“Curmudge, you messed up.”
“Jaded Julie, what do you mean, I messed up? Everything we do is a joint effort. You must mean that we messed up, but what did we do or not do?”
“Back in 2009 we had 12 postings on Patient Safety. Each posting had an extended title so the reader would know in which posting to look for information on medications or infections or falls or whatever. Later we posted series (three or more postings) on Mistakes, Amazing Devices, Evidence-Based Medicine, The Crystal Ball, The Laboratory, and Sepsis without extended titles. Unless he/she had an excellent memory (which you don’t have), the reader would have to search for a particular topic within a series by trial-and-error.”
“You’re right as usual, Julie. Let’s create extended titles or keywords for the postings within those series. That will help me when I want to insert a link back to an earlier posting. As you know, I forget what’s in an article the day after it is posted.”
“You conjure up the subtitles, Curmudge, and I’ll type.”
April 1, 2010: Mistakes—mnemonics, sleep deprivation
April 8, 2010: Mistakes 2—standard work, checklists, ‘Isabel’
July 22, 2010: Mistakes 3—necessary fallibility, see February 19, 2009
Aug. 5, 2010: Amazing Devices—AutoAnalyzer, pulse oximeter
Aug. 12, 2010: Amazing Devices 2—Library resources, PDA Road Map; Information at Your Fingertips;, August 6, 2009
Sept. 2, 2010: Amazing Devices 3—The Wireless Future of Medicine
Sept. 9, 2010: Amazing Devices 4—ultrasound, electronic stethoscope
Sept. 23, 2010: Evidence-Based Medicine—URLs for reviews
Sept. 30, 2010: Evidence-Based Medicine 2—review articles, clinical trials
Oct. 14, 2010: Evidence-Based Medicine 3—evaluating the literature
Oct. 14, 2010: Evidence-Based Medicine 4—“Will it help my patient?”
Oct. 21, 2010: Evidence-Based Medicine 5—getting a second opinion
April 7, 2011: The Crystal Ball—prologue
April 15, 2011: The Crystal Ball 1—need for Lean
April 27, 2011: The Crystal Ball 2—specialized consultancies, IHI
May 5, 2011: The Crystal Ball 3—Sg2
May 12, 2011: The Crystal Ball 4—The Innovator’s Prescription by Clayton Christensen, disruptive innovation
May 19, 2011: The Crystal Ball 5—intuitive & precision medicine, NPs displacing docs displacing other docs, pharmacogenomics
May 31, 2011: The Crystal Ball 6—‘solution shops’ & value-added processes; straightforward and difficult diagnoses
June 3, 2011: The Crystal Ball 7—chronic diseases, integrated fixed-fee providers
June 13, 2011: The Crystal Ball 8—two health care philosophies; HSAs plus high-deductible insurance
June 30, 2011: The Laboratory—phlebotomist, specimen processing, blood bank
July 7, 2011: The Laboratory 2—CBCs, chemistry, troponins (heart attack), hemoglobin A1C (diabetes), microbiology
July 14, 2011: The Laboratory 3—identification of bacteria
July 21, 2011: The Laboratory 4—pathology, histology, cytology
July 28, 2011: The Laboratory 5—quality control, workload, turnaround, education requirements
Aug. 26, 2011: Sepsis—introduction, pathogenesis
Sept. 7, 2011: Sepsis 2—diagnosis, management
Sept. 15, 2011: Sepsis 3—resuscitation bundles, MMC data
“Julie, these should be helpful for our readers and also for me. Let’s do this the next time we write three or more postings on the same general topic.”
“I’ll remind you, Curmudge. If I don’t, you’ll forget.”
Affinity’s Kaizen Curmudgeon
Thursday, September 29, 2011
Friday, September 23, 2011
The Bad, Good Medication
“A long time ago, in my UW-Madison years, I used to share the ride home from campus with my neighbor, Bernie, a physician in the Division of Clinical Oncology. One day we were stopped at a traffic light and Bernie glanced at a passing pedestrian and said, ‘See that guy with the moon face. I’ll bet he’s on steroids.’ ‘If you say so, Bernie,’ and we continued on home.”
“That must have been your introduction to corticosteroid medications, Curmudge. Have you ever experienced them first hand?”
