We use Epic as our EMR and use sepsis order sets. One order is " after IV bolus is given( 30 ml/kg), the nurse is to notify the provider, physician or MLP, to reasses the patient.
We made a post bolus or 3 hour patient reassessment template which pulls in vital signs and addresses cardiopulmonary exam, capillary refill, and other signs of reperfusion. The order to notify the provider is timed and shows up on her task sheet. I can't remember the exact name of the nurses screen. Evan Sorett, MD, FCCP, FACP Director of Critical Care & Informatics St. Francis Hospital Roslyn, New York [email protected] Sent from my iPhone > On Oct 24, 2015, at 10:59 AM, [email protected] > wrote: > > 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. Re: DNR, DNI, and comfort care with regards to the septic > shock requirements (Prabhakar, Brenda) > 2. Repeat Volume Status and Tissue Perfusion Assessment > (Claire Sirois-Melvin) > 3. Re: DNR, DNI, and comfort care with regards to the septic > shock requirements (Delude, Dale) > > > ---------------------------------------------------------------------- > > Message: 1 > Date: Thu, 22 Oct 2015 14:46:49 +0000 > From: "Prabhakar, Brenda" <[email protected]> > To: "Delude, Dale" <[email protected]>, "Townsend, Sean, > M.D." <[email protected]> > Cc: "[email protected]" > <[email protected]> > Subject: Re: [Sepsis Groups] DNR, DNI, and comfort care with regards > to the septic shock requirements > Message-ID: > <[email protected]> > Content-Type: text/plain; charset="us-ascii" > > It seems to me that care was taken to clearly define administrative > contraindications to care with regards to the severe sepsis measure > components but not for the septic shock components. Is this an oversight or > is there some rationale for this decision? > > Brenda Prabhakar RN BSN > Sepsis Steering Committee Co-Chair > Doylestown Hospital > Doylestown, PA > ________________________________________ > From: Delude, Dale [[email protected]] > Sent: Thursday, October 22, 2015 10:27 AM > To: Townsend, Sean, M.D. > Cc: Prabhakar, Brenda; [email protected] > Subject: RE: [Sepsis Groups] DNR, DNI, and comfort care with regards to the > septic shock requirements > > However, without the central line vasopressors can't be administered. > > Dale DeLude > P.I. Specialist > Advocate Condell Medical Center > 801 S. Milwaukee Ave. > Libertyville, IL 60048 > Telephone: 847-990-5863 > Fax: 847-573-4251 > [email protected] > > This e-mail, and any attachments thereto, is intended only for use by the > addressee(s) named herein and may contain legally privileged and/or > confidential information. If you are not the intended recipient of this > e-mail (or the person responsible for delivering this document to the > intended recipient), you are hereby notified that any dissemination, > distribution, printing or copying of this e-mail, and any attachments > thereto, is strictly prohibited. If you have received this e-mail in error, > please respond to the individual sending the message and permanently delete > the original and any copy of any e-mail and any printout thereof. > > > > > -----Original Message----- > From: Townsend, Sean, M.D. [mailto:[email protected]] > Sent: Thursday, October 22, 2015 9:25 AM > To: Delude, Dale > Cc: Prabhakar, Brenda; [email protected] > Subject: Re: [Sepsis Groups] DNR, DNI, and comfort care with regards to the > septic shock requirements > > The reason for no exclusion for central line placement is that the physical > exam option means the line is not mandatory. > > The vasopressor issue wasn't envisioned as something a patient would refuse, > but I suppose it is conceivable. In any case as others have said here there > is no refusal option for vasopressors. > > Sean > > On Oct 22, 2015, at 5:15 AM, Delude, Dale > <[email protected]<mailto:[email protected]>> wrote: > > Good Morning Dr. Townsend, > > I respectfully disagree that the patient refusing vasopressors will be > excluded from the measure. The abstraction guideline and algorithm only > excludes patients who are refusing blood draw, fluid administration, or > antibiotic administration, or those patients who have a directive for comfort > care documented within 6 hours of septic shock presentation. There is also > no out for those patients who refuse to have a central line inserted for > administration of vasopressors. > > Dale DeLude > P.I. Specialist > Advocate Condell Medical Center > 801 S. Milwaukee Ave. > Libertyville, IL 60048 > Telephone: 847-990-5863 > Fax: 847-573-4251 > [email protected]<mailto:[email protected]> > > This e-mail, and any attachments thereto, is intended only for use by the > addressee(s) named herein and may contain legally privileged and/or > confidential information. If you are not the intended recipient of this > e-mail (or the person responsible for delivering this document to the > intended recipient), you are hereby notified that any dissemination, > distribution, printing or copying of this e-mail, and any attachments > thereto, is strictly prohibited. If you have received this e-mail in error, > please respond