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Sepsis Prevention and Early Recognition PowerPoint Presentation

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This medical PowerPoint presentation talks about sepsis, a life-threatening condition that occurs when the bodys response to infection causes damage to its own tissues and organs. It is important to prevent sepsis whenever possible, and to recognize it early if it does occur, as timely treatment can significantly improve outcomes.

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Published on : Mar 28, 2023 | Views : 2009 | Downloads : 2

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MARCH 24, 2021 THE GRANT GROUP LLC. JANET A. PHOENIX, MD, MPH, MS MICHELLE GEORGE, MPH Sepsis Prevention & Early Recognition
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Sepsis Training Day # 2 Outline Pre-Test Institute of Medicine Recommendations Recap of Day One Best Practice Models for Early Recognition Best Practice Models for Implementation of a Quality Improvement/Performance Improvement Initiative Barriers to Implementation Facilitators Questions and Answers Pre-Test Answer Review
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CDC, Sepsis Alliance® and the Rory Staunton Foundation for Sepsis Prevention Fact Sheet Insights from IOM Sepsis Workshop Focus on family and caregiver role in recognition Covid-19 may teach us things that could improve sepsis diagnosis Early sepsis diagnosis and intervention can improve patient outcomes. Quality improvement initiatives can drive behavior change to improve patient care
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MARCH 24, 2021 J Recap of Day One
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TIMELINE SIRS criteria came early and was used for decades. 2014 Society of Critical Care Medicine and European Society of Intensive Care Medicine met Developed SOFA and qSOFA qSOFA required no labs.
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TIMELINE CONTINUED… Minnesota Hospital Association 100/100/100 Screening Tool Recommended for Long Term Care in 2016 INTERACT published Care Path for Sepsis in 2017
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Sloane et. al Comparison of Screening Tools with Hospital Sepsis Diagnosis for 59 Patients Transferred to Acute Care from SNF
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Review of Nursing Home Screening Tool for Use Agreement with Sepsis Diagnosis Glasgow Coma Scale not used 60% had notation of change in mental status 19% had a visit from a NP or physician in 12 hours prior to hospital transfer
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Systemic Inflammatory Response Syndrome (SIRS) CRITERIA (STARFORUM BUG)
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Systemic Inflammatory Response Syndrome (SIRS) > 100.4 degrees F < 96.8 degrees F > 90 Bpm heart rate > 20 per minute respiratory rate > 12,000 WBC count
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SIRS Criteria Moderate sensitivity Low specificity Used extensively from 2003-2013
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SIRS gave way to SOFA in 2014 Quick Sequential Organ Failure Assessment
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Q SOFA A sepsis screening tool for use in the non-ICU setting Developed in 2014 by The Third International Sepsis Consensus Definitions Task Force (a panel of sepsis experts) 3 criteria used to generate a score that identifies patients with suspected infection who are at greater risk for poor outcomes outside of the ICU.
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Q SOFA 3 criteria used are as follows: Altered mental status (Glasgow coma scale <15) Low blood pressure (SBP≤100 mmHg) High respiratory rate (≥22 breaths per min) One point is assigned for each criterion met. The presence of 2 or more Q SOFA points near the onset of infection is associated with a greater risk of death.
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Q SOFA FOR DEMONSTRATION OF Q SOFA CALCULATION VISIT https://qsofa.org/calc.php and enter the necessary values
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Q SOFA LIMITATIONS Accurately assessing altered mental status can be difficult at the bedside. Q SOFA uses the Glasgow coma scale to define altered mental status for sepsis, however, the scale was created to measure a person's level of consciousness after a brain injury - and those with suspected sepsis may not necessarily have a brain injury. Lactate level was not included as a biomarker; this is a well-documented prognostic marker in patients with sepsis.