“Right hand as well as left hand, Jaded Julie. Tendonitis in several of my fingers was treated with cortisone injections. The pain was exquisite as the doc probed around with the needle inside each finger trying to locate the tendon. But I never had to take prednisone, the common oral corticosteroid that is the topic for today’s discussion.”
“Pray tell, O Unpredictable Oracle, why your brain decided to focus on prednisone, of all things.”
“Prednisone has been around since the 1950’s, and it is prescribed for a wide variety of conditions. Patients who are anywhere north of clueless probably have heard that there is something about prednisone that they won’t like, but they might not recall what it is. We are going to tell those patients what is in store for them by sharing what I have observed in the past year.”
“In my training I learned that cortisone is produced in the body’s adrenal glands, and its synthetic form is prednisone. It was originally hailed as a wonder drug for its effect on patients with rheumatoid arthritis, and it is used for other autoimmune diseases like multiple sclerosis and lupus. A valuable property of corticosteroids is their ability to prevent release of substances in the body that cause inflammation; that explains the injections into the tendons of your fingers. Other treated conditions include inflammatory bowel disease, some lung diseases, severe allergies, and asthma.”
“Because of its amazing versatility, prednisone is sometimes prescribed when nothing else seems to work…sort of a medication of last resort or a forlorn hope.”
“Forlorn hope? What is that?”
“It’s like a ‘Hail Mary’ pass, Julie, only an ‘incomplete’ has much greater significance for the patient.”
“Except for the ‘forlorn hope,’ everything we’ve said about prednisone sounds pretty good. What about side effects?”
“The package insert with most medications describes a lot of side effects that rarely occur. With prednisone, many of the side effects almost always occur, especially if the med is taken for many weeks or months. Most patients seem to gain weight around the middle and acquire the ‘moon face’ that my neighbor, Bernie, observed. You know how female patients feel about that. A patient with the beginnings of cataracts will find that they bloom dramatically and soon require surgery.”
“I’ve read, Curmudge, that mood changes are common and that prednisone tablets have been referred to as ‘nasty pills.’ Other threats are osteoporosis, increased susceptibility to infections, general malaise, and shaky handwriting. Prednisone even has side effects if one suddenly stops taking it. The body’s own corticosteroid factory goes on standby in the presence of an external source of the chemical, and it takes awhile for it to resume production.”
“I observed a patient entering a physician’s waiting room who had apparently been on prednisone long term for a lung condition. She was grotesquely obese, in a wheelchair, and clutching an oxygen cylinder with a plastic tube leading up to the cannula in her nostrils. I heard another patient whisper with fierce resolve, ‘I don’t want to ever be like that.’ Little did she realize that death was the only sure way to avoid that fate. Can’t you envision a patient’s final words before expiring, ‘At least I won’t have to take any more prednisone.’?”
"Yuk! What a morose ending. Can’t you think of a brighter way to conclude today’s discussion?”
“I can, Jaded Julie. It’s called ‘precision medicine.’ As we quoted Clayton Christensen in The Crystal Ball 5, it is ‘the provision of care for diseases that can be precisely diagnosed, whose causes are understood, and which consequently can be treated with rules-based therapies that are predictably effective.’ If society doesn’t stifle creativity, our grandchildren won’t have to be treated with medications that have as many side effects as benefits.”
“Halleluiah amen, Curmudge!”
Affinity’s Kaizen Curmudgeon
“That must have been your introduction to corticosteroid medications, Curmudge. Have you ever experienced them first hand?”
“Right hand as well as left hand, Jaded Julie. Tendonitis in several of my fingers was treated with cortisone injections. The pain was exquisite as the doc probed around with the needle inside each finger trying to locate the tendon. But I never had to take prednisone, the common oral corticosteroid that is the topic for today’s discussion.”
“Pray tell, O Unpredictable Oracle, why your brain decided to focus on prednisone, of all things.”
“Prednisone has been around since the 1950’s, and it is prescribed for a wide variety of conditions. Patients who are anywhere north of clueless probably have heard that there is something about prednisone that they won’t like, but they might not recall what it is. We are going to tell those patients what is in store for them by sharing what I have observed in the past year.”
“In my training I learned that cortisone is produced in the body’s adrenal glands, and its synthetic form is prednisone. It was originally hailed as a wonder drug for its effect on patients with rheumatoid arthritis, and it is used for other autoimmune diseases like multiple sclerosis and lupus. A valuable property of corticosteroids is their ability to prevent release of substances in the body that cause inflammation; that explains the injections into the tendons of your fingers. Other treated conditions include inflammatory bowel disease, some lung diseases, severe allergies, and asthma.”
