SEPSIS

Jeannine Gerolamo, MSN, BS, CPPS

Safety/Quality Specialist
The Center for Patient Safety and Healthcare Quality

Dr. Christopher Hartwell

Emergency Room Physician

Kelly Purpura MSN, RN

Sepsis Nurse Navigator
Rory’s Story

• https://www.youtube.com/watch?v=t4FQrRRTUnY
The Stages of Sepsis

• Sepsis = SIRS plus a presumed or known infection

• Systemic and toxic response to infection leading to
severe sepsis
• Severe sepsis =acute organ dysfunction (decreased
urine output, change in mental status, difficulty
breathing, abdominal pain) due to a known or
suspected infection
• Septic shock= severe sepsis plus hypotension that
does not respond to fluid resuscitation
Sepsis Statistics

• 750,000 Americans diagnosed annually- 220,000 die

• National mortality rate= 25-50%
• Abington mortality rate (to date) ≈14%
• Preventing progression from severe sepsis to septic
shock:
• Saves approximately $3,000 per patient
• Decreases morbidity and mortality
• Sepsis is the most expensive disease to treat- estimated
$24 billion annually
• Thousands of survivors with life-altering effects
Why is Sepsis So Unique?

• It can be so subtle
• Not simple to diagnose- no biomarker
• Very different from stroke, MI- it is a syndrome, not a
disease
• The most lethal killer in hospitalized patients
• Patients don’t die from infection, but from the body’s
response to the infection
• Treatment is generally the same regardless of source,
patient age, comorbidities
Who Can Develop Sepsis?

• Anyone can get sepsis, but it is most common in patients who:

• Are very young/Are very old

• Aging population- highest risk age group >65yr
• 13 times more likely to get sepsis and mortality >50%
• Current illness
• Are immunocompromised
• Have wounds or injuries
• Have serious comorbidities
• Have invasive devices
• Drug-resistant bacteria
Causes

• Any type of infection can lead to sepsis

• Most common infections
• Pneumonia
• Abdominal infection
• Kidney infection
• Bloodstream infection
Prevention

• Get vaccinated against the flu, pneumonia, meningitis

and any other infections that could lead to sepsis
• Prevent infections that can lead to sepsis by:
• Cleaning scrapes and wound
• Practicing good hygiene (e.g., HAND WASHING,
bathing regularly)
• If your patient has an infection, look for signs like:
fever, chills, rapid breathing and heart rate, rash,
confusion, and disorientation
• Smoking cessation
Why is Early Detection so Important?

• Vital in preventing advanced illness and death

• Decreased morbidity and mortality
• Decreased progression to septic shock
• Decreased overall length of stay
• Decreased length of stay in ICU/PCU
• Cost savings ($24 billion annually)
• Every hour antibiotics are delayed results in an increase in
mortality by 7.6%
Standard Initial Treatment

• IVF
• Blood cultures
• Measure lactic acid
• Administer broad spectrum antibiotics
Background Information

• Henry Ford Hospital

• Detroit, MI
• 877 Bed Tertiary Care Facility
• Level 1 Trauma Center

• Training
• Emergency Medicine
• Internal Medicine
• Critical Care Medicine
Goals of the Lecture…

• How do patients present to the ETC from a nursing home or

rehab facility?

• What information do we need as providers for these

patients?

• How do we diagnose and treat patients with sepsis?

How do patients present to the ETC from
a nursing home or rehab facility?
Sometimes…
Patient X

• I am working clinically the 5P – 2A shift

• Stop seeing patients at 1P
• 99% of the time nothing in the last 20 minutes
• Ankle sprain
• Laceration
• R/O UTI

• Something Simple…
Patient X

• EMS Call at 12:48AM

• 68 F with PMH HTN, DM, Morbid Obesity, Called for AMS

• Having difficulty getting vitals, (? Don’t have the right cuff)
• Not breathing well
• Tachycardia in the 130’s
• Can’t establish IV
• DNR/DNI, No invasive measures…
 Patient X Patient X
• Arrival VS… • DNR/DNI/No Invasive measures

• HR 140’s
• BP 68/40 • Arrives at 12:58
• RR Agonal
• Temp 102.7
• Pulse Ox – Could not obtain… • Pronounced at 1:10
Sometimes…
Patient Y…

• 74 M, recent hospital stay for SBO,

still has indwelling Foley presents
with some blood in catheter causing
retention
• Pt looks great on my exam, foley
switched out, output 1100 cc
urine. Flushed for hematuria, and
• EMS AO X 3
now clear…
• HR 104
• RR 21
• Temp 99.3 • Urine not grossly infected
• Pulse Ox 98%
• BP 136/90
• Labs unremarkable
• No WBC count, Creatinine stable
• EMS States Nurse who takes care of • +/- UTI
him said he seemed “off” earlier • Lactate NML
today
“Seemed Off”

• Not really sure what that means…

• Called Nursing facility

• Nurse gone for day, night nurse states he looked fine to her…

• Patient refusing to stay in hospital…

• Was just here
• Wants to go back to facility
 Options

• Patient is AOX3, Set up IV ABX at

facility Vs PO Abx?

• Make him leave AMA?

• Convince him to stay overnight?

• VS normalized (? Retention)
• Problem resolved

• Sign him out to oncoming

physician?
• Go home and have a beer
Plan – All because he seemed “off”

• He will stay for a bit… Refused overnight stay in hospital

• Dose of IV ABX

• We will watch for a few hours

• Arrange Abx at Nursing home

ED that night…

• Walked by room a couple of

hours later…

• VSS..
• Sleeping…

• I will roll with it

• Let him sleep
• More observation time
• Abx are in
Patient wakes up 4.5 hours later…
Stroke patient comes in via EMS…

• Patient will be delayed again a bit…

NOW !!!
Can’t get him D/C fast enough…

• Explained delay in D/C

• Ambulance in 30….

