Nursing Point-of-Care Tools: Sepsis

Surviving Sepsis 1-Hour Bundle is not without controversy, especially among ED Providers nationally.  They are described as aspirational goals.  The faster patients can receive care, they are more likely to have a better outcome. The one-hour bundle is also a great way to educate peers about goals of the bundle.

Look at bundle elements rather than the "1-hr." timeframe. Sooner is better. Currently CMS measures us against the 3 & 6 hr. bundles.

The Sepsis Guidebook was developed by Ascension to help guide care & sepsis improvement opportunities across our ministries.

Ascension WI (AW) antibiotics have been updated recently 7/18. During the review from Ascension national, it was determined that were unapproved variations from the national sepsis "Guidebook". New & approved AW antibiotic table is published below.

Variations from the national "Sepsis Guidebook" that have been approved

• Omission of PO antibiotics when pneumonia is the source of sepsis. Most patients with sepsis are severely ill, and IV antibiotics are indicated.
  • The intent of including PO antibiotics in the "Guidebook" was to encourage the transition from IV to PO antibiotics as soon as possible.
  • With most pharmacy policies, that transition can still be easily made at many sites.
• Urinary-source sepsis: The national guidebook had one recommendation for ciprofloxacin alone in one category. Since many organisms, especially in southern WI are resistant to cipro alone. We were permitted to omit that recommendation, and leave the decision up to the provider.
• Bacterial Meningitis:  Ascension national has no current recommendations for bacterial meningitis. We were approved to keep our current recommendations. National is working on bacterial meningitis guidelines.

Highlights of recent changes in the sepsis orders

• Urinalysis reflex to culture: This test (automatic urine culture when specific indications are present within the routine urinalysis) was removed from the orders, instead listing a plain urinalysis and urine culture.
  • Rationale is that urine cultures are often showing colonization, as opposed to true infection, predisposing patients to unnecessary antibiotic use.
  • The intent is that providers choose urine culture more thoughtfully based upon patient symptoms.
  • However, it remains as critical to achieve timely antibiotics in sepsis, including when urinary infection is the source.
• Procalcitonin: Removal of procalcitonins from convenience orders in the sepsis orders: Rationale is that procalcitonin is believed to be less useful, except perhaps in pneumonia. See procalcitonin information tab.

Not changed: But pneumonia recommendations are intended both for sepsis and pneumonia (without sepsis). Cellulitis orders are also in process from Ascension national.

Refer to the "guidebook" to understand additional sepsis goals such as:

• Transition to IV push antibiotics for: Cefepime, Ceftriaxone, Cefazolin & Meropenem (more timely administration of first dose)
• Improving processes to track sepsis performance.

There "may" be associated education. Check back in a few weeks & toolkit will be posted