- 12. Thank You! Reference Picard, K. M., O'Donoghue, S. C., Young-Kershaw, D. A., & Russell, K. J. (2006). Development and implementation of a multidisciplinary sepsis protocol. Critcal Care Nurse, 26(3), 43-54. Shapire, N., Fisher, C., Donnino, M., Cataldo, L., Tang, A., Trzeciak, S., Horowitz, G., & Wolfe, K. (2010) The feasibility and accuracy of point-of-care lactate measurement in emergency department patients with suspected infection. Journal of Emergency Medicine 39(1), 89-94. Shapiro, N. I., Howell, M. D., Talmor, D., Lahey, D., Ngo, L., Buras, J., . . . Lisbon, A. (2006). Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Critical Care Medicine, 34(4), 1025-1032.
Notas do Editor
- Thank you for the opportunity to describe our study Sepsis in the Emergency Department
- The main objective is to decrease the time between identification of patient with sepsis and the start of the sepsis protocol. ----- Meeting Notes (11/15/11 17:05) ----- as well as empowering nurses and physcians to use the protocol to manage these patients
- The incidence of sepsis has steadily increased during the past several decades, the associated mortality rates have remained constant. As you can see from the graph the comparison of mortality in the US by cause severe sepsis is almost equal to the rate of acute myocardial infarction.
- What we want to do is identify patient’s >18yr suspected of infection and treat them using the sepsis protocol. We want to identify and treat these suspected patient within one hour upon admission to a level one emergency room. To have them transported from the ER to an ICU with initiation of the protocol within 4hrs. Most patients will be admitted to the ICU due to the fact of being placed on vasoactive drips that require titration ----- Meeting Notes (11/15/11 17:05) ----- This type of titration can only be performed in an ICU setting.
- How these patients will be identified. Suspected infection included PNA, meningitis, intra-abdominal infection, UTI. Serum lactate > 4mmol/L
- Data Collection- using electronic medical record. Printing reports such as vital signs, CVP readings, lab results. Trained nurses will collect this information on a weekly basis and enter this data into a system that will provide statistical analysis of the data.
- Serum lactate via iSTAT will be measured before initiation of sepsis protocol and 12 hrs after protocol. Each patient with suspected sepsis will automatically have blood cultures drawn. With this blood drawl, we can go ahead and obtain a serum lactate.
- In service programs will be provided for nursing staff. These in-services will be held at various times to cover all shifts in the ER. Collaboration with the medical director in the ER to help education physicians during their ground rounds as well as online training. Placed in various placed on the ER will be poster size sepsis protocols for reference as well as on on call trained nurse on the sepsis protocol.
- Outcome of interest is reducing the mortality rate of patients with sepsis within 24 hours. We would like to meet the above goals in 12 hrs. CVP….
- We want to know if obtaining serum lactate levels on patients admitted to the ER meeting criteria for sepsis reduces mortality rate when using a specfic set of treament interventions. Thank You