“Because of its amazing versatility, prednisone is sometimes prescribed when nothing else seems to work…sort of a medication of last resort or a forlorn hope.”
“Forlorn hope? What is that?”
“It’s like a ‘Hail Mary’ pass, Julie, only an ‘incomplete’ has much greater significance for the patient.”
“Except for the ‘forlorn hope,’ everything we’ve said about prednisone sounds pretty good. What about side effects?”
“The package insert with most medications describes a lot of side effects that rarely occur. With prednisone, many of the side effects almost always occur, especially if the med is taken for many weeks or months. Most patients seem to gain weight around the middle and acquire the ‘moon face’ that my neighbor, Bernie, observed. You know how female patients feel about that. A patient with the beginnings of cataracts will find that they bloom dramatically and soon require surgery.”
“I’ve read, Curmudge, that mood changes are common and that prednisone tablets have been referred to as ‘nasty pills.’ Other threats are osteoporosis, increased susceptibility to infections, general malaise, and shaky handwriting. Prednisone even has side effects if one suddenly stops taking it. The body’s own corticosteroid factory goes on standby in the presence of an external source of the chemical, and it takes awhile for it to resume production.”
“I observed a patient entering a physician’s waiting room who had apparently been on prednisone long term for a lung condition. She was grotesquely obese, in a wheelchair, and clutching an oxygen cylinder with a plastic tube leading up to the cannula in her nostrils. I heard another patient whisper with fierce resolve, ‘I don’t want to ever be like that.’ Little did she realize that death was the only sure way to avoid that fate. Can’t you envision a patient’s final words before expiring, ‘At least I won’t have to take any more prednisone.’?”
"Yuk! What a morose ending. Can’t you think of a brighter way to conclude today’s discussion?”
“I can, Jaded Julie. It’s called ‘precision medicine.’ As we quoted Clayton Christensen in The Crystal Ball 5, it is ‘the provision of care for diseases that can be precisely diagnosed, whose causes are understood, and which consequently can be treated with rules-based therapies that are predictably effective.’ If society doesn’t stifle creativity, our grandchildren won’t have to be treated with medications that have as many side effects as benefits.”
“Halleluiah amen, Curmudge!”
Affinity’s Kaizen Curmudgeon
Thursday, September 15, 2011
Sepsis 3
“Jaded Julie, I’ve read so many articles on sepsis in the past few weeks that my head is spinning.”
“I know you are confused most of the time, Curmudge, but do you have chills, a fever, or are you hyperventilating? Here, let me check your blood pressure.”
“No, Julie. I don’t have sepsis. It’s just that the articles are generally similar, and as a layperson, I wouldn’t understand subtle differences if I saw them. So from now on, I’m not going to sweat the details. I’ll leave them to the physicians and nurses. Our focus today will be on Affinity’s experience with sepsis, including diagnosis and management.”
“But we’ve already discussed diagnosis. Is there anything special that we do?”
“There is, Julie, and it’s a mannequin called iStan. iStan is the smartest dummy in town because he can be programmed to portray a vast array of symptoms of a host of diseases. For example, iStan’s software comes with a sepsis simulation scenario.”
“Well at least if he exhibits oliguria, there won’t be much of a puddle to clean up.”
“iStan is a new addition to our staff and has been used thus far for orientation of new hires. His use will grow as people get more familiar with his operation. I’m looking forward to being impressed whenever I can arrange a demonstration.”
“So what else is new, Curmudge? The links to Affinity documents in Sepsis 2 suggest that our hospitals are doing the right things in sepsis diagnosis and management.”
“There’s more to be told, Julie, but I promise…no clinical details. We have been using IHI’s Surviving Sepsis Guidelines since 2005 and the IHI Sepsis 6-Hour Resuscitation Bundle. These have been translated into pre-printed order sets, the Severe Sepsis Screening Tool and the Severe Sepsis Septic Shock Order Set: 6-Hour Resuscitation Bundle. If you read any of these, they would look pretty familiar.”
“And that’s the Lean standard work you were talking about. The value of these is that for severe sepsis and septic shock, one can’t afford to overlook any of the critical steps.”
“The ICU’s also use spreadsheets to track their compliance with each step in the resuscitation and management bundles for each patient.”
