Empowering Nurses for Early Sepsis Recognition

[ Music ]>>Good afternoon, and welcome
to today’s webinar, Empowering Nurses for Early Sepsis Recognition
hosted by the Centers for Disease Control and Prevention in collaboration with the Society for Critical Care Medicine and
American Nurses Association. My name is Abbigail Tumpey. I’m Associate Director for Communications
Science at the Centers for Disease Control and Prevention, Division of
Healthcare Quality Promotion. This webinar is part of a series of webinars
that CDC will be hosting with a variety of external partners and experts. Today’s webinar features an expert
panel, including Dr. Ernest Grant, President of the American Nurses
Association; Dr. Anthony Fiore, Chief of the Epidemiology Research and
Innovations Grant at CDC’s Division of Healthcare Quality Promotion,
who will provide an overview of CDC’s recently released vital signs
report on sepsis; Dr. Sean Townsend, Vice President of Quality and Safety
at California Pacific Medical Center, who will discuss expanding sepsis early
recognition and lessons learned from engagement of nurses; Mary Ann Barnes-Daly, Clinical
Improvement Performance Specialist at Sutter Health System,
who will discuss a pilot of sepsis early recognition in Sutter Health. Also joining us is Christa Schorr,
Associate Professor of Medicine at Cooper University Hospital,
who will discuss lessons learned from implementing sepsis
screening on hospital wards. Before we get started, there are
a few housekeeping items to cover. First of all, we welcome your questions. Please submit any questions or comments
you have via the chat window located at the lower left-hand side
of your webinar screen. You may submit questions at any
time during the presentation. Questions will be addressed after
all presentations as time allows. To ask for help, please press
the “raise hand” button located at the top left-hand side of your screen. If you need to chat with a
meeting chair person for assistance on technical difficulties during the webinar. As a reminder, the audio for today’s webinar
should be coming through your computer speakers. Please ensure that your speakers
are turned on with the volume up. Now it’s my pleasure to introduce Dr. Ernest
Grant, President of American Nurses Association. Dr. Grant?>>Thank you, Abbigail, for
that kind introduction. Although I must make a correction. I am the Vice President of
the ANA, not President. But it is my pleasure to say a few words
about the American Nurses Association and the nurse’s role in sepsis
recognition during Sepsis Awareness Month. First, a few words about ANA. ANA has a long history of supporting
the nation’s registered nurses. This year, we’re celebrating
our 120th anniversary. As the premier organization for
all RNs, we represent the interest of the nation’s 3.6 million registered nurses. ANA is at the forefront of improving
the quality of care for all. Infection prevention is a major
priority for ANA and the nation’s nurses. ANA knows that nurses play a
pivotal role in recognizing and preventing sepsis for a number of reasons. As the most trusted profession
14 years in a row now, nurses share in patients’
most vulnerable moments. There is also strength in numbers. 3.6 million RNs means that there are
more than 7 million eyes on patients, monitoring their vitals, and looking for
the key signs of sepsis, including fever, disorientation or shortness of breath. Finally, nurses spend the
most time with patients. It’s likely that a nurse will be able to
recognize subtle changes in health status and behavior that could indicate
the onset of sepsis. One common way for patients to develop sepsis
is through urinary tract infections, or UTIs. In fact, UTIs are the most common
reported hospital acquired condition. And 75% of UTIs are catheter-associated UTIs. RNs can play a major role in reducing
CAUTI rates to save lives and prevent harm, including the development of sepsis. This is why ANA developed this
evidence-based clinical tool in conjunction with leading experts, including
many from the CDC. The tool is an easy-to-use checklist and
decision algorithm and free to download. Please see the ANA CAUTI
website for more information. This tool is just one way ANA is working to help nurses prevent infection
that can lead to sepsis. In closing, ANA is proud to partner with the
Centers for Disease Control and Prevention on this webinar and in a number of other ways. Over the next two years, ANA and the CDC
will be working together to enhance education and training on infection
control for U.S. nurses. ANA will leverage its relationship with more
than 20 specialty nursing organization partners to develop training, to improve
nurses’ adherence to, and confidence in performing
infection control procedures that could protect both themselves
and their patients. ANA and the CDC have also partnered to identify
nurses’ roles in antibiotic stewardship. Through this work, we will codify how nurses
contribute to antibiotic stewardship programs. As we know, antibiotic misuse
contributes to the emergence and spread of antibiotic-resistant super
bugs that can lead to sepsis. Finally, as part of our ongoing partnership
with the Association of Professionals in Infection Control and Epidemiology,
ANA has launched our infection prevention and control website shown on the slide. I encourage you to take a look
at the evidence-based prevention and control practices on the site. As you will hear throughout the hour, nurses are
vital to preventing sepsis and other infection. I look forward to hearing
from our esteemed panelists. Now I’d like to turn this over
to Dr. Fiore with the CDC.>>Thank you, Dr. Grant. I’m really happy to be here and to– I look
forward to hearing more from the other speakers about the important role
the nursing staff can play. So I’ll be very brief in describing what
came out of the CDC vital signs report on August 23rd, and that we continue to promote
over the course of Sepsis Awareness Month. First, we found that sepsis begins outside
of the hospital for nearly 80% of patients. Another important finding with finding that 7 in
10 patients with sepsis had recently interacted with healthcare providers
who had chronic diseases that required them to get frequent medical care. And what this tells us is that there are
opportunities to better prevent infections and recognize sepsis early to save lives. There’s a chance here for providers to talk
to the patients about infections and sepsis, about how infections that can lead to
sepsis can be prevented or recognized early, and what they can do if an infection
is not getting better and looks like it could be at risk for sepsis. Now, nursing staff, of course, plays a role
both in in-patient and out-patient settings. And you’ll hear a lot about
