islhd procedure cover sheet - medfromtheshed.com.au · sepsis pathway should be followed where:...

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ISLHD PROCEDURE

COVER SHEET

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NAME OF DOCUMENT

Sepsis Pathway – Emergency Department

TYPE OF DOCUMENT

Procedure

DOCUMENT NUMBER

ISLHD CLIN PROC 137

DATE OF PUBLICATION

October 2016

RISK RATING

Medium

REVIEW DATE

October 2018

FORMER REFERENCE(S)

Nil

EXECUTIVE SPONSOR or

EXECUTIVE CLINICAL SPONSOR

Director of Medical Services

AUTHOR

Robert Marco - Inpatient Sepsis Project Manager

[email protected]

Sarah Dwyer - Senior Nurse Educator- Wollongong Hospital

[email protected]

KEY TERMS

Emergency, sepsis, antibiotics, guideline, escalation, auditing

SUMMARY

This document is to act as a guideline for staff who suspect patients to have sepsis.

The procedure includes the Clinical Excellence Commissions’ (CEC) sepsis pathway and antibiotics guidelines

mailto:[email protected]



INTERNAL ONLY ISLHD PROCEDURE

Sepsis Pathway – Emergency Department ISLHD CLIN PROC 137

Revision 0 Trim No. DT16/8628 October 2016 Page 1 of 16

THIS DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS REGISTERED BY LOCAL DOCUMENT CONTROL PROCEDURES

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1. POLICY STATEMENT

The Emergency Department (ED) Sepsis Pathway is based on the CEC Sepsis ED

guidelines and aims to guide the recognition and management of emergency patients

who are suspected of severe sepsis.

Clinicians are required to refer to the Sepsis pathway when they recognise a patient’s

clinical condition is deteriorating. Where signs and/or symptoms of sepsis are

identified the Sepsis Pathway must be followed until the AMO determines that sepsis

is not the cause of deterioration.

Quick administration of antibiotics and resuscitation fluids is vital in the management

of the patient with sepsis. The goal is to commence antibiotic therapy within the first

hour of recognition and diagnosis of sepsis.

The guideline is based on the Therapeutic Guidelines: Antibiotic Version 15 and

incorporates best available evidence and the principles of appropriate use of

antibiotics. The selection of appropriate antimicrobial therapy in sepsis management is

complex and this guideline is not intended to cover all possible scenarios.

AIMS of the Sepsis Pathway

Recognise sepsis early and escalate appropriately.

Initiate appropriate management: Give IV antibiotics and fluids within one hour of

identification.

Provide appropriate follow up management to ensure sepsis is treated adequately

or pathway is ceased if not required.

2. BACKGROUND

Sepsis is a medical condition where the immune system goes into overdrive. This process

releases chemicals into the blood to combat infection and trigger widespread

inflammation. If the body is unable to control this immune response, it then overwhelms

normal blood processes. This progression can lead to severe sepsis and septic shock

which leads to organ dysfunction, hypotension, or hypoperfusion to one or more organs1.





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3. RESPONSIBILITIES

This guideline applies to all medical, nursing and allied health staff who attend to the care

and treatment of hospital inpatients.

4. PROCEDURE

4.1 Procedure for Milton Hospital, Shellharbour Hospital, Shoalhaven District Hospital and Wollongong Hospital

Consider Sepsis and refer to Sepsis Pathway when at triage, performing an A-G

assessment or when asked to review a deteriorating patient.

Sepsis pathway should be followed where: there are concerns that a patient has

sepsis, there is a risk factor/s, sign or symptoms of infection (see pathway above)

PLUS:

Two Yellow Zone breaches or additional criteria:

o Sepsis pathway model of care is to be activated on eMR (FirstNet)

o Obtain senior clinician review to confirm diagnosis

o Commence treatment as per guidelines

Any Red Zone breaches or additional criteria:

o Sepsis pathway model of care is to be activated on eMR (FirstNet)

o Obtain immediate clinician review

o Commence treatment as per guidelines

4.2 Sepsis Resuscitation Guidelines

Clinicians are required to perform six key actions within 60 minutes (refer to Sepsis

Resuscitation Guideline below)

1. Administer oxygen (M.O. approval if O2 contraindicated)

2. Take blood cultures and other specimens – Do not delay the administration of

antibiotics or wait for the results of investigations2.