to the individual sending the message and permanently delete > the original and any copy of any e-mail and any printout thereof. > > > > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Townsend, Sean, M.D. > Sent: Wednesday, October 21, 2015 5:16 PM > To: 'Prabhakar, Brenda'; > [email protected]<mailto:[email protected]> > Subject: Re: [Sepsis Groups] DNR, DNI, and comfort care with regards to the > septic shock requirements > > As regards your questions, yes if they are refusing a required intervention > then they may be excluded (vasopressors). > > With respect to the later question on DNI patients, I think to get to use the > comfort measures exclusion I would document that rather than being intubated > the patient prefers comfort strategies and thus trigger the exclusion. > > Sean R. Townsend, M.D. > Vice President of Quality & Safety > California Pacific Medical Center > 2330 Clay Street, #301 > San Francisco, CA 94115 > email [email protected]<mailto:[email protected]> > office (415) 600-5770 > fax (415) 600-1541 > > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Prabhakar, Brenda > Sent: Wednesday, October 21, 2015 4:50 AM > To: > [email protected]<mailto:[email protected]> > Subject: [Sepsis Groups] DNR, DNI, and comfort care with regards to the > septic shock requirements > > Hello everyone. Thank you all for you questions and answers online. They've > been very helpful. > My physicians are wondering how to handle those patients who have advanced > directives but are not yet comfort care. > > * If they are refusing vasopressors, is it correct that they would NOT be > included in the measure for septic shock with persistent hypotension? They > are refusing one the measure components to give vasopressors. > * If they are a DNI (Do Not Intubate), often times the physicians are > concerned they could put their patients into CHF if they order the full > 30ml/kg fluid bolus without the ability to intubate if required. I've read > the prior lively discussions about fluid resuscitation and the lack of data > reporting any harm from administering the boluses, but Dr. Townsend also > brought up the good point that intubation isn't always an adverse outcome. > Any insight with how to manage these patients would be greatly appreciated. > > Thank you, > Brenda Prabhakar RN BSN > Sepsis Steering Committee Co-Chair > Doylestown Hospital > Doylestown, PA > This e-mail, and any attachments thereto, is intended only for use by the > addressee(s) named herein and may contain legally privileged and/or > confidential information. If you are not the intended recipient of this > e-mail (or the person responsible for delivering this document to the > intended recipient), you are hereby notified that any dissemination, > distribution, printing or copying of this e-mail, and any attachments > thereto, is strictly prohibited. If you have received this e-mail in error, > please respond to the individual sending the message and permanently delete > the original and any copy of any e-mail and any printout thereof. > This e-mail, and any attachments thereto, is intended only for use by the > addressee(s) named herein and may contain legally privileged and/or > confidential information. If you are not the intended recipient of this > e-mail (or the person responsible for delivering this document to the > intended recipient), you are hereby notified that any dissemination, > distribution, printing or copying of this e-mail, and any attachments > thereto, is strictly prohibited. If you have received this e-mail in error, > please respond to the individual sending the message and permanently delete > the original and any copy of any e-mail and any printout thereof. > > > > ------------------------------ > > Message: 2 > Date: Thu, 22 Oct 2015 17:02:38 +0000 > From: Claire Sirois-Melvin <[email protected]> > To: "[email protected]" > <[email protected]> > Subject: [Sepsis Groups] Repeat Volume Status and Tissue Perfusion > Assessment > Message-ID: > > <by1pr0601mb152982bdd1cbf7bdde8fd057d7...@by1pr0601mb1529.namprd06.prod.outlook.com> > > Content-Type: text/plain; charset="us-ascii" > > Hello, > > > Do any facilities have anything built into their electronic medical record to > assist in addressing the Repeat volume status and tissue perfusion > assessment piece of the bundle and if so, is there a mechanism to trigger the > Physician/ PA/ APN to perform this within a certain timeframe. > > > > We would be grateful for anyone willing to share what they have currently or > what they are in the process of building. > > > > Thanks so much, > > > > Claire > > > Claire Sirois-Melvin RN, BSN > Quality Measure Resource Specialist - Steward Healthcare > 824 Oak Street, Brockton, MA 02301 > Email: [email protected] > > -------------- next part -------------- > An HTML attachment was scrubbed... > URL: > <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20151022/bf5dade0/attachment-0001.htm> > > ------------------------------ > > Message: 3 > Date: Thu, 22 Oct 2015 12:15:19 +0000 > From: "Delude, Dale" <[email protected]> > To: "Townsend, Sean, M.D." <[email protected]>, "'Prabhakar, > Brenda'" <[email protected]>, "[email protected]" > <[email protected]> > Subject: Re: [Sepsis Groups] DNR, DNI, and comfort care with regards > to the septic shock requirements > Message-ID: > > <bn3pr0701mb1621508f623b38ecf63acf979d...