the in-patient setting. And I’m talking now a little bit about what goes on with what happens before
people get to the hospital. But it’s also important to know about the
risk factors for sepsis, and this applies both to people in and out of the hospital. Sepsis most often occurs in the
people that are most vulnerable. And those are over the ages of 65, infants
that are less than one year of age, those with chronic diseases, particularly
diabetes or weakened immune systems. It also most commonly occurs after an
infection in the sites of the lung, of the urinary tract, the skin or the gut. There are certain very common
bacteria that cause sepsis. And it’s going to come as no surprise to you
that the most common are Staphylococcus aureus, E. Coli and some types of Streptococcus. However, for many patients, no cause
of bacteria is ever actually isolated. But it’s important to remember despite
me telling you about the risk factors that even healthy people can
develop sepsis from an infection. And it’s especially true if the infection
is not treated properly and early. So what can healthcare providers do? Well, you’re going to hear a whole wealth of
practical information in just a few minutes. But the overarching message is that
healthcare providers really are the key to preventing the illnesses
that can lead to sepsis. They should educate their patients and their
families about the early signs and symptoms, what to do if they feel like something,
that infection is not getting better. And this is especially important for
those at higher risk of getting sepsis. Remind patients that taking care of chronic
illnesses is one way to prevent infections that can lead to sepsis, and encourage
typical infection control measures, including things like hand
hygiene and also vaccination against infections that can cause sepsis. And what you’ll hear particularly more about
today is sepsis recognition and treatment. So it’s important that healthcare
providers think sepsis and knowing about sepsis signs and symptoms. Act fast if it’s suspected. And then once the intervention bubbles have
begun, reassess patient management and tailor it to the conditions of the patient, including
changing antibiotic therapy as cultures and other laboratory tests dictate. And so with that brief overview
of the vital signs report, I’m going to turn it over to Dr. Sean Townsend.>>Thank you, Dr. Fiore. Appreciate that very much,
very important information and very interesting vital signs report. As part of our work today, I’d like to introduce
the topic regarding how the surviving sepsis campaign worked to improve sepsis recognition
in the wards and how we worked with nurses across the country to make this possible. We have several objectives
that we’d like to accomplish. I want to talk, of course, about sepsis on
the boards, and what we did to get there, and my colleagues will speak mainly about this. We’ll talk a bit about the pilot program we did
and how we got this started across the country. And then we’re going to talk about
lessons learned along the way. And integral to all of this, of
course, was the key assistance of nurses to make the work possible. I’d like to start, though, first by telling
a story about a patient who developed sepsis. This is Rory Staunton. Rory Staunton was 12 years old, living in New
York City when he was playing sports outside, outside of school with his
friends, and he slipped and fell on the basketball court and scraped his arm. Rory then got that wound dressed,
went home and was brought home by his parents and started to feel ill. He developed a fever that day and then
became nauseous and vomited several times. This didn’t stop and he became
progressively more ill. His parents got rather concerned. They contacted a pediatrician. And the pediatrician said that he probably had
gastroenteritis and thought he was dehydrated. He recommended that Rory be brought to
an emergency department for rehydration. And, in fact, his parents did that. They brought him to the hospital. When Rory was seen in the hospital, he
got some IV hydration, they took his labs, and they also checked his vital signs. But after the hydration finished, he was discharged from the emergency department
before his labs were actually finally checked, the final results were in and when his
last set of vital signs were taken. Had he not been discharged so quickly after
receiving his fluids, they would have noticed that Rory had a very high white blood cell
count and that he had tachycardia in excess of what you would expect for his age. He did go home, however, and
he got worse that evening. He became progressively ill, more
nausea, more vomiting, very high fevers, couldn’t sleep that night and
neither could his parents. By the time he got so ill that he was not
responding to his parents appropriately, they brought him back to
the emergency department. And unfortunately, for Rory’s case, when he
arrived, he was unable to tolerate the burden of his illness anymore and
suffered cardiac arrest and died. This story is integral because it’s
really changed the face of the way we look at sepsis in the last four or five years. Rory’s tragedy, of course, wasn’t
taken lightly by his parents. They took the matter into their
own hands because of the fact that he left the emergency department
without having a complete check of his vitals and a complete check of his labs. And they recognized something that we’ve all
come to know now, which is that sepsis is hard to identify, and that even when at the
hospital and in the presence of providers, you can oftentimes miss the disease. Rory’s parents are shown here in this slide,
and you can see that they got to the– they made it to the Today
Show to tell their story. And they not only were on the Today Show, they continued to advance this
story and didn’t let go of it. They, in fact, have now started a
foundation to advance the care of patients that have sepsis, severe sepsis and shock. And they’ve tried very hard to make
an impression upon our leaders. They did, in fact, approach the Department
of Public Health in New York State, and they worked very closely with that
department to begin the process of finding ways for hospitals to improve the
care for sepsis patients. They didn’t stop there, though. They went to the U.S. Congress, the
Department of Health and Human Services, they testified before the Senate
House and Human Services Subcommittee. And they also lobbied the Centers for Medicare
and Medicaid very effectively about the need to establish measurement with the
way we care for patients with sepsis. You can see that they ultimately
achieved success in New York first. Governor Cuomo signed into effect rules that