3. IV antibiotics

4. IV fluid resuscitation

5. Measure serum lactate

6. Monitor input and urine output (Fluid Balance Chart), vital signs and reassess.





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Blood cultures: Take two sets of blood cultures before administering antibiotics. Obtain other clinical specimens as appropriate but do not delay administration of antibiotics or wait for results of investigations

ISLHD Antibiotic Guidelines: Medical officers should follow the ISLHD Sepsis

antibiotic guidelines (Appendix 5) unless otherwise indicated. Infectious disease

should be contacted if there are any prescribing issues.

Administration of antibiotics should be prioritized by the nurse and given as soon

as possible once prescription is available, ensuring that bolus antibiotics are given

prior to those requiring infusions.

Before leaving the patient medical staff should ensure that:

o Antibiotics are commenced.

o A clear patient management plan is documented in the medical notes, with the

CEC guidelines in mind.

4.3 After treatment has commenced:

A sepsis data form must be completed by a clinician (a nurse in most instances) and

the completed form placed in a collection tray.

A detailed management plan should be written in the patient’s progress notes. This

will help to alert clinicians that the Sepsis Pathway was commenced and provide a

management guide for their ongoing care.

Sepsis Pathway sticker (NH700072) to be placed on the medication chart.

If the patient is to remain in hospital, they are to be admitted to an appropriate ward.

Patient status on the sepsis pathway is to be handed over to both medical and nursing

staff.

**If your emergency department is using the sepsis pathway patient form (NH700066),

please fill this in and insert this into the patient notes before discharge from the ward**

5. DOCUMENTATION

Staff are to use the appropriate sepsis pathway and medical records to document patient progress.

6. AUDIT

Auditing ensures that clinical practice changes are carried out and provide a source of

feedback and learning. We are currently measuring time taken to first antibiotics and IV

fluid. Additional measures will be used by each facility to ascertain the effectiveness of

the program Notification form data must be entered into the CEC sepsis database (http://sepsis.cec.health.nsw.gov.au/).

http://sepsis.cec.health.nsw.gov.au/





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7. REFERENCES

Internal:

ISLHD CLIN PD 86 – Sepsis Management

ISLHD CLIN PROC 136 – Sepsis Pathway - Inpatient

ISLHD CLIN PROC 95 - Transfer to Higher Level Care

ISLHD CLIN PD 52- Between the Flags (BTF) - Patient with Acute Condition for Escalation (PACE) - Management of Clinical Deterioration:

ISLHD CLIN PD 54 - Emergency Department Admission Process External: 1. Chang, H, Lynm, C & Glass, R, 2012, ‘Sepsis’, Journal of the American Medical

Association, vol. 304, no. 16, pp.1813. Available from: http://jama.jamanetwork.com/data/Journals/JAMA/4534/jpg1027_1856_1856.pdf

2. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care Standard. Sydney: ACSQHC, 2014

3. Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic Version 15 Melbourne: Therapeutic Guidelines Limited; 2014 Accesses through eTG complete (via CIAP)

