OVERLAKE HOSPITAL OB SEPSIS Pacific NW Regional Sepsis Conference - - PDF document
6/4/2018 OVERLAKE HOSPITAL OB SEPSIS Pacific NW Regional Sepsis Conference ABOUT OVERLAKE > 349-bed, nonprofit regional medical center offering a full range of advanced medical services to the Puget Sound Region > Level III Trauma
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> 349-bed, nonprofit regional medical center
services to the Puget Sound Region > Level III Trauma Center > Approximately 22,000 admissions/year > Over 45,000 ED visits/year > Around 3700 Births/year
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Margie Bridges, DNP, RNC-OB, ARNP-BC Perinatal Clinical Nurse Specialist Women and Infant's Services Betsy Pesek, MN, BSN, RN, CPHQ Quality Improvement Consultant Quality Department
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Sepsis Quality Improvement work
population
professional education on early recognition and management
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CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
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CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
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https://www.doh.wa.gov/Portals/1/Documents/Pubs/140-154-MMRReport.pdf
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> Severe Sepsis is the 3rd leading cause of maternal death > Incidence of sepsis increasing over the years > Once Severe Sepsis and Septic Shock develops mortality approaches 60% > SEP-1 Core measure since 2015
Critical Care Medicine.2013;41:945. Confidential: Protected Quality Improvement Document
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GROUP A SEPSIS CASE
16 year old Vacuum delivery 1st degree laceration
Postpartum Day 1:
WBC 16.4 T 36.2 BP 118/71 Pulse 115
3 hours later :.
WBC=*1.7 repeat 1.6 T: 38.7 HR: 120-156 BP: 95/45- 76/34 RR: 40-47
Mother comments that this is not her typical response to pain or stress
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RRT Called Transferred to CCU Test & Treat: CT Scan, Pulmonary angiogram, Abdominal Ultrasound, Blood & Urine Cultures, IV Unasyn, clindamycin, Vancomycin, fluid volume resuscitation, vasopressor support, respiratory support with intubation
Sa02 87% on 6L Lactate 2.8
Major Goals of sepsis management were met: She was treated
emergently with fluid resuscitation, antibiotic administration….What else?
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Postpartum Day 3: To OR for Surgery: TAH, APPY, and Abdominal washout. Uterus was “mushy” tissue friable.
Day 17: T: 36.5, BP: 127/75 P: 88 RR: 16 Sao2 100% RA Discharged: Ambulating, Eating and Breastfeeding!
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Medical Director CCU Medical Director ED Medical Director Quality Nurse Managers CCU & ED Group Health Urgent Care Group Health MD Hospitalist MD Inpatient Nurse Manager ED & CCU RNs CCU, ED, OB CNSs Inpatient RN Champions Epic ASAP Epic Liaison Pharmacy Lab MI, VIR
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Hospital–wide Sepsis education
Sepsis Committee formed Best practice review
Spring 2014
ED workflow planned for early Identification & Treatment Pharmacy &Director of IP develop Antibiotic list. ED Sepsis Quicklist amended . PHASE 2 BPA built & tested behind scenes; iStat training done Sepsis Checklist Mar ‘15 ED BPA in Production
Jan 2015
Sepsis Order Set Inpatient Build, Provider Education RN Sepsis Champion Sepsis Checklist OB Checklist
Mar 2016 Mews for Inpatient.
RRT Protocols ED Fluid Documentation
Oct 2016
MEWT in OB MEWT in EMR Sepsis Checklist in EMR ALL RN Protocol
TBD 2018 Oct 1, 2015 Dec 2015 Sep 2014 Mar – May ‘15 March 2018 June 2018 Aug 2017 Dec 2017
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Bedside RN Champions Paper Checklists Policy Protocols Order Sets CCU ED Inpatient Education Equipment
EMR BPA Workflows: ED CCU Inpatient OB
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General Population: Primary sources in ED: Pna, UTI, Abdominal & Wound/skin OB Population: CHORIOAMNIONITIS…. AND Endometritis, Wound, Pyelo, Pna, Necrotizing fasciitis CHORIO – AND SEPSIS > Providers & Nurses thinking chorio is different than sepsis > Not understanding Sepsis is a body’s adverse reaction to ANY infection > Providers and nurses thinking delivery is cure > Not thinking more than one infection can be occurring at same time
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Any two SIRS/symptoms below
AND Suspected infection?
HR>110 RR>24 Temp < 36 OR >38 WBC > 14 OR <4 Acute Change in Mental Status SBP <90
ANY ISOLATED TEMP of 390 Notify MD
Any suspected or Known infection? Yes 1.
Call Rapid Response Team unless MD is available for immediate assessment and
2. RRT initiates Sepsis (nurse initiated Orders)
No Continue to monitor patient Early intervention was implemented for all patients who screen positive for sepsis RN champions instrumental Perinatal staff educated on early recognition and management of maternal sepsis
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G1P0, 37 weeks gestation, with uneventful pregnancy 0300: Admitted to L&D
1200: Temp (38°C) Tylenol was administered and …..
RRT was called & Sepsis Bundle was initiated
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> MEWT build in Epic > Checklist build in Epic > Once hardwired, monitor process
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Quality Improvement work
population
education on early recognition and management of maternal sepsis
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Confidential: Protected Quality Improvement Document
For more information, contact: Betsy.Pesek@overlakehospital.org
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Acosta, C.D., & Knight, M. (2013). Sepsis and maternal mortality. Current Opinion Obstetrics and Gynecology,25 (2), 109-116. Doi: 10.1097/GCO.0b013e32835e0e82. Barton, J. & Sibai, B. (2012). Severe sepsis and septic shock in pregnancy. Obstetrics & Gynecology, 120(3), 689-706. Doi:10.1097/ACOG.Ob013e318263a52d Bural, K., & Rich, D. (2014). Code sepsis: development of a sepsis protocol for the obstetric patient. Journal of Obstetric, Gynecologic & Neonatal Nursing, 43(1). S13. CDC (2016). Inpatient care for septicemia or sepsis; a challenge for patients and Hospitals. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db62.htm CDC (2017). Pregnancy mortality surveillance system. Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html Downs, B. (2013). Development of a maternal sepsis tool …from scratch. Surviving Sepsis Campaign
https://www.doh.wa.gov/Portals/1/Documents/Pubs/140-154-MMRReport.pdf World Health Organization (2017). Global Maternal Sepsis Study. Project brief. www.who.int/entity/reproductivehealth/projects/Project-brief-GLOSS.pdf?ua=1