Sepsis Care in the ED

Sepsis Care in the Emergency Department

Presented by: Rebecca KalakewichDNP FNP Student Johns Hopkins University

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Objectives

Sepsis Basics

Case Study #1

Index

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Summary

Case Study #2

Case Study #3

Objectives of the Education

1. Review the basics of sepsis care​2. Outline SEP-1 bundle measures with emphasis on timely administration of antibiotics ​3. Illustrate importance of rapid sepsis identification and treatment via case studies

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Back to Basics

Review of sepsis basics and current practices

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Back to Basics: What is Sepsis?

• Sepsis is defined by the Surviving Sepsis Campaign as a "life-threatening organ dysfunction caused by a dysregulated host response to infection".​
• 1.7 million U.S. adults develop sepsis with 350,000 individuals dying annually.​
• Sepsis accounts for 20% of global deaths with over 11 million sepsis-related deaths worldwide.​
• Any infection can result in sepsis, including the common cold or flu, with 87% of cases originating outside of the hospital setting.​
• 50% of survivors develop post-sepsis syndrome with complications leading to long-term physical and psychological effects.​

Sepsis is a leading cause of death in the U.S.

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Centers for Disease Control and Prevention [CDC], 2023; Evans et al., 2021; World Health Organization [WHO], 2023

Sepsis Basics

Risk Factors of Sepsis

While any infection can result in sepsis, some co-morbidities and conditions can put you at a greater risk for developing sepsis.

Chronic medical conditions(diabetes, liver and kidney disease)

Recent hospitalization or severe illness

Burns, majory surgery, traumas

Indwelling catheters

Weakened immune systems or malignancies

Sepsis survivors

Chronic use of corticosteroids

Age >65 years OR <1 year

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(CDC, 2023; Mahapatra & Heffner, 2023)​

Sepsis Basics

JHH Adult ED Current Practicies

• Utilizes Sepsis Navigator as a clinical surveillance tool.​
• System alerts Sepsis Best Practice Advisory (BPA) for patients based on Sepsis Predictive Model Score (SPMS).​
• The SPMS is a proprietary decision-making tool designed by Epic that compiles data including vital signs, laboratory values, medications, patient history, age, and gender. ​
• Overall goal of the system is to reduce sepsis-related mortality and improve sepsis order bundle compliance.

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Schertz et al., 2023​

1 - Hour Goals

Sepsis Basics

Sepsis management bundle: sep-1

The Severe Sepsis and Septic Shock Managment Bundle or SEP-1 is an “all or none” management bundle developed using the SSC guidelines ​

1 - Hour Goals

3 - Hour Goals

6 - Hour Goals

Blood cultures drawn before giving antibiotics​ Serum lactate levels (repeat lactate if initial is > 2mmol/L)​ Antibiotics within 1 hour of starting timer (within 30 minutes of STAT order)

Fluid bolus 30mL/kg for hypotension SPB<90mmhg or serum lactate > 4mmol/L

Persistent hypotension? ​ Start vasopressors and initiate transfer to ICU​

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Alexander et al., 2022​

Sepsis Basics

Antibiotic Administration

Time to Antibiotic Administration: Why does it matter?

Time to antibiotic administration is critically important within sepsis care

Failing to address a delay in antibiotic administration would lead to

1 - hour benchmark for delivery of initial antibiotic therapy

Has been demonstrated by the SSC to improve patient outcomes and reduce patient morbidity and mortality ​

Every hour delay linked to an 8% increased risk of mortality​

Increased financial burden, worsening of patient outcomes, long-term disability for survivors, and Increased patient mortality

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Evans et al., 2021; Galang et al., 2020​

Sepsis Basics

Care in the emergency department

How care in the ED effects to continuum of care

Early phases of sepsis treatment are the most consequential for the patient​

Sepsis and septic shock is one of the highest mortality conditions treated in the ED

Timely and comprehensive sepsis treatment in the ED is critical for patient survival ​

80% of patients receive initial sepsis care in the ED​

Time to antibiotic therapy is a strong predictor of overall patient outcome

​Every hour delay in administering antibiotic therapy is associated with an 8% increase mortality of patient in septic shock

