Define sepsis

Systemic inflammatory response syndrome (SIRS) criteria

• Temperature > 38.3 C (> 100.9 F)
• Temperature < 36.0 C (< 96.8 F)
• Heart rate > 90
• Respiratory rate > 20
• White blood cell >12,000 or < 4,000 or > 10 percent bands

Sepsis is:

• 2 SIRS +
• Confirmed/suspected source of infection

Severe sepsis* is:

• Sepsis +
• Organ dysfunction (any one of below)
  • Urine output < 0.5 mL/kg/h x 2h
  • SBP < 90
  • MAP < 65
  • Creatinine > 2.0
  • Bilirubin > 2 mg/dL
  • Platelets < 100,000
  • INR > 1.5 or aPTT > 60
  • Lactate > 2 mmol/L
  • Acute respiratory failure with new need for mechanical ventilation or NIPPV

Septic shock is:

• Severe sepsis +
• Persistent hypotension (two consecutive low blood pressures within the hour after crystalloid fluids)
• SBP < 90
• MAP < 65
• SBP decrease > 40 from norm

or

• Lactate ≥ 4 mmol/L

*All three clinical criteria (SIRS +, infection, organ dysfunction) must be met within six hours of each other to determine severe sepsis presentation time.

Treatment bundles

Presentation time is defined as the latest time all criteria align within six hours.

or

If all criteria are not met but provider documents “severe sepsis” or “septic shock,” then time of documentation becomes presentation time.

Severe sepsis

Within three hours of presentation:

• Lactate
• Blood cultures
• Broad-spectrum antibiotics given
• 30 mL/kg bolus for hypotension

Within six hours of presentation:

• Repeat lactate level (if initial > 2)

Septic shock

Within three hours of presentation:

• 30 mL/kg bolus

Within six hours of presentation:

• Vasopressors if hypotension persists after fluid administration
• (Focus exam) Repeat volume status and tissue perfusion assessment by using smart phrase “septicshock”

Additional documentation to meet volume status and tissue perfusion assessment can include two of the following:

• CVP
• ScvO2
• Cardiac ultrasound
• Passive leg raise

Documentation

Best practice/meet requirements:

• Use sepsis order sets:
• Adult sepsis antibiotic orders [3040030350]
• Inpatient treatment sepsis bundle [3040030112]
• ED treatment: sepsis bundle set [1600030110]
• ED treatment: suspected/severe sepsis/septic shock [16000301147]
• Order serial lactate levels (repeat is required for initial level > 2)
• Order blood culture (must be drawn prior to antibiotic administration)
• Order broad-spectrum antibiotic
• Order/administer 30 mL/kg crystalloid fluids for:
• Initial hypotension (six hours before through six hours after severe sepsis presentation time)
• Lactate level ≥ 4 mmol/L
• Documented presence of septic shock
• Use smart phrase templates:
• emacoreinfection
• sep
• septicshock (for the focus exam)
• SIRS criteria or sign of organ dysfunction normal for patient: Document that criteria is:
• normal for patient
• due to a chronic condition
• due to an acute condition, not an infection
• due to a medication

Excludes that criteria from determining presentation of severe sepsis

Frequently used broad-spectrum antibiotics

Not an exhaustive list; review order sets for combination dual-therapy coverage

• Cefepime
• Ceftriaxone
• Levofloxacin
• Piperacillin/tazobactam

Sepsis Pearls

• Physician documentation of reason not to give bolus does not exclude patient from this measure.
• If patient is obese (BMI > 30) then bolus can be dosed using patient’s ideal body weight (IBW) — clear documentation by the physician must be noted in chart stating IBW is being used.
• Reassessment of volume status must be completed after initiation of bolus up to six hours after presentation time.
• If you document sepsis, severe sepsis or septic shock, ensure bundle is initiated.
• Cipro/Flagyl combo does not count for broad-spectrum coverage.
• If a physician, nurse practitioner or physician assistant documents the presence of difficile within 24 hours prior to the antibiotic start time, one of the treatments below can be initiated within three hours following severe sepsis presentation:
• Oral vancomycin with or without oral or IV metronidazole (Flagyl)
• Rectal vancomycin with or without IV metronidazole (Flagyl)
• IV metronidazole (Flagyl) monotherapy
• If an antibiotic is ordered for a condition that may be inflammation (any “itis”) or a sign or symptom of infection (leukocytosis, fever, etc.), there must be physician documentation linking the antibiotic to this condition to be considered an infection.
• The Centers for Medicare & Medicaid Services considers certain conditions to meet the infection criteria if present. Acute exacerbation of COPD is one example. Contact your site coordinator for a full list of conditions.

Health care Providers

• Prevent infections
• Educate patients and families
• Think sepsis
• Act quickly
• Reassess patient management
• Suspect sepsis, save lives