Nursing Care Plan For Uti

>> good afternoon and welcome totoday's webinar, advances in sepsis: protecting patients throughout the lifespan. my name is abbigail tumpey. i'm associate director for communicationsscience at the centers for disease control and prevention division ofhealthcare quality promotion. this webinar is part of a series of webinarsthat cdc will be hosting with a variety of external partners and experts. today's webinar features an expertpanel, including: doctor anthony fiore, chief of the epidemiology research andinnovations branch at the centersss

for disease control and preventiondivision of healthcare quality promotion. doctor fiore will provide an overview ofcdc's recent vital signs report on sepsis. doctor mitchell levy, who is a professorof medicine and chief in the division of critical care, sleep medicine atbrown university, and founding member of the surviving sepsis campaign. he will discuss sepsis in acute care settings. doctor joseph carcillo, assistant professorat the department of critical care medicine and pediatrics at the children'shospital of pittsburg who will cover septic shockguidelines for pediatrics.

and, doctor susan levy, presidentof amda - the society for post-acute and long term care medicinewho will discuss sepsis in post-acute and long-term care settings. before we get started there's afew housekeeping items to cover. first of all, we welcome your questions. please submit any questions orcomments you have via the "chat" window, located on the lower left-handside of your webinar screen. you may enter these questionsanytime during the presentation. questions will be answered afterall presentations, as time allows.

to ask for help please press the "raisehand" button, located at the top left-side of the screen if you need to chat witha meeting chairperson for assistance or technical difficulties during the webinar. as a reminder, the audio for today's conferenceshould be coming through your computer speakers. please ensure that your speakersare turned on with the volume up. with that, i'd like to turn itover to doctor anthony fiore who will start discussing cdc'srecent vital signs report. doctor fiore. >> hi. thank you for the invitation.

you have a lot of very interesting informationupcoming, so i will very briefly tell you about some of the highlightsfrom the vital signs report. the vital signs report had several keyfindings that are really important for thinking about ways that we might actually preventsepsis and identify patients earlier. first is that sepsis begins outside of thehospital for nearly 80 percent of patients, and the second that we found in this recentvital signs report is that seven in 10 patients with sepsis had recently interacted withhealthcare providers or had some sort of chronic disease that required them tohave frequent interaction with medical care. and what this means is that there areopportunities here to better prevent infections

for patients who are prone to go in to sepsis,and recognize sepsis earlier to save lives, and we can do this by having providerstalk to their patients about infections and about sepsis, about howinfections that can lead to sepsis can be prevented how they canbe recognized early, and what they can do when they have an infectionthat is not getting better. the epidemiology of sepsis has beenfairly consistent over the past few years and this was underscored inthe recent vital signs report. it most often occurs in people over the ageof 65 or in infants less than one year of age, or in people that have some sortof chronic disease such as diabetes

or have a weakened immune system. it most commonly occurs after an infectionof the lung, urinary tract, skin, or gut. there are several common germs that you probablycould guess that are the most common causes of sepsis including: staphylococcus aureus,e. coli, and several types of streptococcus, but importantly many people withsepsis don't actually have a germ or microorganism identified as their cause. however, it's important to remember thateven healthy people can develop sepsis from an infection, especiallyif it is not treated properly. so, what can healthcare providers do?

the vital signs provided healthcare providerswith some simple to implement activities that many of these are probably beingdone already, but tying them together as sepsis prevention and recognition wethink is important for patient education. first, educate your patients and familiesabout the early symptoms of severe infection and sepsis, and when to seek care, especiallyamong those patients who are at a higher risk. remind patients that taking care ofchronic illnesses helps prevent sepsis, and encourage infection prevention measures,such as hand hygiene and vaccination. so, think sepsis. know the signs and symptoms ofsepsis to identify patients early.

act fast if sepsis is suspected, andimplement the intervention bundles that you hear more about later in this webinar. and then, after sepsis intervention hasoccurred, reassess patient management. think about controlling the source of infection. think about tailoring antibiotic therapy tothe suspected infection in the laboratory and culture results and reassess howthe patient is being managed in order to better help them get throughthis sepsis episode. and with that, i'll say thanks and i'llturn it over to the experts that are going to be giving the remainder of this webinar.

>> and, doctor levy we'll hand it to you. >> thanks abbigail, and welcome everybody. i'm glad to be here and i want to thankthe cdc and sccm, and the other co-sponsors for hosting this important webinar. what i'd like to talk toyou - i have no disclosures. what i'd like to talk to you about overthe next 15 minutes is a little bit about where we've been, and where are we now,and where are we going, especially in light of the fact that, as we all know, thecms is now mandated national reporting of compliance for sepsis measures.

