Sepsis Standard Work: Improving Compliance with Early Recognition and Management of Perinatal Sepsis

Sepsis Standard Work: Improving Compliance with Early Recognition and Management of Perinatal Sepsis


[ Music ]>>Hello and welcome to today’s webinar,
Sepsis Standard Work: Improving Compliance with Early Recognition and
Management of Perinatal Sepsis. Thank you for tuning into today’s webinar. My name is Kate Wiedeman, and I am
a Health Communication Specialist in CDC’s Division of Healthcare
Quality Promotion. The mission of CDC’s Division of Healthcare
Quality Promotion is to protect patients, protect healthcare personnel and promote
safety, quality and value in both national and international healthcare delivery systems. This webinar is part of a series of
infection control-related webinars that CDC will be hosting with a variety
of external partners and experts. Before we get started, there are
a few housekeeping items to cover. We welcome your questions. Please submit any questions or comments
you have via your chat window located on the lower left-hand side of the webinar
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speakers are turned on with the volume up. The audio for today’s conference should
be coming through your computer speakers. In addition, the speaker’s slides have
been sent to all participants via email and will also be provided to
participants in a follow-up email. Now it is my pleasure to introduce Dr. Seun
Ross, from the American Nurses Association, who will be providing an introduction for
today’s webinar, along with Dr. Elizabeth Rochin from the Association of Women’s
Health, Obstetric and Neonatal Nurses. Dr. Ross.>>Thank you, Kate. The American Nurses Association represents the
interests of the nation’s 3.6 million nurses. ANA has a longstanding involvement
in infection prevention and control, and recent emerging disease threats
have presented unique opportunities for formalized collaboration with organizations
such as the Association for Professionals and Infection Control in Epidemiology and the
Centers for Disease Control and Prevention. As the largest and most trusted profession for
the last 15 years, nurses are uniquely qualified to identify and prevent the
spread of infections like sepsis. Nurses spend the most time with patients and
their families providing them with opportunities to prevent, identify and treat infections. ANA has several infection prevention
and control online resources on the www.nursingworld.org website. The first is CAUTI, catheter-associated urinary
tract infection prevention tool developed by a team of experts, including ANA members, representatives from specialty
nursing organizational affiliates, infection control specialists
and patient safety authorities. Nurse consultants from the Centers for
Medicare and Medicaid services, CMF, partners for patients, PFP
team and representatives from CDC were included in the panel. The one-page tool is based on the
CDC’s 2009 guideline for prevention of catheter-associated urinary tract infections
and incorporates an algorithm to determine if a urinary catheter is appropriately
based on nurse screening and assessments, as well as alternatives for retention and
continence, timely removal and a checklist on catheter insertion, cues for essential
maintenance and post-removal care. The Safe Patient Handling and Mobility
website provides several resources, including an online assessment tool to identify
facilities’ successes and opportunities for improvement, YouTube videos on early
mobility and safe patient handling standards and other educational resource packages. The ANA-APIC Association for
Professionals in Infection Control and Epidemiology Resource Center is a
centralized web-based information site, birthed from the lessons
learned from the Ebola crisis. ANA, APIC and other external stakeholders
sought to identify and address knowledge gaps in evidence-based infection prevention
and control practices among their members. The Nice Network, or Nursing
Infection Control Education Network, is the official brand for
a two-year CDC contract. The CDC network seeks to empower nurses
to protect themselves and their patients by providing real-time tailored
infection control training to nurses. It is the hope that the educational
materials and training developed through the NICE Network will increase
nurses’ adherence to and confidence in infection control protocols from the
prevention of healthcare-associated infections to provide care for patients
with highly contagious diseases. Now introducing Dr. Rochin from AWHONN.>>Thank you Dr. Ross, and
good morning everyone. My name is Dr. Elizabeth Rochin, and I’m
the vice-president of nursing at AWHONN, the Association of Women’s Health,
Obstetrics and Neonatal Nurses. Collaborative interdisciplinary care and
teamwork are hallmarks of effective sets of prevention and early detection. We, as obstetric nurses, play a pivotal role
in this process, and it is very important to better understand the contextual
aspect of this essential work. Maternal sepsis continues to be
a clinical challenge worldwide. On a global scale, material sepsis
is the leading cause of death, accounting for 15% of maternal deaths worldwide. Closer to home in the United States, maternal
sepsis is considered to be the leading cause of death in the peripartum period. As we explore the demographic and patient
history context, we see recurring themes that are associated with other maternal
morbidity and mortality reports. Specifically, through the lens of sepsis,
we see the demographic characteristics such as advanced maternal age, race
and those who are covered by Medicaid to have had reported association. In addition, patient medical and surgical
history lends itself to association with a diagnosis of sepsis,
