Contributed Commentary By Amy Sprague
May 2, 2017 | Contributed Commentary | Sepsis is the result of an untreated bacterial infection that may worsen if not properly treated, leading to serious consequences such as organ failure or even death. In fact, the syndrome is currently one of the leading causes of death in the intensive care unit of U.S. hospitals and costs associated with hospitalization for the syndrome amount to over $24 billion each year. In an effort to increase awareness surrounding this deadly syndrome and to reduce associated hospital costs, the Center of Medicaid and Medicare Services (CMS) released a new sepsis management bundle in 2016 as part of the Hospital Inpatient Quality Reporting (Hospital IQR) program. Similar to bundles specific to other syndromes that commonly develop within the hospital setting, including diabetes, strokes, pneumonia, and congestive heart failure, the new sepsis management bundle aims to improve care coordination. These bundles are a new strategy for Medicare reimbursement which incentivizes hospitals for providing quality care for patients.
The new sepsis management bundle, based on research from the Surviving Sepsis Campaign, concentrates on the treatment and reporting of sepsis during the first three and six hours of diagnosis – the most crucial time to best control a patient’s outcome. The bundle outlines detailed actions hospitals and emergency departments should take to reduce a patient’s risk of developing sepsis or to prevent the syndrome from worsening. Based on these guidelines, providers should assess the patient’s symptoms and monitor for the possibility of developing sepsis when indicators are first presented in a medical setting. Within the first three hours after sepsis is identified, providers should take the following actions:
1. Measure lactate levels
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
Within the first six hours, providers should:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings
7. Re-measure lactate if initial lactate elevated
These new guidelines specifically discuss the use of lactate, a biomarker that measures tissue perfusion and allows providers to gauge whether perfusion is improving or not. To ensure the patient’s syndrome is not worsening, providers should continue to monitor lactate levels after the first three hours (CMS requires < 6 hour repeat). Once levels begin to decrease, this is an indication that the patient is experiencing better tissue perfusion.
Although it is not included in the most recent CMS sepsis bundle, research published in Critical Care shows that procalcitonin (PCT) plays a critical role in sepsis management, as it is one of the most sensitive and specific biomarkers to bacterial infections (doi:10.1186/cc5926). PCT levels provide further indication on whether a patient is at higher or lower risk of progression to severe sepsis or septic shock. Additionally, this information can help providers determine both the severity of illness and adequacy of source control.
There are some cases where sepsis is easily identified and treatment is administered, but in other cases, the use of biomarkers can better assess the risk of sepsis and help to inform decisions on which therapies are appropriate for treatment. When monitoring a patient with a bacterial infection, it is crucial for providers to concentrate on both lactate and PCT levels. Specifically, lactate provides insight into potential organ dysfunction, while PCT represents the underlying causes of infections as bacterial. These biomarkers are complimentary and when used together, providers become armed with additional resources that can help them to determine not only if a patient has a bacterial infection, but also the severity of the infection as well.
Today, there is limited awareness around sepsis and the risks involved. By implementing these sepsis management bundles, CMS is putting new protocols in place that will assist providers in combatting this deadly syndrome. To be successful in combatting sepsis, it is imperative for providers to follow the guidelines outlined in the sepsis management bundle closely. This will ensure that patients are receiving the quality care they need to have the best outcome possible, while also reducing hospital costs. When providers follow the proper protocols and use the variety of tools accessible to them, it can lead to an increased chance of survival for patients facing this deadly syndrome.
Amy Sprague, DNP, RN, ACNS-BC, CCRN is a patient safety manager at Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. She is responsible for the hospital’s Patient Safety Program and promotes a Culture of Safety. She can be reached at Amy.Sprague@va.gov.