Maternal Sepsis

1. Implementing a Protocol and
Interprofessional Education for Early
Recognition and Management of
Maternal Sepsis
Presented by: Lori Olvera DNP, RNC-OB, EFM-C

2. Objectives
At the conclusion of this learning session the participant will be able
to:
 Identify differences between Sepsis, Severe Sepsis, and Septic
Shock
 Identify symptoms for early recognition and how to manage the
septic patient
 Identify the importance of implementing OB sepsis screening in
the perinatal setting
 Identify the importance of implementing protocols for early
recognition and management of maternal sepsis
 Identify the importance of using key stakeholders, RN
champions, Physician champions for implementing sepsis
screening and management of maternal sepsis.
 Identify the importance of using data collection to develop a
program in maternal sepsis.
 Identify the importance of training all perinatal staff in early
recognition & management of maternal sepsis.
2

3. Code Sepsis in OB: Let’s Intervene before it
hits!

4. Maternal Sepsis Video
• http://bcove.me/sd6wl76t

6. Katie dies of FLU at 26!

7. Pregnant Patients
need to be included in
our Sepsis Protocols!
“Pregnancies complicated by severe
sepsis and septic shock are associated
with increased rates of preterm labor, fetal
infection, and preterm delivery. Sepsis
onset in pregnancy can be insidious,, and
patients may appear deceptively well
before rapidly deteriorating with the
development of severe shock, multiple
organ dysfunction syndrome, or death.
The outcome and survivability in severe
sepsis and septic shock in pregnancy are
improved with early detection, prompt
recognition of the source of infection, and
targeted therapy”
Barton & Sibai,
2012

8.  Acute Pyelonephritis
 Retained Products of Conception
 Neglected Chorioamnionitis or endometritis
 Pneumonia
1. Bacterial
2. Viral
 Influenza
 H1N1
 Unrecognized or inadequately treated necrotizing fasciitis
1. Abdominal incision
2. Episiotomy/Perineal Laceration
 Intraperitoneal Etiology
1. Ruptured Appy
2. Acute Cholecystitis
3. Bowel Infarction
 Urinary Tract Infections
 Mastitis
CAUSES OF SEVERE SEPSIS &
SEPTIC SHOCK IN
PREGNANCY & PUERPERIUM

9. Infectious disease ranks one of the four most
common causes of maternal mortality and
severe morbidity
Sepsis is one of the leading causes of
preventable maternal deaths.
This is an example text. Go ahead and
replace it
The lack of recognition of early warning signs
of sepsis and guidelines to manage treatment
of sepsis contributes to these preventable
deaths
1
2
3
4
5
Sepsis bundles – even when used
incompletely –significantly decrease mortality
(SSC 2013)
Septic shock is rare affecting
.002-0.01 % of all deliveries
Sepsis Facts

10.  Sepsis is one of the top four causes of maternal mortality
 Pregnant women are more vulnerable to infection and
susceptible to serious complications
 Screening protocols are needed for early recognition and
management of maternal sepsis
 All perinatal staff must be trained on early recognition and
management of maternal sepsis.
What does the literature say…..
Acosta, Kurinczuk,
Lucas, Tufnell, Sellers
& Knight, 2014

11. 1. More women over 40 becoming pregnant
2. Availability of “assisted reproductive technologies” results
in more invasive monitoring due to incidence of multifetal
gestation
3. Disorders of pregnancy such as preeclampsia, placental
abruption, amniotic fluid embolism, and PPH
4. Increasing rates of Obesity, diabetes, and C/S delivery
5. C/S delivery: 3 times more likely to develop sepsis
Maternal Sepsis
Why is maternal sepsis on the rise?
Acosta &
Knight, 2013

12.  C/S delivery
 Emergency C/S
 Prolonged Rupture of the
Membranes
 Retained products of Conception
 Preterm Labor
 Multiple Vaginal Exams
 Obesity
 Diabetes
 Anemia
 Low socioeconomic status
 Winter months
 Failure to recognize severity
Risk Factors for Sepsis

13. OB Sepsis Syndrome
OB Specific Criteria
SIRS = Systemic Inflammatory Response Syndrome

14.  Definition
A clinical manifestation resulting from an insult,
infection, or trauma, that includes a body-wide
activation of immune and inflammatory cascades
Systemic Inflammatory Response

15. Insult: Can be from anything
• Burn
• Trauma
• Infection
• Surgery
• Myocardial Infarction
• Pancreatitis
• Anesthesia
• Allergic reaction

