New Code Sepsis Protocol Launched in November

SHC Sepsis Program: Code Sepsis
Severe Sepsis and Septic Shock (SS/SS) have high rates of mortality. In looking at SHC data for a 23-month period, cases that are present on admission (POA) have a mortality rate of 20 percent, and those that are not present on admission (NPOA) have a mortality rate of 36 percent. Vizient (UHC) data from first quarter 2016 shows that compared to other Vizient participating hospitals across the nation, Stanford ranks 104/137 for Sepsis Observed to Expected (O:E) mortality.

To improve SHC’s performance in sepsis care, an interdisciplinary team developed Code Sepsis. Effective November 7, 2016, this new protocol helps ensure that prompt care is delivered to septic patients with hypotension or elevated lactate (≥4mmol/L). The goals of Code Sepsis are to drive improvement in outcomes for patients, and compliance with the CMS Sepsis Core measure and the Sepsis O:E Mortality performance.

Basic Workflow for Code Sepsis
In the new hospital, there will no longer be overhead code pages. In preparation for this, Code Sepsis will not be announced overhead and will serve as a pilot for running codes by pagers.

1. Upon responding to a septic patient, if the critical care response nurse believes the patient meets the criteria for sepsis (2 SIRS + Infection) and is either hypotensive or has an elevated lactate, they will activate Code Sepsis
2. The operator will page the Code Sepsis response team, which consists of the Critical Care Response RN, Bedside RN, ICU Fellow, Pharmacist, Lab Assistant, Respiratory Care Practitioner, Administrative Nursing Supervisor and Charge Nurses.
3. The Charge Nurse will alert the treatment team that Code Sepsis has been activated.
4. The ICU Fellow will confirm the presence of sepsis (2 SIRS + Infection) and either hypotension or elevated lactate.
5. The Fellow will run the code, ensuring that proper care is provided, including:
   • Lactate
   • Blood cultures
   • Appropriate antibiotics
   • 30mL/kg Crystalloid Fluids
     • If at any point during the fluid administration the patient appears to be fluid overloaded, fluids will be held and reassessment of volume status will be made. If the patient is indeed fluid overloaded, vasopressors will be initiated if patient continues to be hypotensive.
   • Repeat lactate
   • Vasopressors
6.  Patients will be transferred to the appropriate level of care
7. Code If at any point during the fluid administration the patient appears to be fluid overloaded, fluids will be held andSepsis ICU fellow will document entire process as well as the reassessment examination in an already created Epic Code Sepsis Template

Patients at Elevated Risk of Fluid Overload
If hemodynamics permit, fluid status (CVP if available, TTE with IVC and EF evaluation, PAOW if available, passive leg raise if possible) will be examined prior to administration of 30mL/kg fluids.

The table outlines care for specific patient populations at elevated risk of fluid overload.