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MINNESOTA HOSPITAL ASSOC. TOOL
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MINNESOTA HOSPITAL ASSOC. TOOL 100: 100: 100 USES A screening triage tool for detection of sepsis in long term care settings Created in response to rising sepsis mortality among older adults. Initiates intensive surveillance of sepsis by front line medical staff. Targeted to provide for more structured communication between front line medical staff (CNAs/GNAs/Med-Techs/Medical Assistants) and clinicians
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MINNESOTA HOSPITAL ASSOC. TOOL 100; 100; 100 100 ↑ - is their temperature above 100. 100 ↑ - is their heart rate above 100. 100 ↑ - is their blood pressure below 100. Does the resident just not look right? Has the resident’s mental status changed? Screen for sepsis and notify the physician immediately.
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ATLANTIC QUALITY IMPROVEMENT SEPSIS TOOL
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ATLANTIC QUALITY IMPROVEMENT SEPSIS TOOL: USES A screening tool for early recognition of Sepsis in the NH setting Incorporates Q SOFA and 1 hour bundle of care for sepsis. Includes screening for sepsis AND septic shock. Takes into consideration the resident’s wishes for treatment – which is something other screening tools do not mention.
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ATLANTIC QUALITY IMPROVEMENT SEPSIS TOOL: LIMITATIONS Successful management and treatment for sepsis in the NH setting is heavily reliant on early detection and rapid response. Reliance on necessary labs places burden on NH to ensure that lab used has a fast turnaround time – this may likely be out of the NH’s control. This tool encourages management of sepsis and septic shock in the facility – however, it should also include the need to transfer to the hospital setting for specialized care if necessary.
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INTERACT TOOL INTERACT focuses on reducing hospitalization of residents and begins with recognition of a change in status of a resident and provides a method to evaluate this change, for which there are many causes including infection.
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INTERACT TOOL The INTERACT program includes more than a dozen separate tools. Some are designed to facilitate early identification of changes in condition while others are designed to improve communication between NH staff, medical providers, and other facilities. Some tools address implementation of advance directives, thereby reducing the use of acute hospital care when it is clearly not necessary (such as if the resident does not wish to be transferred to a hospital, and when the NH has capacity to handle sepsis) “Interventions to Reduce Acute Care Transfers” – INTERACT, is a quality improvement program that focuses on the management of acute changes in condition among residents in a skilled nursing facility, and other long-term care settings.
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STOP AND WATCH
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SEVERE SEPSIS SCREENING TOOL
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MEASURING VITAL SIGNS Temperature Pulse Respiratory Rate Blood Pressure Oxygen Saturation
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CDC, Sepsis Alliance® and the Rory Staunton Foundation for Sepsis Prevention Fact Sheet Tool Comparison Chart
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DETERMINING IF THERE IS AN INFECTION Assessing Symptoms Identifying a System that Might be Infected.
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DOCUMENTING CHANGE IN SYMPTOMS ASSOCIATED WITH A SYSTEM Use of Assessment Checklist SBAR to report results of Assessment.
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INFORMING CARE MANAGERS ABOUT THE RESULTS OF ASSESSMENT CNAs need clear guidance about when to report. Care managers need to take those reports seriously and to act upon them according to established protocols. Feedback to CNAs and others who report about the disposition of the findings and why.
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SBAR MARCH , 2021 Sepsis Training Day 2
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AHRQ: SBAR Tool Design S – Situation: A concise statement of the problem (what is going on now). B – Background: Pertinent and brief information related to the situation (what has happened). A – Assessment: Analysis and consideration of options (what you found/think is going on). R – Request: Ask for/recommend action (what you want done). Nursing Home Antimicrobial Stewardship Guide Determine Whether To Treat
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SBAR
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SBAR
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SBAR
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If Transfer to an Acute Care Facility is needed MARCH 17, 2021 Sepsis Training Day 1
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ACUTE CARE TRANSFER
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Considerations for Transferring a Resident to Acute Care Determine if patient record indicates that acute care is part of the treatment plan Determine if there is a DNR on record Discuss with nursing/medical staff Notify family members
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Considerations for Transferring a Resident to Acute Care Determine if patient record indicates that acute care is part of the treatment plan Determine if there is a DNR on record Discuss with nursing/medical staff Notify family members
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When Considering Transferring a Resident to Acute Care Make sure a complete record of symptoms, treatment, response to treatment by resident accompanies them to acute care. Make sure all laboratory results, whether positive or negative are sent to acute care facility preferably through a shared EMR but if not by fax or email. Make sure acute facility has contact information for the lab so they can discuss results if needed. Provide contact information for POC at LTC so that acute care staff can contact if they have questions about the transferred patient.
