Harbor:Sepsis core measures

Sepsis Core Measure

PERFORMANCE GOALS

• Inclusion:
  • Age 18 and older
  • ICD-10 diagnosis

• Exclusion:
  • Comfort care
  • Transferred from another acute care facility
  • Expire within 3 hrs of severe sepsis presentation or 6 hrs of septic shock presentation
  • Received IV antibiotic more than 24 hrs prior
  • Documented treatment refusal

DEFINITION

Source + 2 of the following:

• T>38.3 or <36
• HR >90
• RR>20
• WBC >12 or <4, or >10% bands

ACTIONS

• Use Sepsis Order Set "ED Sepsis Screening and Management Bundle" for labs, IVF, and antibiotics
• 3-hour bundle (within 3 hours of severe sepsis recognition):
  • Draw initial lactate
  • Obtain blood cultures prior to antibiotics
  • Administer broad spectrum antibiotics targeted at source
  • IV fluids (within 6 hours before recognition and up to 3 hours after recognition of severe sepsis)
    • Nursing reassessment within 1 hour of IVF bolus completion
• 6-hour bundle:
  • Clock starts when patient meets criteria for severe sepsis or septic shock
  • Repeat lactate if initially 2 or greater
  • Provider reassessment within 6 hours of recognition of septic shock

DOCUMENTATION

• Utilize .edsepsisprotocol
  • Can addend the chart up to 30 days after initial presentation (review real-time scorecards for any opportunities to fix)
  • Use the "not sepsis" statement if abnormal vital signs are not felt to be from sepsis but you document sepsis anywhere in your MDM; must specify “not septic shock or severe sepsis”
  • Specify how much IVF you are giving and WHY you are not doing 30ml/kg if not clinically indicated
    • The patient has a BMI > 30 so their ideal body weight of [ _ ] Kg was used and [ _ ] mL of fluids were given instead of the calculated target volume
    • Due to concern for volume overload ( [ _ ] CHF, [ _] non-collapsing IVC on ultrasound, [ _] CKD, [ _ ] signs of volume overload on exam), [ _ ] mL IV fluid bolus was given instead of the calculated target volume
    • The patient received _ ml of blood (colloid) and this was subtracted from the calculated target volume of [___] mL (30 mL/kg)
    • The patient improved after [____]mL
  • Focused exam requirement is met by writing “I completed the sepsis reassessment” within 6h of start of last fluid bolus
  • BCx after abx is OK only if provider documents that a deteriorating condition would make a delay in starting the antibiotic detrimental (eg, rapid deterioration would place patient at risk if delay in antibiotics)
  • The time on the note will apply to everything on the note (including recognition of septic shock) unless there is an updated time stamp, so please clarify the time recognition occurred.

Severe sepsis

DEFINITION

• Sepsis + acute organ dysfunction
• 1 or more of the following:
  • Hypotension: SBP < 90 or MAP < 65 or SBP decrease >40
  • Hypoxia: requiring oxygen (includes all supplemental O2 from NC to BiPAP, CPAP, mechanical ventilation)
  • Kidney Injury: creatinine > 2 or UOP < 0.5 ml/kg
  • DIC: PLT < 100, INR > 1.5
  • Hepatic dysfunction: bilirubin > 2
  • Lactate > 2

ACTIONS

Same as sepsis

DOCUMENTATION

None specific

Septic shock

DEFINITION (One of the following)

• Severe sepsis + persistent hypotension within one hour of completion of 30ml/kg IVF bolus
• Lactic acid >/= 4

ACTIONS

• 3 hour bundle:
  • Start 30ml/kg IVF bolus for ideal body weight
• Document contraindication for fluid overload patient, use your clinical judgement, and document accordingly.
• 6 hour bundle:
  • Start vasopressors if no improvement
  • Document reassessment after IVF completed (Can use F5 in Cerner for time stamp)

DOCUMENTATION

• .sepsissepticshocktreatment (especially important in cases in which a 30mL/kg bolus is contraindicated)
• .sepsisreassessment

See Also

• Harbor:Antibiotics in Sepsis