Sepsis in your facility/ED

[Lev, MSN, RN, NP]

My hospital is trying to improve its sepsis numbers and I've been asked to be involved on the ED end of things. We do really well with the STEMI and stroke patients so they are trying to make a "code sepsis" of sorts. I've been looking at a triage alert with provider notification and RN initiation of orders as well as up triaging patients to an ESI 1 for suspected sepsis and at least a 3 for SIRS without a noticeable source of infection. What is being done at your facility?

[TheSquire, DNP, APRN, NP]

Our facility has the best sepsis mortality rate amongst our nationwide chain. While the floors have a code sepsis, the point of a code is to pull resources from outside the unit; the ED is a mostly self-contained unit, and so no code is necessary.

Our facility starts with a triage screen, which was written by someone who doesn't understand how the ED works (it includes white cell counts - when would I ever have that in triage?). However, the other "indicators of infection" are all easily checked in Triage, and if I suspect sepsis but don't have a room immediately handy I do have an iStat machine in triage: I can have my tech draw blood and run a POC Lactic Acid level. If the lactate's > 2.2, I can then claim SIRS and can argue my charge to give the patient a room stat (or if things are going to Hell, start a line and hang a liter in triage while they wait).

As far as ESI goes, if the patient is in septic shock, then they're in shock and an ESI-2 anyway. Remember, ESI-2 needs a room and a nurse immediately, and if your ED already has nurse practice guidelines or the like, you can start a line, draw and hold blood cx and other blood tubing, hang a liter (on a pressure infuser), and even run POC tests before the doc shows up; the doc can then order the antibiotics and the rest of the sepsis bolus. ESI-1 is overkill; it's a 3-hour bundle, so you have a little time, and as I said, it'll take a few minutes to establish vascular access and draw labs, which doesn't require an MD to do.

As for suspected sepsis cases, they're obviously an ESI-3...just like anything else that you expect to require 2+ resources. Draw the labs in triage or upon arrival.

If your ED has decent protocols already, nothing new should be required for sepsis on that end. However, your staff need to be well-educated on sepsis and how to spot it; making your nurses fill out the full sepsis screen prior to admission is a good way to get them to have sepsis on the brain. MDs and RNs need to know that you draw a lactic every time you draw blood cx (and to draw cultures before ​hanging abx), that you need to do the 30ml/kg rapid bolus for lactate >4 or hypotension regardless of whether the pt has CHF or renal failure, and most importantly that if the patient progresses to full-on septic shock that you're already too late. In departments with even moderate levels of staff turnover on either the RN or MD side, this education is crucial.

[Lev, MSN, RN, NP]

Thank you so much for your detailed response. I have never heard of an I-STAT. Checking lactates at triage is a great idea!

[TheSquire, DNP, APRN, NP]

Thank you so much for your detailed response. I have never heard of an I-STAT. Checking lactates at triage is a great idea!

Abbot makes them; our ED uses them to run POC BMPs, Troponin Is, and Lactates - each on its own cartridge. I'm sure they have a couple competitors, I've just not run across them yet.

[torie RN, NRP, CEN]

We call our sepsis protocols in triage a "Code Purple". We overhead page it in the ER so phlebotomy and an ED MD knows to come to triage or the exam room the patient is brought to to evaluate the patient.

Our criteria for "Code Purple" is two of the following as long as they are 18 or greater years of age: HR >90, RR >20, SBP 11 (if sent by PCP or an urgent care that has already drawn bloodwork), or temperature > 100.4.

I can hear everyone now: BUT SO MANY PATIENTS FIT THAT CRITERIA! Yep, they do. And they are considered Code Purples until ruled out otherwise.

These patients are made Level 2's and get the first available room. Labs are drawn in triage or immediately at bedside: CBC, CMP, Lactate, & paired blood cultures. 12-lead EKG is obtained. The MD must order the 30 ml/kg initial NS bolus. If initial lactate is >2, the patient continues with the bolus. If less than, the bolus will be tapered down. If the patient doesn't produce a urine specimen within 30 minutes, or we suspect UTI as the culprit, we obtain a straight cath specimen.

