Good morning, afternoon or evening to you all, and I hope things are going well. We need to learn a little bit about the new sepsis alert system that will start at Holy Cross next month. Thanks for taking the time to listen to this brief introduction.
The purpose of this Power Point is to orient you to the new sepsis alert functions that will operational in the Cerner electronic health record at Holy Cross. These changes will begin on June 1, 2011 and it is very important that you have a basic understanding of how the alerts work beforehand to avoid unnecessary confusion and frustration. These alerts are part of the Sepsis Initiative at Trinity Health hospitals which has already begun in the Emergency Department last year. Remember that the goals of the initiative are to identify potentially septic patients early on, begin aggressive treatment, and reduce mortality. In keeping with these goals, both First Net and Power Chart will begin to generate electronic alerts for patients with infection and/or potential sepsis.
These electronic alerts are a form of clinical decision support---intended to help improve care and assist clinicians to “do the right thing”. Similar to current warnings about drug allergies and positive troponins that appear in the system, the sepsis alerts are triggered by clinical data entered by providers or derived from laboratory results or vital signs. The system will require a response from you, the user, to continue on with the charting process. The new sepsis alerts will be used at Holy Cross and throughout all Trinity hospitals. While I know our pediatric colleagues will be very disappointed, the patient must be over 18 years old to trigger the sepsis alerts.
For simplicity’s sake, you should think of the sepsis alert system are consisting of three phases. The first phase contains the Alert Triggers, which are generated by data entered by nursing personnel and derived from laboratory results. The second phase contains the Sepsis Alerts, which must be responded to by physician and midlevel provider staff. The final phase includes the specific Sepsis Power Plans, which allow providers to more easily order care consistent with the sepsis protocols developed using current sepsis guidelines. We will go over each phase in some detail. Although the system may seem a bit confusing at first, I believe it will be clearer once you use the new system.
The first phase of the sepsis alerts begins with identifying criteria from nursing and laboratory data in the Cerner system. The initial criteria will be the presence of at least two elements of the Systemic Inflammatory Response Syndrome (SIRS). If SIRS is present, the nurse will be queried by the system whether or not there are signs of infection in the patient. Keep in mind that one can meet SIRS criteria and not have infection. Finally there are additional criteria for triggering alerts for organ system dysfunction. We will review the definitions for SIRS and organ dysfunction briefly.
Recall that the SIRS criteria include at least two of the following: temperature greater than 100.9 or less than 96.8, pulse over 90, respiratory rate greater than 20, glucose over 140 , or a WBC greater than 12,000 or less than 4000 or over 10% bands. Once nice thing is that the system will now pick up these criteria automatically. Keep in mind that the alert will be not fire in the patient is on diabetic medication or diabetes listed as a problem. Again keep in mind that SIRS does not necessarily equal infection.
To minimize the triggering of excessive alerts from the SIRS criteria, the nurse will have to answer the question as to whether or not the patient has signs or symptoms of infection. If yes, the criterion for the Initial Sepsis Alert will be met. In this manner, the tachycardic anxious patient who is hyperventilating who does not have signs of infection will not be identified as a patient with sepsis.
The nurse or tech will then receive this alert to notify the nurse, and in turn the physician, about the possibility of sepsis. Do not be surprised when the nurse comes up and tells you this fact before you even open the chart. They are required to notify you.
There are additional criteria to attempt to detect severe sepsis with organ involvement that involve hypotension, oxygenation, renal function and other hematologic factors. I won’t go into details other to point out that lactate over 2 will be trigger an alert.
If any one of these factors are present, an alert for “Organ Involvement Sepsis” will be triggered. For those of you who are into strange little icons, this weird little bug will appear on the tracking board to show that organ dysfunction may be occurring.
If the patient fulfills the criteria for a sepsis alert, you will be notified by the nursing staff, and in addition, will receive electronic notification on First Net/Power Chart. Upon opening the patient’s chart, you will see a sepsis risk alert. You must respond appropriately to proceed.
The initial sepsis alert warning will look like this. This means that the patient has signs and symptoms of infection and has met two SIRS criteria.
The organ involvement sepsis alert looks like this, only will say “severe sepsis”. This means patient has met the first two criteria and one of the organ dysfunction criteria, suggesting the possibility of severe sepsis. Experience to date shows that approximately 10% of ED patients will get the initial sepsis alert and approximately 2% will get the alert for severe sepsis with possible organ dysfunction.
You can respond to a sepsis alert in one of two ways. If you don’t know enough about the patient when you first see the alert you can select the option in blue, “OK”. This will suppress the alert for an hour, but it will reappear in an hour. When you know enough to document more about the clinical course, choose the option in green, “Document”.
If you choose “Document” you will see the screen above, which will you allow you to choose whether or not the patient has sepsis and how severe it is. If you choose no sepsis, the alert will fire again in 24 hours if the criteria continue to be present. Although this will not be our problem, it may annoy our friends on the hospitalist service… It is important to remember that after you make your choice, you have to click the green checkmark on the upper left in order to continue.
