Integration*of*Infection*Control*and*Antimicrobial* Stewardship*with*Sepsis*Initiatives

Transcription

1 Webinar*series Sepsis:*Across*the*Continuum*of*Care Integration*of*Infection*Control*and*Antimicrobial* Stewardship*with*Sepsis*Initiatives Cindy&Hou,&DO,&MA,&MBA,&FACOI,&FACP Infection&Control&Officer,&Jefferson&Health&= New&Jersey Marianne&Kraemer,&RN,&MPA,&ED.M.,&CENP,&CCRN=K Assistant&Vice&President&for&Clinical&Services&&&Chief&Nursing&Officer& Jefferson&Stratford&Hospital This webinar series is made possible with support from biomérieux, Inc.

2 About&Sepsis&Alliance Dr.'Carl'Flatley Founded'in'2007 Nation s'leading'sepsis'organization Working'in'all'50'states Sepsis.org' 2.5'million'visits'a'year Focus'on: Public'awareness Provider'education Survivor'support Advocacy Partnership

3 It s%about%time TM,%a%national%initiative

4 SCN$activities$support$ongoing$communication,$education$and$network$ building$among$health$professionals$passionate$about$improved$sepsis$ care.$activities$include: Educational$webinars$that$ Training$and$education$opportunities highlight$sepsis$best$practices$in$ Resource$drive$to$find$information$on$a$ a$variety$of$healthcare$settings range$of$topics,$including$core$ Active$discussion$and$peer$ measures,$clinical$practice$guidelines,$ support$via$an$online$community patient$screening$and$identification$ tools,$education$resources$and$more JOIN%NOW%AT%SEPSISCOORDINATORNETWORK.ORG Our$Mission To$provide$sepsis$bestEpractice$resources$and$guidance$to$sepsis$ coordinators$and$all$health$professionals$across$the$country$

5 Integration of Infection Control and Antimicrobial Stewardship with Sepsis Initiatives Cindy Hou, DO, MA, MBA, FACOI, FACP Infection Control Officer, Jefferson Health - New Jersey (JH-NJ) Marianne Kraemer, RN, MPA, ED.M., CENP, CCRN-K Assistant Vice President for Clinical Services & Chief Nursing Officer, Jefferson Stratford Hospital October 17, 2018

6 Financial Disclosures We have nothing to disclose.

7 Objectives Define Sepsis and Antimicrobial Stewardship. Describe how infection prevention can help prevent cases of sepsis. Discuss how the review of cultures can help to combat sepsis.

8 Jefferson Health New Jersey, About Us Formerly Kennedy Health. Located in South Jersey Overview: Total Revenue = $635.3 M Charity Care = $10.4 M Capital Improvements = $51.2 M 607 total acute care beds: Jefferson Cherry Hill Hospital (CH) Jefferson Stratford Hospital (ST) Jefferson Washington Twp. Hospital (WT)

9 Defining Sepsis and Antimicrobial Stewardship

10 Sepsis as a Continuum Sepsis response of the body to an infection. Before sepsis occurs, there are warning signs/symptoms. When sepsis occurs, identify the source of the infection in order to properly kill the infection. Early identification and treatment of sepsis can potentially prevent the cascade to severe sepsis and septic shock.

11 Know the SIRS criteria! Systemic Inflammatory Response Syndrome (SIRS) Temp >100.4F or < 96.8F WBC >12, <4 or Bands >10% RR >20 or PaCO2 <32 HR >90 ***Remember: SIRS can be caused by non-infectious entities i.e. pain, mad, sad, SOB*** ***SIRS of non-infectious etiology is very different than sepsis.

12 Severity of Sepsis Sepsis = suspected or confirmed infection + > 2 SIRS [Sepsis = Infection + > 2 SIRS] Severe sepsis without septic shock = Infection + > 2 SIRS + lactic acid > 2 or organ damage/dysfunction Severe sepsis with septic shock = Infection + > 2 SIRS + lactic acid 4 or SBP <90/MAP <65

13 Sepsis Cascade SEPSIS SEVERE SEPSIS SEPTIC SHOCK SIRS CRITERIA WITH INFECTION SEPSIS AND ORGAN DYSFUNCTION LACTIC ACID > 2 SEVERE SEPSIS WITH BP REFRACTORY TO 30 cc/kg, PRESSOR(S) LACTIC ACID > 4

14 Sepsis Bundle Blood cultures. Bcx before Antibiotics. Give antibiotics. Lactic acid. 30 cc/kg bolus with sepsis plus lactic acid > or = 4 or hypotensive.

15 Published online September 2018

16 Study and Results 3-hour bundle: antibiotics, bcx before antibiotic, lactic acid. 6-hour bundle: if SBP < 90 or lactate 4 mmol/l, 30 cc/kg bolus, if needed, vasopressors, repeat lactic acid. Of 91,357 patients, 74,293 (81.3%) sepsis protocol. 3-hr bundle compliance from 53.4% to 64.7% (p< 0.001). 6-hr bundle compliance from 23.9% to 30.8% (p< 0.001). Mortality (risk-adjusted) from 28.8% to 24.4% (p< 0.001). With higher compliance, shorter length of stay and lower mortality.