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Sherwin et al., 2017; Yealy et al., 2021

Case Study #1

Ann 50-year-old female

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Case Study #1

Ann's Scenario

• Past medical history significant for COPD, coronary artery disease, hypertension, and hyperlipidemia
• ​ Presented to ED with chief complaints of abdominal pain, right flank pain, and shortness of breath.​
• Abnormal vital signs included a temperature of 101F, respiratory rate of 22, and blood pressure of 187/111​
• Abnormal labs included WBC 16,000 and glucose 127
• ​ CT of abdomen and pelvis demonstrated 5x7 mm stone in right ureter with moderate right hydronephrosis.​
• Diagnosis was acute abdominal pain, renal colic, and UTI with fever. Patient prescribed oral ciprofloxacin and discharged.

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Mapes, n.d.​

Case Study #1

Ann's Scenario

Are there any early warning signs of sepsis in Ann's case? Click the warning signs of sepsis below.

Past medical history of hypertension and hyperlipidemia

Blood pressure of 187/111

WBC count of 16,000

Temperature o f 101 F

Respiratory rate of 22

While important, this is not a warning sign of sepsis

Yes!Fever > 38C (100.4F)

While important, this is not a warning sign of sepsis

Yes!Tachypnea or respiratory rate > 20 breaths per minutes

Yes!Leukocytosis WBC > 12,000

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Case Study #1

Ann's Scenario

Ann returns to the ED the next day

• Worsening right flank pain

• ​ Decreased urine output​

• Vitals signs: blood pressure 151/86, heart rate 93, respirations 24, oxygen saturation 97% on room air, temperature 96.8F orally​

• Ann is discharged again on ciprofloxacin, told to follow-up with urology, and return to ED if condition worsens​

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​ Mapes, n.d.

Case Study #1

Ann's Scenario

Ann returns to the ED for the final time

• Arrives with altered mental status and fever​

• Admitted to ICU for dehydration, neutropenia, urosepsis, and ureterolithiasis​

• Suffered a stroke during admission and died from complications​

What can we learn from Ann's case?

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​ Mapes, n.d.

Case Study #1

Early signs of sepsis

SIRS (Systemic Inflammatory Response Syndrome)Confirmed or suspected infection with:

Fever or Hypothermia

Leukocytosis or Leukopenia

Tachycardia

Tachypnea

Fever > 38C (100.4F) or hypothermia < 36C (96.8F)

Tachycardia or heart rate > 90 beats per minute​

Tachypnea or respiratory rate > 20 breaths per minutes

Leukocytosis WBC > 12,000 or leukopenia WBC < 4,000

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Mahapatra & Heffner, 2023​

Case study #2

Charles 79-year-old male

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Case Study #2

Charles' scenario

• Arrives via ambulance for possible "environmental hypothermia"​

• He is confused and lacks self-awareness, pulse is weak, and breathing is shallow​

• Family stated they have been "controlling fever" with acetaminophen over the last 5 days​

• Temperature 96 degrees F, blood pressure 90/62, and heart rate of 48​

Code sepsis called on arrival

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Langley, 2019​​

Case Study #2

Stages of sepsis

Clinical differences between sepsis, severe sepsis, and septic shock

Septic Shock

Severe Sepsis

Sepsis

Suspicion of infection or confirmed infections ​ +​ >2 SIRS (more sensitive)​ OR​ >2 qSOFA (more specific)​ Glascow Coma Scale <14​ Respiratory rate > 22/min​ Systolic blood pressure < 100

Infection with dysregulated systemic host response​ ​ Acute Organ Dysfunction:​ Lactate > 2 mmol/L​ Systolic blood pressure < 100 or MAP < 65 ​ Drop in systolic blood pressure > 40 mmHg​ Urine < 0.5 mL/kg/hr x2 hours​ Acute respiratory failure

Sepsis/Severe Sepsis ​ +​ Elevated lactate > 4 mmol/L​ Persistent hypotension requiring vasopressors to maintain a MAP > 65 mmHg (despite adequate volume resuscitation)