so, what i'm going to do is show you a littlebit of what we've done over the last 10 to 12 years in this surviving sepsiscampaign to develop these sepsis measures. we first started by developing thesesurviving sepsis campaign guidelines. this is the 2012 iteration. we're about to publish the 2016iteration, and i want to show you, as a lead in to where we're going next, alittle bit about what the impact has been with this sepsis performancemeasures over the last few years. these are data that we published in 2015 onthe results of this surviving sepsis campaign, worked with the performance measures in threecontinents, and it was a 7.5-year analysis,

and i want to show you a little bitof the impact of just participating in a performance improvement work theimpact of the duration of doing it, and finally when hospitalsactually did it better. so this is just the participation event effect,and this shows you the change in mortality over the four to five-yearhistory of this study. and, you see here on this slide that mortalityin the beginning was 36.6 percent and it went down to 25.6 percent which is actually abouta 27.3 relative risk reduction of mortality, and that was severity adjusted,and statistically significant, so good evidence that just participating ina performance improvement effort that looks

at facilitating compliance risk performancemeasures resulted in a declining mortality rate and this is in 220 hospitals in europe,north america, and latin america. in addition, the longer hospitals participatedthe steeper the decline in mortality, and if fact we were able to demonstrate that forevery site quarter that a hospital participated in the performance improvement effortthere was about a one percent decrease in the hospital mortality from sepsis,so really nice data that suggest that not only participating, but doing it for longer improves survivalin participating hospitals. and, that was followed by a dose effect.

so, the dose effect is basically that welooked at hospitals who performed well in terms of compliance, especially with theresuscitation bundles, the three-hour bundle versus hospitals that performed less well. and you can see here on this slide that therewas about an additional five percent reduction in mortality in hospitals that werehigh compliers, and that was independent of whether those patients were identifiedin the emergency department, on the wards, or in the intensive care unit, and so infact the mortality reduction was even higher in patients who were identifiedin the wards in hospitals, and in the icu's versus thoseidentified in the emergency department.

so, good evidence from these slidesthat i just showed you of the fact that just participating improves survival. participating longer improvessurvival, and doing it better. that is better compliance with performancemeasures led to an even steeper decline in mortality, and it's really these dataand other published data in the literature that led cms to adopt thesemeasures for national reporting. these are data from intermountainhealthcare in salt lake city in utah, and you can see if you look at the lowerright of this slide the change in six years in hospital mortality went from 20 percent downto 8.7 percent, and the associated increase

in bundle compliance went fromfive percent to 75 percent. and, these studies have beenreported now internationally. there are now about 60 publishedreports in peer-reviewed journals that are published looking at the relationshipbetween compliance for sepsis measures, or sepsis bundles, and change in mortality,and this is a recent systematic review that we've did of sepsis bundles and you cansee at the bottom there that the point estimate in looking at all of these, nowthey're prospective cohorts, they're not randomized controlled trials, butoverall there was about a 40 percent reduction in mortality and that wasstatistically significant when all

of these studies were pulled together. so really good evidence thatcompliance, with performance measures, published in the literature in peerreview journals strongly suggests that when compliance is facilitated with performance measures there'san associated mortality decline. so where are we now? well, these are slides that doctorfiore eluded to a little bit. sepsis now is being recognized as a verycommon, and very expensive diagnosis, and this is in many ways why there'sso much increased attention by the cdc,

by federal and state governments. it's now the single most expensivecondition treated in the united states, and just as important, this is probablywhy more hospitals are paying attention. we know that re-admission, 30-day re-admissionrates are becoming an important quality indicator for hospitals and for cms,and here you see that septicemia and sepsis is now the second most common cause of 30-day re-admissions amongstmedicare patients. so, this tells us that sepsisis already important, but it's importance is now being recognizedon a national and an international level.

and, that's in fact what'sleading to the increased attention and requests for mandated public reporting. i show you these slides just toemphasize that it's not just sepsis in the emergency departments that'simportant, because that's where a lot of the attention has been placed over the last10 years, but it's also sepsis on the wards, and you can see in this slide that themortality in patients who are identified on the medical wards is higher, by almost 10percent, both in europe and north america, than if it's identified inthe emergency department. and in fact, the mortality for patients whoare identified on the wards is closer to that

of the mortality in patients who areidentified with nosocomial infections in the intensive care unit, and theseare data that we just completed, an 18-month study that shows that routine nursescreening on the hospital wards was associated with a decline of about four percent permonth that this is adjusted mortality, four percent per month hospital mortality ofpatients identified in the wards, and in fact, routine screening on thehospital wards was also associated with a decreased rate of icu transfer. so, i show you these data just toemphasize that it's not just identification in the emergency department that is important,

but it's identification onthe hospital floors as well. so where are we going? and, i think many of us knowalready where we're going, because our hospital administrators are talkingto us more and more frequently about the need to pay attention to sepsis and becompliant with sep one, the cms measures. in many ways the increased national attentionstarted with this person, rory staunton. a tragic case of a young 14 year old boywho, and i'm sure many of you heard of rory, who had a sports related injury whichwent undiagnosed, and died three days after first appearing in anemergency department in new york city

with unrecognized group a beta hemolyticstrep, and succumbed three days later in a pediatric icu which led to starting,two years ago, mandated reporting across all hospitals in new york state, andbasically that reporting began in april of 2014, and we are in the process of analyzing andpublishing those data over the next six months as mandated public reportingbegins to appear in new york state. so, new york state was really the first to makethis step towards mandated public reporting, and it will be very interesting to see oncenow that we have two years' worth of data which includes over 100,000 patients in anew york state database, to see if compliance with these measures on a statewide levelleads to improve survival in the patients

in new york state, and this is a reportcard that's going to start to appear on public websites in new york state as aresult of this mandated public reporting. and, this all led, and much of the build-up thati've done up until now has been about leading up to the sepsis sep - 1 initiativewhich is the mandated issue from cms, and these are the measures, and thesep - 1 they are essentially the nqf in "surviving sepsis campaign" tobundles that i talked about earlier. this is the three-hour bundle which is measuringlactate, obtaining blood cultures prior to administration of antibiotics. administering broad spectrum antibiotics, andgiving 30 cc's per kilogram of crystalloid

