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Surviving sepsis, 2013 kristy molnar, critical care consultants

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Surviving Sepsis: Improving Care, Saving Lives
Kristy Molnar
Critical Care Consultants
(sponsored by Philips Healthcare, Alberta Health Services and supported by Edwards Lifesciences)

Published in: Health & Medicine
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Surviving sepsis, 2013 kristy molnar, critical care consultants

  1. 1. SURVIVING SEPSIS: Improving Care … Saving Lives Kristy Molnar Professional Education Services, Critical Care Consultants Critical Care Consultants, 2013
  2. 2. Sepsis … Claiming Lives Leading cause of morbidity and mortality worldwide Critical Care Consultants, 2013
  3. 3. Critical Care Consultants, 2013
  4. 4. Critical Care Consultants, 2013
  5. 5. Critical Care Consultants, 2013
  6. 6. The “Face” of Sepsis Systemic inflammatory response initiated by a source of infection Critical Care Consultants, 2013
  7. 7. Critical Care Consultants, 2013
  8. 8. http://www.sepsisalliance.org/resources/video/ Critical Care Consultants, 2013
  9. 9. Critical Care Consultants, 2013
  10. 10. Rory Staunton’s Story (Profiled on Today’s Show & Dr. Oz) Performance Gaps! http://www.youtube.com/watch?v=k3qz9wCc69w http://www.youtube.com/watch?v=MTeBukCSot8 http://www.youtube.com/watch?v=xwOKZsKlwWs http://www.youtube.com/watch?v=J-bLDoVHYSs Leading to NY State Department’s Cuomo Initiative & Legislation Critical Care Consultants, 2013
  11. 11. Critical Care Consultants, 2013
  12. 12. What does this mean? Critical Care Update Sp on so re d By Critical Care Consultants, 2013 ICU admissions from EDs up nearly 50% in U.S. U.S. researchers looked at data from the National Hospital Ambulatory Care Survey and found that intensive care admissions from the emergency department rose by nearly 50%, from 2.79 million in 2002- 2003 to 4.14 million in 2008-2009. Of all the ED patients, those aged 85 and older had the highest increase in the rate of ICU admissions. The findings appear in the journal Academic Emergency Medicine. Nurse.com (5/15)
  13. 13. Critical Care Consultants, 2013
  14. 14. THE BURDEN OF SEPSIS Healthcare Resources Critical Care Consultants, 2013
  15. 15. Critical Care Consultants, 2013
  16. 16. Critical Care Consultants, 2013
  17. 17. Sepsis Costs! • 40% of total ICU expenditure • Average cost per individual case is approximately $22,000.00 Critical Care Consultants, 2013
  18. 18. GAPS IN CARE Quality Improvement Initiatives - IHI Critical Care Consultants, 2013
  19. 19. Critical Care Consultants, 2013
  20. 20. Critical Care Consultants, 2013
  21. 21. Critical Care Consultants, 2013
  22. 22. Critical Care Consultants, 2013
  23. 23. Critical Care Consultants, 2013 Sepsis Detection & Management Rapid Response Systems Patient Flow for Efficiency & Safety Early Warning Systems
  24. 24. DIFFUSE SYMPTOMS Occult, systemic wide responses Critical Care Consultants, 2013
  25. 25. CRITICAL SIGNS … MEDICAL EMERGENCY! Critical Care Consultants, 2013 http://www.sepsisalliance.org/resources/video/
  26. 26. SCORING SYSTEMS APACHE II, SOFA … not Screening Systems Critical Care Consultants, 2013
  27. 27. Phases & Degrees of Sepsis “A Clinical Spectrum” http://www.sepsisalliance.org/resource s/video/ Critical Care Consultants, 2013
  28. 28. TERMS SIRS, SEPSIS, SEVERE SEPSIS, SEPTIC SHOCK, MODS … Critical Care Consultants, 2013
  29. 29. Critical Care Consultants, 2013
  30. 30. SUSPICION OF SIRS Systemic Inflammatory Response Syndrome Critical Care Consultants, 2013
  31. 31. INTERVENTION IN SIRS Speedy Intervention & Response for Survival Critical Care Consultants, 2013
  32. 32. The Challenge … The Campaign The Response Critical Care Consultants, 2013
  33. 33. SEPSIS IS A TRAGIC & DEADLY DISEASE Increasing Awareness Critical Care Consultants, 2013
  34. 34. Critical Care Consultants, 2013
  35. 35. Critical Care Consultants, 2013
  36. 36. ESTABLISHING BEST PRACTICE Surviving Sepsis Guideline updates (using the GRADE system) Critical Care Consultants, 2013