16. Pathophysiology of Sepsis
https://www.youtube.com/watch?v=o5sYBUarpmI

17. Inflammatory mediators
(histamines, serotonin,
cytokines) cause increase
vascular permeability and
vasodilation
Vascular Permeability: Increase
permeability of blood vessels; leaky
vessels
• Migration of leukocytes to site of
injury
Vasodilation: widening of blood
vessels, resulting in pooling of blood,
causing a relative decrease in
intravascular volume; plasma &
molecules leak into extravascular
space
Pathophysiology
Obstetrical patient with Sepsis

18. • Small molecules such as Na,
H2O leak through leaky vessels
• Some larger molecules such as
ALBUMIN will escape as well (loss
of osmotic pressure)
• Loss of fluid from intravascular
space (tank is dry)
Pathophysiology
Continued

19. Effects of Increased Vascular
Permeability of Capillaries
Reduced Circulating
Volume
Hypotension
Tachycardia
Pathophysiology
Continued

20. This Results in….
The following symptoms…..
Hypotension
Tachycardia
Organ
Dysfunction
Decreased
oxygen to the
organs

21. Accumulation of Extravascular Fluid
Causes…..
Peripheral
Edema
Pulmonary
Edema
Renal
Edema
Liver
Impairment

22. In Sepsis, there is increase oxygen
demand
Increased
oxygen
demand
Requires
increase in
oxygen delivery
Need to
increase HR

23. Metabolic Acidosis
Increased Respiratory Rate
Cardiac depression
Confusion
Anaerobic Respiration Occurs
Lactic Acid is a by-product (serum lactate)
Pathophysiology of Anaerobic Respiration
If Oxygen Demand of the tissues is not met by oxygen delivery
Conversion to Anaerobic
Respiration
Lactate Acid production…..

24. Disseminated Intravascular Clotting
Sepsis
causes
widespread
clotting
This causes
consumption of
platelets, clotting
factors and
fibrinogen,
Impaired
coagulation
Impaired
risk of
bleeding
CONSUMPTIVE
COAGULOPATHY
BLEEDINGCLOTTING

25. Perinatal Parameters
• Because of the physiology of pregnancy and labor, we
adjusted the screening criteria for Perinatal patients
• Increase in blood volume increases maternal heart rate by
10-20 bpm
• Minute volume (RR x Tidal Volume) increases 50% due to
an increase in Tidal Volume
• Due to diaphragm position, lung volumes change causing
increased respiratory rate
• Increase in WBC in labor and immediate postpartum
• Increase in blood flow to the kidneys causes a decrease in
the creatinine level
25

26. “Severe Sepsis and septic shock in pregnancy: indications for
delivery and maternal and perinatal outcomes”
– Retrospective chart review of OB patients with severe sepsis in the ICU
• Severe sepsis N = 20
• Septic shock N = 10
– 24 were antepartum
– 6 were postpartum
• 11 pylonephritis – responsible for one maternal death
• 7 pneumonia
• 4 chorio
• 2 fatty liver
• 1 bacterial meningitis
• Mortality rate 33% with septic shock
The Journal of Maternal-Fetal
Medicine, 2013. Snyder, Barton,
Habli, Sibai

27. Screening Criteria
Variable Severe Sepsis Septic Shock P value All patients
Temp >38.9 10/20 (50) 7/9 (78) ns
SBP <90 6/19 (32) 10/10 (100) <0.001
DBP <50 7/19 (37) 10/10 (100) 0.001
HR > 110 18/20 (90) 9/9 (100) ns
RR > 24 14/18 (78) 8/9 (89) ns
WBC > 15, 000 16/20 (80) 9/10 (90) ns
Lactate >1.0
mmol/L
10/10 (100) 10/10 (100) ns 20/20 (100)
Lactate >4.0
mmol/L
2/10 (20) 2/10 (20) ns 4/20 (20)
Plt > 60s 0/18 (0) 3/9 (33) 0.03 9/30 (30)
Mental status 1/20 (5) 8/10 (80) <0.001 9/30 (30)

28. Sepsis Screening Criteria for Non-OB adults vs. OB
Screening Tool - adjusted for the physiological
effects of pregnancy
Adult Screening Criteria
• Temp > 38°C (100.4°F) or < 36°C
(96.8°F)
• HR > 90
• Resp Rate> 20
• WBC >12,000, < 4,000 or >10%
Bands
• New mental status change
• Blood glucose > 140 mg/dl in the
absence of diabetes
Perinatal Screening Criteria Adjustments
• Temp > 38°C (100.4°F) or < 36°C
(96.8°F)
• HR > 110
• Resp Rate > 24
• WBC > 15,000 or < 4,000 or
> 10 % immature neutrophils
• Altered Mental Status present
• Blood glucose > 140 mg/dl in absence
of diabetes