for either hypotension or patientswith a lactate greater than four. and, this is a six hour bundlewhich is applying vasopressors to maintain a mean arterialpressure greater than 65, and in the event of the persistenthypotension after the initial fluid bolus or a lactate greater than four, to do oneof these things, and i'm sure many of you, many of you on this call are familiarwith the controversy around this table, but this is the current table eithera repeat focused clinical exam by a licensed independent practitioner, whethera nurse practitioner, a registered nurse, or a physician, or a physician's assistant,or two of the following; either a cvp,

a central venus oxygen saturation, ora bedside cardiovascular ultrasound, and dynamic assessment of fluidresponsiveness with passive leg raising, and so that's the three and six hour bundles. well, i think it's, in my opinion, safeto conclude, and i tried to show you some of the studies that stronglysupport this, that published studies that do demonstrate wide practice variation. there's poor compliance with known qualityindicators, and clinicians do benefit from being reminded, and that there'sbenefits from standardization. it's feasible to use data to auditand change clinical behavior.

the studies i showed you, all of those studies from the published literature veryheavily relied on data collection that audited clinical practice andprovided feedback to clinicians in order to change clinical practice, and i showedyou the data that suggests strongly that increased compliance with performancemeasures is associated with improved survival. and in addition, i showed you somesuggestions that patients with severe sepsis and septic shock on the medical wardshave actually a higher rate of mortality than their counterparts identified in theemergency department, likely due to delays in recognition and treatment,and that it's important

that across all hospitals we pay attentionnot just in the emergency department, but on the hospital floors aswell, and that it's possible to integrate routine nurse driven two-shiftscreening on the medical wards to aid and facilitate in earlier identification andmanagement of this vulnerable population. so, i'm going to close by showing you what ithink is a current management in sepsis for all of us to keep in mind, and i know we allknow this, but it's helpful to be reminded. early identification using lactateand routine screening whether it's in the emergency department, on the medicalwards, or in the intensive care unit, whether by paper tools or electronic toolsto risk assess and to identify patients

with sepsis and septic shock earlier. aggressive source control. blood cultures before antibiotics, as long as it does not delay theadministration of antibiotics. rapid administration of appropriate antibiotics. understanding the importanceof antibiotic stewardship so that although we facilitate rapidadministration of appropriate antibiotics, we also reassess within 24 hours sothat we reduce the use of unnecessary or inappropriate antibioticsby discontinuing them

if we don't think our patient isseptic at the end of 24 hours. and finally, early, aggressive resuscitationutilizing some monitoring technique as a target to ensure that we have some version ofadequate resuscitation in our patients. and with that i'll say thank you. thank you doctor levy. and now, we'd like to hand itover to doctor joe carcillo. doctor carcillo you may begin. thank you. i'd like to also thank the centers for diseasecontrol, and the children's health association,

and american college of critical care medicine. many of these slides will be borrowedfrom the children's health association. so a child has a fever, and an infection,and strep throat, and many thousands of these children will have theseinfections and get better in a few days, but for 2,000 years we know that others whocan't control their infection go on to sepsis. so, you cut your finger. it becomes red. it becomes swollen, and there's puss. and, the way we all treat that is to removethe puss, and if the finger continues

to become red we start antibiotics. and then, if we become red ourselves,have an altered mental status, or fever, then we fall into sepsis. now in children, unlike withadults where they look at lactate, we simply look for prolongedcapillary refill time, or painful legs; difficulty walking, and anabnormal mental status. if you pick it up early youdon't go to this point where sepsis is very seriousand sometimes lethal. health education is probablythe most important way to go.

my daughter is a rower atoakland catholic high school. her teacher taught her that if you have acut and it becomes hot, and warm, and tender, then it's cellulitis, andthe next step is sepsis. so, she came home to show us, my wife andi, that she indeed had cut herself rowing and we took her to the emergency room whereaccording to the idsa recommendations, they unroot the pustule, remove thesource, and start her on antibiotics, and she was back rowing the next day. this young man rowing inthe paralympics right now, did not have that health education at the time.

he instead, went on to becominga bilateral amputee. so really, health educationis probably the major way to impact prevention of pediatric sepsis. antibiotics are the cure. few people realize this, but pathogensactually double in less than 30 minutes, so if you suspect sepsisyou must give antibiotics. here you can see that the increase in mortalityrate without giving antibiotics goes up from, in children, about 10 percent,up to 70 percent after two hours. so really, in pediatrics, we askthat they be started in the first one

to two hours, as opposed to the three hours. not only for septic shock and skin infections,but even when you look at respiratory or severe bacterial community acquired pneumoniawhere you see that survival really is associated with getting your antibioticsin less than two hours. now to do that isn't so easy, because there'sbeen a safety initiative nationwide now where a doctor can't just say tothe nurse, "start antibiotics." things are now controlled from thepharmacy so that there's no medical errors. so, in fact, in this study it was shown thatyou have to have the antibiotics all ready, and you have to have in yourhospital a set of risk factors.

