COOKEVILLE REGIONAL MEDICAL CENTER



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|Title: |Effective/Revised Dates: |Approved by: |

|Adult Sepsis Screening Protocol for CRMC |3/17, 5/16, 3/16, |10/10 | |

| |9/13, 6/13, 6/09 | | |

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|Department: |Review Date: | |

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|Page 1 of 4 | | |PC-239 |

Purpose: Provide early identification and management of patients with sepsis, severe sepsis and septic shock.

• Definitions:SIRS= Systemic Inflammatory Response Syndrome as evidenced by:

-Temperature < 36 °C (96.8F) or > 38 °C (100.4F)

- HR > 90

- RR > 20 or PaCO 2 < 32

- WBC > 12000 < 4000, or > 10% immature (band) forms

The new guidelines state:

• Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection.

• Septic Shock is a subset sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.

The past definitions are defined below as CMS is still utilizing these definitions:

• Sepsis is defined as a documented or suspected infection with two or more signs of SIRS

• Severe sepsis is defined as known or suspected infection, 2 or more signs of SIRS, and organ dysfunction unrelated to primary pathology.

• Septic shock is defined as known infection with 2 or more signs of SIRS , organ dysfunction, and hypotension which is defined as Systolic B/P less than 90mmHg or MAP less than 65 or 40mmHg decrease in B/P from baseline after a 30mL/Kg Fluid bolus or Infection with 2 or more signs of SIRS, organ dysfunction, and hypo-perfusion evidenced by a lactic acid level greater than or

= to 4

• Time Zero = Time the clock starts ticking toward our 3 hour and 6 hour goals. Time Zero for the patient that is in the Emergency Department is time of arrival. Time zero on the floors is when the patient meets criteria for severe sepsis or septic shock allowing 1 hour for patient to respond to fluid see below.

• It is important to note even if the screening looks at SIRS criteria some patients may not exhibit the SIRS criteria that is expected for a septic patient. Patients on beta blockers or immunocompromised patients are just two examples of patients that may not exhibit SIRS when they may clearly be septic. Collaboration with the provider regarding these findings are essential.

• Time Zero for Severe Sepsis and Septic Shock:

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3 Hour Bundle and 6 hour bundles are the goals of care from time zero. They are as follows:

3 Hour Bundle:

• Measurement of lactate level within 3 hours of presentation of severe sepsis

• Broad spectrum antibiotic administration within 1 hour of presentation of severe sepsis. First dose should be ordered stat.

• Blood cultures X2 drawn prior to antibiotic administration if not done in prior 48 hours. (If unable to draw within 45 minutes hang antibiotic).

• Resuscitation with 30mL/kg crystalloid fluids within 3 hours of presentation of septic shock

6 Hour Bundle:

• Repeat lactate level only if initial lactate level is elevated within 6 hours of presentation of severe sepsis

• Vasopressors within 6 hours of presentation of septic shock only if hypotension persists after fluid administration

• Repeat volume status and tissue perfusion assessment within 6 hours of presentation of septic shock only if hypotension persists after fluid administration consisting of either

▪ Focused exam documented by provider which includes ALL the following:

• Vital Signs

• Cardiopulmonary exam

• Capillary refill evaluation

• Peripheral pulse evaluation

• Skin examination

OR

▪ Any two of the following (must also be documented by provider):

• Central venous pressure measurement

• Central venous oxygen measurement

• Bedside Cardiovascular Ultrasound

• Passive Leg Raise or Fluid Challenge

Process

• When an adult patient arrives in the ED with a known or suspected infection, abdominal pain, or altered mental status, they will be screened utilizing the electronic screening tool OR the Adult Severe Sepsis/Septic Shock Screening Tool and Protocol for ED (See Form ER-31)

• Patients at CRMC, where applicable, will be screened utilizing the electronic screening tool OR the Adult Severe Sepsis/Septic Shock screening tool on admission, every shift, and PRN (CVICU/ICU see form 1107-PRN & for other units see form 1138-PRN ).

