Sepsis protocols causing a future superbug??

[Alexx_xox]

I am sure we all work at a hospital where code sepsis's are now a huge deal as evidence has shown that preventing septic shock helps increase the chances of survival. **insert shocked face** (like we all didn't know that.)

Anyways, we all know that is true and people with the potential of becoming septic should be treated with antibiotics and fluids STAT. Although this protocol is probably saving lives all over the U.S., I also think it may be the beginning of a superbug.

Many people that walk through the ER are going to flag for sepsis, but does that truly make them septic?

What is your guys' hospital protocol when it comes to treating sepsis??

I am afraid that if we continue to treat everyone as a code sepsis and load them with tons of antibiotics, we are running the risk of future superbugs which won't respond to these antibiotics.

Any opinions out there?? How can we effectively treat sepsis and distinguish septic from non septic patients to help prevent a future superbug?

Let me know your opinions, or maybe what your guys' hospital protocols are when it comes to a code sepsis.

[vanilla bean]

I am sure we all work at a hospital where code sepsis's are now a huge deal

Nope. What's a "code sepsis"?

[CoolKidsRN]

Nope. What's a "code sepsis"?

I think she is referring to rapid responses called to initiate sepsis protocol for at risk patients.

And for the record, the "sepsis code" did save my life. Call me biased, but early detection and intervention is very necessary.

[K+MgSO4, BSN]

In my mainly paper based hospital we do have an electronic handover tool. If the correct box is checked for "sepsis pathway" the antimicrobial stewardship team come and review the patient and narrow down treatment early, including earlier conversion to orals.

After 10 years of working with surgeons who treat with wide spectrum antibiotics this is fantastic. Narrow the treatment, reduce the length of the IV treatment and reduce risk.

Sepsis pathway has at my hospital reduced deaths by 47%, length of ICU stay 53% length of overall hospital stay by 42% and reduced the need for subacute stays in rehab as patients less deconditioned.

[Rocknurse, MSN, APRN, NP]

The sepsis protocol (Rothman Index) was established in 2003 so if there was likely to be a problem we would probably have heard about it by now. The fact is, it reduces 24 hour and 1 year mortality dramatically, and reduces the number of codes and rapid responses. A severe sepsis comes on very fast and can kill the patient pretty quickly, so the point of all the studies is to show that action must be quick. Since its inception, the decrease in sepsis mortality has been between 30 and 50%. Many hospitals are now incorporating a sepsis alert in their EHR which is brilliantly designed and programmed to detect possible sepsis parameters much more quickly than the naked human eye alone can. It actually detects up to 50 parameters, and if a patient is exhibiting a positive in many of these markers, it's highly recommended that they begin therapy as soon as possible, as every hour that goes by increases their mortality. The pathway is not applied willy-nilly...many things are taken into consideration before the application of antibiotics. I was on the team that developed the sepsis pathway in our EHR and it's an amazing tool.

It detects the following parameters:

Two signs of systemic inflammatory response syndrome, one sign of organ dysfunction and utilizes Temp, BP, HR, RR, Glucose, Lactate, bands, creatinine, bilirubin, platelets, PTT, blood cultures, UA and WBC measurements. In the event of a number of these being highlighted as positive, there is an increased likelihood ratio that the patient is positive for sepsis and so administration of antibiotics is appropriate and timely. Many studies have shown that initiation of the sepsis protocol lowers 24 hour mortality, reduces 30 day readmission rates and reduces the number of codes and rapid responses and also reduced LOS of sepsis patients from 16.5 to 13.6 days, achieving $5,882 in medical savings per treated patient, a 21 percent reduction in length of stay, and a 24 percent reduction in in-hospital patient mortality (Cerner).

Finlay, G. D., Rothman, M. J., & Smith, R. A. (2014). Measuring the modified early warning score and the Rothman index: advantages of utilizing the electronic medical record in an early warning system. Journal of hospital medicine, 9(2), 116-119.

