Long Term Care Skilled nursing facility Early Sepsis sepsis algorithm for adults Identification Suspected infection and 2 or more SIRS criteria Early detection tool 100-100-100 Suspected infection SIRS criteria Saves Lives Fever/chills Temp ≥100.0 or ≤96.8 Currently on antibiotics Pulse ≥100 Severe sepsis, a rapid onset Cough/SOBS BP <100 or >40 mmHg from baseline Cellulitis/wound drainage Resp. rate >20/SpO2 <90% NO of organ dysfunction caused Weakness Altered mental status by an overwhelming immune SIRS = Systemic Inflammatory Response Syndrome Negative response to infection, is a screen deadly threat to residents. YES for sepsis Prior to calling provider Positive MHA coordinated Seeing screen  Educate resident/family about status for  Review Advance Directives and options Sepsis, a program to decrease sepsis Early detection the incidenceEarly of sepsis. detection Notify provider saves lives. Currently thesaves national mortality lives. rate is 16%. If this was reduced Transfer Stay in facility 10% to 40% 28,692 to 114,770  Prepare If Advance Directives and/or resident’s wishes are in transfer sheet agreement, consider some or all of following order options: lives would be saved. This is  Call ambulance  Labs: CBC w/Diff, lactate level (if possible), UA/UC, blood  Call report to cultures if able; from 2 sites, not from lines. Send all labs ASAP. for all patients, not just long hospital term care.  Report positive Establish IV access for the following: sepsis screen  IV normal saline 0.9% @ 30ml/kg if BP <100  Administer IV, IM or PO antibiotics  Comfort care

Monitor for progression into Multisystem Organ Dysfunction Syndrome Comfort care Examples:  Pain control  Progression of symptoms despite treatment  Analgesic for fever  Urine output <400ml in 24 hours  Reposition every 2-3 hrs  SBP <90 despite IV fluids  Oral care every 2 hrs   Altered mental statusYes Offer fluids every 2 hrs  Keep family informed Consider transferring to another level of care -  ACT FAST! hospital, palliative, or hospice Adjust care plan as needed Early detection of SEPSIS requires fast action Intermediate care and assisted If resident has suspected infection AND two or more: Every hour a resident living algorithm for adults • Temperature >100°F or <96.8°F in septic shock doesn’t • Pulse >100 • SBP <100 mmHg or >40 mmHg from baseline receive antibiotics, Suspected infection and 2 or more SIRS criteria Early detection tool • Respiratory rate >20/SpO2 <90% 100-100-100 Altered mental status Suspected infection SIRS criteria • the risk of death Fever/chills Temp ≥100.0 or ≤96.8 Currently on antibiotics Pulse ≥100 Plan for: increases 7.6% Cough/SOBS BP <100 or >40 mmHg from baseline • Review advance directive Cellulitis/wound drainage Resp. rate >20/SpO2 <90% NO • Contact the physician Call the doctor! Weakness Altered mental status • Contact the family SIRS = Systemic Inflammatory Response Syndrome If transferring resident to hospital: Negative • Prepare transfer sheet YES screen • Call ambulance for Call in report to hospital Prior to calling provider • Positive sepsis Report positive sepsis screen • screen x Educate resident/family about status x for Review Advance Directives and options If resident stays in facility, consider options below sepsis that are in agreement with resident’s advance directives: Is their • Labs: CBC w/diff, lactate level (if able) temperature Notify provider • UA/UC, blood cultures, as able from 2 sites, above 100? not from lines • Establish IV access for IV 0.9% @ 30ml/kg Is their Administer IV, PO or IM antibiotics • heart rate Transfer Stay in facility • Monitor for worsening in spite of treatment, above 100?Severe sepsis and septic shock such as: Care of the resident x Prepare transfer If Advance Directives and/or resident’s wishes are in • Urine output <400ml in 24 hours Is their sheet agreement, consider some or all of following order options: x • SBP <90 despite IV fluids Call ambulance x Administer new oral antibiotics blood pressureOUTCOME DEFINITION DISTINCTIONSx • Altered mental status Call report to hospital x Encourage oral fluid intake below 100? x x Comfort care: Initiate the 100, 100,Report 100 rulepositive staff screen. sepsis x Comfort care • x Symptoms: Just screendon’t look right. Resident weak, more confused, and have other symptoms of • Pain control And does the resident just not infection • Analgesic for fever look right? Tell the nurse, o Urinary Tract = frequency, urgency, burning on urination, or pain Respiratory = cough, shortness of breath, increase in sputum • Reposition every 2-3 hrs Symptom o screen for sepsis and notify Skin = draining wound, redness, swelling, and warm to touch • Oral care every 2 hrs Identification o o Neurologic = confusion, headache, stiff neck and sensitivity to light Offer fluids every 2 hrs the physician immediately. x • Notify the RegisteredMonitor Nurse for progression into Multisystem Organ Keep family informed x Identify Advance Directive Wishes Comfort care • Dysfunction Syndrome • Adjust care plan as needed x Notify the Physician x Pain control x Call Family Consider transferring to another level of care Examples x Analgesic for fever • x Verify Residentx Wishes such as palliative care, hospice or hospital Progression of symptoms despite treatment x Reposition every 2-3 hrs No treatment Advance Directives o x Altered mental status x Oral care every 2 hrs o Treat and do not transfer x Keep family informed ComfortConsider Care transferring to another level of care - o x Adjust care plan as needed Initial LTC bundle x Obtain Cultureshospital, and Blood SNF, for Lactate palliative Level or hospice) Based off Level of x Start IV and give fluids Care and Ability x Start Antibiotics x Identify resident /family wishes to treat in acute care hospital x Transfer Triggers Lactate greater than 4 Transfer Trigger o Severe sepsis and septic shock o Persistent hypotension despite fluid resuscitation o Evidence of organ dysfunction Care of the resident o Progression of symptoms