particularly surgical interventions and other maternal morbidity and mortality
diagnoses, such as postpartum hemorrhage. As we just discussed, health and racial
disparities within maternal morbidity and mortality in general must
be recognized and addressed. The trend you see is unsustainable and
must be considered a call to action by all who are participating on this call. There is another alarming trend
that also must be highlighted. Callaghan and colleagues reviewed nearly
50 million obstetric visits over a period of ten years within the national
and patient sample. During this time, no significant
increases or changes in substance diagnoses were
found prior to delivery. However, during the same time period,
postdelivery sepsis rates increased by 148%. It is data such as this that was the foundation
of a new postpartum discharge education toolkit that was developed and launched
by AWHONN in 2016. Specific discharge information targets
specific conditions such as sepsis, hemorrhage, preeclampsia and others that
may place new mothers at risk for morbidity and mortality postdelivery. In closing, you will hear from all of our
speakers today, early detection is key to successful prevention and treatment. From a healthcare provider perspective, what is
the primary preventative measure we can offer? You guessed it, good handwashing. As sepsis may be difficult to
identify, particularly during labor, as symptoms may be similar, it is
critical to understand the pathophysiology and physiologic changes of pregnancy
that may mask sepsis diagnosis. Interdisciplinary training, simulation
and teamwork is vital to assure systems and processes are in place
to provide care to the mother if indeed sepsis is suspected or identified. Communication and teamwork strategies
such as code sepsis OB programs and team seps training provide the foundation
for coordinated efforts and assures skillful and timely care is available
in the perinatal setting. Thank you for the opportunity for AWHONN
to contribute to this essential work. I would now like to introduce
Dr. Lauren Epstein, who will provide the CDC vital signs overview.>>Thank you. The CDC Vital Signs is a monthly
report that was published in 2010. Each Vital Signs report is linked to a
scientific publication from CDC’s morbidity and mortality weekly report and highlights
important public health issues using a graphic fact sheet and website, a media
release, and a social media tool. In August 2016, we published a
Vital Signs focusing on sepsis. Today I’m going to present
some of the key findings and messages from the report and next steps. We conducted a pilot assessment
of patients with sepsis and performed a retrospective chart
review in four New York hospitals. Medical records of 325 patients,
both adults and children, were reviewed to better describe the
epidemiology of sepsis, including demographics, underlying clinical characteristics
and infections leading to sepsis. This is published in CDC’s morbidity
and mortality weekly report. As part of the sepsis Vital Signs report, key findings were highlighted
throughout the analysis. We found that sepsis most often occurs in people
over the age of 65 or infants less than one-year of age or among people with chronic diseases
such as diabetes or weakened immune systems. Sepsis is most often associated with infections
of the lungs, urinary tract, skin or gut and common pathogens that are the cause of
sepsis are staph aureus, E. coli and some types of strep, although a majority of patients
do not have a pathogen identified. Finally, while healthy adults,
children, while healthy infants, children and adults can develop sepsis from
an infection, especially if not identified and treated properly, this is less common. We found that sepsis begins outside the
hospital for nearly 80% of patients. In addition, seven in ten patients
with sepsis had recently interacted with healthcare providers for a chronic
disease as requiring frequent medical care. Overall, there are opportunities for better
prevention of infections that lead to sepsis and improvement of recognition of sepsis. The report highlighted the important role of healthcare providers regarding
sepsis prevention and recognition. We encourage providers to talk to patients and
families regarding signs and symptoms of sepsis, infections that lead to sepsis,
and how infections that can lead to sepsis can be prevented or
recognized early and what to do when an infection is not getting better. In addition, healthcare providers should
act quickly if sepsis is suspected. Based on this pilot assessment,
we are expanding the project to ten sites throughout the US using
CDC’s Emerging Infections Program Network. Data collection is currently underway, and the goal is to further describe underlying
characteristics of patients with sepsis and septic shock and identify
opportunities for prevention. We are also conducting a national sepsis
educational effort to improve sepsis prevention, early suspicion and recognition
leading to timely treatment. The launch is scheduled for fall, 2017. Anticipated outcomes of the campaign,
including increased awareness of sepsis, and prevention of infections
that lead to sepsis. Additionally, the goal is to increase
awareness of the need for rapid recognition and prompt treatment, especially in
areas outside of acute care facilities. Thank you. Please visit the CDC Vital Signs
webpage for more information. Now I’ll hand it over to Dr. Sean Townsend.>>Dr. Townsend?>>Yes, I’m here. Thank you very much for the opportunity
to be a part of this presentation today on maternal fetal sepsis and the
opportunities to address early recognition in maternal sepsis in particular. It’s my pleasure to introduce two
of my colleagues at Sutter Health who will be presenting our
key information on this topic. The first colleague is Dr.