Hagland, M. (2015). Applying the Rothman Index to Reduce Mortality: Oconee ... Retrieved October 24, 2016, from Applying the Rothman Index to Reduce Mortality: Oconee Memorial’s Bold Push | Healthcare Informatics Magazine | Health IT | Information Technology

[KatieMI, BSN, MSN, RN]

It does, and providers are well aware of it. It leads to much more negative sequela than just creation of "superbugs"

NEJM - Error

As a matter of fact, wide application of ANY screening authomatically leads to increase of false positives (i.e. overdiagnosis) of the given condition. That's just how laws of statistics work.

Unfortunately, the system just seems to be made for current CYA/KTA (""cover your a**/kiss their a**) way of practicing medicine and also gives a nice nudge to pharm research. So, things are not going to change in the near future.

P.S. link says "error" but it works

[ruby_jane, BSN, RN]

It does, and providers are well aware of it. It leads to much more negative sequela than just creation of "superbugs"

NEJM - Error

As a matter of fact, wide application of ANY screening authomatically leads to increase of false positives (i.e. overdiagnosis) of the given condition. That's just how laws of statistics work.

Unfortunately, the system just seems to be made for current CYA/KTA (""cover your a**/kiss their a**) way of practicing medicine and also gives a nice nudge to pharm research. So, things are not going to change in the near future.

P.S. link says "error" but it works

That's a lot of food for thought. Thank you. It's been a long time since I was bedside but at the time I worked ICU we were taught to see sepsis everywhere and aggressively treat (for many good reasons).

[Here.I.Stand, BSN, RN]

At my hospital we DON'T give antibiotics based on a protocol. I mean, in my early 20s my BP lived in the low 90s and as low as 80s/40s. Add to that some tachycardia from dehydration or exertion, and look at that -- I just had a positive sepsis screen.

A hospital example is neurogenic fever. Pts with severe brain injuries can run high fevers, and lots of times they become tachycardic because of the fever. They might be completely free of infection and thus don't require antibiotics.

Also consider what we do in the community. Do we get antibiotics the second we get a fever? Of course not -- and we manage to NOT go into septic shock. I work in an ICU, and THOSE people don't even require pressors the second the team takes the time to investigate clinical appropriateness.

[xoemmylouox, ASN, RN]

Nope. What's a "code sepsis"?

Do you work in an inpatient acute care setting? If so does your employer have any sort of sepsis alert or protocol? Most places call them different things, but in reality the goals are the same: early detection, early treatment, reduction in complications including death.

If not maybe you should talk to your supervisor about starting a program.

[vanilla bean]

Do you work in an inpatient acute care setting? If so does your employer have any sort of sepsis alert or protocol?

Yes and yes. I had never before heard of the term "code sepsis." I envisioned an overhead page and a team of people responding in urgency. Now I know it's just different terminology from what I'm used to.

This is one of the things I love about AN; I'm still wiping the sleep out of my eyes and drinking my coffee and I already learned something new today

[psu_213, BSN, RN]

My biggest issue is not with treating sepsis or suspected sepsis. I have a problem with "throwing" ABX at a patient with no chance of any meaningful recovery, and just turning those persons into a petri dish in their remaining days/weeks of life.

Example...I had a pt in his 80s, severe dementia. Non verbal, non ambulatory. He was being treated, again, for aspiration pneumonia. He was already on isolation precautions for MRSA and VRE, and we continued to give ABX. His sister was POA. I don't know how the doctor phrased the end of life conversation with her, but she refused to accept that he was dying and she refused to have ABX discontinued. Of course, PO vanc was also added to his regimen because he developed C diff. With people (nurses, techs, radiology, IV team, PT, family etc., etc.) constantly in/out of his room, my guess is not everyone was 100% compliant with precautions. (Despite education, his sister would walk into the hall with her gown/gloves on). I know end of life, especially when to withdraw care, is a delicate issue, but this is not the only time in my career that I have given ABX as part of an obviously futile effort. I find this scenario, where ABX are of very little long term help, just as likely to create superbugs than having a sepsis protocol (that could be quite meaningful in save lives). Of course, there is no easy solution for the (near) end-of-life cases.

[Davey Do]

This is one of the things I love about AN... I already learned something new today

Amen, vanilla bean!

But I just couldn't resist:

I envisioned an overhead page and a team of people responding in urgency.

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