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I NPATIENT A DULT SEPSIS ASSESSMENTS HS
ADULT SEPSIS ASSESSME NT (≥18 years of age) and
Ph ysician App ro ved Sep sis Nu rsi ng Proto co l
PURP OSE
T o u se a standa r diz ed, ph ysici an app r o v ed, nursi ng a ss e ssm ent and pr oto c o l to assess and/or screen all adult patients ≥ 18 years of age for Sepsis, Severe Sep sis o r Sept ic Sho ck and im p l em ent s peci fi ed ele m ents of the Se ver e Sep sis /Septic Shock tr eat ment bund le a s i nd ic ated. T he ph ysici an appr o ved sep sis nu rsing p r oto c ol will be im pl e m ented sys te m wi de fo r a ll qua li f yi ng UC LA Healthcare inpatients ≥ 18 years of age.
SCOPE
T h is heal th sys tem p r otoco l app li e s to R egis te r ed N u rs e s (RNs) only and in clude s the Emergency Department (ED) and inpatient population ≥ 18 years of age at R ona l d R eagan UC LA Med ic a l C ente r and Santa Monic a UC LA Med ic a l C ente r & Or thopaedic H osp i ta l. T he pr oto c ol doe s not apply to the R es nick N eu r op syc h i at ric H o spi tal (RN P H) at UC LA.
PRO TO COL Assessme nt
All patients ≥18 years of age will be screened/assessed for sepsis, severe sep sis , &/o r s eptic s hock upon t ri age to the Em er gen cy D epa r tm ent ( E D). Ongo ing reassess ment will o ccu r i n o r de r to e val uate and/o r update a pat ient’s statu s to r efl e ct changes a s needed and to foll o w up with add i t i ona l l ab test i ng and/o r t r eatm ent as wa rr anted. A ll inpat i ent s ≥18 years of age will be screened/assessed/reassessed for sepsis, s e ve re s ep sis , &/o r s eptic shock upon ad missi on to a ll i npati ent f l oors and/o r un i t s. Ongoi ng r ea ss essment will o cc ur thr oughout the ho s pi taliz ati on i n or de r to e va l uate and/o r update a pat i ent ’s status to r efl ect change s and add i ti onal treat ment as needed. T he adul t sepsis a ss e ssm ent too l m u st be co m pl eted on ly b y a R eg is te r ed N urs e (RN). T he c o m p l eted sepsis a ss essm ent too l will be co mp leted i n the e l e c tr onic m ed ic a l r e cor d ( E MR) and will be c o m e a permanent pa rt of the pat i ent ’s m edic a l r e cor d (s ee Appendix I ).
Cri teria/ Defi ni ti on s
T he fo llo wi ng defi n i ti ons and crite ri a we r e es tablis hed fo r the pur pos es of the UC LA H eal th S ys te m –B ridge to R efo rm : P r opo s al fo r 1115 M edic ai d W aive r unde r the C ali fo r n i a D elive ry S yste m R eform Inc ent ive Pa ym ent P l an (D SR IP) (s ee Append ix IV ); Survivi ng Sep sis C am pa i gn ( SS C) Updated Bund l es 2015;
N at i ona l Spe ci f ic ati on Manua l fo r H o sp i ta l Inpati ent Qua lit y M ea su r es v ersion 5.0a: C o r e M ea s ur e s : Early Manage m ent Bundl e, Se ve r e Sepsis /Septic Sho ck. Sys temic I nf lammato ry R es pon se Synd ro me ( SI R S ) = t wo ( 2 ) o r m o r e of the fo llo wi ng:
- T e m p >38.3°C ( 101 °F) O R <36 °C ( 96.8 °F)
- HR > 90/mi n
- RR > 20/mi n
- W B C >12,000 or < 4,000 O R >10 % Bands Se p sis = Two ( 2 ) or m ore SI R S cri te ri a pl u s a s us pe cted o r c onfirm ed i nfecti on or imm uno co m p r omis ed ( P N A, UT I, wound, etc .) Severe Se p sis = Sep sis p lu s or gan d ys func ti on &/o r o r gan fail u r e Se ptic S ho ck = Se v er e Sep sis p l u s h y poten si on ( SBP ‹ 90 o r M AP ‹ 65 or de crea s e in SBP › 40 fr om ba se line ) &/o r e l e vated l a ctate l e ve l > 36 m g/dL ( 4 mm ol /L )
On ce a pat ient scr een s po sit iv e fo r Severe Se p sis and/o r Sept ic Sho ck, the ph ysici an app r o ved s epsis p r oto co l shou l d be im pl e m ented i n the el e ct r onic m ed ic a l r e co r d (E MR-C are C onne ct ) b y the RN.