is the patient low risk? is the patient high risk? so here you can see for the low riskpatient you have to cover staphylococcus, in this case vancomycin, andstrep, and e-coli, cefotaxime. but when one gets the high riskantibiotics you then have to add antibiotics for multiple drug resistance organismsaccording to your local antibiograms. and when you do this, you can effectively reachyour goal of antibiotics in the first hour. in order to have this time sensitive approacheach institution has to have trigger tools, and there are multiple emergencydepartment initiatives.

this is the tool that we recommend from theamerican academy of pediatrics, septic shock and septic shock identification tool. it can be used in any emergencydepartment setting, and on floors as well. once you trigger the tool it's essentiallya five-step approach as seen here. early recognition, establishment of iv access,giving fluid bolus' if liver isn't down, and then if the patient doesn't succeedin reversing the shock and sepsis with this approach, then the beginningof peripheral epinephrine, or adrenaline. multiple hospitals shown here at tch they wereable to reduce mortality from four percent to 2.4 percent when they implementedthis approach, and improved the time

to receiving fluid bolus andantibiotics quite dramatically. with this resuscitation bundle you not onlysave lives but you prevent acute kidney injury and the need for dialysis, and otherlong-term management strategies in the icu. adrenaline is the peripheral start. it's better than dopamine. here you can see that if you start peripheraldopamine it was a 20 percent mortality versus peripheral epinephrine whichgives you only seven percent mortality in patients who were fluid refractory. this requires a team approach.

this is a very interesting study. it was done by doctor raina paul,implementing these five-step guidelines. initially she showed that whenyou look at the percent adherence, percent adherence was anywhere from 40 percentto 70 percent for the goals of recognition, vascular access, giving fluids andantibiotics, or starting inotropes. she embarked on a program looking withan ishikawa fishbone diagram to look at what the barriers were at each point. and, wherever your hospital may be, thebarriers, of course, are going to be different. and, what she found quite interestingly, wasthat our human interactions are very important.

for example; she started with a clock in the emergency department goingfrom 60 minutes to zero minutes. so when she did this compliance actuallyworsened as the parents were afraid that the children would die when onegot to zero minutes, and the physicians and nursing staff themselves became anxiousas they saw the clock go from 60 to zero. simply by changing the clock from zerominutes to 60 minutes, anxiety went down and compliance improved dramatically. she also found that if you gave each oneof the providers a clock to look at rather than have a clock on the wall, thenthe providers tended to concentrate

on their own task and not on the task of others. and with this, she obtaineda hundred percent compliance, and statistically significantlyimproved survival in the setting, again from that magic number ofabout four percent to 1.5 percent. you can't just do this as abunch of well-meaning people. this has to come from an institutional approach, and here's where the children's healthassociation has started two major initiatives. this is the pediatric septic shock,and this is in an emergency department, and they showed in their first year thatthey were able to improve compliance

with that five-step bundle in terms oftime to fluid bolus' and antibiotics. and importantly, this was associated witha reduction in mortality from 11 percent to three percent with severesepsis and septic shock. so what about advocacy, governor cuomo, andthe centers for disease control and prevention? really, i'm so happy the centers fordisease control has taken this on, and the vital signs initiativeis really very great. it's going to save a lot of kids. just to add a little bit of granularityto what doctor levy was speaking about. what came out of the new york hospitalinitiative was the following thing.

very simple, just like i said, you teachmy daughter in health care class how to recognize infection and sepsis. here, the mandate is, from now on if youbring your child to the emergency department, if you're going to get laboratorytests, you must discuss the results of the test before you send the parents' home. in this case, this child did have a highwhite blood cell count that was not discussed with the parents before the child left. more than likely if the parents hadknown that there was a high white count and that the physician mightbe concerned about sepsis,

then they would have brought roryback sooner to the physician, and to the emergency department for timely care. the second thing is that all hospitalsmust now have protocols and have a policy for sepsis recognition and managementwhich is controlled locally, not centrally. now, with the cdc behind in sepsis and medicalemergency, and now we must treat sepsis as stringently, and in a time sensitive manneras we do stroke, acute myocardial infarction, status epilepticus, trauma, diabeticketoacidosis, or status asthmaticus. so this is the recommended bundles from theamerican college of critical care medicine. first recognition bundle is screen thepatient for septic shock using the ap tool.

there should be a clinician assessment within15 minutes for any patient who screens positive, and then that clinician should be ableto trigger a resuscitation bundle. this is the trigger tool we mentioned. it includes not very difficultfactors to obtain. you do have to measure bloodpressure, capillary refill, heart rate, what the underlying diagnosis is, respiratoryrate, but no clinical laboratories. if the patient has prolonged capillaryrefill, or pulses it's expected that you obtain iv access, or io access and begin fluid resuscitationin a time sensitive matter.

give the broad spectrum antibioticsin the first 60 minutes and begin the peripheraladrenaline in the first 60 minutes. this is done through this algorithm, and what you do after you do the algorithmis not all patients get everything. you might not get fluids, or you might,depending on the patient's condition, you might not give adrenaline, or you might not. you might not give antibiotics,or you might not. but, if you're going to the goal isto do everything in the first hour. after this point it's the stabilization bundle.

this occurs in the icu. here, it's expected that you usemultimodal monitoring to make sure you're on the right fluids, the right hormones,the right cardiovascular therapies to attain the hemodynamic goals that youfeel appropriate, and most importantly that you confirm every day that you'veadministered the appropriate antimicrobial therapy and more important thanthat, that you have source control. doctor barry has shown, forexample with intraperitoneal sepsis that if you remove the sourceyou have 96 percent survival. if you do not remove the source,you only have four percent survival.