4. Burridge N (ed). Australian Injectable Drugs Handbook (5th Ed). The society of Hospital Pharmacists Australia; 2011

8. REVISION AND APPROVAL HISTORY

Date Revision No. Author and Approval

October 2016

0 Robert Marco - Inpatient Sepsis/VTE Project Manager

Draft for comment February 2016

Endorsed ISLHD Drug & Therapeutics June 2016

IV Antibiotic Guideline Update and Pathway Updates August 2016

Distributed to Divisional Co-directors August 2016

Approved Clinical Governance Council October 2016

http://islhnintranet/Policies_Procedures_Guidelines/Clinical/Governance/default.asp#Sepsis

http://islhnintranet/Policies_Procedures_Guidelines/Clinical/Governance/default.asp#Sepsis

http://islhnweb/Policies_Procedures_Guidelines/Clinical/Emergency_Medicine/documents/ISLHD-CLIN-PROC-95-TransfertoHigherLevelCare.pdf

http://islhnweb/Policies_Procedures_Guidelines/Clinical/Emergency_Medicine/documents/ISLHD-CLIN-PD-54-EmergencyDepartmentAdmissionProcess.pdf

http://jama.jamanetwork.com/data/Journals/JAMA/4534/jpg1027_1856_1856.pdf





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Sepsis pathways should not be printed from this procedure. For the most up to date pathway please check via the following link: http://cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/sepsis-kills/sepsis-tools

Appendix 1 – Adult Sepsis Pathway

http://cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/sepsis-kills/sepsis-tools





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Appendix 2 – Paediatric Sepsis Pathway





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Appendix 3 – Maternal Sepsis Pathway





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Appendix 4 – Newborn Sepsis Pathway





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APPENDIX 5 – Antibiotic Prescribing Guide

ADULT SEVERE SEPSIS INTRAVENOUS ANTIBIOTIC GUIDELINE (Review after 24 hours)

Sepsis = Infection + SIRS (Temp <36/ >38, RR > 24, HR >90, WCC < 4/ > 12) SEVERE SEPSIS= Sepsis + Deteriorating Organ Function

ACTIONS (For ALL Sepsis) 1. Lactate 2. Blood cultures 3. IV antibiotics 4. Fluid Resus

Follow the sepsis pathway in conjunction with your local BTF RED & YELLOW Zone escalation procedures.

Source not covered below, recent travel, or HIGH risk of multi-resistant organisms? Antimicrobial stewardship (AMS) hotlines: 3838 (TWH, SHH, SDMH, CDH); #2828 (BDH, MUH); 3535 (PKH)

For patients already on antibiotics: Contact AMO or ID (AMS hotline or switchboard) for advice.

For sepsis in renal patients (e.g. PD peritonitis), contact the renal team via switchboard.

Doses below are for SEVERE sepsis and SEPTIC SHOCK. For non-severe sepsis doses, refer to the Therapeutic Guidelines

Likely source of SEVERE sepsis

Preferred regimen Penicillin allergy (NOT anaphylaxis)

Penicillin/cephalosporin allergy (anaphylaxis)

Severe sepsis of unknown origin

OR intravascular device source

OR surgical site source

Flucloxacillin 2g 6-hourly PLUS

gentamicin 7mg/kg IDEAL body weight

PLUS vancomycin 25-30mg/kg

ACTUAL body weight

If gentamicin contraindicated, use piperacillin/tazobactam

4.5g 6-hourly instead of flucloxacillin and gentamicin

Cefazolin 2g 6-hourly PLUS

gentamicin 7mg/kg IDEAL body weight


ACTUAL body weight

If gentamicin contraindicated, use meropenem 2g 8-hourly

instead of cefazolin and gentamicin

Gentamicin 7mg/kg IDEAL body weight


ACTUAL body weight

If gentamicin contraindicated,

call AMS/ID for advice

Severe sepsis due to community-acquired

pneumonia

Ceftriaxone 1g 12-hourly PLUS

azithromycin 500mg daily


azithromycin 500mg daily

Moxifloxacin 400mg daily

Severe sepsis due to hospital acquired

pneumonia - low risk of MRO

(no recent intubation)


metronidazole 500mg 12-hourly



Moxifloxacin 400mg daily

Severe sepsis due to hospital acquired

pneumonia - high risk of MRO (recent intubation,

prior infection,

Piperacillin-tazobactam 4.5g 6-hourly

If risk of MRSA, ADD vancomycin 25-30mg/kg

ACTUAL bodyweight

Cefepime 2g 8-hourly

If risk of MRSA, ADD vancomycin 25-30mg/kg

ACTUAL bodyweight

Call AMS/ID for advice

Consider vancomycin if Staphylococcal pneumonia suspected (recent ‘flu, cavitation, rapid progression)

http://seslhnweb/Antimicrobial_Stewardship/Policy/documents/VancomycinDosing%20guidelines.pdf