The third and final phase of the sepsis alerts contains the Sepsis specific power plans. Sepsis alerts will generate specific Power plans to help you more easily order therapy for septic patients. The sepsis power plans are based on the early goal directed therapy for sepsis and are based on evidence based medical practice. The power plans will eventually include an antibiotic “advisor” that will allow you to easily choose antibiotic regimens from a single pick list which will mean less clicks for the end users. The implementation of the antibiotic advisor has been delayed for several months. Once this feature is finished, the antibiotics will be customized for resistance patterns seen at our hospital and developed with input from local infectious disease experts. An important distinction for users is that these power plans are only “suggested” and must be “accepted” in order to be used. The way this is done is somewhat “awkward” and certainly different than the way we usually enter orders in First Net. We will show you how to select or reject these power plans.
Before we get into what is contained in the sepsis power plans, you have to learn where to find them and activate them. In typical Cerner fashion, they don’t make it easy for you. You have to look for the suggested Power Plans on the left hand window of the orders screen under the column for “suggested plans”.
Please be aware that the suggested plans may be collapsed and you may have to double click the area to open it up and see the plans within.
Once you see the plan you want, you must then right click the plan and either “accept” or “reject” it. Again, remember this is a right click, not a left click.
Once you accept the suggested plan, you can now order like any other power plan. Click off what you want and sign the orders.
There are a number of sepsis power plans available for Trinity hospitals. In the ED management of patients, you should be familiar with the two main sepsis order sets. The first is the Sepsis Initial Evaluation power plan. The second is the Sepsis Ongoing Management power plan.
This is the “sepsis initial evaluation” power plan, and is the one that you use will use the most. It will allow you to order, from one screen, all of the labs, nursing orders, x-rays, and fluid resuscitation you will commonly need for the patient with potential sepsis. Although you don’t see it in this screenshot, our power plans will include the point of care lactate test used in our ED. This plan will also have the “antibiotic advisor” to allow you to pick appropriate antibiotics. Once again, this functionality is not completed at this point, but is expected to be available in the near future.
The other power plan you should know is the “sepsis ongoing management”. You will use this less commonly but it will be very helpful in management of patients with severe sepsis and septic shock. It will allow you to order, again from a single screen, appropriate orders for fluid resuscitation and pressors in the critically ill septic patient. The red circle highlights where you will access the antibiotic advisor when it is deployed.
I know many of you will be a bit confused and frustrated with these new changes initially. I know that I was. However, I can assure you that it gets easier after you actually use it a few times. Just keep in mind that the ultimate goal is to improve care of our patients, no matter how difficult they can be at times. All of us have dealt with the septic patient who “crashes” before our eyes. If we can prevent that from happening a little less often, then this effort will be worth it in the end. In addition, we have the possibility that this new functionality, once perfected, will eventually make our work just a little bit easier. As they say, hope springs eternal….
Sepsis Alerts for Physicians<br />New functionality in Cerner<br />Will begin on June 1st, 2011<br />Part of Sepsis Initiative @ Trinity Health<br />Identify and treat septic patients early<br />First Net/Power Chart will generate alerts for patients with potential sepsis<br />
Clinical Decision Support<br />Electronic reminder system intended to improve care<br />Triggered by clinical data<br />Sepsis alerts are hospital wide<br />Patients must be >18 years old<br />
The Sepsis Alerts-- Overview<br />Phase 1 Alert Triggers<br />Phase 2 Sepsis Alerts <br />Phase 3 Sepsis Power Plans<br />
Phase I - Alert Triggers<br />Sepsis alerts triggered by nursing and lab data in Cerner system<br />Must have at least 2 SIRS criteria<br />Nurse queried for signs of infection <br />Additional alerts for organ dysfunction<br />
Systemic Inflammatory Response Syndrome (SIRS)<br />Temperature > 100.9F or < 96.8<br />HR >90<br />RR>20<br />Plasma Glucose >140<br />WBC >12K or <4K or 10% bands<br />SIRS does not = infection<br />
Nursing Prompt<br />Does this patient have signs or symptoms of infection?<br /> Yes or No?<br />
Organ Dysfunction in Sepsis<br />SBP < 90 or MAP < 70 or drop in SBP > 40<br />Pulse ox <90<br />Creatinine >2<br />Change in mental status<br />Platelets <100,000 or INR>1.5<br />Bilirubin >2.0<br />Ileus or edema<br />Lactate > 2<br />
Phase 3 Sepsis Power Plans<br />Alerts will generate specific Power Plans<br />Sepsis Power Plans based on goal directed Rx<br />Will eventually contained HCH specific antibiotic recommendations<br />Power plans are “suggested”, must be “accepted” in order to be used<br />