Implementa ti on
F o r a ll po si tive severe sep sis and/or se pt ic sho ck a ss e ssm ents, the RN will immed i ate ly i n i t i ate an ele ct r on ic o r der i n C ar eC onne ct to obta in the fo ll o wi ng lab s: ( ph ysici an m a y choo se to o r de r add i t i ona l l ab s, te s t s, and/o r p r ocedure s ; ho we ve r , the fo ll o wi ng a re mi n im u m r equ ir em ents pe r the six hou r Sep sis bund le ) 1 ) Se ru m lac t a t e l e vel ( 4 m L to be obtai ned i n a g r e y top tube to be s ent to l ab on I C E wi thi n 15 minute s of b l ood dr a w) and d r a w TW O ( 2 ) sets of b l ood c u l tu r e s ( to be obtai ned f ro m t wo di ffe rent si te s); a total of 4 bott l e s, mi n im um of 8 - 10 mL pe r bottl e. R epeat l ac tate i f i ni ti a l l a ctate le ve l is > 18; and RN will a ls o imm ediate ly not if y ph ysici an of po si tiv e sep sis a ss essm ent and r eque st the fo ll o wi ng e l e ctr onic ph ysici an or de rs. Ph ysici an m a y a ls o o r der add i ti ona l l abs and/o r te st s o r p r oc edu r e s a s i nd ic ated. (RN ma y u se Append ix III-N urs e C a ll S cript as needed ) 2 ) B ro a d- s p ec t ru m a nti b i ot ics , using the el e c t r on ic adu l t s ep sis or der set i n C a r e C onne ct, to be in i t i ated wi th i n one ( 1 ) hou r of po si tiv e a sse ssm ent; and 3 ) IV fl u id bo lu s of 30m L /k g to b e in i t iat ed wi th i n 1 hou r of t ime of p rese nta t ion (T OP ) a nd c o mp let e d wi th in 3 hou rs of t ime of p rese nta t ion (T OP ) of se pt ic s ho ck ( per 2015 N at ional Speci fic ation Manua l fo r H os pi tal Inpat i ent Qua li t y M ea su r e s ve rsion 5.0a: C o r e Mea su re s : Early M anage m ent Bund l e, Se ve r e Sep sis /Septic Sho ck
N u rsing P r oto c ol. Add i ti ona lly , a ll ne wly hir ed RNs a re requir ed to c om p l ete ho sp i ta l wi de nursi ng ori entat ion w h ic h i ncl udes the sa m e educ at i on c o m ponent, tr a in i ng, and po st - tes t/e va luati on a s what is offer ed fo r the annua l nu rsi ng co m peten ci e s. With the a ssis tanc e of the UC LA H ea l th Sys te m Hu man R e s ourc es D epart ment and N u rsi ng R es ea rc h and Edu cati on, a ll nu rsi ng edu c ati on, annua l co m peten ci e s , and pos t- te sti ng co m pli an c e e xa ms fo r a ll sep sis educ ati on and tr a in i ng is t r ack ed on li ne b y the Sepsis C oor d i nato r and ea c h U n i t Dir e c tor.
FORM S
Append ix I – E l ec tr onic Ve rsi on of the Adu l t Sepsis A ss e ssm ent (C a r e C onne ct )
*Appendix II – Posi t ive Sep sis A ss e ssm ent: N urs e C a ll S cript ( fo r u se b y RN a s needed )
Append ix III - Adult Sepsis Order Set for inpatients ≥18 years of age (Form# 16037 -r e v. 7/29/2015. Written o r ders ar e the s am e a s e l e ct ron ic o r de rs i n C a re C onnect )
*Appendix IV – Inpatient Adult Sepsis Assessment Tool (≥18 years of age). Written fo rm to be u s ed du ri ng E MR / C ar e C onne c t do wnt ime on ly ( *) Append ic es i n cl uded with on li ne pr oto co l pos ti ng
REFERENCES
C a lifo rn i a Safet y N et Insti tute ( S N I) Sepsis P r e vent i on Co ll abo r ative UC LA H eal th S ys te m –B ridge to R efo rm Pr opos al fo r 1115 M ed ic ai d W aive r, C atego ry 4, P r oj e ct 2; pg. 27 - 29 eff. April 2011 ( no w in Yea r 5 of p l an) Revised 9/11/15 ( nf)
D e lli nge r RP, Le vy MM, C a rtet, JM, et al. Survivi ng Sep sis C a m pai gn: Inte r nat i ona l gu i de li nes for m anage m ent of se ve r e sep sis and s ept ic s ho ck: 2008 [pub lis hed co rr e cti on appea rs in Crit C a r e M ed 2008; 36: 1394 - 1396]. Cri t C a re M ed 2008; 36: 296- 327.
D e lli nge r RP, Le vy MM, R hode s, A, et a l. Survivi ng Sep sis C a m pa i gn: Inte r nat i onal Gu i de li nes fo r M anage m ent of Se v ere Sep sis and Septic Sho ck:
- Cri tic al Car e Medici ne F ebruary 2013; 41- 2: 580- 637
Spe cif ic ati ons fo r N ati ona l H o sp i ta l Inpati ent Qua lit y M ea sur e s, Versi on 5.0a. ( Octobe r 2015 ) , R et ri e ved f r o m http s :// www .quali t ynet.or g/d cs/C ontentSe rv er? c=Page&pagena m e=QnetPub lic % 2 F Page%2 F QnetTi e r 4& ci d=
CONTACT:
Qualit y Managem ent Servic es, UCLA Heal th S ys tem Pat ricia W alker, RN- Evi dence Based P rac tic e Manager Brenda Clemen s, RN- Director of Qualit y and Pat ient Safet y Qualit y Managem ent Servic es, Ronal d Reagan UCLA Med ical Center
REVISION HIS TORY
Effective Date : Septem ber 13, 2013 (REV); March 1, 2013 (NEW) Review Date(s): 02/13/13; 09/13/13; 01/08/14; 09/10/ Revise Date( s): V2.0 9/13/13 ; v1.0 3/2013; No v em ber 19, 2015 Distri bution Dates: V2.0 10/2013 ; V1.0 3/1/
APPROV AL – ALL APP ROV AL S: 2/2013 and 3/
Allied H eal th Pr ofessi onal Committee Interdiscipli nary Committee Credent i aling Committee Med ical E xecutive C ommi ttee
