LLUMC Sepsis Activation Process and Bundle Requirements
Definitions:
· Sepsis: 2 SIRS criteria + suspected or known source of infection
o Clinical Suspicion for infection is seen by the system as either:
§ Triage nurse screening positive for infection
§ Antibiotic ordered for proven or suspected infection (not prophylaxis)
· Severe sepsis: Sepsis + evidence of end organ damage or initial hypotension even if it resolves
· Septic Shock: Severe sepsis that does not respond to 30 cc/kg of IV fluids based on actual or ideal body weight or an initial lactate that is >4 mmol/L
End Organ Dysfunction:
· Systolic BP <90 or decrease of more than 40 mmHg from last recorded SBP considered “normal” for that patient or MAP <65. This is on arrival and even if it improves after IVF.
· Creatinine >2.0 (that is new) or urine output <0.5 mL/kg/hr for 2 hours
· Bilirubin (Total) > 2 mg/dL
· Platelet count <100K
· INR >1.5 or aPTT >60 sec
· Lactate > 2.0 mmol/L
· SpO2 <90% on room air
· Elevated troponin
· Altered mental status
PATIENTS WITH SEVERE SEPSIS OR SEPTIC SHOCK REQUIRE 30 CC/KG OF CRYSTALLOID FLUIDS, UNLESS THERE IS AN EXCLUSION TO FLUIDS DOCUMENTED
PATIENTS WITH SEPSIS, WITHOUT END ORGAN DAMAGE, DO NOT.
IF THE PATIENT MEETS SEPSIS CRITERIA (2 SIRS + SUSPECTED/KNOWN SOURCE OF INFECTION) PLEASE ACTIVATE SEPSIS AND USE THE SEPSIS ORDER SET TO EVALUATE FOR END ORGAN DAMAGE EVEN IF YOU THINK THEY MAY GO HOME
1. How do I activate sepsis? What does this do/mean?
· 2 ways to activate:
o Tell the red pod tech/any tech to activate sepsis (this helps our educators track sepsis patients)
§ If telling the tech, please also use the order set
o Signing orders from the sepsis order set
· This lets everyone in the department know there is a septic patient and it gets the bedside nurse the appropriate resources to carry out the sepsis orders. Helps them get a bed prepared for the patient.
· This tells nursing, CCST (critical care specialty transport) nurses, and other staff that patient needs their bundle elements completed (antibiotics, fluids, lactates, etc.)
2. What needs to be done for septic patients?
· CMS dictates that there are 1 hour, 3 hour and 6 hour bundles for patients with severe sepsis. It is difficult to have this all completed in 1 hour when we are unclear about patient’s severe sepsis or septic shock status
o 1 hour bundle
§ 2 sets of blood cultures are collected
§ Lactate and other labs drawn
§ One broad spectrum antibiotic is given after cultures are drawn
§ Administer IV fluids (usually 1500 mL if order set used)
o 3 hour bundle
§ Repeat lactate if first was >2 mmol/L
§ Fluid reassessment
§ Documentation of this reassessment
o 6 hour bundle
§ Need to show a lactate decrease by 60% or lactate <2. Repeat lactate until it is <2.
§ Fluid reassessment and documentation of it
§ Sepsis reevaluation documentation needs to be filed/started
3. What are all of these pop ups?
· If a patient meets 2 SIRS criteria in LLEAP and there is a documented suspected infection by the triage nurse, there is antibiotics ordered, or there is evidence of end organ damage, the “Sepsis Alert – Physician Evaluation Needed” BPA (Best Practice Advisory) will appear as below. It should outline what the SIRS criteria are, where the information with suspicion of infection comes from, and what the end organ damage is, recent vitals, etc
·
If there is no concern for sepsis, you can click the button that says “Do Not Open” next to the “ED sepsis – Adult” order set. Then you should click “Document” next to where you need to “Document to suspend or stop sepsis alerts” (Red Box)
·
To clear sepsis BPA, select an option for reason for suspending sepsis alerts by clicking magnifying glass (Green Box)
· If the patient is septic, you can directly open the sepsis order set from the BPA by clicking accept without changing any options, as it is the default option for this BPA.
4. What do I do about ordering fluids?
· There are three options:
o Patients are given 1500 cc of NS or LR upfront for suspected sepsis without end organ damage
o Patients are given 30 cc/kg of NS or LR of NS or LR upfront for concern of end organ damage (elevated lactate, hypotension on arrival, etc.)
o You don’t feel patient is appropriate for fluids – thus you place a fluid exclusion order and only order 500 cc of fluids
5. I don’t want to give my patient 30 cc/kg of fluids. What do I do?
· Please place a fluid exclusion order and order 500 cc of fluid or any amount you feel comfortable with. CMS states we cannot give zero fluids.
6. I gave the initial 1500 cc of fluids. Do I have to give the rest of the 30 cc/kg of fluids?
· If the patient meets severe sepsis criteria after getting 1500 cc of fluids, yes it is recommended we give the rest of the 30 cc/kg of fluids – can be ideal or actual body weight at discretion of the ED provider, it just must be documented
· You can document an IVC reevaluation that shows patient is not fluid responsive or document a passive leg raise(PLR)/NICOM completed by nursing that states the patient is not fluid responsive.
· There is a BPA when the patient meets criteria for severe sepsis or septic shock that prompts the provider to finish the 30 cc/kg of fluids, document an exclusion, or document an IVC US or PLR.
7. My patient meets severe sepsis criteria on arrival. Should I order 30 cc/kg of fluids?
· Since the patient meets severe sepsis criteria, we would recommend the patient get 30 cc/kg of fluids if they do not have an exclusion.
· If you choose to use the 1500 cc of fluids first, and their BP responds, you can report in the follow up BPA (from #7 above) under “Order” for “Reason patient unable to receive IV fluids for sepsis treatment”, that the patient’s BP responded to less fluid. Without this documentation, 30 cc/kg of fluids is expected.
8. My patient meets severe sepsis criteria. I gave 30 cc/kg of fluids based on ideal or actual body weight. They are still hypotensive. What needs to happen?
· Documentation of a blood pressure within 1 hour of completion of the 30 cc/kg of fluids is required.
· If patient is still hypotensive, despite 30 cc/kg of fluids, vasopressors must be initiated
9. I activated sepsis on a patient. How do I document my sepsis care so that Rossie won’t harass me anymore?
· After using the sepsis order set, please use the dot phrase “.sepsisactivationlluonly”
· If you use the order set and have exclusions ordered for the patient, these will auto populate.
· Otherwise, please place the amount of fluids you ordered, if you used 30 cc/kg of fluid per IDEAL VS ACTUAL body weight, and the time of reevaluation.
· Time of reevaluation must be < 6hours from time of sepsis activation.
· If the patient does not meet severe sepsis or septic shock criteria, simply select the patient does not meet criteria and you are done.
· If the patient does meet criteria for severe sepsis or septic shock, please select that option and this will auto populate. Fill out completely and choose actual vs ideal body weight used. You can also manually select a fluid exclusion here as well.
10. Where can I find ideal body weight?
· Hover over the patient’s vital signs and this window will pop up.
11. Where can I provide any feedback or ask any questions?
· Please at any point reach out to Dan Rossie at drossie@llu.edu, Securechat, or by text at 818-359-4465