1. Sepsis Education and Prevention
For Piedmont Healthcare
Final WORKING Draft
June 29, 2009
Submitted by:
Michele Glazer
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2. Sepsis Education and Prevention
Audio Video
GRAPHIC TITLE:
MUSIC UP:
Narrator: (V.O.) Piedmont Healthcare’s Sepsis
Collaborative Presents…Severe Sepsis
Prevention. The McLean-Piedmont Method for
Arresting Sepsis.
Music Transition into Video Montage
Insert: Video Montage of Interviews – 8-10 second
effect transition with sound bites from interviews
DISSOLVE TO:
Dr. Hamby: By definition, sepsis is a term used INT. ICU Nursing Station: Dr. Hamby (O.C.)
to define a continuum of problems. In general, Title: Dr. Leigh Hamby, M.D., EVP/Chief Medical
it means infection of the blood stream Officer/Chief Quality Officer
accompanied with a profound inflammatory
response. And while that sounds like a relatively
non-serious explanation, complications from
exacerbated sepsis or severe sepsis, can be life
threatening.
Severe sepsis is an expression of multi-organ
dysfunction created by both an un-contested
pro-inflammatory and hyper coagulation
syndrome. Those clots block small vessels,
impacting normal flood flow to vital organs.
Both inflammatory organ attacks as well as
ischemia from lack of blood flow affect many
organs and may cause them to operate in a
dysfunctional manner, even to completely fail.
Early diagnosis is crucial, since one third of the
patients diagnosed with sepsis die from the
complications associated with it.
MUSIC TRANSITION
GRAPHIC:
NARRATOR (V.O.): So exactly how common is 750,000 Cases of Severe Sepsis Annually in the U.S.
sepsis? (Angus, Crit Care Med 2001)
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3. More than 750,000 cases of severe sepsis occur
each year in the United States, with a mortality
rate at around 30%.
GRAPHIC Slide #2 on
A sepsis death occurs every 2 ½ minutes. In the
United States, approximately 1,400 people die
every day from severe sepsis, making it the 10th
most common cause of death. Annual death
rates from sepsis rank higher than other Major
Diseases such as heart attack or stroke. In fact,
10% of all patients admitted to the ICU are
diagnosed with sepsis.
CD
And the issue is not limited to human cost. The
GRAPHIC:
economic cost to the country is roughly $17
Sepsis Healthcare Cost: $17,000,000,000 annually
billion each year.
DISSOLVE TO:
Music Transition
Slide #3 – Erin Flatley
Narrator (V.O.) - Erin Flatley from Dunedin,
Florida was 23 years old when she underwent a
simple hemorrhoidectomy procedure in 2002.
Her father, Dr. Carl Flatley, said he had no idea
what to watch for when Erin developed sepsis.
Erin went into the hospital for a minor
hemorrhoid operation and five days later was
dead from sepsis.
Slide #4 – Mariana Bridi de Costa
NARRATOR: Brazilian model Mariana Bridi da
Costa was a healthy 20-year-old when doctors
told her she had a urinary tract infection, her
family says. The infection spread, and after
amputating her feet, then her hands, doctors
thought they had the situation under control.
Four days later, da Costa was dead.
Mariana Bridi da Costa, Brazilian model
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4. Slide #5
NARRATOR: And what began as a case of
pneumonia in 1990 for Muppets creator Jim
Henson, resulted in his death from sepsis at the
age of 53.
Jim Henson, Muppets creator
CUT TO:
Music Transition
GRAPHIC – Slide #6
NARRATOR: So how CAN we reduce sepsis
mortality?
Slide #7 – Sepsis Team
Narrator: Well, Piedmont accomplished just
that. By creating a joint effort among multiple
organizations that share resources and
information. By creating a collaborative
between all of Piedmont’s hospitals, along with
Chief Quality Officer Dr. Leigh Hamby, and the
sepsis expert, Barbara McLean. And by
establishing a procedure for early recognition
and treatment, which in turn, has resulted in a
significant impact on the reduction of sepsis
mortality.
Animate pic – separate into quadrants then recover
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5. Graphic: - Slide #8
MUSIC TRANSITION
NARRATOR: Beginning in February 2004
Piedmont Healthcare initiated methods to
detect severe sepsis, and implement the
evidence-based guidelines proposed by the
surviving sepsis campaign. Eventually,
Piedmont formed The Sepsis Collaborative in
January 2007. An international sepsis expert,
Barbara McLean came on board to assist with
developing methods for an earlier diagnosis and Cut To:
treatment protocol.
Interview with Barbara McLean (see specific segment
[INSERT BARBARA MCLEAN SOUND BITE] – “…It in audio)
seemed to be a simple extension that if we
could identify those patients at risk for sepsis,
via a vigilant analysis, that we could treat with
volume and BSA while diagnosing and do both
within 60 minutes of initial identification. The DISSOLVE TO:
strategy was to prevent sepsis from evolving…”
GRAPHIC:
NARRATOR: Now we had a new goal: Reducing Guidelines:
morality by early recognition and treatment. Evaluate and Identify
Treatment
The team established guidelines to evaluate Understanding Pathophysiology
and identify patients at risk for severe sepsis.