OUTCOME DEFINITION DISTINCTIONS PROCESS

x Initiate the 100, 100, 100 rule staff screen. Surviving Sepsis Campaign’s 3- and 6-hour Bundles: x Symptoms: Just don’t look right. Resident weak, more confused, and have other symptoms of infection WITHIN 3 HOURS: Advance Directive Bundle: x x o Urinary Tract = frequency, urgency, burning on urination, or pain Measure lactate level. Treatment status x x o Respiratory = cough, shortness of breath, increase in sputum Obtain blood cultures prior to administration of Code Status Symptom x o Skin = draining wound, redness, swelling, and warm to touch antibiotics. Comfort Care Status Identification x o Neurologic = confusion, headache, stiff neck and sensitivity to light Administer broad spectrum antibiotics. o Analgesic for fever x Notify the Registered Nurse x Administer 30 ml/kg crystalloid (0.9% Sodium Chloride) o Pain Control x Identify Advance Directive Wishes for hypotension or lactate ≥4mmol/L. x Notify the Physician x Identify resident wishes to be transferred for care. x Call Family ADDITIONAL PROCESSES x Verify Resident Wishes x Percent antibiotics administered w/in 1 hour of triage (= first set of vital signs) or w/in 1 hour of Code Sepsis activation. o No treatment Advance Directives x Serum lactate w/in either 3 hours of triage or w/in 3 hours of Code Sepsis activation. o Treat and do not transfer x Adherence to Sepsis Transfer Protocol within appropriate time frame. o Comfort Care x Adherence to Sepsis Trigger Tool. Initial LTC bundle x Obtain Cultures and Blood for Lactate Level x Advance Directive. Based off Level of x Start IV and give fluids Care and Ability x Start Antibiotics x Identify resident /family wishes to treat in acute care hospital x Transfer Triggers Lactate greater than 4 Transfer Trigger o o Persistent hypotension despite fluid resuscitation o Evidence of organ dysfunction o Progression of symptoms

PROCESS

Surviving Sepsis Campaign’s 3- and 6-hour Bundles:

WITHIN 3 HOURS: Advance Directive Bundle: x Measure lactate level. x Treatment status x Obtain blood cultures prior to administration of x Code Status antibiotics. x Comfort Care Status x Administer broad spectrum antibiotics. o Analgesic for fever x Administer 30 ml/kg crystalloid (0.9% Sodium Chloride) o Pain Control for hypotension or lactate ≥4mmol/L. x Identify resident wishes to be transferred for care.

ADDITIONAL PROCESSES x Percent antibiotics administered w/in 1 hour of triage (= first set of vital signs) or w/in 1 hour of Code Sepsis activation. x Serum lactate w/in either 3 hours of triage or w/in 3 hours of Code Sepsis activation. x Adherence to Sepsis Transfer Protocol within appropriate time frame. x Adherence to Sepsis Trigger Tool. x Advance Directive.