required every hospital in the State of New York to report on the processes of care that they
were going to use to identify sepsis parents, and then to care for those
patients after that time. This landscape clearly was changed by
Rory’s story, and governments began to respond to the nature of the disease. In the United Kingdom, all of Great Britain
developed sepsis measures very similar to the ones that were put in place in
New York State in the United States. There were some reasons why the
Centers for Medicare and Medicaid began to take root or notice too of this disease. Not only were Rory’s parents lobbying CMS to get
the work done that was necessary to improve care for sepsis, but there were some
demographic reasons why also Medicare and Medicaid began to look at this more closely. So here you’re seeing data from the
Center for Health Statistics, part of HHS, and what you’ll see is in the blue, you’ve
got men in blue and women are listed by the green chart, the green bars. Across the bottom on the X axis, you have
H. And on the Y axis, on the far left, you have the rate of the disease per
hundred or rather 10,000 of the population. And what’s pretty clear, I think, from this
graph, is that the disease takes its effect and begins to pick up at age 65 to 74. At 75 to 84, it’s even more
prevalent to the population. And finally, 85 and over is the
highest incidence of the disease. Of course, this is very important to Medicare. Unlike Rory’s story, Rory, of course, being
only 12 was somewhere down here in this fraction of folks who developed the disease. But what you see in this peer group
here is what Medicare’s population was. And so hence there was a great emphasis to
establish a sepsis measure across the country. The next slide shows you the final reason why
I think Medicare took an interest in this. And this has got a lot to do with the
work of nurses and doctors at the bedside. You can see between the years 2000 and 2008 on
the X axis on the bottom, the rate per 10,000 of population for diagnosis of sepsis, green
represents here sepsis as a primary diagnosis, and blue represents sepsis as a
primary or a secondary diagnosis. And just looking at the green
line, you can see back in 2000, the rate per 10,000 of population was 11.6. That rate nearly doubled by 2008 to 24.0. And the reason for this are two things. The population was aging, for one thing. And we just saw in the previous
slide that as the population ages, we’re likely to detect the
disease more frequently since it is a disease mainly of the elderly. But also the work that was happening with the
surviving sepsis campaign encouraging screening. And the screening that was going
on by bedside nurses began to pick up increasingly across the country. With increased screening and detection, of
course the incidence would rise as well. These things together brought a new era
of sepsis measurement to our hospitals under the form of SEP-1, the
national measure for sepsis. Key to detecting that, however,
there was going be the work that nurses do to do the screening for sepsis. Finally, one key point to make
here on demographics is just this. Sepsis remains the number one cause of
in-patient death across the country. This is data from my own institution,
Sutter Health in Northern California. And in 2014, if you look at all the
discharges in our hospital on the far left, you see that only 11% of them had
sepsis as a diagnosis at discharge. But if we looked at the deaths that
occurred in my health system in 2014, 48% of the patients someplace had a
diagnosis of sepsis in their chart. And so this remains true
not only at my institution, Sutter Health, but it’s a national trend. And we know that the majority of deaths
that occur in hospitals share a diagnosis of some type of sepsis at
the point of discharge. So people do die from this disease. And where they die is an
important consideration. I’d like to just point out to you that the work on Medical Surgical floors is really critically
important to finding patients with this disease. The ED is where we typically present, we think
people present to, much like Rory’s case. He came into the Emergency Department. But there are a large number of patients who
are already in the hospital who develop sepsis, and the work on the Medical Surgical floors
is very important to detect sepsis there. In this publication, you can see that
the source is listed on the far left and where the patients presented from. And the mortality is listed on the far right. And please note here that the
patients who are on the wards where their sepsis was identified
had the highest mortality compared to the Emergency Department and the ICU. At 46.8%, that’s higher than the ICU patients who did develop sepsis at
41%, and the ED at 27.6%. So clearly, the high mortality in the wards
justifies a good screening effort that we hope to do on Medical Surgical floors. And that can all be said one other way. If we risk-adjust all that data and
say, well, let’s look at these patients to see what their co-morbidities were, does
that still stand out that patients who presented in the wards are more likely to die than
patients who come from the Emergency Department? Well, the answer is yes. The same publication showed that the odds
ratio of death for patients who present on the Medical Surgical floors is 1.87. And clearly that’s an unacceptable risk overall. This makes the work that we’re going to describe to you really important on
the Medical Surgical floors. And it’s my pleasure now to
introduce Mary Ann Barnes-Daly, who’s going to tell you quite a
bit more about that initiative.>>Thank you, Dr. Townsend. Good afternoon, or good morning, everyone. I would like to take this opportunity to
share with you some work that was done at Sutter Health in 2010, about the same time that the article was published
that Dr. Townsend just shared. It was clearly understood that although much
work was happening in the Emergency Departments where patients typically present, and also in
the ICU where we treated our most ill patients, typically with septic shock, that
there was a missed population. That is, patients who were right under
our noses who either had worsening sepsis or were developing severe sepsis or
shock while patients in our hospital. I’m going to briefly describe to
you a program that was undertaken at Sutter Health in Northern California. This project was supported in part by a grant
from the Gordon and Betty Moore Foundation. And the foundation tasked us with continuing to
make improvements in both the ED and ICU venues, but to add a new focus to our work,
and that is early identification and the early implementation of treatment
for patients in the med-surg areas to prevent those patients
from worsening and dying. In the particular hospital where we