An ongoing education program included GRAPHIC – Slide #9
definition, recognition, treatment and
explaining the pathophysiology of sepsis, severe Recognize Sepsis
sepsis and septic shock.
S evere S epsis
This collaborative has helped establish a Prevention P ackage =
procedure for early recognition and treatment,
In 60 minutes:
which in turn, has had the biggest impact on
20 ml/kg IV Fluid,
the reduction of sepsis mortality.
Blood Culture and
IV Antibiotics
The goal of the collaborative consisted of a
simple directive: Fluid, Culture and Antibiotics
in 60 Minutes.
CUT TO:
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6. Dr. Hamby (O.C.): Early recognition and INT. ICU Nursing Station – Dr. Hamby O.C.
aggressive resuscitation initiated within the first Cut to:
hour has reduced mortality in our system by as (Split screen: Dr. Hamby with following graphic?)
much as 34%. Graphic: Slide #10
Sepsis Mortality:
[PAUSE]
PIEDMONT HEALTHCARE
18.00%
16.00%
14.00%
12.00%
12.98%
10.00%
8.00%
8.93%
6.00%
4.00%
2.00%
0.00%
FY2007 (n=2271) FY2008 (n=3247)
Dr. Hamby: If we can improve our methods of
how we treat sepsis, we can improve our
outcomes. We can save lives. ISO on Dr. Hamby for final line
CUT TO: CUT TO:
Narrator: Several healthcare providers share Open on Freeze of Dr. Core interview
their experiences as they followed the McLean-
Piedmont collaborative.
MUSIC TRANSITION:
INSERT :
PHYSICAN/STAFF INTERVIEWS PHYSICIAN/STAFF INTERVIEWS
DISSOLVE:
MUSIC TRANSITION:
GRAPHIC: Slide #11
NARRATOR: Piedmont’s Sepsis Evaluation
Process relies heavily on an algorithm -- the
McLean-Piedmont Method – which aids the
clinician in evaluating patients that are at high
risk for sepsis. It helps to identify the patient at
risk for sepsis and assists with monitoring those
patients in the continuum of the disease
process should it progress from Uncontrolled
Inflammation… to sepsis… to severe sepsis, and
escalating into septic shock.
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7. Evaluation Process
NARRATOR: Referring to Category A in the
Evaluation Process - once there is a suspicion of
infection and/or exposure to infection, the
patient receives one point for each item
checked in his or her Clinical Suspicion such as
lung infection; trauma, exposure to illness,
chemotherapy, altered mental status, recent
abortion, recent antibiotic therapy, chills or
fever and any indwelling catheters.
Evaluation Process
NARRATOR: And the patient receives one point
for exposures in the hospital such as surgery; all GRAPHIC: (create on Avid)
indwelling catheters such as a central line, a Patient has history of, but not limited to:
pulmonary artery catheter, a vas-cath and a Lung Infection
femoral sheath; any urinary catheters; Trauma
ventilation procedures; open wounds and Exposure to Illness
antibiotic therapy. Chemotherapy
Altered Mental Status
Recent Abortion
Recent Antibiotic Therapy
Chills / Rigor / Fever
Indwelling Catheters
NARRATOR: So in looking at the Category A
block, the Clinical Suspicion area…a patient GRAPHIC: (create on Avid)
suspected of sepsis would receive one point for Exposures in Hospital
each Clinical Suspicion checked in this category. Surgery
A strong clinical suspicion of the involved Indwelling Catheters
practioners is also considered as a qualifier of
Urinary Catheter
suspicion. Largely, since Sepsis sources are vast
Ventilated Patients
and sometimes impossible to recognize early.
Open Wounds
Currently on Antibiotics
GRAPHIC: Slide
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8. Evaluation Process
NARRATOR: For example… let’s say the patient
under your care, we’ll call her Mrs. Smith, has
an upper respiratory infection and a Triple
Lumen catheter. Mrs. Smith would receive two
points in Category A.
NARRATOR: Let’s look at the second level of our
algorithm, the SIRS portion - Systemic
#12
Inflammatory Response Syndrome, or
Uncontrolled Inflammation throughout the
INT. PATIENT ROOM – Nurse and Patient
entire body…
Patient in bed. Nurse providing care; checking vitals
NARRATOR: Clinical signs of SIRS consist of a
central temperature greater than 101° F or less
than 96.8 °F. A sustained heart rate of greater
GRAPHIC: Create on Avid
than 90 beats per minute. A sustained
respiratory rate of greater than 20 breaths per S – Systemic
minute. The heart rate and respiratory rate I – Inflammatory
must be measured at least two different times, R – Response
at least five and no more than 15 minutes
apart.
S – Syndrome
NARRATOR: Again, utilizing the point system, GRAPHIC: Slide #13
your patient receives one point from the B
category for each of the clinical signs of SIRS. Evaluation Process
Mrs. Smith has fever of 101.7° and a persistent
heart rate of 100 - 104. You would assign her
two points from Category B – temperature and
heart rate.