importantly then, we want a group of people whohave an interest in sepsis, if not an expertise in sepsis to then have a performance bundlewhere for each patient they measure adherence to the trigger, resuscitation,and stabilization bundles. perform root cause analysis to identify barriersto adherence, and provide an action plan to address those identified barriers. this is being formalized in the children'shospital associations improving pediatric sepsis outcomes, a collaborationof children's hospitals to prevent severe sepsis and sepsis deaths. hopefully it will be rolled outeventually to community hospitals as well.

the cha rapid cycle collaborativestarted from 2012 to 2013. the emergency departments started in 2013 to2016, and the 2016 initiative is just begun. the timeline for this last initiative isthat by 2020, similar to what we've seen in the emergency department, we canhave a 75 percent reduction in mortality and hospital onsets of severe sepsis. i thank you for your time. thank you doctor carcillo, and now we'dlike to turn it over to doctor susan levy. doctor levy. >> thank you very much.

again, i'm very pleased tohave been asked to be able to present today a topic that's extremelyimportant to all of us, and certainly for those of us who spend a lot of ourtime in caring for patients in the post, acute, and long-term care arena. so i'm actually -- a few things to disclose. no actual dme or pharmacy relationships. again, i think for definition in terms ofsepsis, most of us are familiar with it. it's a life-threatening organ dysfunction causedby dysregulated host response to infection, and certainly as people age we know thattheir response to a variety of insults,

including those that can cause an infectionmay vary and be altered, and so we're going to talk a little bit about some of the changeswith aging that occur, and then talk about some of the specifics in the post-acute setting. so with aging we know in regards to sepsisand frankly in regards to infections overall, that there's a higher incidence,greater severity, and greater mortality. what many of us often forget thoughis the important impact this often has or that of severe infection or franksepsis has on a patient in terms of their post-illness functional status. and frequently, in terms of even longer termmortality and morbidity, we're always concerned

about what happens functionallyto someone after an acute illness. so again, that's anotherimportant factor regarding sepsis and severe illness in the elderly. so what about some risk factorsfor sepsis in the elderly overall? and, some of these have already been mentioned. we've got multiple co-morbidities. again, if an individual - you'll hear a lotabout the term frailty, for those individuals that already have pre-morbid, pre-illnessimpaired functional status, they certainly are at a higher risk for bothdeveloping and having poor outcomes.

many of the medications we use for illnessesas people age can impact the risk of infection and certainly the risk of sepsis. instrumentation and proceduresare more common as we age. many older individuals have recurrenthospitalization, and as a result are exposed to, if you will, more drug resistantorganisms, and develop, because of a variety of reasons, a higher risk for infection. endocrine disorders such as diabetes are muchmore prevalent as we age, and in and of itself, although we don't like to equate normal agingwith disease, there are changes that occur in the body, the immune senescence, changesin host defenses, that increase our risk

of becoming infected and ultimatelydeveloping sepsis as we age. let's talk a little bit about thepost-acute and long-term care continuum, and i think it's important to realizethat these are all a variety of settings that individuals may residein following a hospital stay. they may be in a very highlevel of care, such as an ltach, or may actually be managed with home care. a lot of our discussions are going totalk about primarily patients who are in skilled nursing facilities, butmany of the same principles will apply to patients throughout thispost-acute continuum.

so, i think that that's important to recognize. probably over eight million people areserved by post-acute care services every year in this country, receivemedicare post-acute services. a little bit about the nursing home population. we know there's roughly 15,000nursing homes in this country. probably over 1.4 million beds, and becauseas we say below, there's a difference between people who come short stay forafter a hospitalization to a nursing home for rehabilitation versus those that maystay there long term to live for the rest of their lives, that these aredifferences in the population,

and so as a result we may actuallyhave many more patients moving through those 1.4 million beds. in addition, we're havingsome shift in population, so we are seeing younger patients residing bothshort and long term in nursing homes today. we've talked about the common sourceof infection, and we know that those, particularly where there's an underlyingpulmonary gi source tend to be associated with poor outcomes and higher mortality. so what are some of the issues in nursinghomes that create problems with, if you will, early recognition which isparticularly important

in this setting to have more important outcomes. more frequently, because of the populationwe're dealing with, is the classic signs and symptoms we like to see withinfection may be absent, blunted, or we may find that those signs andsymptoms do have a non-infectious cause. so we know the patients who are olderin nursing homes may be afebrile. we know that there are manycauses of altered mental status. in nursing homes there's not the same accessas there is in hospitals or emergency rooms to diagnostic testing, and even when thereis, the turnaround times are often longer, so there's important need for empiricdiagnosis and empiric treatment.

many patients in these settings are colonized, and so when we're obtaining cultures we'll oftenstruggling with a difference between trying to sort out whether the individual is trulyinfected, or whether they are just colonized. so another important concept that isintroduced in the post-acute setting. staff education and training in the earlysigns and symptoms of infection may be lacking, and in particularly in nursing homes alot of the front-line care has been given by nursing assistants, and so we needto make sure that they're educated in those early signs and symptoms. there's often a lots of onsitepractitioners in most nursing homes.

