Should Nurses Participate in M&M?

M&M has traditionally been a physician attended conference.  It is an excellent way to review cases in a non punitive manner.  The concept  is to look at the events that transpired during a patients stay in order to improve care.  Let’s face it we learn from all experiences, the good and the not so good.  For whatever reason M&M hasn’t been something that has been open to the nursing ranks, and if you think about it that seems like a missed opportunity.  Nurses are at the bedside delivering the care that is ordered.  In the event that something occurred and the patient had a less than desirable outcome, this would be a great place to learn and ultimately improve our own practice.

As and ED nurse I can definitely recall getting a really sick patient working with shutterstock_222269452our team to stabilize them and off to ICU they would go.  We rarely would hear back about how the patient made out.  If you’ve worked in a busy ED you know that there is very little time for follow up, but if we did have the time, imagine what we could learn.

Not long ago a patient came in with respiratory distress related to CHF.  The patient had a long standing history of heart failure and an EF of about 20%.  Hewas put on bipap and a nitro drip.  His BP tanked while on the drip and he was given a fluid bolus.  He eventually stabilized and was moved to a step-down room.  A few weeks later his relative was in the ED and I found out he had died within a few days of his arrival.

Our facility has a policy for vasoactive drips, q 5 minute vitals until the patient is titrated.  Unfortunately  for whatever reason this patient wasn’t
monitored according to policy and the fluid bolus was given to correct the hypotension.

His death frustrated me. I did what I thought should be done.  I spoke with the educator and an assistant director and suggested that the nurse who was caring for the patient review the policy.  I’m not sure if that was ever done.  I had suggested that the entire staff be reminded of the policy, because this was possibly something that could have been prevented.

M&M could be very helpful in nursing education.  Perhaps this situation could have become something that changed a practice because it would essential provide a 360 view of this patient’s experience as well as a platform for improvements in a department.

As nursing professionals we can only improve if we know where we need to improve.  Moving someone out of an ED or ICU isn’t the end of their care journey.

 

Sepsis Incentive Pay Is Coming to Town

 

Just in time for the holidays a new crowd favorite, sepsis incentive payments.  That’s right, brought to you by the folks at the Centers for Medicare & Medicaid Services (CMS).  So here’s the list, be sure to check it twice, because not recognizing sepsis and meeting the bundles set by CMS can certainly lead to a poor patient outcome as well as an unpaid bill and lost revenue for your department and facility. CODES

Sepsis identification can be a bit of a minefield, the symptoms could be sepsis and then again it might not be sepsis.  This very discussion is something that I know all to well.  As one of two nurses who helped develop a SIRS and Code Sepsis protocol in my shop, this was something that the physicians and nurses agonized over, but this is the criteria that CMS is utilizing, and yes this will make flu season interesting.

So here is the SIRS criteria— if you have two or more of the following with a known or suspected infection call Sepsis!

  1. Temperature greater than 101.0 F or less than 96.8 F
  2. Respiratory Rate greater than 20
  3. Tachycardia, rate greater than 90
  4. WBC count above 12,000 or less than 4,000 (this one is kind of hard unless they come in with labs and present them to you in triage)  *If your patient from triage is on Neupogen there’s probably a reason why.. “Do you known what your last WBC count was?”

Additional signs include:

  • Altered mental status
  • Elevated lactate, greater than 2.0, at 4.0 you might be dealing with a the beast!
  • Hypotension SBP below 90
  • Hyperglycemia without history of diabetes

The sepsis time clock begins clicking the moment the patient is triaged for CMS reimbursement, but the patient’s sepsis timer started counting long before they came through your door.

The Bundles (tied to your reimbursement)
TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

“Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
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 according to Table 1.
7. Re-measure lactate if initial lactate elevated.

DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH:

EITHER:

• Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.

OR TWO OF THE FOLLOWING:

• Measure CVP
• Measure ScvO2
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

Of note, the 6-hour bundle has been updated; the 3-hour SSC bundle is not affected.

We are still woking out the kinks in our sepsis response.  We have a cancer institute attached to our facility as well as a sea of nursing homes and assisted living facilities.  Often enough the folks that roll through our doors are coming to us in less than ideal health and likely well into the sepsis spiral.  This isn’t the time to play hot potato patient and park them out of the way because nobody wants the work! Sepsis is work.  Sepsis work ups are a lot of work, especially if you are doing it by yourself.  You need a team willing to work together to get-it-done! Every minute that goes by is a minute you never get back.  Small delays add up at the patient’s expense both literally and figuratively speaking.

If you have a bias about a million dollar workup on a 90-year old aspiration pneumonia urosepsis repeat offender, then you have two choices: 1) leave the profession or 2) check your ego and bias at the ambulance bay and get to work, because it doesn’t matter what you think is a ridiculous treatment, this is someone’s loved one and if they are in your ED they deserve to be cared for according to their wishes and best practice.

While the majority of septic patients will be part of the elderly population you have to keep an eye out for the younger SIRS crowd.  The potential for these folks to go bad is absolutely a good possibility especially if there are preexisting illnesses.  Your walking SIRS patients deserve a good triage, and not the 2 minute get them in and out of your chair, because you think it’s a treat em’ and street em’ flu.  Spend that extra minute to ask a few deeper questions and take  a better look.  That extra minute might mean the difference as to where you put them in your ED and how much monitoring they get before they crash.

A 34 year old female with a history of HIV comes in complaining of 3 days of fever and a non productive cough.  Vitals on triage are T 103, P 115, BP 100/62,  RR 20 and POX on room air is 97%  She is compliant with her HIV meds and AOX3.  She meets SIRS criteria because of her temperature and heart rate, we have a suspected infection.  She’s not meeting septic criteria because she isn’t hypotensive, doesn’t show altered mental status or low pulse ox.  She gets a set of labs, a chest X-ray that shows a right lower lobe pneumonia.  She gets IV hydration 2 liters of NS.  Unfortunately she’s not being closely monitored.  Two hours later, it’s shift change and time for repeat vitals: BP 74/43, HR 110, POX 95%, T 99.1, RR 20.  An additional 1 L NS bolus is given and a repeat lactate is drawn, the first lactate was 1.6, blood cultures are drawn.  The patient’s vitals are checked every 15 minutes per policy.  The SBP after bolus is 98, but doesn’t hold.  The patient is moved to the more critical part of the ED and is admitted to ICU.  The nurse that had originally received the patient had 7 additional patients before change of shift vitals were completed. The triage nurse didn’t call the sepsis alert because she didn’t feel that there was a site of infection, the patient wasn’t coughing at the time.

There are a few issues in this case that warranted sepsis re-education.  One of the biggest obstacles though wasn’t clinical, it was peoples preconceived ideas of sick and not sick. There was a sense of false security that sepsis is a disease process of older people. News flash: Sepsis does not discriminate!

https://youtu.be/DnsQ4RlXsZY