piloted, we made up a great little acronym, the Medical Oncology Surgical
and Telemetry patients, or MOST. And they were, in fact, most of the
patients who were in our hospital. Our outcomes were for those patients who were eventually transferred
to the Intensive Care Unit. We looked at mortality and bundle
compliance data for these patients. They were analyzed by their location
at time of sepsis presentation. And we used these data for
continuous quality improvement. I’d like to share with you our
baseline and then outcome findings. So you’ll see here in the blue bars are data for
mortality rates for the calendar year of 2010. You can see that our overall combined
mortality rate for patients who went to the ICU, both coming from the Emergency Department
directly or from an in-patient med-surg unit, combined we had a mortality rate
overall of severe sepsis of 22.8%. What you’ll also notice here is
exactly what Dr. Townsend shared with the surviving sepsis campaign
data is that patients going directly from the Emergency Department to
the ICU, although presumably sicker, actually had a lower mortality rate than
patients who were identified on the in-patient or most units who eventually
were transferred to the ICU. So we set about to create a model or a protocol
around which we would have better opportunities to recognize and intervene
earlier in this patient population. So we created a protocol by which the med-surg
nurses would screen patients once per shift, they would call a sepsis alert at
which point the rapid response team and the physician would respond, and
they would begin the severe sepsis bundle and evaluate the patients for
the presence of septic shock. After piloting, implementing
and piloting that for a year, we then felt we had sustainment
the following year in 2011, and we collected and reported data at that time. You can see then the 2011 data
represented in the red bars, and we see two things that are very notable. The first is that our overall
combined mortality rate was about dropped in half based on the work. The second thing that we can see is that
the mortality rate for patients originating in the Emergency Department was almost identical
to the mortality rate for those patients who were identified on the MOST units. We felt that that showed that we had
correctly identified and intervened on that patient population, and we felt that
at that point that our program was a success. We spread it then to the other seven
hospitals in that region of our medical system, and ultimately to our entire 25 hospital
acute care, our 25 acute care hospitals. I would like at this time to turn the
presentation over to Christa Schorr.>>Thanks, Mary Ann. I’m actually just going to give an overview
of the Surviving Sepsis Campaign phase for sepsis on the wards collaborative. And this is actually springboarded from some of
the work that actually Mary Ann has presented in addition to our continuation of the
Surviving Sepsis Campaign work in phase 3, the data that actually Dr. Townsend had shared. This is the timeline for
the phase 4 collaborative. We had 60 volunteer participating sites within
4 regions of the United States, the east coast, west coast, midwest and southern
states primarily within Florida, the Adventist Health System. We kicked off the project in January, 2014. We had three in-person learning
sessions within the four regions. Each had three sessions. We also included either a monthly
webinar or a conference call, coaching calls to help the
sites move the project forward. Each particular region actually had a
specific faculty that included a member of the Surviving Sepsis Campaign
leadership, a nurse leader, a performance improvement
leader, as well as a hospital. And we thought that that was really important. We did partner with the Society
of Hospital Medicine, recognizing that our hospitalist partners were
going to be key in moving this program forward. And, again, the project was funded in part
by the Gordon and Betty Moore Foundation.>>Christa, if I can just pause you for a
second, if you could get closer to your phone. Some of our participants are
having trouble hearing you.>>Okay, is that better?>>Yep. Even a little louder would be great.>>Okay, so our primary focus
was on early identification. So, again, similar to what Mary Ann
had mentioned, our goals really were to identify patients early, whether it was a
confirmed diagnosis or a suspected diagnosis, our goal was really to identify patients
early so that we can implement the bundle. So our focus on the wards was really the
three-hour bundle, which includes lactate, blood cultures, early antibiotics,
and if necessary, implementation of early fluid resuscitation. And, again, we felt that these
interventions could be implemented on the general medical floor. And if we were able to identify patients early
and implement these three-hour bundle elements, that potentially the patient could
remain on that general medical floor. Or if they did require an ICU
stay, that our thought was that their outcomes would be improved, or
their stay in the ICU would be shortened. The tool that we provided at our first
learning session, again, was the evaluation for severe sepsis screening tool, which we had
used in the Emergency Department and the ICU in collaborative in previous work. And our goal really was to use a tool
that we had shown that was successful, and this is actually very useful in a
general medical floor in identifying patients with infections, signs and symptoms
of infection, and organ dysfunction. And what is unique about this particular tool
is that the thought process behind the tool is that we could help the nurses understand all the
potential signs and symptoms to be observant of and to assess patients for the
development of organ dysfunction, and those patients potentially that
are being treated for an infection. So, for instance, if we have a patient
who is admitted to a general medical floor with pneumonia, and they’re actively being
treated with antibiotics, and on day two or day three, the patient is not
improving or actually worsening, developing a new organ dysfunction, our thought
behind this was that the nurses would be able to recognize that and intervene sooner. Because the patients actually
have a progression of the disease, and the nurse can potentially
intervene at that particular point. So, again, this particular screening tool we
felt was really important and a paper form that the nurses understand the process and
how to think critically through each stage to identify a patient that is developing
severe sepsis or who is presenting even. Unfortunately, we do have patients that
develop nosocomial infections and can progress through this process very quickly. So, again, we felt that this tool was