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Day One Case Study The time is 0900 pm. Deborah is a 73-year-old female who has chief complaints of weakness, dizziness, fever, and chills. She had great difficulty standing this afternoon when she tried to go to dinner. It required two staff members to assist her. She is a full code. Her medical history includes heart failure and hypertension. She is a one pack per day smoker. She has lived at the nursing facility for two years since her husband died. Her current weight is 230 pounds. She has no known drug allergies. She has had limited oral intake over last two days due to nausea and decreased appetite. Her skin is pale and moist. Respirations are labored. No family has yet been notified of her condition.
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Resident Assessed for Infection and Organ Function Labs were Ordered with instructions to rush results Lactate Blood cultures UA/UC, Electrolytes BUN Creatinine PT/INR
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Sepsis Bundle Orders Standing orders were present in the Electronic Health Record 30 mL/kg crystalloid bolus 230 pounds (104 kg) x 30 mL/kg = 3136mL for bolus (3 L of fluid) Started on broad spectrum antibiotics Vital signs at least every 15 minutes
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Resident Reassessed Vital signs following fluid bolus: Blood pressure: 78/46 (Initial Value 84/52) Pulse: 150 (Initial Value 145) Temp: unchanged Oxygen saturation: 88% on 2L Respirations: 20 – shallow (initial value 22) Mental State: Remains confused: answers questions inappropriately
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Laboratory Values Labs are in Lactate: 4.2 WBC: 2.0 Hemoglobin: 9.2 Creatinine: 2.4 INR: 2.1
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Best Practices for Initiation of Quality Improvement/ Performance Improvement Initiative on Sepsis MARCH , 2021 Sepsis Training Day 2
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ROLE OF THE ELECTRONIC HEALTH RECORD Prompts in Electronic Health Record that alert for additional monitoring. Prompts in Electronic Health Record for order sets. Prompts for high-risk patients for sepsis. Ability to auto populate vital signs and labs to trigger alerts for clinical staff.
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Use of the Electronic Health Record can support sepsis Decision Making An electronic alerting system was shown to reduce the time to initiation of therapy for sepsis. High risk patients were identified and advanced practice nurses and attending physicians were notified when certain criteria were met. The alert required some action be taken in response to cancel the alert. The group of septic and septic shock patients prior to implementation of the alert had a mean of 3.5 hours longer time to treatment initiation when compared with patient post-implementation.
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Notification Algorithm for Electronic Health Alerts Web-based/EHR predictive algorithms that elicit specific data such as but not limited to vital signs (BP, Temp, HR, RR, and SpO2) lab values, nurses notes, and event reports. EHR serves as a data collection tool and repository for predicting risk of sepsis for patients. A system that provides a data collection tool that allows for continuous analysis and surveillance could be most beneficial. System must be able to identify SIRS criteria and offer clinical decision support (CDS) to healthcare professionals (such as EPIC system developed collaboratively with UCSF or Cerner implementation at Intermountain Healthcare).
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Definition of Sepsis Intervention Fluid Bolus Administration of Broad-Spectrum Antibiotics Collection of Blood Cultures Collection of a Lactic Acid level
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https://journals.lww.com/ccnq/Abstract/2015/04000/Reduction_in_Time_to_First_Action_as_a_Result_of.9.aspx Electronic Alerts for Sepsis Recognition
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Simulation as a Tool for Certified Nursing Assistant and Provider Training Simulation using STOP AND WATCH and SBAR Two step training focusing initially on STOP AND WATCH to recognize sepsis symptoms early. Second training focusing on SBAR to alert clinical supervisors about the septic patient’s condition.