29. When should I perform the sepsis screening?
• Upon arrival to the unit (triage or direct
admit)
• EVERY SHIFT and/or assuming care of
patient
• PRN for suspicion/indication of new
infection

30. Sepsis
• Definition:
• The presence of 2 or
more SIRS criteria with a
presumed or confirmed
infectious process

31. Definition:
Sepsis + Organ Dysfunction (resulting from Tissue
Hypo-Perfusion)
Severe Sepsis

32. Signs of Organ Dysfunction
Respiratory
Inadequate oxygenation
Or ventilation
Neurologic
Change in LOC
Global Hypoperfusion
Lactate > 2mmol/L
Cardiovascular
Hypotension
SBP < 90mmHG or MAP < 65
Renal
U/O < 30ml/hr
Elevated Cr. (>1.5)
Hematologic
Platelets < 100,000
Coagulopathy (INR> 1.5 or aPTT > 60sec)

33. Organ Dysfunction Criteria

34. Definition
Persistent arterial hypotension
despite 30ml/kg volume
resuscitation or
an Initial lactate > 3.9 mmol/L
(Both may be present)
Septic Shock

35. Sepsis Syndrome

36. Bundles
Elements when used together, improve
outcomes more than when used separately!
Evidence based

37. Severe Sepsis Bundle: TO BE
COMPLETED WITHIN 3 HOURS
Time zero = time of confirmed positive sepsis screen by
RRT
– Measure lactate level
– Obtain blood cultures prior to administration of
antibiotics
– Administer broad spectrum antibiotic(s)
– Administer 30 mL/Kg crystalloid for hypotension or
lactate > 3.9 mmol/L

38.  Delay in diagnosis and treatment of sepsis has been
shown to ↑ mortality
 Pregnant patients look deceptively well before rapidly
deteriorating
 Early recognition and treatment of maternal sepsis will
improve survival, decrease length of stay, and length of
stay in the ICU
WHY DO WE NEED BUNDLES FOR
EARLY RECOGNITION?
Barton & Sibai, 2012

39.  Randomly assigned 263 patient
who presented to ED with
severe sepsis/septic shock
 Received either 6 hours of
EGDT or conventional care
before ICU
 Mortality was 30.5% in patients
receiving EGDT
 Mortality was 46.5% in patients
receiving conventional care
Implementation of Sepsis Bundle
for Early Recognition
Rivers, 2001

40. Blood Cultures? Why?
 Recommended to draw prior to antibiotic administration,
but should NOT delay antibiotics.
 If antibiotics have been administered, still have cultures
drawn
 When patient not responding to antibiotic regime, blood
culture results are used to narrow antibiotic treatment to
most appropriate antibiotic choice

41. Measure Lactate Level
Why is it important
1. Prognostic value of raised lactate levels are well
established in septic shock patients
2. Elevated levels in sepsis support aggressive resuscitation
3. Mortality is high (46.1 %) in septic patients with both
hypotension and lactate > 3.9 mmol/L
4. Mortality in severely septic patients with
Lactate >3.9 mmol/L alone is 30%
www.survivingsepsis.org

42. • 52 participants (approximate)
• Exclusion criteria: only healthy without risk factors
• Lactate levels drawn
 Upon admission
 Transition, 7-10 cm dilated
 6 hours postpartum
SMCS Lactate Level in Pregnancy &
Postpartum
By Beth Stephens-Hennessy CNS, RNC
96% Lactate< 4mmol/dl
88% Lactate<2mmol/dl

43. The Median Value of Lactate

44. Fluid Resuscitation
 Administer 30ml/kg Crystalloid for Hypotension or
Lactate > 3.9 mmol/L
NS
 Patients with severe sepsis/septic shock experience
ineffective circulation due to the vasodilation associated
with infection or impaired cardiac output
 Poorly perfused tissue beds result in global tissue
hypoxia, which result in serum lactate level

45. Fluid Resuscitation
 A serum lactate is correlated with  severity of illness and
poorer outcomes even if hypotension is not present.
 Patients with hypotension or lactate > 3.9 mmol/L require
intravenous fluids to expand circulating volume and
restore perfusion pressure
 When to give? Lactate > 3.9 mmol/Lor suspected
hypovolemia
45

46. Broad Spectrum Antibiotics – (Administer as soon
as possible) within 3 hours of T-0
 Administration of APPROPRIATE antibiotics reduces
mortality in patients with Gram-positive and Gram-
negative bacteremias
 Although restricting antibiotics is important for limiting
super-infection and decreasing development of antibiotic
resistance, patients with severe sepsis and septic shock
warrant broad spectrum antibiotic therapy until antibiotic
susceptibilities are defined.
 Combination therapy is more effective than monotherapy
until causative organism is found