@bn3pr0701mb1621.namprd07.prod.outlook.com> > > Content-Type: text/plain; charset="us-ascii" > > Good Morning Dr. Townsend, > > I respectfully disagree that the patient refusing vasopressors will be > excluded from the measure. The abstraction guideline and algorithm only > excludes patients who are refusing blood draw, fluid administration, or > antibiotic administration, or those patients who have a directive for comfort > care documented within 6 hours of septic shock presentation. There is also > no out for those patients who refuse to have a central line inserted for > administration of vasopressors. > > Dale DeLude > P.I. Specialist > Advocate Condell Medical Center > 801 S. Milwaukee Ave. > Libertyville, IL 60048 > Telephone: 847-990-5863 > Fax: 847-573-4251 > [email protected] > > This e-mail, and any attachments thereto, is intended only for use by the > addressee(s) named herein and may contain legally privileged and/or > confidential information. If you are not the intended recipient of this > e-mail (or the person responsible for delivering this document to the > intended recipient), you are hereby notified that any dissemination, > distribution, printing or copying of this e-mail, and any attachments > thereto, is strictly prohibited. If you have received this e-mail in error, > please respond to the individual sending the message and permanently delete > the original and any copy of any e-mail and any printout thereof. > > > > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Townsend, Sean, M.D. > Sent: Wednesday, October 21, 2015 5:16 PM > To: 'Prabhakar, Brenda'; [email protected] > Subject: Re: [Sepsis Groups] DNR, DNI, and comfort care with regards to the > septic shock requirements > > As regards your questions, yes if they are refusing a required intervention > then they may be excluded (vasopressors). > > With respect to the later question on DNI patients, I think to get to use the > comfort measures exclusion I would document that rather than being intubated > the patient prefers comfort strategies and thus trigger the exclusion. > > Sean R. Townsend, M.D. > Vice President of Quality & Safety > California Pacific Medical Center > 2330 Clay Street, #301 > San Francisco, CA 94115 > email [email protected]<mailto:[email protected]> > office (415) 600-5770 > fax (415) 600-1541 > > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Prabhakar, Brenda > Sent: Wednesday, October 21, 2015 4:50 AM > To: > [email protected]<mailto:[email protected]> > Subject: [Sepsis Groups] DNR, DNI, and comfort care with regards to the > septic shock requirements > > Hello everyone. Thank you all for you questions and answers online. They've > been very helpful. > My physicians are wondering how to handle those patients who have advanced > directives but are not yet comfort care. > > * If they are refusing vasopressors, is it correct that they would NOT be > included in the measure for septic shock with persistent hypotension? They > are refusing one the measure components to give vasopressors. > * If they are a DNI (Do Not Intubate), often times the physicians are > concerned they could put their patients into CHF if they order the full > 30ml/kg fluid bolus without the ability to intubate if required. I've read > the prior lively discussions about fluid resuscitation and the lack of data > reporting any harm from administering the boluses, but Dr. Townsend also > brought up the good point that intubation isn't always an adverse outcome. > Any insight with how to manage these patients would be greatly appreciated. > > Thank you, > Brenda Prabhakar RN BSN > Sepsis Steering Committee Co-Chair > Doylestown Hospital > Doylestown, PA > This e-mail, and any attachments thereto, is intended only for use by the > addressee(s) named herein and may contain legally privileged and/or > confidential information. If you are not the intended recipient of this > e-mail (or the person responsible for delivering this document to the > intended recipient), you are hereby notified that any dissemination, > distribution, printing or copying of this e-mail, and any attachments > thereto, is strictly prohibited. If you have received this e-mail in error, > please respond to the individual sending the message and permanently delete > the original and any copy of any e-mail and any printout thereof. > -------------- next part -------------- > An HTML attachment was scrubbed... > URL: > <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20151022/05c2a20a/attachment.htm> > > ------------------------------ > > Subject: Digest Footer > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > > > ------------------------------ > > End of Sepsisgroups Digest, Vol 176, Issue 14 > ********************************************* _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