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colonised)

Severe sepsis with skin source

Flucloxacillin 2g 6-hourly PLUS

vancomycin 25-30mg/kg ACTUAL bodyweight

Cefazolin 2g 8-hourly PLUS


Vancomycin 25-30mg/kg ACTUAL body weight

Severe sepsis with urinary source

(If recent TRUS

biopsy, call AMS/ID for advice)

Gentamicin 7mg/kg IDEAL bodyweight

PLUS ^ampicillin 2g 6-hourly

If gentamicin contraindicated, use ceftriaxone 1g 12-hourly


If gentamicin contraindicated, use ceftriaxone 1g 12-hourly


If gentamicin contraindicated, call AMS/ID for advice

Biliary or gastrointestinal

source


PLUS ^ampicillin 2g 6-hourly

PLUS metronidazole

500mg 12-hourly

If gentamicin contraindicated, use piperacillin/tazobactam

4.5g 6-hourly




Peri- or post-partum severe sepsis

(See maternal sepsis pathway for ongoing

therapy)


If patient meets toxic shock criteria, ADD

clindamycin 600mg 8-hourly



If patient meets toxic shock criteria, ADD

clindamycin 600mg 8-hourly


Severe sepsis with neurological source

(organism or susceptibility

unknown)



If risk of listeria ADD

benzylpenicillin 2.4g 4-hourly

Moxifloxacin 400mg daily PLUS


If risk of listeria,

call AMS/ID for advice.

Moxifloxacin 400mg daily PLUS


If risk of listeria,

call AMS/ID for advice.

If post-neurosurgical, give meropenem 2g 8-hourly PLUS vancomycin 25-30mg/kg ACTUAL body weight

Intravenous dexamethasone may be required before antibiotics – refer to Therapeutic Guidelines






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Severe sepsis due to diabetic foot infection



ACTUAL bodyweight

Ciprofloxacin 400mg 12-hourly PLUS

clindamycin 600mg 8-hourly PLUS


Ciprofloxacin 400mg 12-hourly PLUS

clindamycin 600mg 8-hourly PLUS


Febrile neutropenia

(refer to local protocol)


AND refer to local protocol

Cefepime 2g 8-hourly AND refer to local protocol


Once prescribed, enter antibiotic approval/s in Guidance MS.

^If ampicillin unavailable use benzylpenicillin 2.4 grams 6-hourly.





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TABLE 2: ANTIBIOTIC ADMINISTRATION

Reconstitute antibiotics with sterile water for injection (WFI) unless stated otherwise.

If further dilution is required for IV injection or infusion, use sterile sodium chloride 0.9% or sterile glucose 5% unless stated

otherwise.

Where possible use separate dedicated lines for resuscitation fluid and for medications. When injecting antibiotics directly

into an IV injection port which has resuscitation fluid running:

- clamp the infusion fluid line and flush with 20 mL sterile sodium chloride 0.9% solution

- administer antibiotic over the required time

- flush the line with 20 mL sterile sodium chloride 0.9% solution and recommence resuscitation fluid.