Katarina Lanner-Cusin. She’s medical director at the
Women’s Services in Sutter Health at Alta Bates Medical Center
in Berkley, California. Dr. Lanner-Cusin is the co-chair for the
OB/GYN quality committee for Sutter Health, a healthcare organization delivering
approximately 33,000 babies each year. She was part of the leadership team for
the implementation of the early recognition of perinatal sepsis for the, of the
Sutter Health perinatal population. In addition, I’ll introduce her colleague
as well, Dr., or rather, Lori Olvera, a bedside nurse, at Sutter Medical Center, Sacramento’s Anderson Lucchetti
Women’s and Children Center. Lori was a sepsis lead for rollout
of sepsis bundles for maternal sepsis at Sutter Sacramento, as well as a regional
rollout in Sutter Health for the same. Lori is currently working in collaboration with
Holly Champagn to rollout to Kaiser Sacramento, as well as a regional rollout for
Kaiser Hospitals for early recognition and management of maternal sepsis. So without further ado, I would introduce
them both and turn the presentation over.>>Hi, this is Lori Olvera.>>And this is Katarina Lanner-Cusin,
and I would say it’s no coincidence that we are a team presenting to you because
it’s essential for a successful implementation of sepsis screening that it
is an interdisciplinary team that leads the implementation.>>I’d like to thank Dr. Townsend for
a wonderful introduction, and also, I wanted to thank the CDC AWHONN, ANA and Society of Critical Care
Medicine for sponsoring this webinar. The objectives we’re going to cover are
effectively implement the OB sepsis screen in the perinatal population
using adjusted parameters for the systemic inflammatory response. To identify the importance of
implementing protocols for early recognition and management of perinatal sepsis. And to identify the barriers to implementation
of sepsis bundles in early recognition and management of perinatal
sepsis and how to overcome them.>>And here is the history of sepsis in an
abbreviated format and the perinatal population. And so in 2001, the Rivers study showed
that adult patients that made it to the ICU with severe sepsis and septic
shock are less likely to die when early directed therapy is used. And the mortality rate was
16% lower in the patient that received the early goal-directed therapy. So guidelines for the care of
sepsis was published in 2004. The perinatal population were not included. Perinatal patients are young and
healthy, and septic shock is rare. The normal physiology of pregnancy
can mimic early signs of a sepsis. So however, when reviewing the
causes, which were already now heard, the cause of pregnancy-related deaths in
the United States between 2006 to 2010, infection and sepsis was
the second leading cause. So now gradually, sepsis
screening has become more and more the standard in
the perinatal population. And you are also aware of that the Center of
Medicaid and Medicare Services that link quality and safety with measures of reimbursement
for hospitals has become an essential driver for hospitals to proceed with sepsis screening. And here, again, you see how through 2011
to 2013, again, the sepsis was validated as an important cause of
perinatal deaths in patients.>>So in this slide, it shows a
severe sepsis and septic shock for the adult population at Sutter Sacramento. And this was the mortality
rates, the blue line that goes across the screen is the
mortality rates depicted. The pregnant patients weren’t taken out of. This is just all adult patients. So you can see in September
2015, the mortality rate was 28%. When we started our rollout and implemented
sepsis screening early recognition, we adjusted our SIRS criteria
for the perinatal population. That was actually in February 2016. You can see that the mortality rates,
you know, were lower at that point. But then it kind of jumped up again. And so it has this jagged effect. However, since about August, 2016, we’ve kind
of seen a stabilization of the mortality rates, and we’re thinking that this is
probably going to reflect, you know, our good work that we’ve done at Sutter Health
showing that our mortality rates are decreasing. I want to emphasize that we
have, the patient, it was, our screening for patients were varied
depending on what type of patient. But the response was the same. We had the RRT come to the
bedside and evaluate the screen, and the treatment was the same no matter
where the location of the patient was. So we have the same response
throughout the hospital.>>So what do we know about
pregnancy and sepsis? We know that septic shock is
rare in the pregnant population. And of all septic patients, approximately
half of a percent are pregnant. And there has been noted to be an overall
increase in severe sepsis and septic shock. Mostly due to demographic
changes of pregnant women. And as noted before, advanced maternal
age is important, obesity, diabetes, severe complications of pregnancy such as
placental abruption, placental abnormalities, and also assisted reproductive
technology has played a role. And emerging infections are also
an important contributor worldwide with significant respiratory viruses. And also we all remember Ebola
and how it ravished West Africa. And there are also emerging
bacterial infections, methicillin-resistant staphylococcus aureus for