essential to share with the collaborative sites. We opted to let the sites
determine how they were going to incorporate this tool
into their screening process. So some sites opted to use the paper screening
tool, and others actually incorporated into their electronic health record as an alert. Again, this actually took some time. So some sites right away we got started with
the paper tool, and other sites, you know, slowly incorporated this into their electronic
medical record, which took several months. So there are varying degrees as to how long
this actually took in these particular sites. One particular point I wanted to make was we
recommended that the sites only pilot this on one particular unit because we
recognize that this was a lot of work, and understanding how this particular
screening process would unfold in a hospital setting, we really were unsure. But based on the work that Mary Ann did, the
recommendation was that we pilot this on a unit, and then when we learn from that success,
then we can trickle along to other units. So we actually recommended this as well. The mantra that we acquired during this process
was screen every patient every shift every day. And one point that Mary and I feel very
strongly about is that it is important that we have the nurses understand the screening
tool prior to implementing the electronic alert, because they need to understand the background
for why an alert is potentially firing. And I learned this the hard way when I was in a
recent meeting with new nurses in my facility, and I mentioned that I was involved
with sepsis performance improvement, and I heard a lot of sighs. And the challenge behind that is
that there is an electronic alert. But the new nurses really don’t understand the
background as to why that alert is in place. And I think it’s important that we understand
that there are folks that are actually coming to our facility at different time points,
and that we need to educate the nursing staff as to why some of these alerts are in place,
and they often need to understand the steps, the critical steps in identifying a patient that
potentially is actually on a downward spiral from an infection that is
accurately being treated. So the pilot unit, so we actually had the units
participate in a survey, so there’s 60 sites that participated in this
nationwide collaborative. The units that participated were
primarily medical surgical units at 50%; straight medical units, 34%; and then
we had the other, which was about 16%. And some of these units were very
similar to what Mary Ann described as the MOST units, you know, the oncology unit. We did have one or two labor and delivery or high-risk maternity units
that were incorporated here. But, again, the nurse/patient ratio in these
particular units range between 1 and 5. And there was one particular pilot
unit that actually had a 1 to 9 ratio, which we found somewhat challenging. But the important thing about sharing this
data is that the pilot units that participated in this program had a variety of patient
populations, as well as nurse/patient ratios. And they were not only academic centers, but
they were also community facilities as well. So we had a variety of participants
in this collaborative. So the inspiration I think
should be there for other sites to incorporate this program into their facility. At the end of the program, we
submitted another survey and looked at the screening compliance
on these particular units. And 75% of the sites actually achieved greater
than or equal to 80% screening compliance in every patient every day and every shift. So when we think about the work that is actually
required from the nurses in screening a patient, this is very doable, and we did show success. It was a time sequence. You know, it did take a bit of time. But this is very possible. So if you’re going to present this to the
leadership in your facility or the nurses on your particular unit, I think
we need to ensure that we can share that despite this being a challenge
and may be difficult upfront, it is a possibility, and
we can do this together. So how we actually go about doing this,
and Mary Ann and I both feel very strongly that nurses are in a great position
to help this program move forward. And I think the physicians in
our group, the faculty leadership and the collaborative felt very
strongly that there was no way that this wards program would get off the ground
without the assistance of the nursing staff. So we feel very strongly, and very
similar to what Dr. Grant had mentioned, that the nurses are the eye from the patient. So these are the key staff
members that are really going to help us move this program forward. So I think what I’m going to do is over
the next several slides show some methods on how we can inspire nurses to do their
routine screening that would include leadership and staff, how and why we’re doing sepsis
screening, and how to implement the program. And I just wanted to make a point here that
if you’re going to introduce this program, I learned this again the hard way, that we
don’t want nurse buy-in on this program. We want nurse engagement. Because if we think about buy-in, it’s
basically someone else coming up with an idea and asking the nurses to
accept that idea, move forward. If we have nurse engagement, they’re actually
absorbing this particular disease process, they understand the pathophysiology
behind it, they understand the why, they understand the data,
which Dr. Townsend had shown, and they understand the impact
this is having on their facility, as well as their patients on that unit. So nurse engagement is going to be key. Nurses, again, are in the best
position, we felt, to make a difference. They’re the main caregivers
in the hospital setting. Again, all the eyes are on the patient. They are able to recognize the
changes in the patient condition. And sometimes we, as nurses, see
changes in the patient’s condition, but we’re not sure what to
do with that information. How do we report it? How is it received by our clinical partners? Again, we need to partner with our hospitals
and our internal medicine and our providers, if we have nurse practitioners
and physician’s assistants, again, partnering with our providers is key
into moving this process forward. And again, the nurses are
there, coordinating care. So we need to offer assistance and support
along the way to make this program successful. So the purpose of nurse screening
for sepsis, again, we share all this information with the nurses. We’re not just going to ask the nurses
to start using a screening tool. We need to have the nurses
educated as to why we’re doing this. What’s the purpose of this screening? Show me a patient on our unit who