“Our procedures sound impressive, Curmudge. Are we saving lives?”
“I have some data from Mercy Medical Center, Julie. In 2004 the nation-wide mortality rate for sepsis was 28.6% (215,000 deaths). For MMC, the sepsis mortality rate was 11% in 2005-2006 and 6-7% in 2009. MMC treated 22 patients for sepsis from January 2011 through early August.”
“What might one do to avoid becoming a sepsis patient?”
“Avoid sepsis by avoiding infections. You and I talked about avoiding infections back on January 29, 2009. Although that posting was about nosocomial infections, one should also practice good hygiene at home. Teach your children about washing their hands and not neglecting a cut or scrape. If because of joint or other prior surgery you are directed to take a prophylactic med before having dental work, do it.”
“The mortality rate from sepsis in U.S. hospitals is worrisome enough. It’s undoubtedly higher in hospitals in the Third World.”
“One who travels to undeveloped countries should certainly have air-evacuation coverage in their trip insurance. If you contract sepsis in one of those strange-sounding places, your life may depend upon being airlifted out ASAP.”
“I understand that you found a valuable lesson in your reading last night. (Hey, Curmudge, get a life.)”
“The Smiths took their ill 7-year old son to the ED. Aside from nausea and a heart rate of 148, his vitals were normal. While he was at the ED his heart rate decreased and he was able to receive fluids. The Smiths wanted to leave, although results from the complete blood count were not yet back from the lab. The doctor, believing the child had a urinary tract infection, discharged the patient and told his parents that he should be better in 24 hours but to return if he is not.”
“I see impending trouble. What happened?”
“Within the next few hours, the child developed severe sepsis. He survived but suffered organ damage. The lesson: Stay with your sick child; lose a night’s sleep if necessary. If his condition deteriorates, don’t delay in returning to the ED. Incidentally, this scenario can occur with other illnesses such as appendicitis.”
“Actually Curmudge, that’s one of the perennial concerns of ER docs…that a patient will come in with a condition not well enough developed for a definitive diagnosis. Then the condition intensifies and clobbers the patient within 24 hours after he is sent home. So, Student of Medieval History, do you have a final perspective on sepsis?”
“Back in 1348 when the Black Death ravaged Europe, about three-fourths of the population of Great Britain died. The survivors were possibly not exposed to the sick people or the fleas carrying the disease, or perhaps they possessed a natural immunity. One of the three forms of the medieval plague was septicemic plague (the others were bubonic and pneumonic); its symptoms were similar to modern severe sepsis. In the 14th century, the mortality rate from septicemic plague was 99-100%. Patients sometimes died the same day they contracted the disease. The lesson: Sepsis was—and still is—a deadly condition.”
Affinity’s Kaizen Curmudgeon
“I know you are confused most of the time, Curmudge, but do you have chills, a fever, or are you hyperventilating? Here, let me check your blood pressure.”
“No, Julie. I don’t have sepsis. It’s just that the articles are generally similar, and as a layperson, I wouldn’t understand subtle differences if I saw them. So from now on, I’m not going to sweat the details. I’ll leave them to the physicians and nurses. Our focus today will be on Affinity’s experience with sepsis, including diagnosis and management.”
“But we’ve already discussed diagnosis. Is there anything special that we do?”
“There is, Julie, and it’s a mannequin called iStan. iStan is the smartest dummy in town because he can be programmed to portray a vast array of symptoms of a host of diseases. For example, iStan’s software comes with a sepsis simulation scenario.”
“Well at least if he exhibits oliguria, there won’t be much of a puddle to clean up.”
“iStan is a new addition to our staff and has been used thus far for orientation of new hires. His use will grow as people get more familiar with his operation. I’m looking forward to being impressed whenever I can arrange a demonstration.”
“So what else is new, Curmudge? The links to Affinity documents in Sepsis 2 suggest that our hospitals are doing the right things in sepsis diagnosis and management.”
“There’s more to be told, Julie, but I promise…no clinical details. We have been using IHI’s Surviving Sepsis Guidelines since 2005 and the IHI Sepsis 6-Hour Resuscitation Bundle. These have been translated into pre-printed order sets, the Severe Sepsis Screening Tool and the Severe Sepsis Septic Shock Order Set: 6-Hour Resuscitation Bundle. If you read any of these, they would look pretty familiar.”