For detailed information refer to the SHPA injectable handbook via CIAP:

http://aidh.hcn.com.au/index.php/section-one/drug-monographs-a-z?view=alphacontent

Antibiotic Presentation

(adult)

Recon fluid

/volume

Final

volume

Minimum

admin time

Notes

Ampicillin Vial 1g 10 mL NS 10-20 mL 3-5 min Penicillin class antibiotic

Azithromycin Vial 500mg 4.8mL WFI 250mL 60 min 250mL sodium chloride 0.9%

Benzylpenicillin Vial 1.2g 3.2mL WFI 10mL 5-10 min Penicillin class antibiotic. Do no inject

faster than 300mg/min

Cefepime Vial 1 g 10 mL NS 10 mL 3-5 min

Cephalosporin class antibiotic

Doses ≥ 2 g infused over 20 min

Ceftriaxone Vial 1 g 10 mL WFI 10 mL 2–4 min Cephalosporin antibiotic incompatible

with calcium containing solutions,

flush before and after with sodium

chloride 0.9%

Cefazolin Vial 1 g 10 mL WFI 10 mL 3–5 min Cephalosporin class antibiotic

Ciprofloxacin Infusion bag

400mg/200mL

N/A 200mL 60 min May induce seizures in epileptics

Flucloxacillin Vial 1 g 5 mL WFI 10 mL 3-5 min

(1 g)

Penicillin class antibiotic

Repeated doses of 2 g via a

peripheral line should be further

diluted and infused over 30 min

Gentamicin

Ampoule

80 mg/2 mL

N/A 10- 20 mL ≤ 240mg

3–5 min

Refer to notes for Gentamicin

50 mL or

100 mL

> 240mg

30 min

Clindamycin Amp 600mg N/A 50mL 20 min Do not give as bolus injection

Metronidazole Infusion bag

500mg/100mL

N/A 100mL 20 min

http://aidh.hcn.com.au/index.php/section-one/drug-monographs-a-z?view=alphacontent

http://seslhnweb/Antimicrobial_Stewardship/Policy/documents/AminoglycosideGuidance.pdf

http://seslhnweb/Antimicrobial_Stewardship/Policy/documents/AminoglycosideGuidance.pdf





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Meropenem 1g vial 10 mL WFI 50-250 mL 30-60 min

Moxifloxacin Infusion bag

400 mg/ 250 mL

N/A 250mL 60 min May prolong QT interval and lead to

ventricular arrhythmias.

May induce seizures in epileptics

Piperacillin-

tazobactam

Vial 4 g/0.5 g 20 mL WFI 50 mL 30 min Penicillin class antibiotic

Vancomycin Vial 500 mg 10 mL WFI **5mg/mL

peripheral

Max

10 mg/min

Infusion related effects are common,

decrease infusion rate and monitor

closely






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Sepsis = Infection + SIRS SEVERE SEPSIS= Sepsis + Deteriorating Organ Function

ACTIONS: 1. Follow PAEDIATRIC Sepsis Pathway (Remember lactate/blood cultures/fluid resus/antibiotics)

2. Use local BTF RED & YELLOW Zone escalation procedures. 3. Contact PAEDIATRICIAN through switchboard for advice.

PAEDIATRIC ANTIBIOTIC PRESCRIBING GUIDE FOR SEVERE SEPSIS (Review after 24 hours)

Doses are for SEVERE sepsis and septic shock. For non-severe sepsis doses, refer to local guidelines. This guideline relates to intravenous and intraosseous administration. For intramuscular refer to full CEC guideline.

Likely Source

Preferred Regimen

Penicillin Allergy (NOT immediate hypersensitivity)

Penicillin/Cephalosporin Allergy (Immediate/anaphylaxis)

SEVERE sepsis due to community-acquired

pneumonia (CAP) OR

hospital acquired pneumonia (HAP)

+ low risk of MRO* (eg. no recent intubation)

Cefotaxime 50mg/kg up to 2g, 6-hourly

PLUS vancomycin 15mg/kg ACTUAL

bodyweight up to 750mg 6-hourly




Ciprofloxacin 10mg/kg up to 400mg, 8-hourly

PLUS vancomycin 15mg/kg

ACTUAL bodyweight up to 750mg 6-hourly

SEVERE sepsis due to hospital acquired pneumonia (HAP)

+ high risk of MRO* (eg. recent intubation,

prior infection, colonised)