example and vancomycin-resistant enterococcus. So due to all traveling that can occur in
the world, I think as caregivers we have to pay attention to the emerging
infections as well.>>So this was actually in The Green Journal. This is an article written
by Barton and Sibai in 2012. It was a fantastic article. It’s a must-read. It talks about how pregnant patients need
to be included in our sepsis protocols. And in the abstract, it states the following. Pregnancies complicated by severe sepsis and
septic shock are associated with increased rates of preterm labor, fetal infection,
pre-term delivery. Sepsis onset in pregnancy can be insidious, and patients may appear deceptively well before
rapidly deteriorating with the development of severe shock, multiple organ
dysfunction syndrome, or death. The outcome and survivability in severe sepsis
and septic shock in pregnancy are improved with early detection, prompt recognition at
the source of infection and targeted therapy.>>Dr. Olvera, my apologies for interrupting. Some folks on the phone are
having a hard time hearing you. Would there be any way you
could get a little bit closer to your phone so that we can hear you?>>Can you hear me now? I mean I’m>>That’s much better.>>Can you hear me now?>>Is it? Oh, okay. Okay, sorry. So what does the literature say? Sepsis is actually one of the top
four causes of maternal mortality. Pregnant women are more vulnerable to infection
and susceptible to serious complications. The immune system in a pregnant woman
is down regulated to protect the fetus. And so pregnant women are actually very
susceptible to infection and getting very sick. Screening protocols are needed for early
recognition management of maternal sepsis. And all perinatal staff must be trained on early
recognition and management of maternal sepsis. So it’s really important to educate every
department where a pregnant patient may exist. For example, you know, the ED, the
ICU, as well as like your labor units, your postpartum units and
high-risk maternity units. It’s really important to train all staff. So why do we need protocols
for early recognition? Early recognition and treatment of
maternal sepsis will improve survival, decreased length of stay and
length of stay in the ICU. And it makes sense. You know, a patient with septic shock
gets, you know, they get very sick. They get hypotensive. They go to the ICU. They can be intubated. They’re in the hospital for a long time. What we want to do is create
a system where we intervene when the patient is displaying subtle signs, such as the systemic inflammatory
response criteria. Delay in diagnosis and treatment of sepsis
has been shown to increase mortality.>>The Sutter Health sepsis initiative in
the perinatal population was implemented in early 2016 with an overarching goal
of reducing morbidity and mortality. And I would just mention, morbidity in this
population can go all from separating mother and baby for prolonged periods of time with,
associated with difficulties of breastfeeding. And this morbidity can then ultimately also
include operative procedures, hysterectomy and even more complicated surgical procedure,
bowel resections, skin transplants, etcetera. So morbidity can be quite significant. The mortality also has been noted to be
significant at times in this population. So the implementation strategies
of early recognition and treatment was a chance to alter the outcome. And we use standard work, which
I think many of you are familiar with because the lean has become
a strategy at many hospitals. And so that was the approach that was adopted,
that had been used in manufacturing as well to reduce the variation in
care and errors of omission.>>So what can we do? We want to improve the recognition of
sepsis in the perinatal population. We want to adopt best practices
and provide recommended care. And the recommended care is
ICU level care for a patient who is hypotensive despite giving the fluid
boluses or a lactate greater than 3.9. Best practices are based on organizations
with the lowest sepsis mortality. Its protocol-driven, early recognition
and escalation of care or ICU level care. Code sepsis in OB, let’s
intervene before it hits. This slide was actually from
a video that we made. It’s, I think it was a very
good video that we did. It was actually an educational
video for healthcare professionals. And in this slide, we’re trying to
resuscitate a woman who’s in septic shock. The mortality rate is like 30 to 60%,
dependent upon the source of infection. So we all kind of know what to do at this
stage, but what we want to do is create a system where we’re not intervening at this point. We’re intervening a lot earlier. And once again, it’s when the woman is
presenting and has subtle vital sign changes, such as systemic inflammatory response criteria.>>So, what do we do? What steps do we follow when
we do sepsis screening? So first, we need to define what the
systemic inflammatory response is, which is a clinical manifestation
that occurs from an insult. And these insults could be trauma, pancreatitis. And here we’re focusing on
infection as the trauma. And this will result in a body-wide activation
of the immune and the inflammatory cascade. So why does sepsis kill? And the importance is that