“And that’s the Lean standard work you were talking about. The value of these is that for severe sepsis and septic shock, one can’t afford to overlook any of the critical steps.”
“The ICU’s also use spreadsheets to track their compliance with each step in the resuscitation and management bundles for each patient.”
“Our procedures sound impressive, Curmudge. Are we saving lives?”
“I have some data from Mercy Medical Center, Julie. In 2004 the nation-wide mortality rate for sepsis was 28.6% (215,000 deaths). For MMC, the sepsis mortality rate was 11% in 2005-2006 and 6-7% in 2009. MMC treated 22 patients for sepsis from January 2011 through early August.”
“What might one do to avoid becoming a sepsis patient?”
“Avoid sepsis by avoiding infections. You and I talked about avoiding infections back on January 29, 2009. Although that posting was about nosocomial infections, one should also practice good hygiene at home. Teach your children about washing their hands and not neglecting a cut or scrape. If because of joint or other prior surgery you are directed to take a prophylactic med before having dental work, do it.”
“The mortality rate from sepsis in U.S. hospitals is worrisome enough. It’s undoubtedly higher in hospitals in the Third World.”
“One who travels to undeveloped countries should certainly have air-evacuation coverage in their trip insurance. If you contract sepsis in one of those strange-sounding places, your life may depend upon being airlifted out ASAP.”
“I understand that you found a valuable lesson in your reading last night. (Hey, Curmudge, get a life.)”
“The Smiths took their ill 7-year old son to the ED. Aside from nausea and a heart rate of 148, his vitals were normal. While he was at the ED his heart rate decreased and he was able to receive fluids. The Smiths wanted to leave, although results from the complete blood count were not yet back from the lab. The doctor, believing the child had a urinary tract infection, discharged the patient and told his parents that he should be better in 24 hours but to return if he is not.”
“I see impending trouble. What happened?”
“Within the next few hours, the child developed severe sepsis. He survived but suffered organ damage. The lesson: Stay with your sick child; lose a night’s sleep if necessary. If his condition deteriorates, don’t delay in returning to the ED. Incidentally, this scenario can occur with other illnesses such as appendicitis.”
“Actually Curmudge, that’s one of the perennial concerns of ER docs…that a patient will come in with a condition not well enough developed for a definitive diagnosis. Then the condition intensifies and clobbers the patient within 24 hours after he is sent home. So, Student of Medieval History, do you have a final perspective on sepsis?”
“Back in 1348 when the Black Death ravaged Europe, about three-fourths of the population of Great Britain died. The survivors were possibly not exposed to the sick people or the fleas carrying the disease, or perhaps they possessed a natural immunity. One of the three forms of the medieval plague was septicemic plague (the others were bubonic and pneumonic); its symptoms were similar to modern severe sepsis. In the 14th century, the mortality rate from septicemic plague was 99-100%. Patients sometimes died the same day they contracted the disease. The lesson: Sepsis was—and still is—a deadly condition.”
Affinity’s Kaizen Curmudgeon
Wednesday, September 7, 2011
Sepsis 2
“Hey Curmudge, it was fun last week doing our folksy introduction to sepsis laced with ten-dollar words, but why so much technical stuff?”
“It’s hard to express the complexity of the human body without a few big words, which, you may have noticed, were all defined in the text. I also felt that any terms as hard to learn as those deserved to be spread around. By the way, I haven’t been holding my breath as you recommended last week. I’ve been reading about how health care handles sepsis. May I share?”
“You may, as long as you haven’t been reading a medicinal biochemistry text.”
“Articles on sepsis often start with its diagnosis. In reality, when a patient arrives in an ED, the ED doc’s first question isn’t, ‘Does this person have sepsis?’ His first mental query must be, ‘What’s wrong with this person?’ Then a lot of things happen almost simultaneously. The doc tries to alleviate the patient’s distress (she wouldn’t be in the ED if she didn’t have distress), performs a history and physical, and begins tests and interventions indicated by the history and physical.”
“Of course, several things can help the doc avoid starting at square one. If someone is accompanying the patient, they can help with the history. If the patient can’t communicate, that person would be essential. Similar information might also come along with the patient if she is sent from a skilled nursing facility. In addition, they should know if the patient has a fever and perhaps an infection and what organ is affected. In that case, the physician would order a blood culture before starting a broad-spectrum antibiotic.”
