Sepsis Vitals Training eBook

Careflow Vitals 4.2 Sepsis Module Sepsis Screening and delivering the Sepsis Bundle

CONTENTS NEWS2 and Recognition of Sepsis Risk

3

Careflow vitals: Sepsis Module

4

Sepsis Screening

4

How does care flow vitals Sepsis Module assist...

4

Screening Outcomes

5

Moderate / High Risk of Sepsis and Required Actions

6

Sepsis Checklist

7

Guidance on Lactate

8

Manual Launch of Sepsis Screening

8

Documentation and Communication

9

Discharge information and Further guidance

9

Appendix: SaTH Lactate Diagram Courtesy Dr Ashley Miller Intensivist

2

10

Careflow Vitals 4.2 Sepsis Module

NEWS2 & RECOGNITION OF SEPSIS RISK Why do NEWS2 and Sepsis risk go hand in hand?

• NEWS2 is nationally recognised track and trigger tool which quantifies severity of sickness by attributing a score to individual physiological parameters – the further from the average normal values for each parameter the greater the score resulting in a final cumulative (aggregate) score (see https://www.rcplondon.ac.uk/projects/outputs/ national-early-warning-score-new for more info) • As a consequence of the score there will be resulting actions required to be undertaken by the person at the bedside. This involves escalating clinical concern and attendance of clinicians to ensure the patient receives management in a timely fashion thus preventing further deterioration.

How does NEWS2 help identify Risk of Sepsis?

• NEWS2 is designed to help capture the deterioration of patients before there is significant physiological derangement in order to allow for intervention to prevent further deterioration if possible.

• It sets expectations for escalation, timeframes and actions dependent on the score.

• This process is guidance only and whilst if a patient triggers NEWS2 this should be the default approach, if a patient does not Trigger NEWS2 but there is clinical concern, clinical judgement should be employed and escalation should proceed irrespective of the NEWS2 score.

Sepsis is defined as

• A life-threatening organ dysfunction caused by dysregulated (uncontrolled) host response to infection.

• A patient may develop an infection and their body mounts a response to this by mobilising certain products as part of the inflammatory response (to try and bring the pathogen under control). In ideal world the first contact between the pathogen and the inflammatory response should eliminate the microbe and return the host to homeostasis.

• Dysregulation and organ damage accelerate due to continued activation of inflammatory response.

• Progression results from: mismatch between perfusion and tissue metabolic requirements • Organ Dysfunction is newly defined as a change (an increase by two or more) in baseline Sequential Organ Failure Assessment (SOFA) • SEPTIC SHOCK Is a subset of Sepsis in which particularly profound circulatory cellular, and metabolic abnormalities are associated with greater risk of mortality that with Sepsis alone.

• The main management goals focus is minimising process progression through reducing infective load (Hence treatment with Antibiotics within 60 mins of identified Risk) and source control (which may necessitate surgical or other intervention)

Sepsis Screening and delivering the Sepsis Bundle

3

CAREFLOW VITALS - SEPSIS MODULE SEPSIS SCREENING All acute admissions to the trust should be screened for Sepsis irrespective of whether a screen is triggered automatically. In some instances this will require a Manual Launch of the Sepsis Screen / Assessment (this will be covered in more detail on p8) If the patient then triggers a secondary screen due to worsening physiological parameters this should be completed to reflect the Risk of Sepsis at that point in time.

HOW DOES CARE FLOW VITALS SEPSIS MODULE ASSIST WITH EARLY RECOGNITION AND MANAGEMENT OF SEPSIS RISK? Vitals Sepsis Module – utilises both NEWS2 and the quick Sequential Organ Failure (qSOFA) score (from the set of observations submitted) to identify Risk of Sepsis Physiological triggers that prompt a Vitals sepsis assessment (following NICE guidance) • • • • Obs

NEWS2 5 or greater 3:1 category qSOFA 2 or more (RR>21, SBP <101, GCS <15) GCS<15 (ED only) Low

High

Respiration rate (bpm)

≤8

≥30, U (Patient condition)

SaO2 (%)

≤87

U (Patient condition)

Temperature (°C)

≤35

≥39.1, (Patient condition) (scores 2)

BP Systolic (mm Hg)

≤90

≥220, (Patient condition)

Heart rate (bpm)

≤40

≥131, U (Patient condition)

AVPU

Voice (V), Pain (P), Unresponsive (U)

These triggers cause the system to initiate the screening protocol which in turn asks ‘Could this be due to infection?’ and further gateway questions. No to any assessment question with lactate <2mmol/L will result in the risk category Low Risk Sepsis (at this time) sepsis screening protocol will be repeated if a patient triggers again after further deterioration of physiological triggers.