• Nurse Finishing up final

instructions…

• IV Out, D/C instructions up…

Something wrong…

• Pt confused again, slightly agitated

• Repeat VS…
• HR 130’s
• RR 24
• Temp 101.7
• BP 86/45
Something Wrong…

• Redraw Labs, Re establish 2 IV’s • Case Follow-up

• Volume resuscitation
• Lactate 3.4
• WBC 14,000
• Pressure Bag 2.5 L in • ESBL Ecoli in Urine
• (30 cc/kg) • CX positive
• Started Pressors • Was eventually D/C back to NH
• Broadened ABX after few days in hospital

• Admitted to ICU
All because the nurse said he was “Off”
What information do we need as providers for
these patients?

• Why are they being sent in?

• Weakness vs Left side weakness
• Duration of symptoms
• Let us know what your concern
• Code Status !!!
• What are their medical wishes?
• Are they DNR/DNI, DNH?
• Family Contact Information
• Direct line if possible to discuss case with nursing provider
• Accurate medication list with allergies
• Call and speak with a provider
How do we diagnose and treat a patient with
sepsis?

• Clinical Presentation
• SIRS, QSOFA?
• Quick Sepsis Organ Failure Assessment
• Mentation, RR, BP

• Exam, Labs, Imaging

• Advanced diagnostics
• LP, Peritoneal aspirate, Joint aspirate
• Advance imaging
• CT, MRI

• Most common sources clinically

• Pneumonia, Urine, Skin
How do we diagnose and treat a patient with
sepsis?

• Treatment
• IV Resuscitation (NS or LR)
• Source Control
• Do they need surgery, drainage of an abscess?
• Broad Spectrum Antibiotics
• Ok to tailor down once bug is identified
• Refractory hypotension
• Pressors
• Steroids
• Advanced volume/cardiac measurements
• Clearsight
• Vigileo
How do we diagnose and treat a patient with
sepsis?

• Overall aggressive and fast treatment saves lives…

• This is not someone to sit on in NH...

• Treat this subset of people as you would an MI, or a CVA

• The earlier, the better…

Pearls…

• Mind your vital signs… Follow Trends.. Take accurate VS

• RR - 23
• AMS is always a concern…
• Fever in the elderly is always a concern…

• Earlier treatment and intervention saves lives…

• EGDT Study, Rivers et al, NEJM 2001
• 16 % reduction in mortality

• Always err on the side of caution…

• You will save a life if you do…
Thank you…
References available upon request…
After Sepsis Care
• Pay close attention to these patients and provide
interventions to prevent them from getting sick again.
• Monitor for signs of fluid retention
• Thorough respiratory assessments
• Keep legs elevated
• May need evaluation for short term diuretic or increase in
current diuretic
• Antibiotics
• Do not skip doses
• Administer the medication as prescribed.
• Offer the resident yogurt or a probiotic
• May help preserve normal gut flora while taking an antibiotic.
• Frequent loose bowel movements while on an antibiotic or
after stopping an antibiotic (could be months later)
• Discuss the possibility of clostridium difficile (c-diff).
After Sepsis Care

• Patients recovering from pneumonia

• Order an incentive spirometer
• Encourage cough and deep breathing exercises

• Get patients out of bed

• Will help mobilize secretions and prevent atelectasis.

• If appropriate encourage a lot of water

• Can help thin out secretions so patients can cough and
expectorate.
Sepsis Prevention
The key to preventing sepsis is to prevent infection

• Frequent and THOROUGH handwashing is most important

• Can prevent 1 in 3 diarrhea related sicknesses
• Can prevent 1 in 5 respiratory infections

• Get recommended vaccines (Flu, PNA)

• CDC recommends Prevnar 13 & Pneumovax 23

• Keep insertion sites for catheters, drainage tubes, breathing

tubes, and central lines clean and dry.
 Maintain aseptic technique for cleaning sites.
 Proper cleaning and maintenance of foley catheters (especially after
bowel movements) and central lines (scrub the hub for 15 seconds,
every time you access the port).
Sepsis Zone Tool for Patients
References

• Agency for Healthcare Research and Quality http://www.ahrq.gov/

• Center for Medicare and Medicaid Services (https://www.cms.gov/)
• Elsevier Sepsis 2016: Updates Nurses Need to Know
• Hospitals and Health Networks http://www.hhnmag.com
• Mayo Clinic (
http://www.mayoclinic.org/diseases-conditions/sepsis/more-about/resources/ssc-
20169823
)
• Royal College of Physicians National Early Warning Score (NEWS): Standardising the
assessment of acute-illness severity in the NHS retrieved April 29, 2015 from
https://www.rcplondon.ac.uk/sites/default/files/documents/national-early-warnin
g-score-standardising-assessment-acute-illness-severity-nhs.pdf
• Surviving Sepsis Campaign (
http://www.survivingsepsis.org/Guidelines/Pages/default.aspx)
• The Advisory Board Company (
https://www.advisory.com/technology/crimson-continuum-of-care/members/resou
rces/infographics/2013/improving-sepsis-outcomes-with-crimson
)
• The Joint Commission Centers for Disease Control and Prevention (
http://www.cdc.gov/sepsis/basic/qa.html)