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OVERLAKE HOSPITALOB SEPSIS

Pacific NW Regional Sepsis Conference

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ABOUT OVERLAKE

> 349-bed, nonprofit regional medical center offering a full range of advanced medical services to the Puget Sound Region

> Level III Trauma Center

> Approximately 22,000 admissions/year

> Over 45,000 ED visits/year

> Around 3700 Births/year

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SPREADING EARLY RECOGNITION AND TREATMENT OF SEPSIS TO THE

OB POPULATION

Margie Bridges, DNP, RNC-OB, ARNP-BC

Perinatal Clinical Nurse Specialist

Women and Infant's Services

Betsy Pesek, MN, BSN, RN, CPHQ

Quality Improvement Consultant

Quality Department

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NOTHING TO DECLARE

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OBJECTIVES

1. Recognize rational for including the OB population into Sepsis Quality Improvement work

2. Name 3 considerations that are unique to the perinatal population

3. Describe a step wise approach to incorporating inter-professional education on early recognition and management of maternal sepsis

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TRENDS IN PREGNANCY RELATED MORTALITY IN THE U.S. (1987-2013)

CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

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MATERNAL MORTALITY U.S.A. VERSUSOTHER DEVELOPED COUNTRIES

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SEPSIS IS THE 3RD LEADING CAUSE OF MATERNAL DEATH

CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

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MATERNAL MORTALITY IN WA

https://www.doh.wa.gov/Portals/1/Documents/Pubs/140-154-MMRReport.pdf

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CASE FOR CHANGE

> Severe Sepsis is the 3rd leading cause of maternal death

> Incidence of sepsis increasing over the years

> Once Severe Sepsis and Septic Shock develops mortality approaches 60%

> SEP-1 Core measure since 2015

How many of you have included OB in your work?

Critical Care Medicine.2013;41:945. Confidential: Protected Quality Improvement Document

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WHAT’S UNIQUE ABOUT OB?

• Distraction

• Typically Young & Healthy

• Uncommon

• Limited studies

• TWO patients

• SIRS criteria

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UNIQUE OB PHYSIOLOGY

• Normal OB physiology mimics SIRS:• WBC higher

• HR increases

• RR Increases

• Effect of Labor • HR, RR: pain and pushing

• Temp: dehydration, epidural

• Hypotension with epidural

• Altered mental status

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A STORY THAT MOTIVATESGROUP A SEPSIS CASE

16 year old Vacuum delivery 1st degree laceration

Postpartum Day 1:

WBC 16.4 T 36.2 BP 118/71 Pulse 115

3 hours later :.

WBC=*1.7 repeat 1.6 T: 38.7 HR: 120-156

BP: 95/45- 76/34 RR: 40-47

Mother comments that this is not her typical response to pain or stress

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OB CASE CONTINUED

RRT Called Transferred to CCU

Test & Treat: CT Scan, Pulmonary angiogram, Abdominal Ultrasound, Blood & Urine Cultures, IV Unasyn, clindamycin, Vancomycin, fluid volume resuscitation, vasopressor support, respiratory support with intubation

• BP: 68/40 P: 160 Sa02 87% on 6L Lactate 2.8

• Increasing pulmonary edema/pleural effusions, decreased UO

• Respiratory failure, tachycardia/Hypotension requiring vasopressors.

Major Goals of sepsis management were met: She was treated emergently with fluid resuscitation, antibiotic administration….What else?

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OB CASE CONTINUED

Postpartum Day 3:

To OR for Surgery: TAH, APPY, and Abdominal washout. Uterus was “mushy” tissue friable.

• 4 liters of purulent Ascites

• Positive for GAS

• Remained ventilated 9 days (ARDS)

Day 17: T: 36.5, BP: 127/75 P: 88 RR: 16 Sao2 100% RA

Discharged: Ambulating, Eating and Breastfeeding!

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QI IS A NEVER ENDING PROCESS

Where we were, where we are, and where we’re headed

• ED & CCU Inpatient OB population

• MEWS to MEWT

• GLOSS Study Global Maternal Sepsis Study

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THE SEPSIS TEAM

Medical Director

CCU

Medical Director ED

Medical Director Quality

Nurse Managers CCU & ED

Group Health

Urgent Care

Group Health MD

Hospitalist MD

Inpatient Nurse

Manager

ED & CCU RNs

CCU, ED, OB CNSs

Inpatient RN Champions Epic ASAP

Epic Liaison Pharmacy Lab MI, VIR

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TIMELINE

Hospital–wide Sepsis education

Sepsis Committee formed Best practice review

Spring 2014

ED workflow planned for early Identification & Treatment  

Pharmacy &Director of IP develop Antibiotic list. ED Sepsis  Quicklist amended . 

