170 Form Standard Work Activity Sheet



SeqNoTask Description: Key Point / Image / Measure(what does good look like?)Who Task Time 0.5Sepsis Alert Team assigned.1 RN and 1 ERT should be assigned at the start of every shift.ED CRN1 min1APatient is triaged and assessed for possible sepsis. Triage RN to complete:ULH ED Triage Form Ensure accurate allergies are documented in triage.ED Sepsis Screening FormUtilize bedside triage when beds are available in ED.Triage RN8 min1BAccurate weight is obtained and documented on patient. If Triage occurs in the Triage area, use standing scale.If Triage occurs at the bedside, Triage RN alerts Sepsis ERT to bring standing scale to the bedside for weight. If patient is non-ambulatory and an alternative scale is not available, document a Critical Estimated Dosing Weight on Triage Form.Triage RNSepsis ERT2 min2If Sepsis Screening is Positive, Sepsis Alert is initiated.+ Sepsis Screening = 2 SIRs + possible source of infection. SIRS Criteria includes:Acutely altered mental statusGlucose GREATER than 140 mg/dl in absence of diabetesHeart Rate GREATER than 90 beats per minuteRespiratory Rate GREATER than 20 breaths per minuteTemperature GREATER than 38.3°C (101.0°F) Temperature LESS than 36°C (96.8°F)WBC GREATER than 12,000/?L WBC LESS than 4000/?LVocera: “Broadcast ED; Sepsis Alert Bed #”.Order “ULH TIO Sepsis Alert” PowerPlan. Transport Pt to room.Notify ED Provider of Sepsis AlertTriage RN5 min3AED PharmD receives sepsis alert.Primary preceptor to respondresident to respond if primary preceptor unavailablestudent to respond if resident unavailablePrimary preceptor will hand Vocera off if they need to step away so that Nursing and Providers can quickly reach an available Pharmacy staff member.If there’s no PharmD in the ED, a sign will be displayed at Pharmacy computer with information on how to contact inpatient pharmacy with any questions.ED PharmD/Triage RN03BPatient’s pertinent past medical history is reviewed in Cerner and Theradoc.Past medical history reviewed on inpatient summaryPrevious laboratory values reviewed under Results Review.Microbiology history reviewed from all cultures obtained at this facility from Results Review Microbiology change Order Start Date Between to one calendar yearBest practice is to look back at least one year.For any positive cultures, note susceptibilities and/or resistance geneticsRecent antibiotic use reviewed from:discussion with patient (if possible)External Rx History Theradoc To find Extrnal Rx History in Cerner go to Medication ListExternal Rx HistoryTo see any anti-infective a patient has received at this facility, go to TheradocMedications drop down box that says “Select a View” select “Anti-Infectives-All”89833081671107951623695001976120162369500ED PharmD5 min4Supplies are gathered and brought to patient room.Sepsis RN gathers: Cardiac leads, SPO2, BP cuff, IV angiocath, connector tubing, IV start kit, saline flush, (2) 10 ml syringes.Sepsis ERT gathers: ISTAT machine, green top blood tube, helicopter transfer device, lactic cartridge. 925830102870Sepsis RN, Sepsis ERT2 min5Sepsis Alert Team responds to patient room for assessment and plan.Primary RN, Sepsis RN, ED tech, ED Provider, ED PharmD, and ED phlebotomy to meet within assigned room within 2 minutes. ED Provider: decide and verbalize plan of care at bedside. RNs: obtain IV #1, obtain lab work.ERT: perform POC lactic. Report POC lactic to ED Provider.Phlebotomy: gather lab work, and blood cultures. Pharmacy verifies height, weight, and allergies. Pharmacy also reviews vital signs and pertinent history to assess need for appropriate broad-spectrum antibiotics.Primary RN, Sepsis RN, Sepsis ERT, PharmD, ED Provider,Phlebotomy10 min6ED Provider and PharmD collaborate on medications.PharmD makes antimicrobial recommendations as appropriate. Verify allergies in CernerVerify height and dosing weight in CernerIf student is responding to sepsis alert- staff patient with PharmDED Provider/ PharmD5 min7AOrders for Antibiotics and Fluids