Piperacillin-tazobactam 100+12.5mg/kg up to 4 +0.5g, 6-

hourly PLUS

vancomycin 15mg/kg ACTUAL bodyweight up to 750mg 6-hourly

Cefepime 50mg/kg up to 2g, 8-hourly






SEVERE sepsis due to urinary tract source

Gentamicin 7.5mg/kg IDEAL bodyweight (1mth-12yrs max dose 320mg, 12-16yrs max dose 560mg)

PLUS ^ampicillin 50mg/kg

up to 2g, 6-hourly




Gentamicin 7.5mg/kg IDEAL bodyweight (1mth- 12yrs

max dose 320mg, 12-16yrs max dose 560mg)



SEVERE sepsis due to intra-abdominal source


PLUS ^ampicillin 50mg/kg



Gentamicin 7.5mg/kg IDEAL bodyweight (1mth-12yrs max

dose 320mg, 12-16yrs max dose 560mg)

PLUS

CAP: if atypical pneumonia suspected, ADD azithromycin 10mg/kg up to 500mg, IV daily

For known or suspected ESBL-

producing organisms, see full

CEC guideline





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up to 2g, 6-hourly PLUS

metronidazole 12.5mg/kg up to 500mg, 12-hourly


PLUS metronidazole 12.5mg/kg

up to 500mg, 12-hourly

vancomycin 15mg/kg ACTUAL bodyweight up to

750mg 6-hourly PLUS

metronidazole 12.5mg/kg up to 500mg, 12-hourly

Likely Source

Preferred Regimen

Penicillin Allergy (NOT immediate hypersensitivity)

Penicillin/Cephalosporin Allergy

(Immediate/anaphylaxis)

SEVERE sepsis due to skin infection

Flucloxacillin 50mg/kg up to 2g, 6-hourly



Cefazolin 50mg/kg up to 2 g, 8-hourly



Vancomycin 15mg/kg ACTUAL bodyweight up to

750mg 6-hourly

SEVERE sepsis due to intravascular device (eg. venous access device, permanent

pacemaker or defib, endovascular

prostheses such as stents)

Flucloxacillin 50mg/kg up to 2g, 6-hourly

PLUS gentamicin 7.5mg/kg IDEAL

bodyweight (1mth-12yrs max dose 320mg, 12-16yrs max dose 560mg)



Cefazolin 50mg/kg up to 2 g, 8-hourly





Gentamicin 7.5mg/kg IDEAL bodyweight (1mth-12yrs max

dose 320mg, 12-16yrs max dose 560mg)



SEVERE sepsis due to

meningitis/ encephalitis




If risk of Listeria, ADD ampicillin

50mg/kg up to 2g, 6-hourly




If risk of Listeria, seek advice.

Vancomycin 15mg/kg ACTUAL bodyweight up to

750mg 6-hourly PLUS

ciprofloxacin 10mg/kg up to 400mg, 8-hourly

If risk of Listeria, seek advice.

Dexamethasone may be given before antibiotics: 0.15mg/kg up to 10mg, then 6-hourly for 4 days (If serious concern of encephalitis, do not give dexamethasone.)

If signs of encephalitis, ADD: 1mth - 5 yrs aciclovir 20mg/kg, 8-hourly; ≥5 years 15mg/kg, 8-hourly

For water-related infections, see full

CEC guideline)






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SEVERE sepsis due to unknown source (community OR

healthcare – associated)














Fever OR Suspected Sepsis in oncology/ transplant patients

REQUIRES IMMEDIATE REVIEW & TREATMENT: See NSW Health Guideline – Initial management of fever/suspected sepsis in oncology/transplant patients

^If ampicillin unavailable use benzylpenicillin 60mg/kg up to 2.4g, 6-hourly. Ceftriaxone 50mg/kg up to 2g, 12-hourly, can be used in place of cefotaxime.

Once prescribed, enter antibiotic approvals in Guidance MS.

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