Podcast 89 – Lessons from the STOP Sepsis Collaborative

We have hit the 10,000 patient mark in the NYC STOP Sepsis collaborative. Here are some of the lessons learned…

Want to See the Protocols?

Recognition

  • Let nurses handle recognition

Lactate

  • Send lots of lactates
  • Lactate turn-around 30 minutes or get Point-of-Care
  • Run the lactates on a blood gas machine
  • Make lactate >=4 a panic value

Treatment

  • Prompt palliative vs. curative
  • Non-invasive protocols have evidence and seem to be working

Want to See the Protocols?

Early appropriate antibiotics

  • Empiric Abx Guidelines
  • First dose of those antibiotics in the ED
  • Simultaneous Infusions

Intubation

  • Safe Intubation

Fluids

Pressors

  • Do a sterile neck line or a non-sterile femoral (which should be yanked and replaced as soon as the patient gets upstairs)
  • Norepi should be your 1st pressor choice

Check Your Work

  • Mandate repeat lactates

More Sepsis Resources

 The Proposed NQF Measure

Read it and weep

Please contact the folks in your hospital that will be voting on the measure

On a Side Note…

EMCrit just broke the 3 Million Downloads mark. Yeah!!!!

Like this post? Then tweet the hell out of it

Play

You finished the 'cast,
Now get CME credit

Already an EMCrit CME Subscriber?
Click Here to Get CME Credit for the Episode


Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 2 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. Great post as always Scott.

    Why do you think the NQF is doing this? Are we seeing a 10 year knowledge translation situation where the Rivers paper from 2001 was finally adopted by all, or is this something else? Also, would something like this occurring really mean you couldn’t manage sepsis non-invasively, or is that an exaggeration?

    Happy holidays,

    Chris
    @SOCMOBEM

    • The people advising NQF may have a vested interest in keeping things along the lines of the invasive path, but that is just conjecture. What I can say for sure is that if the measure goes through and is adopted by CMS that is the end of non-invasive approach for the USA–no exaggeration.

  2. Scott,
    Does the STOP Sepsis Iniative deal with ICU care, or just in the ED? I’m interested in the use of protocols to guide continuing fluid replacement/treatment upstairs as well as in the ED. I’m particularly interested in protocols that allow the ICU nurses to “titrate” fluids based on a non-invasive measurement (such as the NICOM). As I’ve been researching this topic, I encounter a lot of people who think it’s crazy to even look at non-invasive measurements, although I tend to agree with you, why put a big neck line in someone who doesn’t need pressors?
    Bryan

    • Bryan you’ll have to clarify if they mean non-invasive measurements such as IVC UTS or they are doubting NICOM. The ongoing fluid decisions after the 1st 24 hours are actually much tougher than the first 24 hours and even the latter is already pretty tough.

  3. Speaking from the nurse side…..
    (Insider tip)
    When physicians what fluids and antibiotics RN’s mix you vanco, zosyn, or whatever in a 1 liter bag. Yes it still must be timed (ie 1 hour 30 min etc) however while you are blasting in a liter of saline bang in your antibiotics over an hour in a liter. Firstly in a resus few people think of maintenance fluids. I need to give them normal maintenance plus what they are missing. I alway imagine a septic patient like a burn patient who comes from a po-dunk hospital that has administered insufficient fluids. Load your patient… then use the antibiotics like MIVF. As that resus fluid begins to third space your are already replacing it…I have found you get your fluids in and your antibiotics and at least diminish that B/P fall in the following hour when your resus fluids third space out. Perfusion is maintained and therefore the antibiotics get to go where they are needed.
    Now the common sense portion….if you have a 80lbs granny who has received 3 liters don’t mix your 2 or 3 antibiotics in another 2 to 3 liters….speak with the MD…perhaps mixing it in 250mL or 500mL will do.

    • Hey there FlyinRN. Thanks for commenting. Not sure I am crazy about the idea of fluid boluses going in under abx administration. Rather just judge what fluid the pt needs and give specific fluids accordingly. The concept of maintenance fluids doesn’t exist during the resuscitative phase of critical illness. We are assessing these patients constantly to see their status and dosing fluids accordingly.

  4. Scott,
    I am a critical care transport nurse and given the given the limited resources (no POC lactate or US capabilities) and information (very little information from the sending facility about source. about half the time the physician is gone and not available to answer questions. so i am talking to an RN who has no idea what is going on with the patient. sometimes I may get one set of labs that is 4-6 hours old that includes a lactate about 25% of the time). What are the most important interventions that I can do in my limited time with the patient (maybe and hour from arrival to transfer to receiving facility staff).

  5. David Cummins says:

    Scott,

    I have a related question for you and your followers: What are your ideas on taking sepsis care to the streets, onto the ambulances?