• (For ED/ICU/CVICU/). If patient’s history is suggestive of a new or known infection and the patient has 2 or more signs of SIRS, the nurse will then order a lactic acid level and blood cultures x2 stat per severe sepsis protocol. If patient has known or suspected infection and 1 SIR the ED nurse can draw a CBC with differential to check the WBC count/presence of Bands. ICU/CVICU sepsis screening to include to screen if any organ dysfunction criteria are present

• For Units other than ED/ICU/CVICU: If patient’s history is suggestive of a known or suspected infection and the patient has 2 or more signs of SIRS, and one or greater organ affected unrelated to primary pathology, the nurse will then order a lactic acid level and blood cultures x2 stat per severe sepsis protocol. The primary nurse will need to communicate with the clinical coordinator prior to drawing the stat labs. (This should not delay the lab draw). If patient fresh post op the evaluation will take place after 36 hours post op. If pt is a CVOR pt the sepsis screening will take place after 48 hours post op. The screening is excluded for Same Day Surgery and Outpatient procedure patients.

Positive Severe Sepsis Screen

• If patient screens positive for severe sepsis (history of suspected or known infection, 2 or more signs of SIRS, and 1 or greater organ affected unrelated to primary pathology) notify the physician for further orders. If systolic BP below 90mmHg or MAP less than 65, notify the physician immediately and obtain an order for a 30mL/kg fluid bolus and obtain order to transfer to step down. Adult Sepsis Orders are available for use. If in ICU or CVICU Nursing to fill out Severe Sepsis/Septic Shock Clinical Pathway (Form 1112-PRN). Patients on Non-Critical Care Units: the nurse to fill out Initial Management of Patients with Septic Shock form (Form 1135-PRN)Nursing to place Physician Progress Note (Form 2000-497) in the patient’s chart under progress notes and notify the physician of the positive screen.

Positive Septic Shock Screen/Code Sepsis

• If patient screens positive for septic shock (patient has known or suspected infection, 2 or more signs of SIRS (may be less if immune-compromised or on beta blockers), and hypotension after fluid bolus or lactic acid greater than or equal to 4) a CODE Sepsis will be paged. Staff to call from phone #5555 and the operator will answer this phone immediately. Nurse to inform operator of Code Sepsis and the operator will notify the following to respond:

• ICU Clinical Coordinator

• Hospitalist Coverage for Code Sepsis

• Clinical Pharmacist (when available)

If the Code Sepsis is called in the Emergency Department, the ED Clinical Coordinator will attend instead of the ICU Clinical Coordinator.

• The Primary Nurse will stay with the patient and work with the Code Sepsis team to give

pertinent details. The Code Sepsis Team will work together to ensure the 3 hour bundle is met and assist with patient being transferred to the appropriate level of care. Primary Provider to also be notified for central line placement, transfer to the ICU (if not already in critical care unit) and obtain order from Provider for the Adult Severe Sepsis/Septic Shock order set.

• Nursing to fill out Septic Shock Clinical Pathway (Form 1112-PRN) if in ICU or CVICU Patients on Non-Critical Care Units: the nurse to fill out Initial Management of Patients with Septic Shock form (Form 1135-PRN) Nursing to place Physician Progress Note (Form 2000-497) in the patient’s chart under progress notes and notify the physician of the positive screen.

Patients with a lactate greater than 2 should have a repeat lactic acid level drawn. This will be a reflex order that automatically orders the lactic acid level to be drawn 2 hours after the first is drawn. Our goal is to normalize the patient’s lactic acid level as soon as possible. The nurse can draw this and send to lab per protocol. If repeat lactate greater than 2 notify the Provider for further orders.

• Nursing is to notify physician of the positive severe sepsis or septic shock screen and document the following

Negative screen

Positive Screen for Sepsis, physician notified

Positive Screen for severe sepsis, physician notified

Positive Screen for Septic Shock, physician notified

Dr. _________________ notified, Date:_____ Time:____

Nurse signature:_______________Date:______Time:____

• Use of Adult Septic Shock Orders to be implemented upon physician order.

• If the patient’s blood cultures are positive the physician should be notified

• If a patient or family refuses treatment this is their right and will be respected. This needs to be documented in the medical record.

References:

• Rhodes et al, Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine. 2017; March.

• Dellinger et al, Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Critical Care Medicine. 2013; 41:580-637.

Form 2000-281 Physician Orders

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