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Houston Medical Center Nurse Based Early Recognition and Response Program Developed by Houston Medical Center to equip bedside nurses with an easier to use tool for sepsis screening. Earlier program failed because bedside nurses found initial tool too cumbersome to use Adapted a tool that used SIRS criteria based on commonly collected data. Heart rate, respiratory rate, temperature, white blood cell count. Used an ordinal scale based on deviations from normal (0 to 4) Combined with a yes/no score for acute mental deterioration
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Nurse Based Early Recognition and Response A score greater than 4 triggers a review by a second responder Positive predictive value was 80.2% Negative predictive value 99.5%
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Nurse Based Early Recognition and Response Started with a paper version Transitioned into a system fully integrated into the Electronic Health Record Auto populates with most recent vitals and labs System integrated throughout hospital, not just ER or ICU Patients screened on admission, at 12-hour intervals and when there is a change in condition
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Nurse Based Early Recognition and Response Positive screen prompts a second responder (nurse practitioner) to evaluate Assess likelihood of sepsis Search for infection source Administer treatment without physician approval (physicians are informed Treatment administered one hour after positive screen reevaluated by second responder
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Nurse Based Early Recognition and Response Training Training on sepsis is required for bedside nurses prior to use of tool and on annual reexamination Simulation training (4 hour minimum) required for second responders.
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Nurse Based Early Recognition and Response Effectiveness Program was fully implemented in 2009 In 2009, 2010 and 2011 the percentage of inpatient with positive screens for sepsis ranged from 11% to 12% The sepsis related death rate declined from 29.7% pre-implementation to 21.1% post implementation This was statistically significant at p <.0001
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Nurse Based Early Recognition and Response Costs Baseline period exhibited 411 sepsis stays (49 sepsis stays per 1000 Medicare stays) 39% reached CMS outlier status Cost of $5.2 billion to Medicare 442 sepsis stays (48 sepsis stays per 1000 Medicare stays) 24% reached CMS outlier status during comparison period Costs $3.2 million Savings of $2.4 million
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Nurse Based Early Recognition and Response Costs Long Term Acute Care Hospital (LTACH) and Skilled Nursing Facility Cohort Goal to Decrease Sepsis Related Admission Back to Acute Care by 25% from baseline Decrease CMS reimbursements for acute care admissions back to SNF by 27% from baseline
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Nurse Based Early Recognition and Response Cost: Primary Drivers Early Recognition in LTACH and SNF can sometimes prevent acute care admission or shorten them Requires a facility wide commitment to improving clinical care in sepsis
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Nurse Based Early Recognition and Response Cost: Secondary Drivers Multidisciplinary Performance Improvement Team with Designated Medical Director Data-based monthly reviews/response Facility level process of care and outcomes Continuing medical and nursing education on sepsis and SEE
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Limitations, Barriers & Facilitators MARCH , 2021 Sepsis Training Day 2
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Vital Signs
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Lower Respiratory Infection
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Lower Respiratory Infection Continued
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UTI
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UTI Continued
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GI
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INTERACT Guidance on Identification & Management of Infections For Vital signs INTERACT compares their tool with standards on infection identification designed by McGreer Surveillance Criteria published in 2012 and with the AHRQ Minimum Criteria for Infections Toolkit For Lower Respiratory Tract Infections and For Urinary Tract Infections, Loeb criteria are added for comparison For Gastrointestinal Infections Interact and McGreer are compared
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INTERACT Guidance on Identification & Management of Infections For each common site of infection that has the potential to lead to sepsis INTERACT provides some recognition tools that are simple and easy to implement For higher level providers such as Nurse Practitioners and Physicians the McGreer and AHRQ criteria are useful. For bedside nurses, the simpler INTERACT criteria may be easier to implement and easier to train nurses and certified nursing assistants to implement. They key is to pick criteria that will not be overly burdensome for the level of personnel who are expected to implement them. These tools will be made available to you so that you can customize them for your institution and your needs.