the infection develops, cascade activation and mediator release follow. And if the infection progresses to
sepsis and severe sepsis, the systemic and body-wide inflammatory response
leads to widespread vasodilatation, capillary permeability, cellular activation,
and derangements in the coagulation. And if this response is not stopped,
then it leads to a circulatory collapse, hypoperfusion and possible death. So this response can be normal
and protective for the body. But if it is not treated, then
the outcome can be very severe. And what you see at the bottom of this slide is
a link to a presentation of sepsis in a YouTube that was produced by the University. And it is an excellent presentation
of the devastation of the systemic inflammatory response. And this link was particularly popular
when we rolled out our initiative because it was 9 minutes and 58
seconds of excellent education.>>So because of the physiology
of pregnancy, we knew that we had to adjust the screening criteria
for the perinatal population. So we looked at the physiology of pregnancy
and looked at what factors we needed to adjust. So in the pregnant woman, there’s
an increase in blood volume that increases the maternal
heart rate by 10 to 20 beats. The minute volume increases 50% due to an
increase in respiratory rate and tidal volume. The position of the diaphragm due to
the growing fetus, decreases lung volume and increases the respiratory rate. There’s an increase in WBC or leukocytosis
in labor and immediate postpartum. Now I will tell you that any OB will
tell you that WBCs can go as high as 20,000 in the absence of infection. But we actually looked at our, we looked
at like 99 patients who screened positive over a ten-month period, and actually their
initial WBC was somewhere around 14, 15. It was not a large number when they first
presented or when they screened in positive. We also noted that there was an
increase in perfusion to the kidneys that caused a decrease in the creatinine level. So this is actually the SIRS
criteria comparison. You can see on the left is
the adult screening criteria, and the right is the perinatal
screening criteria. And anything that you see bolded in red were the
bio signs or factors that we actually adjusted. The heart rate we adjusted from 90 to
greater than 110 for the perinatal patient. The respiratory rate is greater
than 24 breaths per minute. The WBC is greater than 15,000, less than 4,000
or greater than 10% in immature neutrophils.>>Oh, sorry. Sorry. There.>>Okay. This is actually, I call it the
elevator speech because it’s an arrow that we used to show as we were
educating staff, from least mortality and as it grows, of greatest mortality. So we start out with a suspicion of infection. And then as the patient is allowed
to progress along the continuum, they can actually go into septic shock. We looked at the SIRS criteria. There was a lot of discussion
around the SIRS criteria. We looked at what the ACOG recommendations
were for SIRS criteria and the adjustments. We looked at actually hospitals in general, and Dignity had screening
criteria that they developed. And after much discussion, we
came up with our own parameters. I’ll just let you. I’ll let you adjust.>>This is at, we’re returning to the arrow. And we can see how the continuum of the
inflammatory response can lead to severe sepsis. Which is the combination of
sepsis and end organ damage. And here is where you see the
criteria for the end organ damage. So the surviving sepsis campaign are the values
that you see highlighted in the green column. And in the yellow column you see the
Sutter health parameters that were chosen. And so the differences are
actually not very significant, but it involves the oxygen
saturation, which we determined to be any time when it’s less than 92%. I’m sorry, this is not our latest version. So I would just speak to it more precisely. And also when the urine output was less
than 30 ccs over a two-hour timespan. And also, as mentioned earlier, there needed
to be an adjustment for the creatinine. So instead of using values larger
than two, we used values above 1.5. And then I just wanted for
a moment to address lactate, because usually obstetricians are
not very familiar with using sepsis, using lactate as an evaluation tool. So there was quite significant emphasis
on teaching around the lactate levels. Here we go. I’m getting further along in
the path of the severe sepsis. And now we address the organ damage. So what then occurred often is a
dismissal of the abnormal values. And this slide is all thanks to Dr. Townsend. Because it really brought up how many
times when values are noted, there is a, oh this is seen often, and
it has no significance. Particularly in the postpartum period. And the fever was explained by
just an increased metabolic demand. And tachycardia was due to
a relative hypovolemia that many times could be
tolerated by the young woman. And again, coming back to the leukocytosis,
which was just due to the stress of delivery. And even mild hypertension could be dismissed
because of possible hypovolemia in a young woman with a physiologically low blood pressure. So this is an important issue
to address in education.>>So, how did we implement early
recognition as part of our standard work?>>Sorry. I will advance, Lori.>>Got it. Actually, what we needed to do, we