NARRATOR: The final category of the
algorithm, Category C, focuses on the patient’s
blood pressure. Is the systolic blood pressure
less than 90 mm Hg or has it decreased by 20
mm Hg from the previously measured systolic CUT TO:
blood pressure? For example, if the blood INT. PATIENT ROOM – Nurse and Patient
pressure is 89/60, then the patient would Nurse taking patient’s temp.
receive two points automatically for having
systolic hypotension.
CUT TO:
NARRATOR: So what do we do with this
information?
Graphic – Slide #14
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9. To meet the clinical criteria, Category A must
have at least one item checked in order to
suspect sepsis. And at least two different
categories must have check marks in them. To
diagnose Sepsis, we must have at least one item
in Category A checked and any combination of
items from the other two categories, so that
the evaluation totals three points.
To proclaim a sepsis judgment, three total
points must be measured in at least two
categories and one of those must be Category CUT TO:
A.
We add up the total from all 3 categories. For INT. PATIENT ROOM – NURSE and PATIENT
example, our patient Mrs. Smith, with a Nurse taking blood pressure, marking logarithm chart,
diagnosis of pneumonia… a temp of 101.7°… monitoring clock.
and a heart rate of 100 - 104. She has an
evaluation total of three points. CU – Evaluation Process chart in Nurse’s hands –
Nurse marking chart (?) Totaling chart – 3 points.
We suspect sepsis.
SFX: Ticking Clock… GRAPHIC: Create on Avid
SUSPECT SEPSIS!
NARRATOR:
And now the time clock starts ticking… GRAPHIC – Clock Slide #15
NARRATOR: With haste the caregiver should
proceed with fluid resuscitation, collect blood Graphic – Slide 16
cultures, lactic acid and other labs, and begin
antibiotic administration. Every 15 minutes,
vital signs should be checked until stable. Every
hour, organ dysfunction should be evaluated.
MUSIC TRANSITION
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10. DR. HAMBY: The Severe Sepsis Prevention CUT TO:
procedure is a relatively low cost operative with
little chance of negative patient outcome. And
the evidence-based medicine supports the
theory. INT. ICU Nursing Station - DR. Hamby (O.C)
Initiating this protocol within a 60 minute CUT TO:
timeframe has been widely successful at
Piedmont Hospital in reducing sepsis mortality GRAPHIC: - Slide 17
rates in ICU admits. Mortality Rate for ED Admits with ICU stay (Angus Codes +)
0.3
0.25
0.2
Proportion Dying
0.15
0.1
In fact, since 2007, Piedmont Hospital, 0.05
Piedmont Fayette Hospital and Piedmont
Mountainside have reduced the mortality rate 0
Dec- Jan- Feb- Mar- Apr- May- Jun-
05 06 06 06 06 06 06
Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun-
06 06 06 06 06 06 07 07 07 07 07 07
Jul-
07
Aug- Sep- Oct- Nov-
07 07 07 07
of patients coming to the Emergency GRAPHIC – Slide 18
Department with Sepsis by 30-40%. PIEDMONT HEALTHCARE: Sepsis Collaborative
Sepsis Patients - Calculated # Lives Saved
700
611
600
500
400
300
227 214
Part of this is better recognition of Sepsis, 200
170
however not all of the improvement appears to 100
be due to categorizing more patients as having 0
FY07 FY 08 FY09 (Jun - Dec) GRAND TOTAL
sepsis. One patient speaks for himself… LIVES SAVED
CUT TO:
INT. ICU NURSING STATION – Dr. Hamby on camera
[Interview with Gordon Perry]
NARRATOR: After a misdiagnosis at another CUT TO:
area hospital without a sepsis protocol, Mr.
Gordon Perry was admitted to Piedmont in full GRAPHIC – Slide #19
septic shock and perhaps moments away from
multi-system organ failure. He was immediately
treated following the sepsis protocol, the
McLean-Piedmont method. This life-saving
measure resulted in Mr. Perry’s complete
recovery from septic shock.
[Insert sound bite – “…I just can’t say
enough…”+
CUT TO:
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11. NARRATOR: But the change in sepsis protocols
on paper is easy… encouraging the change in Interview with Gordon Perry – final paragraph
personal practice takes more time and effort.
Dr. Hamby: *Insert ad lib: “We recognize that
it’s not a formula, not cookbook medicine, and
the collaborative doesn’t override a physician’s
critical thinking skills in determining the best
course for a patient…”+ The Sepsis INT. ICU Station – Dr. Hamby (O.C) – Medium shot
Collaborative at Piedmont Healthcare has
established a procedure for defining Severe
Sepsis as well as initiating a process to disrupt
the pathophysiology of Severe Sepsis.
(Pause)
We’ve come a long way in increasing positive
patient outcomes. And by continuing with these
measures, we look forward to more stories of FADE OUT:
success.
Credits
MUSIC OUT
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