NB: positive answers indicate Moderate or High-risk of Sepsis dependant on contributing factors and the sepsis six checklist is subsequently launched

4

Careflow Vitals 4.2 Sepsis Module

Whilst awaiting screening to be completed the following icon will show indicating a sepsis screen is required by a suitably trained individual this indicates that this is due.

On the hand held device - this will show as a red clock.

SEPSIS SCREENING OUTCOME Once screened the patient will be identified as either; Low Risk Sepsis, Moderate Risk Sepsis or High Risk Sepsis indicated by the Triangle alert symbol

If requiring treatment with the Sepsis Bundle you will also see the circular alert indicating mthe time frames for the pending action either Due, Overdue or Breached.

If a patient is ‘DEEMED NOT SEPSIS’ after triggering Moderate Risk (Amber) or High Risk (Red Flag) The checklist items should be documented as ‘NOT REQUIRED’ by the senior clinician who made this decision (CT3 / ST3 or above), thus ensuring this is captured with the required ID date and Time stamp of the clinician involved. This can be accessed via PC from the menu on the left near VTE assessment tab.

Sepsis Screening and delivering the Sepsis Bundle

5

RISK STRATIFICATION AND ACTIONS A patient Identified as High Risk of Sepsis is a Medical Emergency and requires intervention to prevent deterioration and progression to Septic shock and or multi organ failure. This treatment should be delivered within 60 minutes from triggering the screen eg when the NEWS2 trigger was recorded.

As such Sepsis Vitals will initiate the Sepsis Checklist protocol which is also indicated as an action outstanding by this symbol The Alert message at the end of screening will give guidance on the immediate actions and management as follows.

MODERATE RISK OF SEPSIS Moderate sepsis risk This patient has a MODERATE RISK of developing sepsis.

As with the current practice, Moderate Risk of Sepsis requires immediate actions and this prompt will pop up on completion of the Screening, however this disappears once acknowledged.

Unlike High Risk a Moderate Risk will not prompt a checklist, so staff must ensure required actions are completed and documented accordingly.

• Required actions include but are not limited to Bloods, including Lactate and • Clinician review of patient and results after an hour of Screening for Moderate Risk.

If a Moderate Risk is identified and subsequent bloods identify a lactate ≥2mmol/L or evidence of AKI – This must result in immediate Manual Launch of a Sepsis Assessment / Screen in order that this new information be factored into the risk stratification, failure to do so could result in delay in treatment and or deterioration in the patient.

High Sepsis Risk This patient has a HIGH RISK of developing sepsis

HIGH RISK OF SEPSIS The alert message (as seen here) requires acknowledgement before the screen closes.

These actions mirror the current High Risk (Red Flag) Sepsis management and to assist in delivery the Vitals Sepsis module initiates The Sepsis Checklist for recording details regarding administration of the Sepsis bundle.

Please tick to acknowledge you’ve read and understood all points above and will act where necessary

6

KEY POINT OF NOTE: Remember this only records the initial 60 minute management, Vitals Sepsis will not prompt ongoing actions beyond this point but these are still required.

Careflow Vitals 4.2 Sepsis Module

SEPSIS CHECKLIST Firstly -Ensure the Sepsis Risk has been escalated to a Senior Clinician (ST3 / CT3 or above) and documented, whilst completing and recording the required actions (Sepsis Bundle) on Vitals Sepsis Checklist.

Those Elements of the bundle deemed not required or the patient being ‘Not deemed Sepsis’ necessitates the clinician who made this decision (ST3 / CT3 or above) to log on and complete the’ NOT Required’ documentation on the Checklist this ensures the Date Time and ID signature Stamp captures the details and designation of the clinician making this decision.

Sepsis Management does not stop once the patient has received the Sepsis bundle.

Patients require ongoing monitoring to gauge the impact of intervention and to capture if the patient deteriorates further.

There may be a transient physiological improvement after the Sepsis bundle is delivered, resulting in a decrease in NEWS2 score, it is important that we continue to monitor these patients closely and frequently to capture if this improvement continues or further deterioration occurs.

To assist with monitoring ongoing improvement (or not) serial lactates are required for at risk of Sepsis and deteriorating patients 1. Initial lactate ( VBG / ABG) in a deteriorating patient 2. followed up with serial lactates initially after 1 hour and 3. Subsequently at 6 and 8 hours to gauge the progression of the patient’s condition

Sepsis Screening and delivering the Sepsis Bundle

7

GUIDANCE FOR ELEVATED LACTATE An elevated Lactate may be caused by a number of contributory factors it is important to consider all possible causes until excluded (including Sepsis) The following guidance suggests some of the possible considerations However it is important to remember a ‘High Lactate signals serious illness, even if the cause is not yet identified’.