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18 Study and Results 82.5% (40,696 of 49,331 patients in149 hospitals) = 3 hr bundle completed on timely basis. Median time until 3 hr bundle completed = 1.3 hrs. Median time to antibiotic administration = 0.95 hrs. Lower risk-adjusted in-hospital mortality 1) Faster the completion of the 3-hr bundle. 2) Faster the administration of the antibiotic.

19 The Right Time Makes a Difference! 35,000 ED Patients. 21 ED , California. Sepsis patients within 6 hrs of ED Registration. Looked at in-hospital mortality. Median time to antibiotic = 2.1 hours. Increase in absolute mortality after hr-delay = 0.3% for sepsis, 0.4% for severe sepsis, and 1.8% for shock.

20 The Right Antibiotic Makes a Difference!

21 Antimicrobial Stewardship, Defined Infectious Diseases Society of America (IDSA): coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. Antibiotic dose, duration, and route for a specific indication. In the hospital, decrease chances of acquisition of MDRO and decrease hospital-acquired CDI & improve patient outcomes.

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23 Antibiotic Administration and Coordination in Sepsis Select Antibiotic(s) Order Antibiotic(s) Obtain Antibiotic(s) Give Antibiotic(s) Document Antibiotic(s) Given

24 JH-NJ Nursing Antibiotic Rounds: Reviewing a Culture To promote awareness of antimicrobial stewardship for nursing systemwide. Nurse rounds 1:1 with IP and clinical nurse to review why patient is on antibiotic(s). Discussed microbiology report and its relation to ordered antibiotic. Brought discussion to physician.

25 JH-NJ Nursing Antibiotic Rounds: Findings Not familiar with how to interpret microbiology report. Not familiar with all classes of antibiotics. Do not see uniqueness of antibiotics. Potassium analogy to antibiotics.

26 JH-NJ Nursing-developed Antimicrobial Stewardship Course Initially, developed survey to determine nursing s perception of cultures and terminology such as sensitive, indeterminate and resistant. Two-hour course to review antibiotics, cultures and importance to nursing.

27 JH-NJ Nursing AS Interventions

28 Antibiotic Stewardship, Sepsis and Infection Prevention: Interrelated Roles

29 The Jefferson Health-New Jersey Integrated Model of Stewardship Infection Control Antimicrobial Stewardship Sepsis

30 Study and Results Prevent infections in patients! Patients can acquire multi-drug resistant organisms from devices and get septic from this. Any device foreign to the human body is a risk factor for infection, but the risk for infection can be decreased with attention to infection prevention at insertion, maintenance, and removal when no longer necessary.

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32 Where possible, avoid invasive lines and consider non-invasive alternatives Each day, document patient s type of IV access/how site looks. Evaluate the site to determine if infection is present. Non-invasive Peripheral IV in the EJ. Extended dwell peripheral IV. Midline. Invasive Triple-lumen central line resident. PICC line. Tunneled PICC.

33 ! Pathogenesis. The most important predisposing factor for nosocomial UTI is urinary catheterization, which perturbs host defense mechanisms and provides easier access of uropathogens to the bladder. The indwelling urethral catheter introduces an inoculum of bacteria (fecal or skin bacteria in a patient s own native or transitory microflora) into the bladder at the time of insertion [78], facilitates ascension of uropathogens from the meatus to the bladder via the catheter-mucosa interface, allows for intraluminal spread of pathogens to the bladder if the collecting tube or drainage bag have become contaminated, compromised complete bladder emptying, and provides a frequently manipulated foreign body on which pathogens are deposited via the hands of personnel.

34 Where possible, avoid invasive devices and consider non-invasive alternatives Each day, determine if your patient has no foley, or a foley (foley catheter, suprapubic catheter). What is the reason for the foley catheter assess daily and whether it is still absolutely categorically needed. NO Foley is better than any kind of foley. Non-invasive: For women: External catheter. For men: Texas condom catheter. A urinal.

35 Prevention of CRE Hand hygiene Contact precautions if infected/colonized with CRE Minimize use of devices (ventilator, central line) Antimicrobial stewardship Environmental cleaning Hou & Kraemer, 3/16

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40 Mandatory ID Consults at Jefferson Health New Jersey Any patient with sepsis, severe sepsis, AND septic shock. Any patient on 3 or more antibiotics. Any patient with Clostridium difficile infection (CDI).

41 The Role of Antibiotics and Cultures in Sepsis

42 Sepsis (and tying in Antimicrobial Stewardship) Select an antibiotic for a bacterial infection that is strong enough to cover the possible bacteria the patient has, without causing more harm. History Physical exam +/- cultures/studies

43 Antibiotics -> Coverage Spectrum of coverage the types of bacteria that the antibiotic are usually efficacious against. Some antibiotics have coverage for resistant types of bacteria, and others do not.