they may not have a doctoror nurse practitioner, or physician assistant inthe building every day. many do, but they're not there after hours,and then they may not be there on weekends. and often we have unclear goals of therapyin terms of poor advance care planning, and that's another area we need to address. so why is there a relationship betweensepsis and advance care planning? and to me this goes back to, if youwill, william osler's old famous quote about pneumonia being the old man's best friend. but, frequently infection and sepsis, ifyou will, are not uncommon terminal events

at the end of life, as the result of thedecline for multiple co-morbid illnesses, and that with appropriate advance careplanning we can certainly make sure that these individuals are not necessarilyrepeatedly treated for these conditions. so what are some of the keyinterventions in nursing homes? well certainly prevention, prevention, prevention is what's particularlyimportant, and some of the basics. we all know in flu seasonit's about immunizations, but it's not just immunizing the patients, it'sthe health care workers, and it's the residents. and, fortunately the nursinghome industry is taking lessons,

i think from the hospitalindustry about increasing efforts to require health care workers inthat setting have those immunizations. the earlier appropriate precautions that we needto be more vigilant about in the nursing home, just like we've learned to bemore vigilant in hospitals, and then issues around environmental cleaning. but, there are other things that are important, and some of those things are justpreventing illnesses that put people at risk for infection, and possible sepsis. trying to prevent aspiration.

trying to address issues related to skinbreakdown where there's a pressure ulcer or skin care, all those breaks fromskin put the individual at higher risk for developing an associated infection. and certainly, getting rid of anyinstrumentation that's present; foley catheters. although we've been, for many years, veryactive because of cms regulations in doing that, it really is very important to get rid of those. so early recognition is key in thissetting, and we'll mention qsofa. there are other tools out there. my own organization has tools botharound for nursing, as well as physicians

to help them identify disease changesearly, as well as the interact tools. and peer treatment is critical. when you think that you do indeed have asignificant infection, and it's important that your policies and proceduresin your organization to make sure that you have rapid access to antibiotics whenthey're needed, and have policies to make sure that they're started as soon aspossible when infection is suspected. and, again antibiotic stewardshipis not in conflict really with what we're trying to do here. i think most people are familiar with theqsofa score, but it really is something

that works very well in a setting where wedon't have access to a lot of lab test results, and this is data that can be collected fairlyeasily on patients in the nursing home setting. and here's just a demonstration of what it is. so again, greater than two of thesecriteria we should be thinking about a serious infection or prime sepsis. so we've talked about theseinitiatives; reducing sepsis, readmission reduction, antibiotic stewardship. they seem to be somewhat in conflict, but actually in reality they oftenoverlap and can support each other.

just referring to an ligreport that talked about, and i think we've actually earlier speakershave talked about some of this information about readmissions related to sepsis. and, we know for nursing home residents that asignificant cause of hospitalizations overall for those residents is what is listed thereat the very top which certainly is sepsis, and also further down the list you'll seeother causes of infection as common causes for hospitalization for nursing home residents,there's tremendous cause associated with that. in addition, we also want to talkabout the concern about re-admissions, and one of the things that we do know is thatre-admissions are common in some studies,

although we are improving, asmany as one in five patients, medicare patients are readmitted to hospitals. that rate can be even higherfor some nursing homes. but, what about why they're being re-admitted,and i think it's important to realize that it's not always thereason they were hospitalized for that's causing the re-admission. and in fact, it's not uncommon that that re-admission followingan acute stay may be related to a subsequent infection, and or frank sepsis.

and, what we talk about then is the work wherewe have reference to the post-hospital syndrome, if you will, that may develop afterhospitalization related to things that occurred to the patient during the hospital that furtherimpact their reserves and then put them at risk for these other adverse effectsfollowing that initial hospital stay. one of those adverse effects beingdeveloping an infection and frank sepsis. we know that antibiotic stewardship and the cdchas done a tremendous amount of work recently around nursing home and antibiotic stewardship. this is certainly an example of a slide fromsome of the work that they've been doing, but also recognizing that upto 70 percent of residents

in nursing homes may receive anantibiotic during the course of the year, and probably as many as threequarters of those on a course of antibiotics may be prescribedinappropriately. either the wrong -- unnecessary, wrongdose, wrong frequency, wrong duration, and so certainly they havepresented the core elements for antibiotic stewardship in nursing homes. for the physician or practitionerwhat are some of the things that my colleagues can doto help address sepsis? as a medical director, which i thinkis a key role in a nursing home,

preferably a certified medicaldirector, is that our job is to make sure that there is good policies and proceduresin place that incorporate best practices. that we put oversight of the performanceof the practitioners in our building, and that we'll be clinicalchampions in our building for efforts such as reducing sepsis in nursing homes. our practitioners, our physicians, nursepractitioners, physician assistants we need to make sure that they have site specificeducation and training, and understand how to practice in a nursing home setting, andhow to recognize condition changes early, and how to work with the rest of thehealth care team in preventing sepsis.

and also, that we need to know that when we arecalled with patients' changes in condition how to have a high index of suspicion forinfection or sepsis, how to respond, and how to evaluate what a nursing home isand isn't capable of doing in a given setting. so, in summary, just basically, it'sdifficult to recognize and manage sepsis in the post-acute and long-term care setting. it's a common cause for hospitalizationof nursing home residents. it's very expensive. it's important to recognize and appropriatelytreat the common infections that can lead to sepsis, early identification, earlytreatment, and use the tools when available.