started with a multidisciplinary team. We included ICU and the ER. We included pharmacy, lab,
leadership team, educators, physicians, nurses from all the units. We had champions from every unit to be
a part of the multidisciplinary team. The focus actually of the team was to
create that workflow and have decisions. And so once again, it was important
to have everybody represented. We came, go back. Thank you. We started out actually doing,
we developed actually a workflow and then we moved on with our education. We actually started out doing
the physician education first. It was really important to
educate the physicians and also to get their feedback into the process. Because when we implemented it out to the rest
of the organization, we wanted to make sure that we had a very concise workable
system that everybody agreed on. So we spent a good time educating physicians
at their physician-attended meetings. We did inter-professional
education for all of staff. Once again, we wanted it to be successful. We wanted all staff to know about the standard
work that was going to be implemented. We developed a new perinatal
sepsis physician order set, and that order set actually was a prechecked
item of once a woman screened in positive for sepsis, that it was a standardized
method for treatment of labs we would order, antibiotics that we would order according to
the source of infection and the fluid boluses. And then last but not least, it was really
crucial to have physician and RN champions. You know, physician champions,
the physician champion was crucial because they actually, physicians
listen to physicians. So if there was things that
needed to be addressed with the physicians, we used our physician lead. Our RN champions were very
crucial because, of course, the patient was not presented
8:00 in the morning. A patient will be there at 2:00 in the morning. And so we had champions on every shift so when
that patient presented, that there was somebody to mentor that newer nurse or
that nurse who did not know the, who was least familiar with the workflow. Next slide.>>And Lori’s extremely correct about this. It required a significant multidisciplinary
team where every skillset was equally valued in order for it to be successful.>>So our standard work for perinatal
sepsis included initiating sepsis screening every shift. It was, you know, every shift
or when the patient transferred or as necessary for a known infection. But we started screening every patient. We created protocols and standardized procedures
for, with SIRS criteria for maternal sepsis. We had early intervention
implemented for all patients who screened positive, as I spoke earlier on. And then the arrival of the rapid response
team, which was quite new for our department. We had the intensivist evaluation as
needed, so when a patient was hypotensive and wasn’t responding to the fluid
boluses, or the lactate was greater than 3.9 that we had an intensivist come and evaluate. The OB physician, of course, was notified
and part of that team collaboration of where the best location was for that patient.>>And I don’t know if you
all have rapid response teams. But our rapid response team, which
is the same as Lori mentioned, includes a respiratory therapist and an ICU
nurse that would then evaluate the patient. And another important component of
this implementation was the creation of a severe sepsis order set,
which Lori mentioned earlier. Because that standardized the treatment of
the patient and gave very good directions for the obstetrician of the
selection of antibiotics, for example, the flow of laboratory tests, as
well as the fluid resuscitation. And here is a sheet, the
instruction sheet, for standard work. And I’m only showing this because we
all worked very hard at creating this. And it’s a very good depiction of the process. And I always think of this as something that
you print out, fold and put in your back pocket because it gives you all the instruction
you need when you encounter the patient. So if any of you are interested,
we would be very happy to forward you the standard
work because it’s very valuable.>>So this is actually our sepsis
alert process or standard work process. A patient who has an infection,
is screening positive for sepsis, the rapid response team responds to the bedside. A sepsis alert is called. It involves lab responding to the bedside
to draw CBC, CMP, lactate, blood cultures. We start broad spectrum antibiotics. Our goal is to get it within an hour. And IV fluids, 30 mils per kg
if the patient is hypotensive. And we have radiology and pharmacy on alert. And of course, the physician is notified if the patient is presenting
more, looking more septic shock. Like with a lactate greater
than 3.9 or hypotensive. Despite that fluid, the ICU
physician is notified. If the patient has severe sepsis, or I should
say just has organ dysfunction, then once again, the rapid response team is called to the
bedside to help mentor in the workflow. The broad spectrum antibiotics are started
if they haven’t already been administered. We give it 30 mls per kg for lactate 2 to 3.9. And we repeat the lactate every three
hours until we get a lactate lesson two. If we’re not being able to monitor the
urinary output or there’s a question, then we will place a urinary
