Sepsis in your facility/ED

Specialties Emergency

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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?

Specializes in Critical Care.

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.

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Specializes in Urgent Care NP, Emergency Nursing, Camp Nursing.
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.
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I disagree with the statement that Code sepsis is not necessary. As pointed out a Code call is to pull resources and that just the type of approach a Sepsis patient needs in order to expedite, rapid MD assessment and initiate treatment. I have introduced this in my ED and we have had great success cutting out door to antibiotic times to below 30 min form arrival. our average is 25 min and best time was 16min. We utilize overhead intercom system within our ED to notify all staff and MD of Code Sepsis patient requiring immediate assessment and team nursing approach to stabilization. All available nurses are to report to the room immediately to initiate care of patient for lactic, Pct and culture collection then initiate IVF boluses and abx immediately after cultures drawn. We all know how septic patients can be hypo-perfused and be difficult to get IV lines and obtain cultures this may take 30 or more minutes alone with one nurse. a team approach has resources at bedside to assist with these tasks. while others are preparing IVF boluses, EKG, monitoring and antibiotics. this approach has improved many factors like patient safety, quality of care, patient and family satisfaction, pt outcomes and decreased complication related to hypo-perfusion and organ failure.

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Specializes in Urgent Care NP, Emergency Nursing, Camp Nursing.
10 minutes ago, EDRN4Life said:

I disagree with the statement that Code sepsis is not necessary. As pointed out a Code call is to pull resources and that just the type of approach a Sepsis patient needs in order to expedite, rapid MD assessment and initiate treatment. I have introduced this in my ED and we have had great success cutting out door to antibiotic times to below 30 min form arrival. our average is 25 min and best time was 16min.

Yes, and through now, ACEP still only promotes the 3-hour bundle in the ED...which an ESI-2 should facilitate handily.

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Anyone fitting criteria should be 2 at least for now. Although they do fit the need a physician at bedside immediately and the life saving interventions. Even though they are extremely sick at least at my ED. Assigning them all level 1 would create an issue of acuity fatigue on provider side. As it is right now they are all level 2 along with neuro symptoms and majority of CP I see this issue where providers are not as responsive to the acuity assignment and may see people in turn to meet their door to doc times. That is where code sepis can help to expedite care. Also we utilize NEWS score in our EMR it is more sensitivity to initially determined a patinets acuity according to score from vital signs and gcs.

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Specializes in Critical Care.
On ‎10‎/‎14‎/‎2016 at 10:30 PM, TheSquire said:

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.

Prior to 2015 the commonly used Sepsis Screening came from the 1992 Bone et al. recommendations which did not include "does the patient have a suspected new infection" portion, this is what I was referencing when I said we've switched to SOFA, which includes lack of suspected infection as a negative screen.

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On 10/15/2016 at 1:30 AM, TheSquire said:

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.

Actually, it isn't. While new source of infection is included on some sepsis screens, it is not universal. And, even with that criterion, most protocols are exactly that, and are to be followed regardless of the judgement of the clinician. Which is why the 200kg heart failure PT with a UTI is harmed, as is the actual septic PT who had tylenol to suppress the fever and is on a beta blocker.

There are reputable medical organizations who strongly object to the removal of critical thinking from patient care, and that "high-quality evidence suggests that protocolized care for sepsis increases utilization of resources without benefiting patients"

I apologize for the thread hijack. The initial question was how the hospital might improve it's numbers. Presumably the numbers in need of improvement are compliance numbers, rather than outcomes.

The best idea I saw was I-Stat at triage, and including the lactate in the decision making process. This alone would rule out a huge number non septic PTs who would otherwise meet the criteria. And, it looks cheap. Less than $1000. It probably pays for itself in a day.

The worst idea would be to modify the ESI system which already prioritizes patients at risk of death without immediate intervention. Changing it to include PTs at risk of decreasing the departments compliance statistics a poor use of resources.

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