@ Dana re: Lactic Acid The different Lactic Acid values correspond with the method of collection. For serum blood draw, >4.0 is considered abnormal high For arterial stick, >1.7 For venous Point of Care testing, >2.0.
Do the articles reference which method they are attaching the value to? Laurie A. Hiebert, BSN, RN Clinical Process Improvement Analyst Critical Care Performance Improvement Florida Hospital System Office: 407-303-2800 ext 110-1572 Cell: 407-312-4294 Fax: 407-303-2705 -----Original Message----- From: [email protected] [mailto:[email protected]] On Behalf Of [email protected] Sent: Friday, November 22, 2013 9:24 AM To: [email protected] Subject: Sepsisgroups Digest, Vol 84, Issue 2 Send Sepsisgroups mailing list submissions to [email protected] To subscribe or unsubscribe via the World Wide Web, visit http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org or, via email, send a message with subject or body 'help' to [email protected] You can reach the person managing the list at [email protected] When replying, please edit your Subject line so it is more specific than "Re: Contents of Sepsisgroups digest..." Today's Topics: 1. Q&A for SSC Data Collection/Abstraction (Stephen Davidow) 2. exclusions (DanaMarie Smith) 3. Lactic Acid (DanaMarie Smith) ---------------------------------------------------------------------- Message: 1 Date: Thu, 21 Nov 2013 12:49:30 -0600 From: Stephen Davidow <[email protected]> To: "'[email protected]'" <[email protected]> Subject: [Sepsis Groups] Q&A for SSC Data Collection/Abstraction Message-ID: <[email protected]> Content-Type: text/plain; charset="us-ascii" Dear Colleagues: One member of the listserv recently posted a number of questions related to data abstraction, the data collection tool and the SSC database. Christa Schorr, RN, MSN, FCCM, the principal architect of the tool responded and I thought the community would find this Q&A valuable. Best wishes, Stephen Hello SSC We recently started abstraction into the SSC database and we have quite a few questions. Please respond back with answers/guidance so we can correctly abstract to give us and the benchmark group accurate data. 1. What is supposed to be used for "Date/time of screening" on Screen 2. In our institution, we don't document the time we screened a patient, we only document Time Zero (Presentation Time) In this case you may want to consider using this time block as the date and time that the abstractor is reviewing the chart as time of screening. Previously abstractors have used this in several ways, one as retrospective review (date and time of data entry) and another method for those doing concurrent bedside review, entering date and time of data entry. This particular item is not dependent on meeting the indicators. 2. If a patient transfers to us from another hospital with a diagnosis of Septic Shock, what to we use as "Date/time of screening" AND what do we use for "Time Zero" . We have recommended not including transfer patients in the database, since the critical first 6 hours of care are most often managed at the outside hospital. Therefore, time zero was at the OSH not the receiving institution. It is quite difficult to interpret/credit the efforts at the OSH. It is therefore a challenge to be meet the indicators when the patient was at another facility during the acute phase of sepsis. 2. We find the instructions surrounding Blood Culture/Antibiotic timing confusing. Can someone send us an example or another descriptor that is a bit more clear. I will do my best to give an example (s). If a patient was in the hospital (floor or ICU) being treated for sepsis (suspicion or confirmed infection), had blood cultures drawn and was started on antibiotics for the infection, now develops acute organ dysfunction (severe sepsis) and antibiotics were continued through the time of presentation, the first box would be checked. Example: Patient admitted to the floor with cellulitis on day 1 (blood cultures done and antibiotics started and continued through day 2), develops hypotension and elevated lactate on day 2 (severe sepsis)-meets criteria for severe sepsis. The blood culture and antibiotic indicators are met and the first check box is used. The date and time are not required in this example. If the patient develops a new suspected of confirmed infection, (for example, presents to the ED, develops a CLABSI on the floor or sternal wound infection in the ICU) and an acute organ dysfunction, the you would enter the date and time of blood cultures and antibiotic administration associated. Example 1: Patient presents to the emergency department with fever, WBC 14,000, lactate 2.5 and hypotension-blood cultures are drawn and antibiotics started. The date and time of the blood cultures is recorded and needs to be prior to antibiotic administration to meet the indicator. The date and time of the first antibiotic should be recorded first and any subsequent antibiotics can be added to the list. Indicator achievement is based on the first antibiotic. Example 2: Patient admitted to the ICU post CABG surgery, has some difficulty with the post-op course and develops a sternal wound infection on ICU day 5 with acute oliguria and hypotension. Blood cultures are sent and antibiotics are started. The date and time of blood cultures is entered as well as the administration of the antibiotics. 