“In the physical—and possibly in triage—the first indication of sepsis will likely be signs of an infection, hypotension, a systolic BP of less than 90 or mean arterial pressure (MAP) less than 65. This tells the provider that time is of the essence, not only because of the crowded ED waiting room but because the patient’s life may be in the balance. All of the actions below should be taken within one hour of the patient’s arrival at the ED. IV access is established, and a fluid challenge and vasopressors (to raise blood pressure) would be ordered. An arterial line to measure consistent and accurate blood pressure and a central venous catheter to deliver IV fluids and vasopressors to the larger veins of the body should be placed immediately.”
“Now that sepsis is suspected, Curmudge, the next task is to learn how bad it might be. Here’s a useful algorithm:
1. SIRS (Systemic Inflammatory Response Syndrome): Temperature >100.4F (38C) or <96.8F (36C), heart rate >90, respiratory rate >20, WBC >12,000 or <4,000. Patient already found to be hypotensive.
2. Sepsis: SIRS plus source of infection.
3. Severe sepsis: Sepsis plus organ dysfunction.
4. Septic shock: Persistent hypotension and organ dysfunction despite aggressive fluid resuscitation.
If sepsis isn’t found, seek an alternative diagnosis. If sepsis is found, admit the patient to the hospital—the ICU for those with severe sepsis or septic shock—ASAP.”
“Transferring the patient to the ICU and to the care of intensivists and critical care nurses will bring the hospital’s best resources to bear on her condition. In general, these are the kinds of therapies that will be used:
1. Increase perfusion to organs and tissues by increasing blood pressure with fluid resuscitation and through the use of vasopressor medications (examples are norepinephrine and dopamine).
2. Treat the underlying infection through use of antibiotic therapy or surgery.
3. Provide oxygen and treat respiratory distress (if present).”
“Here are some (there are more) specific things to be done at Affinity hospitals (and elsewhere) for the sepsis patient. They should occur within the first six hours, and are called Early Goal-Directed Therapy.
1. Draw labs for blood cultures and obtain specimens from other sources for identification of infection. Serum lactate levels are an indicator of oxygen deficits (Curmudge, I put this in because I knew you’d be interested in the biochemistry).
2. Perfusion: If mean arterial pressure is <65, give sufficient IV fluids to assist in raising blood pressure. Start norepinephrine or dopamine to keep systolic BP >90 and mean arterial pressure >65. When fluid challenge therapy is not effective, implement Critical Care Nursing Considerations.
3. Oxygenation: Keep oxygen saturation >90%. Mechanical ventilation if needed.”
“Julie, putting the patient on a ventilator is certain to impress the patient’s relatives of the seriousness of her situation. The only patients that I’ve seen on a ventilator were at death’s door."
“Remember, Curmudge, that not all sepsis patients come in through the ED. Some are inpatients who have taken a turn for the worse. Nurses in the medical/surgical units are taught to watch for these observable symptoms in their routine rounding on the patients under their care:
1. Chills, shaking, low body temperature, or fever.
2. Rapid breathing (hyperventilation), lightheadedness, rapid heart beat.
3. Decreased urine output (oliguria).
4. Confusion or delirium.
5. Warm skin or skin rash.
These should trigger the nurse’s concern about SIRS. She should immediately initiate quantitative measures, like BP and temperature, and should contact the physician. More specific quantitative indicators of sepsis, used to augment routine bedside assessment, are listed in Affinity’s Cellular Perfusion Assessment Parameters.”
“Next week, Julie, let’s focus on Affinity’s experience with sepsis. We’ll point out how our care of sepsis patients exemplifies standard work, which is essential in implementing a Lean culture.”
“Lean, Curmudge! I was afraid that you’d forgotten about Lean.”
Affinity’s Kaizen Curmudgeon
“It’s hard to express the complexity of the human body without a few big words, which, you may have noticed, were all defined in the text. I also felt that any terms as hard to learn as those deserved to be spread around. By the way, I haven’t been holding my breath as you recommended last week. I’ve been reading about how health care handles sepsis. May I share?”
“You may, as long as you haven’t been reading a medicinal biochemistry text.”
“Articles on sepsis often start with its diagnosis. In reality, when a patient arrives in an ED, the ED doc’s first question isn’t, ‘Does this person have sepsis?’ His first mental query must be, ‘What’s wrong with this person?’ Then a lot of things happen almost simultaneously. The doc tries to alleviate the patient’s distress (she wouldn’t be in the ED if she didn’t have distress), performs a history and physical, and begins tests and interventions indicated by the history and physical.”