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Patient Safety Movement: Roles for All Family Certified Nursing Assistant Nursing supervisor Medical Director On Call Physicians Sepsis Coordinators Laboratory
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Patient Safety Movement: Executive Summary Develop a team approach to implement a protocol for early sepsis identification and treatment including representation from Administration, Nursing, Medical Director and Pharmacy. Create a sepsis dashboard for your organization’s leadership. Implement a Sepsis Rapid Response Team or incorporate early detection of sepsis into your existing teams (e.g. rapid response teams). Formalize processes to screen patients for signs of sepsis throughout the entire institution. Implement an effective monitoring and screening system to accomplish continuous monitoring and early detection, based on existing data (SIRS criteria, or any other warning system being used).
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Patient Safety Movement: Surveillance Implement an effective monitoring system to accomplish continuous monitoring and notification based upon acute changes in the following data: Fever (> 38.3°C) Hypothermia (temperature < 36°C) Heart rate > 90/min or 1 or more than two standard deviations above the normal value for age Tachypnea (RR > 20) Altered mental status Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes Leukocytosis (WBC count > 12,000 μL–1) Leukopenia (WBC count < 4000 μL–1) Normal WBC count with greater than 10% immature forms Hypotension (SBP < 90 mm Hg, MAP < 70 mmHg, or an SBP decrease > 40 mmHg in adults or less than two standard deviations below normal for age)
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Patient Safety Movement: Executive Summary Leverage your EHR to serve as a data collection tool and repository for predicting risk of sepsis for patients. A system that provides a data collection tool and allows for continuous analysis and surveillance will be most beneficial. Implementation of automated electronic screening and documentation of process of care based on existing data (SIRS criteria, or any other warning system being used). Design a workflow specific to level of alert Screening: SIRS/Sepsis/Septic shock workflow Mortality Prediction: qSOFA (or “Level of Risk”)
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Patient Safety Movement: Executive Summary Implement a process for continuous monitoring of electronic systems and protocols Compliance, efficacy and outcome measures Implement case reviews for outliers Treatment/Interventions Implement protocol for rapid assessment and intervention at the bedside and initiate sepsis bundles
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Patient Safety Movement: Patient & Family Engagement Create materials or resources (website, classes, pamphlets, videos, etc) for residents and families regarding : A. Sepsis: what it is, risks, prevention, early detection, management, possible trajectory (ICU, post-ICU), outcomes i. How you, as the patient or family member, can participate in prevention and early detection B. The SNF’s sepsis program –what, when, who, etc.? e.g., screening, code sepsis, etc. C. Who and how to contact if the family suspects sepsis
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Patient Safety Movement: Communication Implement standardized protocols for patient/family engagement/communication Coordinate with family or caregiver to reduce sepsis risk factors and identify clinical indicators at first sign Disclose all sepsis related events Provide an explanation as to why/how the sepsis occurred; Explain how the effects of sepsis will be minimized; and Discuss/state steps that the caregiver or organization will take to prevent recurrences of sepsis
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Questions MARCH 24 , 2021 Sepsis Training Day 2
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Pretest Question Review Question One: What factors are associated with higher mortality for sepsis? Old Age Cancer Previous sepsis All of the above Answer One: D (All of the above)
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Pretest Question Review Question Two: Which of the following laboratory studies normally done to confirm or rule out sepsis can be used as a criterion to decide whether to transfer to an acute care facility.? Lactate Creatinine WBC Hemoglobin INR Answer Two: A (Lactate)
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Pretest Question Review Question Three: If you have resident suspicious for sepsis who is being treated in the facility with fluids and antibiotics whose MAP drops below 65 what steps should you take. Document the vitals. Prepare a SBAR. Contact the nursing supervisor. Notify the physician on call. All of the above Question Three: E (all of the above)
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Pretest Question Review Question Four: A family member is visiting and reports that their loved one seems less lucid than at the last visit and won’t eat. What steps should you take? Document the report of a change in mental status. Assess mental status and report the score the nursing supervisor. Wait until the shift changes and put it in your note. A and B. Question Four: D (both A & B)