Search and Rescue: The keys to Surviving Sepsis

1. Search and Rescue: The keys to Surviving Sepsis Emmel B. Golden, Jr., MD, ICU Medical Director Melanie Polzin, RN, CCRN, ICU Head Nurse Mary Ann Northern, PI Specialist July 22, 2008

2. Baptist Memorial Hospital- Memphis • 706 bed tertiary care hospital • 38 bed general ICU • 28 medical -surgical; 10 neuro • Intensivist-led, open unit model • 22 bed CVICU

3. ICU Medical Director Intensivists Nursing PI Specialist Clinical Pharmacist Respiratory Therapist Dietitian Staff Development Physical Therapist Speech Therapist Infection Control Case Manager Staff Development Palliative Care nurse ED nurse Lab- medical technologist Our Team Members

4. Commitment to Improvement • Multidisciplinary team • IHI Model for Improvement • Aim, Measures, Process Changes, PDSA cycles • Incorporating principles of reliability • Using data to drive improvements

5. Six Years on the Path to ExcellenceFY 2002- Present • 40% reduction in ICU Length of Stay • 39% reduction in ICU mortality • 48% decrease in ventilator length of stay • 23% reduction in VAP rate • 33% drop in BSI rate • 50% reduction in Sepsis mortality rate for protocol patients (40% in 2004 for all patients coded in severe sepsis/septic shock. In 2007 mortality was reduced to 19% for protocol patients.) 

6. Establishing the Foundation: ICU Process Changes 2003- 2008 • Intensivist coverage for nights and week-ends • Multidisciplinary rounds • ICU Daily goal sheet/ Patient Plan of Care • Pre-extubation worksheet • Care bundles: Ventilator, Central Line, UTI • Clinical Pharmacy rounds • Glycemic control protocol and policy • Medical Response Team

7. More ICU Process Changes • Sepsis screening • Severe Sepsis protocol order set, including resuscitation and management bundles • Active surveillance/screening for MRSA • Flexible visitation • Now testing a Sedation Protocol

8. Sepsis: Getting Started • Severe Sepsis/Septic Shock Protocol Incorporated resuscitation and management bundles • Start small- lactates • ED & ICU Collaboration • Relationships

9. Early Identification is Key • Screening tools • All ICU admissions & >3day LOS • High risk units- critical care, stepdown, oncology • ED • MRT calls • Case management

10. What we know about our Septic Patients • The ED is a high volume location for septic or potentially septic patients • 78% start their hospital stay in the ED • High Risk Patients- Pneumonia, UTI, Devices

11. Sepsis Bundle Implementation • Start with one patient, one MD, one nurse • One-on-one with physicians • Staff education • Multidisciplinary involvement • Spread • ED/ICU collaboration for resuscitation bundle • Prioritizing ICU bed

12. Sepsis Resuscitation Bundle Serum lactate Blood Cultures Antibiotics CVP Fluids

13. Sepsis Resuscitation Bundle Reliabilty

14. Sepsis Management Bundle Low dose steroids Drotrecogin alfa according to policy Glucose control Inspiratory plateau pressure <30 cm H20

15. 2004 DRG data: 40% mortality Jan06- Apr08: 18% (264 protocol patients) Sepsis Mortality

16. Where are we after 2 ½ years? Good news: • For patients on the protocol, mortality is consistently 20%- historical mortality 40% • ED is now able to volume resuscitate patients • Able to move patients quickly to ICU bed • Identified in ED • Notified by ED • Nurses can execute the protocol • Nurses have accepted the protocol

17. Where are we after 2 ½ years? Fall short: • MDs- “culture eats protocol for breakfast” • Patients not coming from the ED are less likely to go on the protocol • Capture rate for protocol is not 100% for patients that meet criteria for protocol

18. Questions?