we know that many of the current infectionrelated initiatives all have similar goals, so and some of the non-infection relatedinitiatives have very similar goals. we need to engage our medical directorsand practitioners in these initiatives. we need to make sure, as medical directors andpractitioners that our buildings are equipped to handle patients with infections. that they have the antibiotics availablein emergency, and that we set in policies and procedures that make sure that werecheck cultures, that we de-escalate therapy when appropriate, in keeping withantibiotic stewardship principles. and again, thank you very much for allowingme to present the nursing home side of sepsis.

great, thank you doctor levy, andthank you to all of our speakers today. this is abbigail tumpey again, from cdcin atlanta, and before we go to our q and a session we actually have quitea few questions that have come in, i want to take a moment, i shouldhave said at the top of the hour, and thank the three otherorganizations who have worked closely with us to pull off this webinar today. the society for critical care medicine,of which doctor mitchell levy is part of. children's hospital association of whichdoctor joe carcillo is part of, and amda, the society for post - acuteand long - term care medicine,

of which doctor susan levy is part of. so, thank you to sccm, children'shospital association, and amda for their tremendous assistance. a couple questions that we're getting. i know that doctor mitchell levy anddoctor carcillo have been answering some of the questions in the chat box, but doctorlevy we've been getting a couple of questions to clarify a little bit more about the"surviving sepsis campaign bundle", and we're actually going to put a link in thechat box right now for people to be able to see and access those bundles on the"surviving sepsis campaign" website.

but, i wonder if you want to just spend a minute and talk a little bit more clarifying thosebundles and how they've been utilized. >> sure. so the bundles wereinitially developed - oh 15 years ago. we went to the institute for healthcareimprovement, and worked with terry clemmer, and at that time bill sevold,and a few other folks, roger resor and we built the sepsis bundles. so, bundles are a, i guess you could call thema technology or approach that was pioneered by the institute for healthcare improvement. they worked with peter pronovost to developthe ventilator associated pneumonia bundle,

and the central line associatedbloodstream infection bundle, and basically a bundle is agrouping of individual actions. like, get lactate. give antibiotics. get blood cultures. and, they're grouped together by time, so withinthree hours, within six hours, within 24 hours, and basically they're meant to driveimprovements in clinical practice. so we've developed and tested the sepsis bundleswith the institute for healthcare improvement. they were refined over the years.

they were adopted by the national quality forum, and then within the last year the bundleswere adopted by the cms for public reporting. so currently, all the bundles are the same. that is, the ones that i showed in mypresentation, the ones on our website, are approved by the surviving sepsis campaign,the national quality forum, and now the center for medicaid and medicare services, cms. and, in response to another question,the bundles themselves will not change with the release of the 2016guideline, they will stay the same. >> great. thank you for that doctor levy.

we're also getting questionsregarding screening for sepsis. and, one of the questions is askingwhether people should screen when indicated or screen all the time, and whether if you'rescreening all the time, do you end up picking up a lot of patients who maynot actually have sepsis? so, i'm wondering, i think thatthis really impacts both acute care that doctor levy talked about, as wellas pediatrics, as well as long-term care that doctor susan levy discussed. i'm wondering if all threeof our speakers could talk about screening techniquesin each of these settings.

doctor mitchell levy do you want to start? >> sure. well, the biggestchallenge - there are two ways. there's routine paper screening,as i said, and now more and more people are using their electronichealth record for automated screening, and we have one here at brownand rhode island hospital. there's no question that the biggestchallenge of routine screening is you pick up more patients than really have sepsis,or septic shock, and so you are going to do increased numbers of lab tests,but right now the data suggests that although you do more labtests, you identify patients earlier

which may be associated with improved survival. but, there's no way - because there's noideal test that can - with a high degree of specificity and sensitivity rule in sepsisand have a low incidence of false positives, therefore you're left with tests that aretoo sensitive and you're going to pick up patients who don't really have sepsis. >> doctor carcillo, do you want tojump in for a pediatric perspective? >> on which question? >> on the screening of patientsregarding sepsis. >> i'm sorry, on screeningthem in an automated fashion,

or what specific aspect of the question? so we're discussing the benefit - thepros and cons of screening when indicated versus screening all the time, and i thinkpediatrics is really in a very different boat, and you talked quite a bitabout some of the signs that children may actually have versus adults. i didn't know if you wanted to addany additional thoughts on that. >> yeah sure. so if you have electronic medical records,a lot of people are working on screening that is triggered ratherthan screening all the time.

if you do not have electronic medical recordsthen you have to basically screen all the time, and specifically in the emergency roomwhen you come to the triage nurse. if a child has fever, or hypothermia, then thatshould trigger you of a suspicion of infection, and then the pediatric ap trigger toolwill immediately trigger you to a setting where the patient is assessed immediately byan expert clinician who can recognize sepsis. that's basically where we are with pediatrics. one of the questions was askedabout the clinician's office. we have not gotten to that pointyet, but we really must do that, because the clinician's office is as importantas the emergency room in recognizing it.