catheter for strict I and O if needed. An O2 sat monitor is placed. Oxygen is given per protocol. And then if the systolic BP is
less than 90 or a lactate greater than 3.9, a code sepsis is called. This is the overhead page,
and it alerts the ICU. The ICU charge nurse and pharmacy
lab, and it’s a great system. Actually, it’s initiating that six-hour
bundle where we can consider, you know, whether the patient needs central line
or do we need to give vasopressors. And once again, that would be done via
escalation of care or done in the ICU.>>And here is a depiction of the code sepsis
where the RN notifies the OB physician. The OB physician assesses
for criteria of septic shock. And if that has been documented, the OB
physician notifies the ICU physician. And the ICU physician comes to the
bedside, evaluates the patient. And if the ICU physician recommends
for the patient to be transferred for the ICU, that is what would then occur. And this has led to more intense and appropriate
care and earlier treatment for the patient.>>So we wanted to share some of the
data that we had from our rollout. And there’s actually, we’re just sharing
a couple tables in the article I wrote in the AWHONN Journal about early recognition. There is actually more data for you to see. Next slide. So the source of infection
in perinatal patients. This is actually a ten-month
period collected data. It was 99 patients. One of the things we looked at
was the source of infection. The chorio, as we’re not surprised, was
46.4% was the initial source of infection. Pyelonephritis, 14.4%. Endometritis, 5.2%. Urinary tract infection was 5.2%. And what was kind of surprising
was unknown etiology is 29%. So that kind of told, that told us that
we really needed to be able to look at, have our ID team, our ID and pharmacy
with antibiotics stewardship to look at what was the best antibiotics
to give for unknown etiology. Because it was such a high number. Next slide. So looking at sepsis, severe
sepsis and septic shock. This is actually, if you look to the
far left, when you look at a patient, sepsis screen positive, we had 99 patients with
a 4,000 delivery rate during that time period. So it was .024%. Which is a very low number. This observation was actually very crucial to
our organization when we did a regional rollout because everybody thought
that when we rolled this out that everybody would be
screening in positive for sepsis. This convinced our team that it was actually, it was going to be a very
low number that screened in. Looking at severe sepsis,
once again, very low number. It was 47 out of 4,000 deliveries, .012%. And then septic shock, which is .002%. And just this actually was the same
number as when the slide earlier, when we talked about septic shock is rare. So kind of, our data kind of matched
what it said in the literature. Looking at the second observation,
was that we had an RRT come out to actually validate the screen when we
had a woman screen in positive for sepsis. They were just there to concur. We found 98% of the time our nurses
were right on with their assessments. Of those 99 patients, 47 out of 97
were actually, had severe sepsis. That was 48.5%. So that was over half actually
went on to get severe sepsis. And 7.2% went on to get septic shock. We had to address the barriers, and
there, you know, we had several barriers. And I always recommend to address
the barriers before you implement it, because common themes will come up. One of the common themes is our
patients are young and healthy. They don’t look septic. That our bundles will result in overtreatment. And you know, once again,
going back to the data. There was not very many patients
that actually screened in positive. And we also, the education we did for staff
is that we actually create standardization in our healthcare that sometimes
results in overtreatment. However, we want to save that person
who would die of septic shock. And I actually correlated how we treat
our GBS, we do our GBS screening as kind of a correlation of the same type of workflow. You know, but.>>Also what I would say there
was big debates about the lactate. And so there was big objections to the fact that a laboring woman would
normally have an increased lactate. It’s got, very few studies
that have been published. There was no absolute good solution to what
the lactate would be in laboring women. Though I know that Sutter Sacramento and Lori, they did studies on the lactate
levels in laboring women. And it turned out that they were not
significantly different than in anybody else. And another big issue became a second stage
of labor and whether you should screen at all. And so I think ultimately where we ended up
was that screening occurs in the second stage of labor because now with a new
emphasis on allowing the second stage to proceed for a longer period of time. It becomes important to screen the patient. But also to add the clinical situation. And so usually we would say
if the delivery is eminent, then we will re-screen after
the patient delivers. But all of this were barriers
that had to be addressed and is continuously addressed as time proceeds.>>So let’s begin the campaign and promote early
recognition and management of maternal sepsis. Think sepsis and save a life.>>Well thank you very much.>>Now we’re going to turn
it back to Dr. Townsend.>>Thank you very much, Dr.
