“Why worry about sepsis? …
- Increasing incidence of sepsis
- Significant mortality and morbidity
- Failure to recognise and respond
- Failure to manage ongoing care appropriiately
- Failure to see sepsis as time critical ilness”
The foregoing quote from the 1st World Sepsis Conference presentation “Sepsis Kills: Early Intervention Saves Lives” (WSC 15, September 8-9, 2016) by Dr. Harvey Lander, Director at the Clinical Excellence Commission from New South Wales, Australia, summarizes the urgent case for an IT-enabled healthcare transformation solution that is compatible with the CHARTSaaS RA. This case applies not only to managing the frequently occurring and often lethal clinical progression from sepsis to severe sepsis to septic shock in particular but also to the mitigation of medical mistakes and resultant reduction in patient adverse events in general.
The sepsis management clinical pathway/process is complex and time-critical, as the graphic header for this blog, taken from Dr. Lander’s presentation previously cited, implies by the density and complex interrelationship of the included elements; and as is further demonstrated by the following excerpt from the Patient Safety Movement Foundation Actionable Patient Safety Solutions “Challenge #10: Early Detection of Sepsis”, which specifies a diverse and dense aggregate of process design parameters and complex relationships to be monitored:
“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).
- Measure central venous pressure (CVP).
- Remeasure lactate if initial lactate was elevated.”
Process documentation and practitioner education to mitigate medical mistakes further exacerbates the challenge, because the complexity and time-critical nature of sepsis management increases the human/clinician cognitive overload that is the root cause of medical mistakes. However, an appropriately designed and implemented IT solution can resolve this challenge successfully to save patient lives. Please validate to your own satisfaction the capability of a CHARTSaaS RA-compatible IT solution (particularly its capability for case-specific and continuous complex event monitoring) to implement Lander’s and the Foundation’s recommended sepsis management pathways, tools and methods by reviewing the details of the in the presentations at these URLS: