Harbor:Core Measures

• Door to Doc: Door to diagnostic evaluation by a qualified medical personnel
• Fracture to analgesia: Median time to pain management for long bone fractures
• Door to Discharge: Median time from ED arrival to ED departure for discharged ED patients
• Door to Admission: Median time from ED arrival to ED departure for admitted patients
  • Admit decision time to ED departure for admitted patients

• Stroke Head Imaging: Head CT or MRI within 45mins of ED arrival for stroke patients

• Sepsis
  • Overall performance
  • Initial lactate 6hrs prior to 3hrs after presentation
  • Blood culture 48hrs prior to 3hrs after presentation
  • Broad spectrum IV antibiotic administration 24hrs prior to 3hrs after presentation
  • Antibiotic selection post presentation
  • Repeat lactate within 6hrs of presentation
  • IV fluid resuscitation 30ml/kg minimum after septic shock presentation
  • IV vasopressor administration within 6hrs of septic shock presentation (informational only)
  • Repeat focused exam after IV fluid initiation and within 6hrs of septic shock

SEPSIS Core Measure Guidelines

• Joint Commission/Center for Medicare & Medicaid Services (CMS) determined national standard of quality: early management bundle for severe sepsis and septic shock patients
• Time sensitive management and documentation requirements must be met
• Compliance has financial implications, publicly reported
• Clock starts when patient meets criteria for severe sepsis or septic shock
• Inclusion:

**Age 18 and older

• 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 antibiotics more than 24 hrs prior
  • Documented treatment refusal

• Systemic Inflammatory Response Syndrome (SIRS) definition
  • Fever (temperature >38.3 C or >100.9 F) or hypothermia (temperature <36 C or 96.8 F)
  • HR >90
  • RR >20
  • WBC >12 or <4 or >10% bands

• Sepsis definition (not included in Core Measure)
  • At least 2/4 SIRS + Infection Source

*Severe Sepsis (included in Core Measure)

• • Sepsis + acute organ dysfunction
  • Acute organ dysfunction = 1 or more of the following:
    • Hypotension: SBP < 90 or MAP < 65 or SBP decrease >40
    • Acute respiratory failure (Sat <92% without oxygen)
    • Kidney Injury: creatinine > 2 or UOP < 0.5 ml/kg/hr
    • DIC: PLT < 100, INR > 1.5
    • Hepatic dysfunction: bilirubin > 2
    • Lactate > 2
  • Actions required for severe sepsis:
    • Use the ED Sepsis Orderset, and .sepsisseveresepsis autotext for documentation
    • Start 30ml/kg IVF bolus and the below required actions
    • 3 hour bundle:
      • Draw initial lactate
      • Obtain blood cultures prior to antibiotics
      • Administer broad spectrum antibiotics targeted at source
    • 6 hour bundle:
      • Repeat lactate if initially 2 or greater

• Septic Shock (included in Core Measure)
  • Severe sepsis + persistent hypotension despite 30ml/kg IVF bolus OR,
  • Lactic acid > 4
  • Actions required for septic shock:
    • Use the ED Sepsis Orderset, and .sepsissepticshock autotext for documentation
    • 3 hour bundle: (in addition to the above requirements of sending initial lactate, blood cultures, and antibiotic administration within 3 hours)
      • Start 30ml/kg IVF bolus (order needs to include duration over which IVF were given, so use the order in the ED Sepsis Order Set, which has this prefilled for you)
      • Currently no exclusion for fluid overloaded patient, but use your clinical judgement, and document accordingly.
    • 6 hour bundle:
      • Start vasopressors if no improvement
      • Perform repeat focused exam of “volume status & tissue perfusion assessment” within 1 hour after giving 30/ml IVF bolus
        • Option 1 (most used): Must include all elements below
          • Vital signs: Must include actual Temp, HR, RR, BP. In the 'reexamination/reevaluation' section of your provider note, in the 'vital signs' area, click on 'results included from flowsheet' to automatically drop in a selected set of vitals
          • Heart exam: RRR, Irregular, S3, S4
          • Lung exam: Clear, wheezes, crackles, diminished
          • Pulses: 2+, 1+
          • Cap Refill: <2 sec, >2 sec
          • Skin: Must include color. Mottled, not mottled, pale, pink
        • Option 2: Need 2 of the following
          • Central line: CVP, SCVO2
          • Bedside ultrasound cardiovascular/volume assessment (such as IVC, systolic function, pulmonary edema, etc.)
          • Passive leg raise or fluid challenge

• • If you see the SIRS/Sepsis screening icon or think your patient may have severe sepsis or septic shock, use the ED Sepsis Order Set. Has recommended antibiotics based on source of infection, labs, and IVF orders with duration times, etc. Also has some informational text about definitions and management.
  • Use the .sepsis autotext phrases for documentation (.sepsisseveresepsis, and .sepsissepticshock)

Sepsis Abx

• Cefepime 2g should be restricted to:
  • febrile neutropenia
  • HCAP for patient who weighs > 120kg, for others he'd suggest 1g iv q8h over 2g iv q12h based on time-dependent pharmacokinetic of the beta-lactam class
  • Meningitis that may involve hospital acquired organism, e.g. patient with VP shunt
• Meropenem
  • Severe sepsis, septic shock, over cefepime as there is trend for ESBL in ~ 20% of klebsiella pneumonia and E. Coli based on cultures

A.Wu AED Director 6/13/16