unfortunately had a sepsis episode, and maybe had to get transferred to the
ICU or had a poor outcome or a patient where we actually had a good outcome. Show me a patient where we did everything
right, where we were able to recognize the signs and symptoms early, where we
were able to intervene early. Again, I mentioned about the organ dysfunction. I think progression of organ dysfunction
is sometimes what really is a detriment to these patients. So if we’re able to identify the
patients early and prevent progression of organ dysfunction, that’s key. And it’s very difficult to measure prevention. But I think in the overall
scheme of the hospital, you’ll recognize that the mortality
for this disease will go down. And then the other important
factor is evaluating patients. So if we’re treating a patient for an infection, such as pneumonia, is the
patient getting better? Are we evaluating their condition to see if are we treating the patient
with the appropriate antibiotic? So, again, I think the nurses are in a
perfect position to make a difference with early intervention,
prevention, as well as evaluation. Understanding why, I did mention that. It is important for the nurses to understand
why we’re using that particular screening tool, why we’re asking them to screen for
severe sepsis or sepsis in our facility. You know, they need to understand there’s
a pathophysiology that’s occurring behind the scenes. We’re not just asking them to look for
patients with a fever and a high white count. There are other signs and
symptoms that are in the mix. How does infection and resuscitation
go hand in hand? So, again, the understanding of how all these
things come together to display a patient with severe sepsis is really important. And I think we need to give our tools to
the nurses so that they’re knowledgeable, so when they’re delivering this
information to the healthcare providers, that they feel confident in
this particular diagnosis. And I feel personally that the nurses
have the capability of doing this. We just need to give them permission and
the tools to move this program forward. So I’m going to pass the
presentation on to Mary Ann, and she’s going to continue
on with the education process.>>Thank you, Christa. To further add to what Christa mentioned, when
we empower the nurses with the understanding of the pathophysiology of sepsis,
particularly things such as vasodilation, capillary leaking, a decreased cardiac function. When nurses understand that’s why they’re
screening for the items in the sepsis screen, and that they can literally save a life with
some normal saline and an early hung antibiotic, they become zealous for using the
sepsis screen and early identification. But in addition to the understanding
of the pathophysiology of sepsis as previously mentioned, RNs
really need to be trained to effectively communicate the
results of the sepsis screen. And most importantly, they need to be
supported and empowered to make a recommendation for the next steps for patient care. In order to do that, RNs need to know and
understand the elements of the sepsis bundles in order to make those recommendations, and also to prioritize interventions
and to optimize resources. For example, if a patient is going to
require both a 2-liter saline bolus and a broad spectrum antibiotic, it
would be important for the nurse then to prioritize starting the bolus first, and also to give the antibiotic while the bolus
is running so that everything can be given to the patient as early as possible. SBAR is a tool that’s used
successfully for communication. It’s widely used and has demonstrated
success when nurses are sharing information with providers and physician colleagues. The nurses need to understand
the components of the bundles. Here is a pretty handy badge card that’s
available on the Surviving Sepsis Campaign, I’m sorry, Society of Critical Care Medicine’s
website, which allows nurses when communicating with providers to not have to remember
what the steps of the bundle are, but to have them available for reference as
they’re speaking to their physician colleagues. Important is for the nurses to understand where
screening plays a role in their assessments of their patients, both when they start
their shift and on an ongoing basis. So Christa shared the mantra, screen
every patient every shift every day. So that starts off with screening a
patient at the start of every shift. Implicit in that is also screening a
patient that’s received in transfer or from another unit, or,
of course, a new admission. It’s also important to critically
think, as Christa mentioned, that if a patient does have a change in
condition, and the fact that sepsis is one of the most common occurrences in our hospitals,
that when a change of condition does happen, we invite and encourage our nurses to
use a sepsis screen to either rule in or rule out sepsis as a possibility. There should also be things in place
to help the nurse properly respond or to share information when
the screen is positive. And often, that is in the form of a
consult with the rapid response team, where a nurse with a higher level of training
or more experience would come to verify the fact that the sepsis screen is positive, and
to help implement a proper response. Consider using standard work as a
way to empower the nurses to respond and share information around
a positive sepsis screen. This might be a policy or an
algorithm for nurses to follow in response to a positive screen. It would allow the nurse to
coordinate with providers on the rapid response team as a second tier. Also consider in that standard work
a nursing standardized procedure, which will allow specially trained nurses
like the rapid response nurse, for instance, to initiate labs and perhaps a fluid
bolus for hypotension during the time in which the physician is being contacted. It’s also helpful, as I mentioned earlier, for
the rapid response nurse, when he or she comes to the bedside, to either
verify or not the sepsis screen. In addition to providing encouragement
and feedback to the bedside nurse, it’s a very important teaching moment. The rapid response nurse can
initiate the standardized procedure, and also help with the facilitation
of communication with the provider. This is an example of effective
communication using the SBAR format. In this case, the nurse contacts the
provider and says the situation first. Mr. Smith was admitted early this morning
with cellulitis of his left lower extremity. He states the pain in his leg has
increased, and the redness has extended. Another option for providing information
starting an SBAR using situation is simply saying, Mr. Smith in Room 307 now
has a new positive sepsis screen. The background then would be briefly about Mr.