PHASE 2BPA built & tested behind 

scenes; iStat training done

Sepsis Checklist Mar ‘15

ED BPA in Production

Jan 2015

Sepsis Order Set Inpatient Build, Provider Education

RN Sepsis Champion Sepsis ChecklistOB Checklist

Mar 2016 

Mews for Inpatient.

RRT ProtocolsED Fluid Documentation

Oct 2016

MEWT  in OBMEWT in EMR

Sepsis Checklist in EMRALL RN Protocol

TBD 2018

Oct 1, 2015

Dec 2015

Sep 2014

Mar – May ‘15

March 2018

June 2018

Aug 2017

Dec 2017

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BUCKETS OF WORK

TEAM

Bedside RN

Champions

Paper

Checklists

PolicyProtocols

Order Sets

CCU

ED

Inpatient

Education

Equipment

EMRBPA

Workflows:EDCCUInpatientOB

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THERE CAN BE ONLY ONE!

General Population:

Primary sources in ED: Pna, UTI, Abdominal & Wound/skin

OB Population: CHORIOAMNIONITIS…. AND Endometritis, Wound,

Pyelo, Pna, Necrotizing fasciitis

CHORIO – AND SEPSIS

> Providers & Nurses thinking chorio is different than sepsis

> Not understanding Sepsis is a body’s adverse reaction to ANY infection

> Providers and nurses thinking delivery is cure

> Not thinking more than one infection can be occurring at same time

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OB WORKFLOW

Any two SIRS/symptoms below

AND Suspected infection?

HR>110RR>24Temp < 36 OR >38WBC > 14 OR <4 Acute Change in Mental Status

SBP <90

ANY ISOLATED TEMP of 390 Notify MD

Any suspected or Known infection?

Yes 1. Call Rapid Response Team unless MD isavailable for immediate assessment and orders

2. RRT initiates Sepsis (nurse initiated Orders)

No Continue to monitor patient

Early intervention was implemented for all patients who screen positive for sepsisRN champions instrumentalPerinatal staff educated on early recognition and management of maternal sepsis

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AFTER OB SEPSIS PROTOCOL CASEG1P0, 37 weeks gestation, with uneventful pregnancy

0300: Admitted to L&D

• WBC 10,000

1200: Temp (38°C) Tylenol was administered and …..

• Maternal and fetal tachycardia

• Shaking

• Change in mental status

• Increased pain

• Temp spiked to 41.1 °C,

RRT was called & Sepsis Bundle was initiated

• C-Section because of fetal intolerance

• NICU for chorioamnionitis.

• Mother’s blood cultures positive for E. coli.

• Mom & Baby discharged in stable condition

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Challenges• Lactate isn’t B.S.

• Paper checklist “ONE MORE THING!!”

• Consistency in application

• Creating a sustainable process

Successes• Change in culture: OB Hospitalist 24/7

• Engaged, multidisciplinary team

• Improved competence at bedside

• Resource every where they can reach – EMR, Department Internet

CHALLENGES & SUCCESSES

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NEXT STEPS

> MEWT build in Epic

> Checklist build in Epic

> Once hardwired, monitor process

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OBJECTIVES

1. The WHY?? Recognize rational for including the OB population in Sepsis Quality Improvement work

2. The WHAT? Name 3 considerations that are unique to the perinatal population

3. The HOW? Describe a step wise approach to incorporating inter-professional education on early recognition and management of maternal sepsis

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QUESTIONS?

For more information, contact:Betsy.Pesek@overlakehospital.org or Margie.Bridges@overlakehospital.org

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OB Sepsis References

Acosta, C.D., & Knight, M. (2013). Sepsis and maternal mortality. Current Opinion Obstetrics and

Gynecology,25 (2), 109-116. Doi: 10.1097/GCO.0b013e32835e0e82.

Barton, J. & Sibai, B. (2012). Severe sepsis and septic shock in pregnancy. Obstetrics & Gynecology, 120(3),

689-706. Doi:10.1097/ACOG.Ob013e318263a52d

Bural, K., & Rich, D. (2014). Code sepsis: development of a sepsis protocol for the obstetric patient. Journal of

Obstetric, Gynecologic & Neonatal Nursing, 43(1). S13.

CDC (2016). Inpatient care for septicemia or sepsis; a challenge for patients and Hospitals. Retrieved from

http://www.cdc.gov/nchs/data/databriefs/db62.htm

CDC (2017). Pregnancy mortality surveillance system. Retrieved from

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

Downs, B. (2013). Development of a maternal sepsis tool …from scratch. Surviving Sepsis Campaign

Webcast. Retrieved from http://www.survivingsepsis.org

https://www.doh.wa.gov/Portals/1/Documents/Pubs/140-154-MMRReport.pdfWorld Health Organization (2017). Global Maternal Sepsis Study. Project brief. www.who.int/entity/reproductivehealth/projects/Project-brief-GLOSS.pdf?ua=1