placed in Cerner.If MAP < 65 and/or serum lactate > 4 mmol/L, order 30ml/kg of fluid (as clinically indicated) for proper fluid resuscitation. Otherwise, order fluids as appropriate.Fluids should be ordered within 60 minutes of Triage.If Severe Sepsis or Sepsis shock present, order Broad Spectrum antibiotics. If (non-severe) sepsis is present, order focused antibiotics.Antibiotics should be ordered within 60 minutes of Triage.ED Provider/ED PharmD5 min7BAntibiotics and Fluid orders verified.Orders to be verified within 10 minutes of being placed.ED PharmD5 min8All other necessary orders placed in Cerner.ED Provider will go from Sepsis Alert back to computer to place orders in real time to ensure timely ordering and aid in quick completion of orders. CBC, CMP, POC Lactic (if not ordered in triage)Blood Cultures (BC) (ensure order is in for phlebotomy to collect, back time, and send down to lab)Chest X-rayPOC UrinalysisRepeat Lactic for now+2H if initial Lactic 2.0 or greaterED Provider5 min9Perform POC Urinalysis.If patient is unable to provide urine sample within 1 hour of order, advocate for a straight catheter order to collect the specimen prior to antibiotic administration.Primary RN / ERT10 min10Expedite Chest X-ray (if ordered).Mark patient “Off Monitor” or “On Monitor” on FirstNet Tracking Board, and call X-ray at ext. 3111 to request x-ray be completed ASAP.Primary RN / ERT2 min11Antibiotics obtained.Obtain antibiotics from unit-based dispensing cabinet (UBC) or call inpatient pharmacy to have antibiotics tubed. Mix antibiotics if necessary. Obtain primary tubing and IV pumps and prime antibiotics.Hand antibiotics to primary RN for administration. Assist with other medication/fluid procurement as necessary.ED PharmD5 min12Broad-spectrum antibiotics administered within 1 hour of order.Validate that antibiotics have been verified by PharmD.Ensure BCs collected in Cerner prior to administration.Gather antibiotics from UBC or PharmD.Mix antibiotics (if necessary).Gather IV tubing.Gather IV pump.Set-up computer to scan antibiotics.Scan patient.Scan antibiotics.Administer antibiotics.Primary RNED PharmD10 min13Fluids administered within 30 minutes of order. Validate that fluids have been verified by PharmD.Gather fluids and IV tubing.Gather IV pump.Set-up computer to scan fluids.Scan patient.Scan fluids (may have to try more than once if barcode doesn’t read).Administer fluids.Ensure completion of fluids within 3 hours of Triage.Primary RNED PharmD10 min14Document interventions in Cerner and Theradoc.Theradoc interventions: Antimicrobial Stewardship: Drug OptimizationAntimicrobial Stewardship: No Antibiotic CoverageInpatient: New Therapy RecommendationPharmacokinetic note documented in EMR as appropriateED PharmD5 min15Call Sepsis Response Team to evaluate patient.Document Provider Consult in EMR.This should be in the ED Provider Note, and include:Time calledWho was calledWhen they called backED Provider< 3 Hour16Repeat Lactic drawn (if initial POC Lactic is 2.0 or greater).Ensure order is placed and blood is drawn for repeat Lactic Acid timed for 2 hours after initial POC Lactic.Primary RN3 min17Patient closely monitored. Primary RN to monitor patient closely and ensure all ancillary orders are completed. Continue to do so, until disposition determined (discharge or admission). Primary RNVaries18ARe-evaluate patient’s volume status.If septic shock – repeat evaluation of patient’s volume status after fluid bolus – repeat lactic acid, repeat volume stats (US or Physical Exam) within 6 hours.Provider18BConsider Vasopressor.If persistent hypotension after fluids complete, start vasopressor.Provider19APatient Disposition Decided.If patient is stable: discharge. (rare cases)If severe sepsis is present: admit patient to floor/PCU.If Septic Shock is present: admit patient to the ICU.ED Provider19BPatient Admitted.Diagnosis of Sepsis added to patient’s list of Problems.SRT/ Admitting Provider ................
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