  37. 37. TRIAGE Improving Identification & Initiating Timely Intervention Critical Care Consultants, 2013
  38. 38. Critical Care Consultants, 2013
  39. 39. TIMELINES Saving Tissue, Reducing Mortality Critical Care Consultants, 2013
  40. 40. WHO IS RESPONSIBLE? Fighting the War on Sepsis Critical Care Consultants, 2013
  41. 41. TRANSITIONS IN CARE Seamless Critical Care Consultants, 2013
  42. 42. Recommendations & Guidelines The Global Sepsis Alliance Critical Care Consultants, 2013
  43. 43. THE GLOBAL SEPSIS ALLIANCE International Guidelines for the Management of Severe Sepsis & Septic Shock Critical Care Consultants, 2013
  44. 44. GUIDELINES & ALGORITHMS 2004, 2008 … Current Updates Critical Care Consultants, 2013
  45. 45. Sepsis updates (2004, 2008, 2012) 2012 update on YouTube (1 hr, 28 min): https://www.youtube.com/watch?v=v08mYfxBJAE Critical Care Consultants, 2013
  46. 46. Critical Care Consultants, 2013 2005 Manual/User’s Guide (SCCM, ESICM, ISF) Participation in the Surviving Sepsis Campaign Surviving Sepsis Campaign Web site. www.survingsepsis.org
  47. 47. Critical Care Consultants, 2013
  48. 48. Critical Care Consultants, 2013
  49. 49. “Implications of the New International Sepsis Guidelines for Nursing Care” Critical Care Consultants, 2013 Kleinpell, R., Aitken, L., & Shorr, C.A.: AJCC, May 2013, Volume 22, No 3, 212-222.
  50. 50. ENSURING BEST PRACTICES http://www.sepsisalliance.org/resources/video/ Critical Care Consultants, 2013
  51. 51. EDUCATION & COMMITMENT To ALL on the “Front Line” … a Call to Action … Critical Care Consultants, 2013
  52. 52. Sepsis video resources: YOUR SEPSIS TEAM Critical Care Consultants, 2013 http://www.sepsisalliance.org/resources/video/
  53. 53. GAP ANALYSIS Where do you stand in Sepsis Detection & Management? Critical Care Consultants, 2013
  54. 54. THE SCIENCE & MODEL FOR IMPROVEMENT Evidence-Based, Organized & Efficient Care Critical Care Consultants, 2013
  55. 55. SCREENING & IMPLEMENTATION OF THE BUNDLES Critical Care Consultants, 2013
  56. 56. ENSURING EFFECTIVE & SEAMLESS TRANSITIONS The Clinical Environment Critical Care Consultants, 2013
  57. 57. Clinical Decision Support Tools & Documentation Clinical Approaches Critical Care Consultants, 2013
  58. 58. CONSISTENT APPLICATION OF EVIDENCE-BASED PRACTICE Critical Care Consultants, 2013
  59. 59. GOALS & WORKFLOW Improving Communication Critical Care Consultants, 2013
  60. 60. Critical Care Consultants, 2013
  61. 61. PROTOCOLS Paper-Based and/or Electronic Clinical Decision Support Tools? Critical Care Consultants, 2013
  62. 62. Critical Care Consultants, 2013
  63. 63. Critical Care Consultants, 2013
  64. 64. Critical Care Consultants, 2013
  65. 65. Critical Care Consultants, 2013
  66. 66. Critical Care Consultants, 2013 http://www.ajcconline.org
  67. 67. Critical Care Consultants, 2013
  68. 68. The “Bundles” & SSC Algorithm Critical Care Consultants, 2013
  69. 69. “BUNDLE” Evidence-Based, Organized Practice Guidelines within an Organized Process Critical Care Consultants, 2013
  70. 70. Critical Care Consultants, 2013
  71. 71. PROTOCOLS & PATHWAYS Customization within Clinical Environments Critical Care Consultants, 2013
  72. 72. Critical Care Consultants, 2013
  73. 73. WORKING TOGETHER Achieving Better Outcomes? Critical Care Consultants, 2013
  74. 74. Screening Bundle: Timely Triage Critical Care Consultants, 2013
  75. 75. EARLY RECOGNITION! Clinical Assessment, Screening, Monitoring & Surveillance Critical Care Consultants, 2013
  76. 76. TAKING ACTION! Early Warning and Rapid Response Systems Critical Care Consultants, 2013
  77. 77. SCREENING TOOLS FOR SIRS Critical Care Consultants, 2013
  78. 78. Critical Care Consultants, 2013
  79. 79. TIMELY NOTIFICATION & COMMUNICATION Standarized Orders/Protocols? Critical Care Consultants, 2013
  80. 80. Initial Resuscitation Bundle: Time for Action! Critical Care Consultants, 2013
  81. 81. BLOOD CULTURES Prior to Antibiotic Administration Critical Care Consultants, 2013
  82. 82. Critical Care Consultants, 2013