Please see Appendix 1 for Lactate Guidance image

MANUAL LAUNCH OF SEPSIS ASSESSMENT / SCREEN Whilst the screening assessment will launch automatically when triggered by any of the parameters covered previously NEWS2 ≥5, 3 in a single Criteria 2 or more qSOFA etc.

Some occasions will necessitate manual launch of Sepsis Assessment / screening.

• All acute admissions require an Admission Screen for Sepsis irrespective of their physiology so this requires manual launch.

• Those screened and determined Moderate risk but who have an elevated lactate ≥ 2 & or new AKI these patients will need Sepsis Assessment Manually launched and a repeat screening undertaken order to acknowledge this relevant information when determining Sepsis Risk.

• If a Sepsis screen is not completed within 1 hour of triggering and the action is not addressed you will be prompted to complete a new set of observations.

or

Should this set of observation subsequently not prompt a Sepsis screen, a Sepsis Assessment / Screen should be manually launched as a response to the previously triggered requirement.

Failure to do so may result in delay in treatment or further deterioration of the patient and will show as non-compliance.

EDITTESTPATIENT, Seven Born: 06-Jun-1971 Hosp No. 999907T Due

Category

GCS Limb Pupil Peak Flow Rate Sedation Sepsis Assessment

A-Z

MANUAL LAUNCH OF SEPSIS ASSESSMENT: Can be found in the area under OBSERVATIONS where all Risk assessments (e.g GCS) are located.

Scroll down to Sepsis and Select Sepsis Assessment The gateway Questions will load e.g “Could this be due to infection?” etc. and take you through the Sepsis assessment / Screen

Sepsis Six Checklist Urinalysis 8

Urinary catheter mgmt

Careflow Vitals 4.2 Sepsis Module

DOCUMENTATION AND COMMUNICATION Communication is Key; Vitals 4.2 Sepsis Module manages the initial treatment within 60 minutes however Sepsis management goes beyond this point so clinical teams must ensure they continue to monitor response to intervention e.g serial lactates, and escalate if the patient continues to deteriorate or fails to respond to intervention e.g • Systolic is <90mmHg, • they have a persistent altered conscious level, • Lactate fails to reduce by > 20% after resuscitation.

Inform Consultant & consider Referral to Critical Care Team if any of the above present and or Lactate >4mmol/L.

DISCHARGE INFORMATION AND FURTHER GUIDANCE All patients who have received Sepsis management in the form of the Sepsis 6 bundle should (on discharge from hospital) be issued with a signs and symptoms leaflet which will offer guidance on where and how to get help if they believe they have ongoing problems associated with Sepsis such as Sepsis Syndrome.

This leaflet should also be given to patients discharged on treatment for infection as it offer guidance on what signs and symptoms to look out for and nest steps should they believe their condition is worsening.

Provision of this leaflet should be documented in the notes.

Sepsis Screening and delivering the Sepsis Bundle

9

Lactate

If raised (>2 mmol/l):

Care group: All Keywords:

Causes a metabolic acidosis

Liver failure

Metformin (especially with AKI)

Hypoxia Systemic (hypotension, respiratory failure) Local (ischaemic bowel)

Date: 03/21

Review Date: 03/25

Glycolysis Stress response Exercise / seizures B agonists

Sepsis multi-factional Stress response

PDH impairment Hypotension

Krebs cycle

Management

Author: Ashley Miller

Acetyl Co-A

Glucose

Pyruvate

Alchoholic Malnourished

PDH

Lactate

Alkalosis Lactate moves out of cells

Inborn errors of metabolism (infants)

• Treat the cause • Rule in/out Sepsis and Bowel Ischaemia • Recheck in 1hr • Cause unclear, not improving - discuss with ICU registrat

Careflow Vitals 4.2 Sepsis Module

10

REFERENCE Mervyn Singer, MD, FRCP1; Clifford S. Deutschman, MD, MS2; Christopher Warren Seymour, MD, MSc3; et alManu Shankar-Hari, MSc, MD, FFICM4; Djillali Annane, MD, PhD5; Michael Bauer, MD6; Rinaldo Bellomo, MD7; Gordon R. Bernard, MD8; Jean-Daniel Chiche, MD, PhD9; Craig M. Coopersmith, MD10; Richard S. Hotchkiss, MD11; Mitchell M. Levy, MD12; John C. Marshall, MD13; Greg S. Martin, MD, MSc14; Steven M. Opal, MD12; Gordon D. Rubenfeld, MD, MS15,16; Tom van der Poll, MD, PhD17; Jean-Louis Vincent, MD, PhD18; Derek C. Angus, MD, MPH19,20 (2016) The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA.;315(8):801-810. doi:10.1001/jama.2016.0287

NOTES

Sepsis Screening and delivering the Sepsis Bundle

11

Version 1 13/09/2021