and in truth, most parentscan recognize it at home. their child's febrile and isn't interacting,and has prolonged capillary refill, pretty much their child has sepsis. >> and doctor susan levy, wouldyou like to add any thoughts from the long-term care perspective? >> sure. i mean it's actually one of thethings where i said i'd, you know, i'd like to, you know qsofa tool which i think can work well. we are seeing more and more nursing homehealth records that can have triggers for significant changes in conditionthat have may help us pick up infections

in general earlier, and certainly identifypatients that may have early sepsis. so, i think that, you know, beingable to screen and implement that in to your electronic records, if you have them,is certainly, you know, certainly very useful. i think it's also education and making surethat people have a high index of suspicion, and being aware of those patients, particularlythose that have had instrumentation ie; foley catheters, that we need to be veryvigilant, you know in keeping an eye on them for any change in condition. we're also getting questions regardingbalancing appropriate antibiotic use and better care for sepsis.

i know doctor mitchell levy and doctorsusan levy referred to this in your talks, but would you like to elaborate more on howto ensure that those two things are in line? >> well sure i'm happy to go first. i think the biggest challenge, especiallybecause we're advocating for a rapid institution of appropriate antibiotics, that doesn'tmean that we should just be using antibiotics and leaving them on, and one of the biggestchallenges, especially in hospitals, is once an antibiotic gets started it'soften just left there for five, seven, 10, 14 days without any - sometimes it justgets - it drops through the cracks, especially in transitions ofcare from one unit to another.

so, one of the things that we're advocating interms of marrying appropriate rapid institution of appropriate antibiotics with antibioticstewardship is, constant re-evaluation. so whether it's the use of pro-calcitonin,or the use of just thinking, that if we - i feel very strongly, and sep-1 the nationalmeasure, says we should be giving antibiotics within three hours of suspectingor diagnosing sepsis. however, we should also be, the next morning,or within 24 hours, re-evaluating our thought that this patient has sepsis, so if it turnsout that we're convinced now that the patient for instance had congestive heart failure, weshould be aggressively stopping antibiotics just as we aggressively start antibiotics.

>> great. >> yeah i think. >> go ahead doctor susan levy. >> yeah. i think that that's, youknow, certainly on a different level, same principles apply evenin the nursing home setting. i think in terms of early intervention oneof the things i've often said is very key is that even with a routine suspected bacterialinfection, that if you're making a decision to treat you should go ahead and treat. and then sometimes what ends up happening ispeople often, you know, will wait until it comes

from the pharmacy, or we'llwait until tomorrow morning. if i feel strongly enough that i'm going totreat someone empirically pending test results, because my inner suspicion's high enough,whether that's oral treatment, iv treatment, whatever it is for an infection, ireally should get it started quickly, and i think facilities need to have policiesto make sure that that certainly happens. it's probably a wise approach. but also in our settings, we need to makesure that nurses and staff are checking on culture results, are givingregular follow-up on patients. if the reasons that the antibiotic we'regiving seem to be related to another cause

that the antibiotics get stopped, and i also agree that we probably treat manycases way too long, and that shorter courses of therapy, even when they are trulyinfected, are certainly better. and so i do think that both stewardshipand preventing sepsis can work together. >> great. thank you. doctor mitchell levy and doctorjoe carcillo we're getting a lot of questions regarding lactate levels andthe significance of assessing lactate levels. would either of you like to touch on that? >> joe?

>> this is joe. they don't work in kids. mitchell [laughter]? >> they do work in adults. you know, the lactate still canserve as a very good risk assessment. it's still part of the sep-1measure, so a lactate greater than four identifies septicshock, and fluid resuscitation. and finally, in the new definition, thesep-3 definitions that we just released, the diagnosis of septic shock isdependent upon a lactate level greater

than two milimoles per liter, so, and inthe bundle, the sep-1 bundle measurement of lactate is one of themandated performance measures. so i think, unfortunately, ori don't mean unfortunately, but lactate in 2016 is still the best measure wehave for risk assessment, and it's incorporated in the national reporting measures, so we're for at least the foreseeable future,stuck with lactate in adults. >> great. thank you for those answers. we're in our last couple minutes, but doctormitchell we are getting some questions with regards to the role that nurses can play inscreening patients for sepsis, and as you know,

and maybe some of the folks on the phone know, our next webinar on september 22nd isactually discussing empowering nurses for sepsis early recognition. with your colleague doctor shawn townsendand done in association with society's for critical care medicine andamerican nurses association. i wonder if you just want to give a 30-secondkind of preview of what you guys have found about the benefits of empowering nursesthat could highlight this upcoming webinar. >> sure abbigail, and i thinkit's really important. probably one of the most importantthings we have found in the campaign

in the last five years, is it ispossible to integrate routine screening, nurse based screening, everyshift on the hospital floors in an under resourced environment like the hospitalfloors, and we identified 1800 patients through routine screening, appliedthe three-hour bundle earlier and it was associated with improved survival. integrating routine nurse screening is the keyto identifying patients on the hospital floors. >> and with that i want to. >> in children, all the screening is by nurses. >> and with that i want to let peopleknow that our next webinar is going to be

on september 22nd, and if you've registered fortoday's webinar you should receive information on the september 22nd webinar aswell, so we hope to see you there. continuing education for this webinar, when you close out your screens you will receiveinformation with a link to continuing education. there will be a post-test and an evaluationwhich you need to complete in order to get that continuing education. and with that, i'd like to thank all of ourspeakers for the tremendous presentations today, and thank you to the associationsfor assisting us in this webinar. >> thank you.