  83. 83. BROAD-SPECTRUM ANTIBIOTICS Improve Time to Administration Critical Care Consultants, 2013
  84. 84. SERUM LACTATE Early identification: Lactate Measures … When, Why and How Much? http://www.youtube.com/watch?v=LVqt0z4-k6E Critical Care Consultants, 2013
  85. 85. QUESTIONS & DEBATES ABOUT SERUM LACTATE Identification of Hyperlactatemia &/or Reduced Lactate Clearance Critical Care Consultants, 2013
  86. 86. Hyperlactatemia • Regardless of the mechanism of hyperlactatemia, numerous studies show that blood lactate is a relevant prognostic marker of morbidity and mortality in various critical care settings, including patients with Sepsis. • Increased lactate also correlates well with ScvO2 Critical Care Consultants, 2013
  87. 87. SSC International Guidelines • Lactate levels of > 4 mmol/L • Is Lactate > 4 mmol/L or impaired Lactate clearance an obligatory criterion for the diagnosis of septic shock? • No significance difference in 28-day mortality across Lactate categories (non, intermediate & high) Critical Care Consultants, 2013
  88. 88. Missed Identification? • Although a useful adjunct for hypoperfusion … lactate is not present in 45% of septic patients … it may not be adequate as the only marker … we may miss 45% of patients if Lactate used as a sole obligatory criteria. Critical Care Consultants, 2013
  89. 89. Lactate as sole indicator? • One of the fundamental problems of using lactate clearance as a sole resuscitation target is that a normal lactate (< 2mM/L) can be present in 25-50% of septic shock patients. • The mortality of these patients is 20-50% even with aggressive therapy. Critical Care Consultants, 2013
  90. 90. 2012 findings • 2012 studies by the Shock Society found that aggressive resuscitation may be beneficial even in the “normal range” lactate concentration. • How Low? … Lactates of 1.4 – 2.3 mmol/L may also be associated with an adverse outcomes! (2 – 2.5 should be a trigger at admission!) Critical Care Consultants, 2013
  91. 91. 2012 findings • Yes, Hyperlactatemia had a good sensitivity (86%) for prediction of mortality • But, Lactate cannot be used in isolation due to a low specificity (27%) • The clinician must use other perfusion markers such as ScvO2 and UO to enhance the prediction value. Critical Care Consultants, 2013
  92. 92. Lactate as an endpoint for Resuscitation? • These observations indicate that using lactate and ScvO2 are complimentary endpoints, and not mutually exclusive. (8 references; 1993 - 2012) Critical Care Consultants, 2013
  93. 93. Lactate as an Indicator of Tissue Hypoxia? • Journal of Critical Care - 2012 study • Almost ½ of patients with vasopressor- dependent septic shock did not express lactate on presentation, although a high mortality remains in this population! Critical Care Consultants, 2013
  94. 94. Lactate as an Indicator of Tissue Hypoxia? • Use of lactatemia as the sole indicator for additional IV fluid or an end point of resuscitation in septic shock may be inadequate. Critical Care Consultants, 2013
  95. 95. FLUID MANAGEMENT Treat Hypotension, Hypoperfusion & Elevated Lactates Critical Care Consultants, 2013
  96. 96. MAINTAIN APPROPRIATE PRELOAD STATUS CVP, SVV, PPV, SV for Volume Responsiveness Critical Care Consultants, 2013
  97. 97. Hemodynamics…Blood Flow! Critical Care Consultants, 2013
  98. 98. MAINTAIN MAP Vasopressors for ongoing Hypotension? Critical Care Consultants, 2013
  99. 99. Critical Care Consultants, 2013
  100. 100. Administration of Blood Products? Critical Care Consultants, 2013
  101. 101. VENOUS OXYGEN SATURATION Maintain Adequate Central Venous Oxygen Saturation Critical Care Consultants, 2013
  102. 102. Critical Care Consultants, 2013
  103. 103. (Management) Septic Shock Bundle: Meeting the Goals Critical Care Consultants, 2013
  104. 104. Source Control • Within 12 hours • Surgical debridement, draining • Removal of infected devices • Infection prevention! Critical Care Consultants, 2013
  105. 105. STEROIDS? Critical Care Consultants, 2013
  106. 106. GLYCEMIC CONTROL GOAL Critical Care Consultants, 2013
  107. 107. INSPIRATORY PLATEAU PRESSURE GOAL Critical Care Consultants, 2013