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Johns Hopkins Medicine​

Case Study #2

Charles' Scenario

Click on the patients clinical concerns to learn more

Pulse is weak and breathing is shallow; with a HR of 48

He is confused and lacks self-awareness

Blood pressure of 90/62

Temperature off 96 F

Meets qSOFA criteria of Glascow Coma Scale <14​ and acute organ dysfunction

Signs of acute organ failure

Meets SIRS criteria of hypothermia < 36C (96.8F)

Meets severe sepsis presentation of systolic blood pressure < 100 or MAP < 65 ​

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Case Study #2

Charles' scenario

Some signs and symptoms of acute organ dysfunction

• Altered mental status​

• Decreased urine output or no urine output (<0.5 mL/kg/hr x2 hours)​

• Acute respiratory failure; Hypoxia and cyanosis requiring oxygen therapy, NPPV, or ventilation​

• Ileus

• ​Systolic blood pressure < 100 or MAP < 65 ​OR drop in systolic blood pressure > 40 mmHg​

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Johns Hopkins Medicine; Mahapatra & Heffner, 2023

Case study #3

Jeremy 47-year-old male

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Case Study #3

Jeremy's scenario

Atypical presentation

• Non-smoker with no significant past medical history​

• Chief complaint of right upper back pain x1 day that worsens with movement of right arm, when laying down, and with deep inspirations

• Palpable tenderness and spams in right upper back​

• Only significant vital signs was respiratory rate of 20 breaths per minute​

Diagnosed with muscle strainDischarged home​

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Vraa, 2021

Case Study #3

Jeremy's scenario

3 days later Jeremy returns to the ED

• Worsening pain and new onset shortness of breath x1 day​

• Vital signs: heart rate 121, respiratory rate 46 breaths per minute, oxygen saturation 90%​

• Elevated d-dimer, creatinine of 2.4 mg/dL, INR 2.9 and WBC of 2.7​

• Chest CTA was negative for pulmonary embolism, aortic dissection, and infiltrates

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Vraa, 2021

Case Study #3

Jeremy's scenario

Does Jeremy meet any SIRS critera?

Is Jeremy experiencing organ dysfunction?

Shortness of breath with oxygen saturation of 90%

Heart rate of 121 beats per minute

Creatinine of 2.4 mg/dL

Respiratory rate of 46

WBC of 2.7

Change in condition from his first visit; Demonstrating hypoxia

Meets SIRS criteria of leukopenia WBC < 4,000

Meets SIRS criteria of tachycardia or heart rate > 90 beats per minute​

Meets SIRS criteria of tachypnea or respiratory rate > 20 breaths per minutes

Changed from baseline; experiencing acute kidney injury

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Vraa, 2021

Case Study #3

Jeremy's scenario

Jeremy's clinical outcome

• Uncontrollable blood pressure elevated with systolic >200​ shortly after arrival

• He was intubated due to worsening respiratory distress​

• 1 hour after intubation Jeremy went into cardiac arrest and died

This case demonstrates how quickly and rapidly a patient can deteriorate and progress from sepsis to septic shock to death. Administration of appropriate antibiotics is life-saving. Time to antibiotic administration is essential in preventing patient morbidity and mortality.​

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Evans et al., 2021; Varr, 2021

Summary

• Sepsis is a leading cause of death in the U.S.​
• The 1-hour benchmark for the delivery of initial antibiotic therapy has been demonstrated by the surviving sepsis campaign to improve patient outcomes and reduce patient morbidity and mortality ​
• Time to antibiotic administration is critically important within sepsis care, with every hour delay linked to an 8% increased risk of mortality​
• Early recognition and treatment of sepsis in the ED is essential for patient survival​
• Sepsis can progress rapidly from initial illness to death.
• Administration of appropriate antibiotics is life-saving. ​

Timely antibiotic administration is essential in preventing patient morbidity and mortality in sepsis.

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Congratulations, you have reached the end!