    I would like to involve our EMS providers in sepsis care and am considering having our paramedics start the sepsis identification process in the field and maybe even begin antibiotics before arrival. There are a lot of details to work out such as: Is it feasible for a paramedic to accurately identify sepsis? Is there a single antibiotic agent that might be carried that would be appropriate first-agent coverage in most common causes of sepsis? Should we consider developing a “sepsis alert” system for the medics like we do cardiac alert, trauma alert, stroke alert etc?

    I already have begun the push forward with encouraging aggressive hydration on septic patients and many now arrive in the ER with 2 Liters of NS already on board, whereas before they might have gotten 250cc. I am looking for more ways to be more aggressive with the guys and gals in the street and appreciate any feedback you can muster.

  6. Scott, I assume you are using iStat’s as your point of care lactate monitor? I’m in the early plannig phase to see if we can do some sort of our own study and or treatment improvement from a pre-hospital standpoint. Unfortunately, many of our local services won’t be able to afford iStat’s and I am trying to figure out how to get a field lactate done. Any ideas?

    • There are a few options out there for prehospital lactate testing. The two I have seen most often is the lactate scout and the lactate plus. Hope that helps I know they are pretty inexpensive in comparison to an ISTAT. The biger question is however how is getting a lactate in the field really going to change the care provided by the medics. I look forward to hearing every bodies opinions on that.

      • Ah, crap, forgot about those. Thanks for the reminder. As for medic treatment in the field…

        Our transport times are an average of 15-20 minutes, we have a number of hospitals within that region. A protocol like this would be easy enough to implement. I’ll be honest, we do a poor job of identifying sepsis and testing appropriately until we are well behind the power curve and have to dump fluids in and start pressors. Some of that is our problem, some of that is the problem of the nursing home staff and or patients family to recognize how seriously ill a patient is. I like the idea of empiric fluid loading, and a field lactate. Those two topics are easy to teach the how’s and whys of their necessity. As for field initiated antibiotics, I think that, beyond fluid loading and early identification, could potentially make the biggest difference in morbidity and mortality. I don’t think this is outside of our scope of practice, and as long as it follows local patterns and is a safe choice so their isn’t significant interaction with other meds, could really be an option. Research has shown that early ABx administration is beneficial, why not get it to the point of pickup. We can draw cultures, do lactates, and have all of that ready to rock and roll the second we hit the ED doors.

        I know it would be a tough thing to do, but, we as fire based, and even private/third service based medics don’t do change well. But once we all get comfy with the idea, it’s easy to implement anything. And if it benefits the patient? Well hell. That’s a win all day.

        This is a project I’ve kicked around for the last 6 months or so. And I think it’s time to really get it rolling.

        • Sorry. Forgot about the lactate. I think with a bit of effort, and proper understanding, we’d be able to shoot for a goal. If their lactate is 6, we know the patient is rather hypo-perfused and we need to load them with fluids. It’s an easy concept. Sure, that’s the bare bones, Mongo see lactate, Mongo fix lactate, way too look at it. But it works. Combining that with all of the other general cares, you really have a simple tool to improve the outcome in the field, vs. just pouring a random amount of fluid in.

  7. Jeremy M says:

    Dave,

    Here in Canada we in EMS are the first step and primary source of early sepsis recognition. We already practice aggressive fluid administration, early hospital notification/stratification to appropriate facilities. As well some jurisdictions have regional guidelines for prehospital IV antibiotic administration and most have vassopressors(typically dopamine though we are starting to get Levo) I dont have any stats on success or out comes, as far as I know they are not kept. But atleast with the patients I deal with I have seen success. I would love to see for us to ideally carry istats but a lactate monitor would be a great start.

    Jeremy

    • Rebecca says:

      I absoloutley love iStat, but they are not (physically) made for being out of a hospital environment. I spend at least 8 months of the year with the thing stuck down the front of my jacket (so it doesn’t get too cold) or keeping in wrapped in cold packs (so it doesn’t get too hot). The iStat has such a narrow temperature range in which it will operate that it is practically infeasible to use in the transport environment. Once it gets out of temperature range it WILL NOT WORK until it is brought back into its comfort zone by either kangaroo care or an ice bath.
      I’m not sure which is worse…not being able to get a blood gas/lactate when you really need it or having to explain to a patient’s family member why you have a large block of plastic under your shirt.

Trackbacks

  1. […] of sepsis and I think in the end, this is what saves lives. The STOP sepsis collaborative (http://emcrit.org/podcasts/lessons-sepsis-collaborative/), early results seem to support this concept. It is noteworthy to consider that the ProCESS trial […]

  2. […] Lessons from the STOP Sepsis Collaborative! Remember its not about all the invasive measures that makes a difference in septic patients, the non-invasive approach delivers results and Scott tells us how. The ED approach: get and check lactate, early antibiotics and fluids, source control, early critical care/senior review is what its all about when dealing with the septic patient. […]

Speak Your Mind (Along with your name, job, and affiliation)