Lanner-Cusin and Lori Olvera. I appreciate your informative presentation. There have been a number of questions that you
can see have come up in the chat on the side of the presentation during
the course of your comments. A couple general questions came up, and
I’d like to address those to you first. The first question came from Susan
Emerick, and the question was, have there been any reasons
identified as to why black women are at so much more risk of sepsis than white women? Is it correlated with increased
surgical intervention?>>So what I can address is that at
our site where we deliver 6,000 babies, our patient population is 20% Afro-American. And we then also as a corollary to
that, have a more significant presence of cardiovascular disease and preeclampsia. So that then leads to some of the
issues that were presented earlier as to what increases risks of sepsis,
which is, for example, placental abruption. And so I think that is a contributing factor. And then, obviously, it can’t go unmentioned
regarding access of care at which state in the evolution of infection
a patient presents. So those would be some of the explanations
for a higher rate in the Afro-American woman.>>Very interesting. Another question from Kevin Cavanaugh. If sepsis starts outside of the hospital in 80%
of patients, how can staff handwashing be viewed as the primary intervention
needed for prevention.>>Hi, this is Lauren Epstein from CDC. I can go ahead and answer this. So in our analysis, we did see that, and I think
that this has been shown in the literature, that most patients that come in with sepsis, and
about 80% come in from, present to the hospital with sepsis within the first 48 hours. That doesn’t mean that they haven’t
had interactions with healthcare. A lot of these patients have underlying
medical risks, underlying risk factors or had interaction with healthcare. And so we know that hand hygiene is one
of the ways that we can prevent infection. We also know that among the other
20% of patients that develop sepsis within the hospital actually
have worse outcomes. So we know that there’s lots of
opportunities for prevention, and we know that hand hygiene
in any situation is important. So that’s one area that we know
that it’s good infection prevention. And there’s always room for improvement.>>And also, it could stop the propagation
of infection within the hospital for sure.>>Well absolutely. Very difficult to argue against hand
hygiene in virtually any circumstance. So I appreciate the answers. These following questions are for
Dr. Lanner-Cusin and Lori Olvera. First question is from Laura Murrell. I’m spearheading a sepsis
awareness in my facility. Currently I’m having great progress with
the adult sepsis, and now I’m being asked to develop pediatric, neonatal
and maternal sepsis protocols. I was wondering if Dr. Lanner-Cusin and
Dr. Olvera had some ideas to send me that I could use to help
expedite my implementation. Thank you.>>So regarding the maternal
sepsis and the screening, we can obviously contribute from our experience. And again, it comes back to what Lori presented
about the steps that are so essential in order to be successful, which is the multidisciplinary
team, and it’s very essential to find. Now, if you have the luxury of finding
a nurse like Lori, that would be great. And also, if you have perinatologists
on staff, they are essential to participate in an implementation. So I think Lori might have
some other suggestions as well.>>We would, well we actually have tools, I
have tools that I shared actually in my article. But also, I can, I’m willing
to share tools that I have. I’m just thinking I can email
these tools to you.>>We can send a follow-up email after the
webinar with the tools that you want to provide.>>That’s great.>>Okay, perfect.>>Very good. Next question is from Martha Deed. May the seasonal association with
frequency of sepsis on your line chart, watching the rate this summer,
would confirm what you have already, that you have reduced frequency overall. I think the question goes to, is there
seasonal association with the frequency of sepsis on the chart you described. And then, would there be evidence to
suggest that watching the rate this summer?>>So is this addressing the
graph that Lori presented?>>Yes.>>I think it is.>>Yes.>>I don’t, I cannot address. That’s for the respiratory viruses that,
obviously, have significant seasonal variations. I am not sure that I see, can address a
seasonal variation in bacterial infection. And maybe Dr. Townsend has some
insight if that is the case.>>This is Lauren Epstein.>>Well I think that, sure, go ahead. Go ahead.>>I was just going to say that we have
seen some seasonal variation of sepsis in some of the analysis that we’ve done. But as we know that most causes… We have seen some seasonal variation of sepsis. We know that most causes
of sepsis are respiratory. So it does follow common
respiratory pads that we’ve seen.>>And just from my perspective,
from the surviving sepsis campaign and the data we’ve examined, as well as that
I’ve examined within Sutter Health for patients, we do see, in particular in the fall with
the rise of respiratory illness in adults, not specific to the maternal sepsis population,
an increased frequency of the diagnosis. So it’s likely to occur. It’s something we should pay attention
to and reinterpret information. There’s a good question here from Mary Shoupe. She states, at my hospital we screen
all maternal patients for sepsis on admission every shift and
with declining condition. We’re looking for a tool or
guidance on early identification on chorioamnionitis in particular.>>So what, I’ve reviewed some of
our data, and the way the data came to me I received those women
who had had a lactate over two. And in that group of patients were
many of the chorioamnionitis patients. And so I think from looking at that, that there
is early identification of chorioamnionitis. I think that most obstetricians have
become very focused on the early detection of chorioamnionitis because it has
a significant impact on the baby. So I think that we have actually achieved quite
a success at identifying chorioamnionitis early. And I don’t know that we can succeed, or
I can’t think of any other ways to do it. What happened in many of these situations
is as soon as the sepsis alert was called by the nurse, the RRT team and the obstetrician
actually arrived almost simultaneously. And the patient received care.>>Thank you. Katarina, I hate to interrupt you, but
we need to close the questioning period. And there are so many questions that
we won’t be able to get to all of them. But I appreciate the excellent
presentations from all of the presenters. And I turn it back to the staff,
the CDC staff for their commentary.>>Thank you Dr. Townsend. Before we end today’s webinar, I want to provide
instructions to receive continuing education. To receive continuing education, you must
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as well as all of you for taking the time to join us today and for your
commitment to keeping patients safe. Thank you very much.

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