Worldwide, 500,000 People Die from Sepsis Annually (1). Sepsis Conveys a Mortality Rate

1/9/2018 Page 1 Background

Worldwide, 500,000 people die from sepsis annually (1). Sepsis conveys a mortality rate of 30-50% (1). Mortality and morbidity are significantly decreased with early administration of appropriate antibiotics, aggressive fluid resuscitation, and control of the source of infection (1,2,3), which requires coordination of nursing and physician resources. Protocols for septic patients encourage efficiency and reduce delays in care (1,2).

Currently, our Emergency Department (ED) does not have a protocol to address patients who are septic. Unlike level 1 Traumas, in which every participant has a specific role and set of responsibilities and in which there are specific decision points with defined outcomes, critically ill septic patients are often treated with some variability. It is clear that early administration of antibiotics, aggressive fluid resuscitation, central line placement, and source control improve patient outcomes (1,2,3), but achieving these goals is extremely difficult without protocols in place to coordinate physician, nursing, and respiratory care.

The goal of this protocol is to improve the efficiency and timeliness of care for patients who present to the ED with sepsis by standardizing and streamlining their care. We have outlined recommendations for evaluation and goals for treatment from a physician and nursing and respiratory therapy perspective. The leadership of the MICU has agreed on this standard workup for septic patients and has pledged to expedite the transfer of septic patients to the ICU. We expect that implementing an aggressive and standardized care protocol for septic patients will improve patient morbidity and mortality, as it has at other hospitals (1).

References:

1. Gao F, Melody T, Daniels D, et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Critical Care 2005, 9:R764-R770.

2. Rivers E, Nguyen B, Havstad S, et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368-77.

3. Rivers E, Coba V, Visbal A, et al. Management of sepsis: Early Resuscitation. Clin Chest Med 29 (2008) 689–704.

1/9/2018 Page 2 STRENGTHS WEAKNESSES 1. The operations in the sepsis alerts will 1. The ED is frequently at overcapacity be similar to Level 1 trauma, STEMI, and stretching staff very thin and causing a stroke alert operations, which are already shortage in physical space for care. well defined. 2. We have a large number of faculty, 2. The ED and MICU already have a residents, and staff that will need training history of collaboration and this initiative and there is frequent turnover of residents has been produced by joint collaboration. and staff. 3. The IT system at Vanderbilt is state of the art and can be used to reduce variability in care and measure process outcomes easily. OPPORTUNITIES THREATS 1. The use of standardized sepsis bundles 1. ED care is affected by the natural is well established to improved morbidity variability in timing/acuity of patient and mortality. arrivals. 2. Multiple organizations have published 2. Healthcare providers are sometimes on their implementation of sepsis bundles. reluctant to standardize patient care due to a longstanding culture of provider autonomy and individualization of patient care.

1/9/2018 Page 3 Sepsis Alert Protocol, VUH Emergency Department

1/9/2018 Page 4 Identify metrics for evaluation: - time to antibiotics - time to disposition - time in ED bed - ICU and hospital LOS - mortality Identify who needs education on initiative: staff leadership team

Nurse champions

Faculty

Residents

Assign accountability and clear timeline:

Action Person Assigned Timeline Status

Develop & Implement Ian Jones, Stephan Russ Dec 09 / Jan 10 Scheduled Faculty Education Plan Faculty Meetings

Develop & Implement Jeremy Brywczynski, Dec 09 Scheduled Resident Education Plan Candace McNaughton

Develop & Implement Kevin High, Jackie Nursing Education Plan Ashburn and more TBD

Create Sepsis Toolbox Kevin High, Jackie Ashburn and more TBD

Identify Nurse Champions Nursing Leadership Nov 09

Develop Sepsis VGR Jones, Russ, Wrenn, Oct 09 Completed McNaughton Brywczynski

Implement Sepsis VGR Asli Ozdas, Stephan Russ Dec 09 Work Underway

Coordinate Sepsis Alerts Kevin High Dec 09 with LF

1/9/2018 Page 5 Action Person Assigned Timeline Status

Create Coordinated Vision MICU/EM Faculty Aug/Sept 09 Completed of Severe Sepsis Care

Education of MICU staff Art Wheeler, Todd Rice Dec 09

Add a section on sepsis McNaughton and ED Dec 09 alerts to the orientation Chiefs guide for rotation residents

Develop plan for sustained success: sustained success will be achieved through ongoing leader rounding for outcomes, incorporation of education into orientation pathway, at least yearly education to staff, sharing of outcomes data with staff linking them to the initiative.

Identify Methods of Content Delivery:

Physician Staff:

Faculty will be briefed in two consecutive faculty meetings and resident physicians will be given a one- hour lecture during one of their regularly scheduled Tuesday conferences. The physician work force will also receive and email with an explanation of the intended plan. The Chief residents will provide yearly education of incoming interns as part of their regularly scheduled orientation, while the ED Medical Director (Ian Jones) will include the sepsis alert protocol in the new faculty orientation. The monthly M&M conference will serve as a method for reviewing an hurdles that might be incurred during the implementation of the sepsis alert program.

Nursing/Paramedic/Ancillary Staff:

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