Thank you for participating in my Sepsis Education Module Any questions or comments? ​ Feel free to contact me via email at rkalake1@jhu.edu

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References

• Alexander, M., Sydney, M., Gotlib, A., Knuth, M., Santiago-Rivera, O., & Butki, N. (2022). Improving compliance with the CMS SEP-1 sepsis bundle at a community-based Teaching Hospital Emergency Department. Spartan Medical Research Journal, 7(2). https://doi.org/10.51894/001c.37707
• Arina, P. & Singer, M. (2021). Pathophysiology of sepsis. Current Opinion in Anaesthesiology, 34 (2), 77-84. doi: 10.1097/ACO.0000000000000963.​
• Centers for Disease Control and Prevention. (2023, August 24). What is Sepsis? U.S. Department of Health and Human Services. https://www.cdc.gov/sepsis/what-is-sepsis.html​
• Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., … Levy, M. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11). https://doi.org/10.1097/ccm.0000000000005337
• Galang, K., Yescas Garibay, K. S., Asad, M., & Saadat, M. (2020). It’s about time: Improving compliance in the one-hour sepsis bundle using a modified electronic medical record alert prompting a nursing driven protocol. Chest, 158(4). https://doi.org/10.1016/j.chest.2020.08.1218
• ​ Langley, C. (2019, September 30). What if it is not a duck? an atypical presentation of sepsis - Richmond ambulance authority. Richmond Ambulance Authority -. https://raaems.org/2019/09/30/what-if-it-is-not-a-duck-an-atypical-presentation-of-sepsis/ ​
• Mahapatra, S., & Heffner, A. C. (2023, June 12). Septic shock. In StatPearls. StatPearls Publishing. Retrieved March 29, 2024 from https://www.ncbi.nlm.nih.gov/books/NBK430939/​
• Mapes, J. E. (n.d.). Risk management tools & resources. Case Study: Failure to Identify Sepsis and Initiate Treatment Leads to Patient Death | MedPro Group. https://www.medpro.com/delayed-diagnosis-treatment-sepsis-hospital ​
• Post-Sepsis Syndrome. (2021, January 21). Sepsis Alliance. https://www.sepsis.org/sepsis-basics/post-sepsis-syndrome/​
• Schertz, A. R., Lenoir, K. M., Bertoni, A. G., Levine, B. J., Mongraw-Chaffin, M., & Thomas, K. W. (2023). Sepsis prediction model for determining sepsis vs Sirs, qSOFA, and sofa. JAMA Network Open, 6(8). https://doi.org/10.1001/jamanetworkopen.2023.29729 ​
• Sherwin, R., Winters, M. E., Vilke, G. M., & Wardi, G. (2017). Does early and appropriate antibiotic administration improve mortality in emergency department patients with severe sepsis or septic shock? The Journal of Emergency Medicine, 53(4), 588–595. https://doi.org/10.1016/j.jemermed.2016.12.009
• ​ Vraa, E. P. (2021). Atypical presentation of sepsis from community-acquired Staphylococcus aureus pneumonia in a previously healthy 47-year-Old male: Case report. Journal of Emergency and Critical Care Medicine, 5, 38–38. https://doi.org/10.21037/jeccm-21-1 ​
• Wishart, D. S., Feunang, Y. D., Guo, A. C., Lo, E. J., Marcu, A., Grant, J. R., Sajed, T., Johnson, D., Li, C., Sayeeda, Z., Assempour, N., Iynkkaran, I., Liu, Y., Maciejewski, A., Gale, N., Wilson, A., Chin, L., Cummings, R., Le, D., … Wilson, M. (2017). Drugbank 5.0: A major update to the DrugBank database for 2018. Nucleic Acids Research, 46(D1). https://doi.org/10.1093/nar/gkx1037 ​
• World Health Organization. (2023, July 19). Sepsis. https://www.who.int/news-room/fact-sheets/detail/sepsis​
• Yealy, D. M., Mohr, N. M., Shapiro, N. I., Venkatesh, A., Jones, A. E., & Self, W. H. (2021). Early care of adults with suspected sepsis in the emergency department and out-of-hospital environment: A consensus-based Task Force report. Annals of Emergency Medicine, 78(1), 1–19. https://doi.org/10.1016/j.annemergmed.2021.02.006

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