44 Broad-spectrum antibiotic Spectrum of Coverage Narrow-spectrum antibiotic

45 De-escalate (Broad to Narrow) Ex: Ceftriaxone Ex: Cefazolin

46 Broaden out the antibiotic Ex: Cefazolin Ex: Ceftriaxone

47 Many Types of Cultures If the source of infection is UTI, obtain a urinalysis and urine culture. If the source of infection is pneumonia, obtain a sputum culture. Obtain targeted cultures and do not culture every orifice. For simplicity, the next few slides refer to blood cultures.

48 What about those blood cultures? They can be clues to the cause of the sepsis, and a critical part of antibiotic stewardship! A patient could have sepsis (and negative cultures). Initially, an antibiotic is empiric and broad enough to cover the possible bacteria involved (while we wait on the cultures to give us preliminary and final information). The results often come in stages, eg. Gram stain = clue! Micro notifies RN -> physician. Cultures can have preliminary, updated, and final results.

49 A word about blood cultures Positive Blood culture hours = gram stain (if positive) Then additional 24 hrs = name of pathogen Then additional 24 hrs = sensitivity results. Fevers and chills possibility of bloodstream infection. When positive blood cultures (general rules of thumb): What is the cause? Is the treatment correct targeted to the clue? (Is there resistance change in antibiotic)? (Contaminant stop antibiotic?) Repeat blood culture. Avoid placing PICC line.

50 Case Study: 70 year old man Example: Let s say that a 70-year-old man comes in septic due to bacterial pneumonia, and he recently had influenza. He is given empiric ceftriaxone pending cultures. Microbiology calls that this patient has gram positive cocci in the blood. RN calls physician. Physician reviews differential diagnosis of gram positive cocci.

51 Cultures Example: In the petri dish, which antibiotics would definitely work for your bugs? Generally speaking:! S = sensitive; it works (exceptions, eg. MSSA, MRSA)! I = indeterminate! R = resistant; that antibiotic does NOT work.

52 MIC A number is listed next to each sensitivity result = minimum inhibitory concentration -> lowest concentration of antimicrobial to inhibit growth of bacteria after overnight incubation. For MRSA, studies have shown that if vancomycin is sensitive but MIC = 1.5 to 2, chance vancomycin might not work.

53 Blood Culture Example Sensitivity Results Staphylococcus aureus Cefazolin Clindamycin Daptomycin Ceftaroline Oxacillin Vancomycin R S <0.5 S 0.5 S R 2 S

54 Case Study: Sepsis Twice Example, patient was initially with sepsis due to community-acquired pneumonia (pneumonia, RML). They had fevers/high white blood cell count, and then they got better on ceftriaxone. WBC normal and no more fevers. Three days later, the patient is confused, hypothermic, and tachypnic. These are new SIRS criteria and occurred while already on broad-spectrum antibiotics. This suggests a new process (example new pneumonia/lul), and the need to broaden out antibiotics. Example: Stop ceftriaxone, and change to cefepime and vancomycin.

55 Case Study: 76 yo woman with fever 76 yo woman with COPD/seizures and temp 102, R: 18, HR 120. RN triage assessment. RN notifies physician. Sepsis. History: From nursing home/ongoing tobacco abuse. EMS green secretions suctioned. Exam: labored breathing, rhonchi, accessory muscles of respiration. Requires urgent intubation. Targeted labs: STAT CBC, BMP, lactic acid, blood cultures. Post-intubation sputum. Rn draws labs. Targeted studies: STAT portable CXR.

56 Case Study: Change in Antibiotics CXR right lower lobe infiltrate. Lactic acid 4.1, WBC 15, Cr 1.0 Initial orders: 30 cc/kg bolus, vancomycin, piperacillin/tazobactam: RN administers IVF/Antibiotics. Later on in the hospitalization, blood cultures come back as positive. Vancomycin is stopped. What about piperacillin/tazobactam?

57 Blood Culture Start with S/I/R! Pseudomonas aeruginosa! Ceftriaxone R! Cefepime < 1 S! Ciprofloxacin I! Piperacillin/tazobactam 64 S! Imipenem/cilastatin < 1 S! Cefazolin R

58 Outcomes Data from Jefferson Health - New Jersey

59 JH-NJ ASP (Selected) Milestones

60 Jefferson Health New Jersey Data DOT vs CDI Overall 2014 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Overall DOT Overall CDI

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62 Hospital Compare Data Jefferson-ST = JH-NJ

63 Contact

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65 Sepsis(Gap(Analysis(Results(and( Next(Steps(at(your(Facility,(Part(2 October(24(2(pm(ET Pat(Posa,(RN,(BSN,(MSA,(CCRNFK,((FAAN( Quality(Excellence(Leader St.(Joseph(Mercy(Hospital Ann(Arbor,(Michigan Angela(Craig,(APN,MS,CCNS ICU(Clinical(Nurse(Specialist Cookeville(Regional(Medical(Center Cookeville,(TN Founding(Sponsor(((((((((((((Network(Sponsors FOUNDING(SPONSOR

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