Smith, his age, his history of co-morbidities, and the fact that his wound on his left lower
leg has been present for about two weeks, and he was admitted through
the Emergency Department. The assessment then that the RN provides is
the vital signs this morning and any changes or concerns with those vital signs as
reported to the physician in addition to laboratory results that are germane. And most importantly then is the recommendation. In this case, the nurse says, I would like
to request an order for a chemistry panel, a CBC with differential, and a lactate level. Based on the patient’s vital signs, the nurse
may also ask for a fluid bolus order in review of current antibiotics to be sure that we are
adequately covering any suspected organisms, or perhaps ask for an order to
give a broad spectrum antibiotic if the organisms have not been yet identified. It is so important to empower the nurses to
feel comfortable providing this information to physicians on the phone and the presence
of the rapid response nurse or having that nurse actually provide the communication to
the physician can model and mentor this behavior to the bedside nurse who may feel less confident
and encourage that nurse to use the same type of communication strategy
and to improve confidence with the next time a call needs to occur. If you haven’t yet started a program
such as this on your in-patient units, there are considerations for piloting the
program as Christa elucidated earlier. It’s really important to choose
a single unit to start first. As in the IHI Model for Improvement, doing
small tests of change are really important, both to not overwhelm people, but to
also implement a project and then learn from several iterations over time. When you’re considering a
unit in which to pilot, these considerations we feel are important. Choose a unit with a positive environment. We all know that med-surg nurses are
among the busiest in our hospitals. And it’s important to choose an environment in which you think the test
or pilot could be successful. It’s also important to have engaged
and supportive unit leadership. And also supportive leadership in nursing
administration all the way up to the CNO. Choose a unit that has good
teamwork and coordination. And also be sure that when the sepsis screen is
taught and the standard work is put into place, that when the nurses pick up the phone, they’ll be contacting supportive
and responsive providers. I made the mistake and learned that it’s
not sufficient to simply train nurses on the pathophysiology and
the use of the sepsis screen. It’s also important to engage and educate. Those folks are going to be on the other
end of the phone receiving the information with an expectation to act and rapidly
implement the items in the sepsis bundle. While you’re piloting, it is of paramount
importance to get feedback from all staff. As I mentioned earlier, using rapid-cycle
improvement with a plan to study act for instance, to implement a small
test of change with maybe one nurse with just two patients on one day, to learn from
that first test, to iterate, change or update, and then plan how to improve
with the next cycle. When you feel you have something that could
be relatively successful, at that point then, spread to more nurses and more patients. When you feel that you have a system
in place that works on your unit, then consider piloting it on one or two other
units until you ultimately reach the spread through your entire med-surg
population in your hospital. It’s also important to reward
engagement and innovation. Remember, we don’t want to
start with the laggards. You want to start with folks that are
interested and passionate about the work. It is also important, though, to
include people who may be resistant, to have them in at the outset of
the project, to allow them to feel as if they have been given input and
that their input is important and valued, and to reward your nurses for doing
a good job and highlight their work when you’re spreading to other units. I’d like to pass off to Christa
then to summarize our presentation.>>Thanks, Mary Ann. I think this was very informative
from several different aspects. And I think one piece that I think is really
important and hopefully Sean will comment on this as well is that we really
need to partner with our hospitals and our physicians and their
providers on the unit. So this is not a process where the
nurses are actually diagnosing patients, but yet working with their providers
to recognize patients early. So we do understand that hospitalization
for sepsis is common, it’s costly, and ward patients have disproportionately
high mortality, as Dr. Townsend had eluded to in his presentation, nurse engagement and
sepsis screening programs may be accomplished, but it’s necessary that we
include our leaders and our staff. And it’s important that we
establish an understanding as to why sepsis screening is important. We need to put a face to these
patients so that the nurses feel a sense of engagement as opposed to buy-in. And we can do this through
education and support. And I cannot underestimate the need for support. This is not something that you roll out and
expect that this is going to flow on its own. We do need to support the
nurses through this process. And we need to also introduce this program
on a pilot unit and test processes, allow staff feedback and modification of
the program before spreading to other units. And I want to encourage you
that this is possible. We’ve had success with this. And I wish you all the best in your endeavors to implement this type of
program in your institutions. Thank you so much, and we appreciate your time.>>So thank you, Dr. Townsend
and Mary Ann and Christa. We have several questions, and
we have about 10 minutes left. So I’d like to go ahead and take the
opportunity to jump into questions. We have over 2,200 people who have logged
in to some portion of this webinar. And we have dozens of questions
that have come in. Many of the questions are around screening. So the first one is, many of our staff
are struggling with screening the patients with regards to “suspected source of infection.” Any suggestions for in-patient nurses
on how they can identify this rapidly?>>So one of the– and I’ll
let Mary Ann comment as well. One of the things– we actually had this same
question when we initiated this collaborative. And basically, what we did was we taught a
head-to-toe assessment assessing for infections. So we look at, you know, wounds,
lines, signs and symptoms. We really taught the nurses to think critically when they’re doing their physical
assessment for the patients. And we didn’t want them to have to diagnose,
so we can even basically say to them, do you think the patient has a suspicion or
an active infection that is being treated? We didn’t necessarily require them to say
the patient has endocarditis or pneumonia. Basically, if they could come up with the
pieces of information that identified a patient as having a potential infection, that
was really our potential first goal. And then the nurses actually
build on that process. And Mary Ann, you might have
comments on that as well.>>Yeah, Christa, and I think
you’re absolutely right. To delve a little bit further,
when we educated our nurses, we told them that they should understand that
the most likely causes of infection that lead to sepsis are pneumonia,
urinary tract infection, wounds or infections of the
skin, and in the gut. So when we ask nurses, again, as Christa
said, not to diagnose these things, but to look at patients admitting
diagnosis, and combine that with findings of their physical exam, to
see if there was a likelihood that any of those things may be present. The easy part of this is if a patient is
admitted with a diagnosis of infection or is on any type of antibiotics
that are not considered prophylactic, but nurses soon became pretty astute at
recognizing the fact that, for instance, if a patient came from a skilled nursing
facility with an upper respiratory infection, cough, or it had an indwelling Foley, that there