“Of course, several things can help the doc avoid starting at square one. If someone is accompanying the patient, they can help with the history. If the patient can’t communicate, that person would be essential. Similar information might also come along with the patient if she is sent from a skilled nursing facility. In addition, they should know if the patient has a fever and perhaps an infection and what organ is affected. In that case, the physician would order a blood culture before starting a broad-spectrum antibiotic.”
“In the physical—and possibly in triage—the first indication of sepsis will likely be signs of an infection, hypotension, a systolic BP of less than 90 or mean arterial pressure (MAP) less than 65. This tells the provider that time is of the essence, not only because of the crowded ED waiting room but because the patient’s life may be in the balance. All of the actions below should be taken within one hour of the patient’s arrival at the ED. IV access is established, and a fluid challenge and vasopressors (to raise blood pressure) would be ordered. An arterial line to measure consistent and accurate blood pressure and a central venous catheter to deliver IV fluids and vasopressors to the larger veins of the body should be placed immediately.”
“Now that sepsis is suspected, Curmudge, the next task is to learn how bad it might be. Here’s a useful algorithm:
1. SIRS (Systemic Inflammatory Response Syndrome): Temperature >100.4F (38C) or <96.8F (36C), heart rate >90, respiratory rate >20, WBC >12,000 or <4,000. Patient already found to be hypotensive.
2. Sepsis: SIRS plus source of infection.
3. Severe sepsis: Sepsis plus organ dysfunction.
4. Septic shock: Persistent hypotension and organ dysfunction despite aggressive fluid resuscitation.
If sepsis isn’t found, seek an alternative diagnosis. If sepsis is found, admit the patient to the hospital—the ICU for those with severe sepsis or septic shock—ASAP.”
“Transferring the patient to the ICU and to the care of intensivists and critical care nurses will bring the hospital’s best resources to bear on her condition. In general, these are the kinds of therapies that will be used:
1. Increase perfusion to organs and tissues by increasing blood pressure with fluid resuscitation and through the use of vasopressor medications (examples are norepinephrine and dopamine).
2. Treat the underlying infection through use of antibiotic therapy or surgery.
3. Provide oxygen and treat respiratory distress (if present).”
“Here are some (there are more) specific things to be done at Affinity hospitals (and elsewhere) for the sepsis patient. They should occur within the first six hours, and are called Early Goal-Directed Therapy.
1. Draw labs for blood cultures and obtain specimens from other sources for identification of infection. Serum lactate levels are an indicator of oxygen deficits (Curmudge, I put this in because I knew you’d be interested in the biochemistry).
2. Perfusion: If mean arterial pressure is <65, give sufficient IV fluids to assist in raising blood pressure. Start norepinephrine or dopamine to keep systolic BP >90 and mean arterial pressure >65. When fluid challenge therapy is not effective, implement Critical Care Nursing Considerations.
3. Oxygenation: Keep oxygen saturation >90%. Mechanical ventilation if needed.”
“Julie, putting the patient on a ventilator is certain to impress the patient’s relatives of the seriousness of her situation. The only patients that I’ve seen on a ventilator were at death’s door."
“Remember, Curmudge, that not all sepsis patients come in through the ED. Some are inpatients who have taken a turn for the worse. Nurses in the medical/surgical units are taught to watch for these observable symptoms in their routine rounding on the patients under their care:
1. Chills, shaking, low body temperature, or fever.
2. Rapid breathing (hyperventilation), lightheadedness, rapid heart beat.
3. Decreased urine output (oliguria).
4. Confusion or delirium.
5. Warm skin or skin rash.
These should trigger the nurse’s concern about SIRS. She should immediately initiate quantitative measures, like BP and temperature, and should contact the physician. More specific quantitative indicators of sepsis, used to augment routine bedside assessment, are listed in Affinity’s Cellular Perfusion Assessment Parameters.”
“Next week, Julie, let’s focus on Affinity’s experience with sepsis. We’ll point out how our care of sepsis patients exemplifies standard work, which is essential in implementing a Lean culture.”
“Lean, Curmudge! I was afraid that you’d forgotten about Lean.”
Affinity’s Kaizen Curmudgeon
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