3. If fluid completion time is not documented, what do we do? We included this element to help sites track their resuscitation efforts, as many reported challenges with early, appropriate resuscitation. In order to determine if a patient met the fluid resuscitation requirements within the 3 hour time window, the abstractor would need to determine if 30 ml/kg was administered. Based on documentation, the abstractor may have use his/her best judgment as to when the 30 ml/kg was completed. 4.5 BP-Fluid Resuscitation tab. question 7d, for how long does the MAP need to remain >= 65 for the question "did MAP rise and remain >= 65". ex. if it rose and remained for 3 hrs, but then dropped how do we answer this question. This is not clearly defined, but we should consider at least during the initial resuscitation period. As we know some patients are a challenge and we will have some that do not fit into each box in the same way. This is also an important item for those who have an elevated lactate >=4 and require fluids but are not hypotensive. 5. In our institution, we count a Lactic Acid >4 as Septic Shock. Is there any plan for SSC to do this in the future? The definition for septic shock is sepsis induced hypotension not responsive to adequate fluid resuscitation (30 ml//kg), requiring vasopressors to maintain a MAP >=65 mmHg. If the patient does have a lactate >4, this subject falls into severe sepsis with sepsis-induced organ dysfunction or tissue hypoperfusion. 6. How do we document date/time for a CVP line that was in place prior to admission. The database does not currently include this option of checking that a line was previously placed. If the line was placed after time of presentation with severe sepsis that would be our first choice. In this case where the line was placed prior to time of presentation, the most appropriate date and time is the time of presentation. This would be interpreted as a line already in place at time of presentation. 7. If a patient is made comfort care within 24 hours, do you include them in the database? We have recommended that these patients not be included in the database, as there are limitations placed on the ability to achieve the indicators. If there are limitations on support such as, refuses central line or mechanical ventilation, this would impact the ability to fully manage the patient's care. However, if there is a DNR status documented, but aggressive procedures have been done for this acute illness, we would include this patient. The DNR status in this case would be if a cardiac arrest should occur, the patient/family does not want CPR. 8. How often do you recommend Export/Transfer of data. We have recommended export/transfer data monthly. Stephen L. Davidow, MBA-HCM, APR | Manager, Quality Implementation Programs | Society of Critical Care Medicine 500 Midway Drive, Mount Prospect, IL 60056-5811 USA t: +1 847.827.7088 | f: +1 847.827.7123 | www.sccm.org www.facebook.com/SCCM1 | www.twitter.com/SCCM | www.youtube.com/SCCM500 -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20131121/ff4892b5/attachment-0001.htm> ------------------------------ Message: 2 Date: Fri, 22 Nov 2013 09:00:04 -0500 From: "DanaMarie Smith" <[email protected]> To: <[email protected]> Subject: [Sepsis Groups] exclusions Message-ID: <[email protected]> Content-Type: text/plain; charset="us-ascii" Hi Everyone, I am collecting data on Sepsis Alerts we are currently running in our three EDs not inpatient yet. I also get HIM reports on severe sepsis we might have missed in the ed and not alerted. My question is on exclusions I know if they come in and are made comfort measures right away they are excluded. I have had some cases where the person came in as a STEMI and was treated for that first then discovered they also have sepsis and another case came in for severe GI bleed had to be stabilized and then realized they had severe sepsis. So I just want to be clear what patients should be excluded from the data collection. Thank You, Dana Dana Marie Smith RN Clinical Data Analyst Quality/Performance Improvement Phone # 215- 612-5354 Fax # 215-612-4463 This message and any attachments contain information that may be confidential and privileged. If you have received this in error and are not the intended recipient, you may not use, copy or disclose this message or its contents to anyone. If you have received this message in error, please advise the sender by reply e-mail, and delete or destroy this message and its attachments. -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20131122/da565eeb/attachment-0001.htm> ------------------------------ Message: 3 Date: Fri, 22 Nov 2013 09:09:35 -0500 From: "DanaMarie Smith" <[email protected]> To: <[email protected]> Subject: [Sepsis Groups] Lactic Acid Message-ID: <[email protected]> Content-Type: text/plain; charset="us-ascii" Im sorry just one more question. For the Lactic Acid, I have been collecting if its >4 as criteria for severe sepsis but I have been seeing articles saying they are considering >2 as criteria for severe sepsis. So I guess my question is do I count Lactic Acid >2 as severe sepsis and the Lactic Acid >4 is for the 6 hr bundle? Thank You, Dana Dana Marie Smith RN Clinical Data Analyst Quality/Performance Improvement Phone # 215- 612-5354 Fax # 215-612-4463 This message and any attachments contain information that may be confidential and privileged. If you have received this in error and are not the intended recipient, you may not use, copy or disclose this message or its contents to anyone. If you have received this message in error, please advise the sender by reply e-mail, and delete or destroy this message and its attachments. -------------- next part -------------- An HTML attachment was scrubbed... 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