was a likelihood because those two things are so prevalent that there was a
possibility of an infection. Again, I think two things to
remember with sepsis screening, particularly on the med-surg unit, number
one, this is a screen and not a diagnosis. We expect to cast a broad net with our screen. And we’re not always going to be right. The goal of a screen being sensitive enough is that we will have some false-positives
that we don’t miss patients. It is then up to the collaboration of the RN
and the provider to decide whether the findings of the screen are, in fact,
linked to an infection, and whether the patient actually
does have sepsis. The second important thing to remember
is that the rate of positive screens in the med-surg area should
actually be quite low. So often nurses feel a little bit frustrated
with the fact that they’re doing hundreds of screens maybe in a month, and they’re
only getting one or two positives. I think we should educate the nurses to expect
this, but to still understand the importance of the screen when it is positive, and also
to communicate the findings of those screens to providers to implement care if required.>>So I think your comment segues
into our next series of questions. We’ve had several questions with
regards to use of a paper tool. So if you’re using a paper screening
tool, where would you keep it, how would you communicate those results? And any advice that you guys have on collecting
the data and communicating it back in realtime.>>Yeah, this is Mary Ann. The paper tools are definitely challenging. But on the other hand, they also
facilitate learning and early adoption. So in our– as Christa mentioned earlier
when she described the collaborative, she said we basically had three
situations with implementing a screen. We had sites that were not yet using an EMR. And so they documented everything on paper. And so that was really their only option. And in those cases, once the screen was
accepted as part of the medical record after several tests and iterations, it
actually became part of the paper record. We also had two other cohorts, two other
sections of our collaborative who had, as Christa mentioned, had implemented an EMR. But because it took basically an act of God
to get anything added in a quick manner, they began doing sepsis screens on paper. And to be honest, it was not really ideal. Obviously those screens could be
scanned and put into the EMRs. But for collecting data from those screens,
it was manual and very labor intensive. And then we had our third group, who had EMR
implementation already, and they were able to either access a screen already
present in their EMR or they were able to rapidly add one that the nurses could use. I think Christa touched on one other issue. And that is the use of alerts. And so alerts are really important because the
nurses aren’t always in the patient’s chart. And usually clinical decision support, or
CDS, running in the background that looks at new findings such as newly entered
vital signs or new lab results, and can alert the provider,
either the nurse or the physician, to a change in the patient’s
condition that may indicate sepsis. Those prompts should really be used to encourage
the nurse to perform an actual sepsis screen. Number one, as advanced as our clinical
decision support may be, in my opinion, it does not ever substitute for the
critical thinking of a well-trained RN. It also allows the nurse to take part in the
screening and continually familiarize themselves with the contents of the screen
and what the findings mean, and also to have a better
understanding of the assessment when they’re communicating with their provider. Christa, or Dr. Townsend, anything to add?>>So I just wanted to add to the beginning
part of the question, you know, how do you– what do you do with a tool after
the nurse has actually completed it? And I failed to mention that all the
units we actually had nurse champions, whether it was an educator or a staff nurse on
the different shift, there would be support, another set of eyes, actually,
on the screening tool. So the one question, you know,
said, is there realtime feedback? And having that champion would actually
allow the nurse who is screening the patient to confirm or accelerate the process
up the ladder to the provider in making the determination as to whether or
not the patient actually met the screening tool. And then that information was actually collated,
and there was someone designated on the unit, whether it was the nurse manager or the
nurse educator, to review those forms, look for false-positives, false-negatives, and
learn from that and get feedback to the team. So it wasn’t just that the
nurses were completing this form and then there was no one looking at it. We actually did look at compliance. We were looking to see that every nurse
was screening every patient every shift. And even if the patient was admitted with a
sepsis diagnosis, we still required the nurses to screen that patient every day
every shift because it’s possible that the patient could progress,
maybe develop a new organ dysfunction that we could identify early. So this screening tool was used. It was evaluated. And, again, that’s why we
recommend that you only use– pilot the program on one unit because
we recognize the work that’s involved in getting this program up and off the ground
and offering the support that the nurses need to feel confident about the program.>>So one last question. We’ve been talking quite a bit
about screening patients on wards, but we’re also getting questions about patients
presenting in the Emergency Department. What advice do you have on how triage
nurses can quickly assess for infection and overcome any barriers to quickly
recognizing and initiating sepsis protocols?>>Sean, do you have comments on that?>>I do. I think, you know, to a large
extent, what’s really important I think is that we empower nurses to start to
use their judgment and have the sense that the patient is becoming
infected for some reason or another. And I think to a large extent
nurses actually do know that. And it’s only through lack of willingness
to speak their minds in certain cases, or out of fear that they could be
wrong, that they sometimes don’t. There’s oftentimes a very clear sense
that the patient may be infected, but a reluctance to actually express that. And so working to overcome that
by having a positive program that empowers people I think
is an important feature. The other thing is that, some very practical
advice, if that’s just too difficult to do, is to rely on SIRS criteria
to point you in that direction at screening an Emergency
Department, for example. At triage, you can check for fever, you
can check for elevated respiratory rate. Those things are easily available
to you at that point. Tachycardia is easily assessed at triage. And patients who have those signs of
inflammation, if they’re positive, can lead you to think, well, wait, I better
ask the question, is there an infection here, and then look more carefully at that point. So there are some objective data points,
even in triage and in an Emergency Department where you can say, well, if I’ve
got some positive SIRS criteria, perhaps I have to make a little bit deeper
of a dive to see if there’s an infection.>>So we’re at time. I want to thank Dr. Sean Townsend,
Mary Ann Barnes-Daly and Christa Schorr for their time today, as well as the
Society of Critical Care Medicine and American Nurses Association for
sponsoring this webinar with us. We know that there are several
questions that we are not able to answer, and we’ll try to answer some
of those in follow-up e-mails. When you close out on the webinar,
a post-meeting web page will appear, which will have detailed instructions about completing the continuing
education post-test and evaluation. The access code for accessing the
continuing education is WC0922. And with that, thank you for
joining our webinar today.

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