Challenge 9

Early Detection Of Sepsis

Executive Summary Checklist

  • Commitment from hospital governance and senior administrative leadership to support early detection and appropriate management of sepsis in their healthcare system.
  • Develop a team approach to implement a protocol for early sepsis identification and treatment.
  • Create a sepsis dashboard for your organization’s leadership.
  • Implement a Sepsis Rapid Response Team or incorporate early detection of sepsis into your existing medical emergency teams (e.g. rapid response teams).
  • Formalize a process to screen patients for signs of sepsis throughout the entire institution.
  • Implement an effective monitoring system to accomplish continuous monitoring and notification based on acute changes to the following patient data:
    • Fever (> 38.3°C); Hypothermia (temperature < 36°C);
    • Heart rate > 90/min or 1 or more than two standard deviations above the normal value for age;
    • Tachypnea (RR > 20);
    • Altered mental status;
    • Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes;
    • Leukocytosis (WBC count > 12,000 μL–1); Leukopenia (WBC count < 4000 μL–1); Normal WBC count with greater than 10% immature forms;
    • Plasma C-reactive protein more than two standard deviations above the normal value;
    • Plasma procalcitonin more than two standard deviations above the normal value;
    • Hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or less than two standard deviations below normal for age); Hypoxemia (Pao2 < 60 mmHg or Sp02 < 90%);
    • Acute oliguria (urine output < 0.5 mL/kg/hr. for at least 2 hrs. despite adequate fluid resuscitation);
    • Creatinine increase > 0.5 mg/dL. or 44.2 μmol/L;
    • Coagulation abnormalities (INR > 1.5 or aPTT > 60 sec);
    • Thrombocytopenia (platelet count < 100,000 μL–1);
    • Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 μmol/L);
    • Hyperlactatemia (> 2 mmol/L); or
    • Prolonged capillary refill time or mottling.
  • Select an EHR to serve as a data collection tool and repository for predicting risk of sepsis for patients. A system that provides a data collection tool and allows for continuous analysis and surveillance will be most beneficial.
  • Implementation of automated electronic screening based on existing data (SIRS criteria, MEWS or any other warning system being used).
  • Design a workflow specific to level of alert:
    • SIRS met – assess for infection.
    • If patient has sepsis – increase monitoring or assessment for presence of severe sepsis.
  • Implement a process for continuous monitoring of electronic systems and protocols:
    • Compliance, efficacy and outcome measures.
  • Implement case reviews for outliers.
  • For severe sepsis:
    • Implement workflow for rapid assessment and intervention at the bedside.
    • Initiate severe sepsis bundle (3 hour elements):
      • Measure lactate level.
      • Obtain blood cultures prior to administration of antibiotics.
      • Administer broad spectrum antibiotics.
      • Administer 30 mL/kg Crystalloid for hypotension or lactate ≥4 mmol/L.
    • Build electronic documentation of process of care (fluids, antibiotics, clinical assessment etc.).
  • For septic shock:
    • Implement workflow for rapid assessment, intervention and need for higher level of care.
    • Initiate septic shock bundle (6 hour elements):
      • Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥65 mm Hg).
      • In the event of persistent hypotension despite volume resuscitation (Septic Shock) or initial lactate ≥4 mmol/L (36 mg/dL):
        • Measure central venous pressure (CVP).
          • Measure central venous oxygen saturation (ScvO2).
      • Remeasure lactate if initial lactate was elevated.

Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.