  108. 108. Patient Outcomes Reducing Sepsis Mortality & Morbidity Critical Care Consultants, 2013
  109. 109. Implications for Practice • Integration of the new recommendations can help ensure that critically ill patients with sepsis receive expert nursing care to promote optimal outcomes. Critical Care Consultants, 2013
  110. 110. Implications for Practice • By initiating resuscitative measures and indicated sepsis care that are based on the new guidelines, critical care nurses can improve care for patients with sepsis. Critical Care Consultants, 2013
  111. 111. Resources, Workflow & Efficiencies Critical Care Consultants, 2013
  112. 112. Early Identification “ Observe for the convergence of nonspecific diagnostic criteria and physical assessment cues early in the development of the condition and positively affect outcomes”. Karen Giuliano, 2006 Critical Care Consultants, 2013
  113. 113. Critical Care Consultants, 2013 Continuous Monitoring, Physical Assessment & Surveillance Giuliano KK, Kleinpell R. AACN Clin Issues. 2005 Apr-Jun;16(2):140-8
  114. 114. Comprehensive Sepsis Treatment • Antibiotic administration • Circulatory assessment & support … Fluids, inotropic agents, vasopressors • Supportive treatment with oxygenation & ventilation Critical Care Consultants, 2013
  115. 115. Comprehensive Sepsis Treatment • Use of measures recommended in sepsis guidelines • Monitoring & Surveillance • Reporting patients’ response to treatment Critical Care Consultants, 2013
  116. 116. World Federation of Critical Care Nurses (WFCCN) International task force – produced/published a companion guide to the 2008 guidelines in 2011 that outlines 63 additional recommendations. • http://en.wfccn.org/resources_sepsis.php • Crit Care Med. 2011; 39(7):1800-1818 Critical Care Consultants, 2013
  117. 117. World Federation of Critical Care Nurses (WFCCN) Crit Care Med. July 2011; 39(7):1800-1818 “Nursing considerations to complement the Surviving Sepsis Campaign guidelines” http://journals.lww.com/ccmjournal/Fulltext/20 11/07000/Nursing_considerations_to_comple ment_the_Surviving.25.aspx Critical Care Consultants, 2013
  118. 118. “EXTEND THE CHAIN” Improve the Flow of Care Critical Care Consultants, 2013
  119. 119. SEPSIS PRACTICE SUPPORT Industry, Professional Associations & Practice Groups Critical Care Consultants, 2013
  120. 120. Critical Care Survival Guide – Sepsis Management https://www.youtube.com/watch?v=rSIoG_QuMmg Critical Care Consultants, 2013
  121. 121. iMedicalSchool: Update in Sepsis, 2013 http://www.youtube.com/watch?annotation_id=annotati on_377513&feature=iv&src_vid=o8K3IC1RrP8&v=UcivG HBfSb4 Critical Care Consultants, 2013
  122. 122. Critical Care Consultants, 2013
  123. 123. Documentation & Reporting Compliance & Quality Improvement Critical Care Consultants, 2013
  124. 124. COMPLIANCE & QUALITY IMPROVEMENT Achieving Compliance within the Resuscitation & Management Bundles? Critical Care Consultants, 2013
  125. 125. DATA COLLECTION & REPORTING Critical Care Consultants, 2013
  126. 126. Call to Action Implementing the Surviving Sepsis Campaign … 10 years later! Critical Care Consultants, 2013
  127. 127. 2012 Surviving Sepsis Guidelines - Summary http://www.youtube.com/watch?v=v08mYfxBJAE Critical Care Consultants, 2013
  128. 128. “From Time Zero ….” http://www.youtube.com/watch?v=v08mYfxBJAE Critical Care Consultants, 2013
  129. 129. World Sepsis Day (September 13, 2013) Critical Care Consultants, 2013
  130. 130. Critical Care Consultants, 2013
  131. 131. Winning the War on Sepsis Stories of Success & Improvement Critical Care Consultants, 2013
  132. 132. Phase IV SCCM Surviving Sepsis Campaign 2012 Guidelines – YouTube video 2013 … Winning IF we stay in the game 2016 - Focus on Guidance, Involvement, Compliance, Quality, Technologies/Processes … ongoing Mortality reductions! Critical Care Consultants, 2013
  133. 133. Surviving Sepsis Improving Care … Saving Lives Critical Care Consultants, 2013
  134. 134. Critical Care Consultants, 2013

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