We have 3 hours from the time the patient presented to initiate the first antibiotic. Obtaining paired blood cultures must be done prior to antibiotics unless there is a documented extenuating circumstance (such as we can't get blood for a second culture because the patient's pressure is crap). The quickest antibiotic is hung first (typically over 30 minutes), then followed by the longer broad spectrum.

If the patient's initial lactic is >2, they will have repeat lactates drawn every 4 hours until lactic is

My facility is the #1 in my state right now for sepsis compliance. While it was a pain in the orifice when the new protocols were rolled out, it's become a part of our ED culture. We've seen decreased mortality rates since the implementation of the sepsis protocols.

[Lev, MSN, RN, NP]

We call our sepsis protocols in triage a "Code Purple". We overhead page it in the ER so phlebotomy and an ED MD knows to come to triage or the exam room the patient is brought to to evaluate the patient.

Our criteria for "Code Purple" is two of the following as long as they are 18 or greater years of age: HR >90, RR >20, SBP 11 (if sent by PCP or an urgent care that has already drawn bloodwork), or temperature > 100.4.

I can hear everyone now: BUT SO MANY PATIENTS FIT THAT CRITERIA! Yep, they do. And they are considered Code Purples until ruled out otherwise.

These patients are made Level 2's and get the first available room. Labs are drawn in triage or immediately at bedside: CBC, CMP, Lactate, & paired blood cultures. 12-lead EKG is obtained. The MD must order the 30 ml/kg initial NS bolus. If initial lactate is >2, the patient continues with the bolus. If less than, the bolus will be tapered down. If the patient doesn't produce a urine specimen within 30 minutes, or we suspect UTI as the culprit, we obtain a straight cath specimen.

We have 3 hours from the time the patient presented to initiate the first antibiotic. Obtaining paired blood cultures must be done prior to antibiotics unless there is a documented extenuating circumstance (such as we can't get blood for a second culture because the patient's pressure is crap). The quickest antibiotic is hung first (typically over 30 minutes), then followed by the longer broad spectrum.

If the patient's initial lactic is >2, they will have repeat lactates drawn every 4 hours until lactic is

My facility is the #1 in my state right now for sepsis compliance. While it was a pain in the orifice when the new protocols were rolled out, it's become a part of our ED culture. We've seen decreased mortality rates since the implementation of the sepsis protocols.

Curious to know if your facility has done a study of the effects of your sepsis protocol...If so, I would like to know how to access it.

[applesxoranges, BSN, RN]

Well, I think it is RN initiated order set on the floors but we usually let the providers order it in the ED. There's a chart we follow for X, Y, Z. I can scan it and show you it.

Code purple would never work around here, especially during flu season.

[renzlao, MSN, APRN]

We do have code sepsis. We replaced WBC's with altered mental status or LOC as there is no way to know the WBC at triage.

[Lev, MSN, RN, NP]

For anyone who uses the I-STAT, how is competency determined?

[TheSquire, DNP, APRN, NP]

It's included as part of the long list of competency skills during orientation at my ED. When we added the TropI and Lactate cartridges, those of us who were there at the time were reeducated and checked for competency. Other than how to handle and fill the cartridge properly, there's not much to it.

[MunoRN, RN]

We used to use common sepsis screening, and since Sepsis 3 came out we've switched to SOFA scoring. Our experience was similar to what the Sepsis 3 conference concluded; that too big of a net when screening for sepsis probably does more harm than good. We've tracked Sepsis failure to rescues and delayed recognition as well as adverse events related to being treated for sepsis inappropriately, and we had more than twice as many events of causing harm to patients due to unwarranted treatment for sepsis just because they screened positive.

One example was a patient in her 80's with a GI bleed. Her Hgb was in the 4's, and as a result she was in hypovolemic shock which made her sepsis screen very positive (hypotensive, tachycardic, elevated lactate, ARF, etc.) Because she screened positive for sepsis she was provided with the standard first treatment; 3L of fluids. This drove her already low Hgb down even further and caused an MI, she eventually died. Sepsis screens have their (limited) place, but they don't replace critical thinking.

[TheSquire, DNP, APRN, NP]

Sepsis screens have their (limited) place, but they don't replace critical thinking.

The first step of a sepsis screen is critical thinking, asking "Does the patient have a new source of infection?" Your GI lady didn't have one, so should've screened negative.