47.  Chorioamnionitis
 Ampicillin 2 g IV Q6hr for 60 minutes
 Gentamicin 1.5mg/kg/dose IV Q8H for 60 min
 Add Clindamycin 900mg IV Q8H for 30 min (for
anaerobe coverage if patient has C/S)
 Endometritis
 Ampicillin 2 g IV Q6H for 60 min
 Gentamicin 5mg/kg/dose, IV Q24H for 60 min
 Clindamycin 900mg IV Q8H for 30 min
Gold Standard Antibiotics for Common
Infections In Obstetrical Patients
Your Logo

48.  Pyelonephritis
 Rocephin 1g in 50ml NS IV Q24H for 30 min
 For Rocephin allergy, order Ampicillin 1 g IV Q6h for 60
min and Gentamicin 1.5 mg/kg/dose, IV Q8h for 60 min
 Community Acquired Pneumonia
 Rocephin 1g IV Q24H for 30 min
 Azithromycin 500mg IV Q24H for 60 min
 IF MRSA suspected, Add Vanco 1mg IV Q12H
Gold Standard Antibiotics for
Common Infections In
Obstetrical Patients
Your Logo

49. Medications:
Severe Sepsis &
Septic Shock
Give First
pharmacy
recommendation
Zosyn (Piperacillin-
Pazobactum)
3.375 MG IV now and
continue pharmacy doing
OR
If penicillin allergy: Maxipime
(Cefepime) 2 gm IV now
For Significant PCN allergy
(angioedema, resp distress,
urticaria), GIVE ATREONAM 2gm
IV q8H
Vancomycin
Per pharmacy
dosing schedule
and
Discontinue all current antibiotics, then give:

50. Purpose
To Evaluate Staff compliance with early
recognition and management of management of
maternal sepsis before and following the
implementation of standardized physician
order set and interprofessional education for
nurses and physicians in the perinatal setting

51. Women screening positive for Sepsis between April
2014-January 2015
Women > 20 weeks gestation
N=99 Sepsis Screen positive patients
IRB Approval obtained
METHODOLOGY
•

52.  Using a systematic health record review, COMPLIANCE to the
Sepsis Bundles was measured before, during, and following
implementation of perinatal sepsis physician order set &
education for physician & nurses (n=400)
PROJECT DESIGN

53.  Task Force Team
 Physician Education First
 A Multidisciplinary Team (stakeholders)
 Interprofessional Education from Aug-Nov 2014
 A new perinatal sepsis physician order SET was
implemented October 2014
 Physician & RN Champions
 Engagement of frontline leaders
INTERVENTIONS

54. Task Force
How we got started….
A small interdisciplinary group
collaborated to design the
framework for perinatal sepsis
orders and protocol

55.  RN Champions were recruited to represent all departments
on all shifts
 Pharmacists were recruited including Antimicrobial
stewardships
 Engaging frontline leaders was crucial to the success of
project
 Physician Champions
 RRT
 Laboratory Supervisors
 ICU educator
 Emergency Room Educator
Perinatal Sepsis Committee
Formed

56. Physician Champion
Physician Buy-in crucial for the
success of the project
Provided education to physicians
Provided opportunity to discuss
“difficult sepsis cases” at MD Grand
Rounds
Provided literature for physicians

57. RN Champions
Provided 1:1 education to RN’s and
MD’s
Education re: Sepsis screening,
standardized physician order set, and
evidence based practice for recognition
and management of maternal sepsis
Mentoring of bedside RN how to
manage patient screening positive for
sepsis

58. Interprofessional Education
 Formal 2-hour education for RN’s
 M&M Conference for Physicians
 Grand Rounds for Physicians
 Poster Presentation
 Case Studies
 Evidence-based literature displayed
 A single sheet, quick reference guides
 Mandatory completion of computer based
module with a post-test

59.  Guided the practitioner in giving appropriate antibiotic
based upon source of infection
 Antibiotics safe in pregnant women for common infections
such as chorioamnionitis and pyelonephritis were included
in order set
 Antibiotics safe for pregnancy to treat severe sepsis and
septic shock
Physician Order Set

60.  Our patients are young & healthy, did not look septic
 The bundles would result in over-treatment
 Risk of Pulmonary of Edema
 Women with epidurals have fevers
 Antibiotic Resistance
 Lactate is normally elevated in the laboring woman
 To avoid doing Sepsis Screening during second stage of
labor
Education for Physician & Nurses
Addressing the Barriers

61. Outcome Measure
 Health Records of women screening positive for Sepsis
were reviewed to determine if educational intervention
increased SEPSIS bundle compliance.
 Data was divided into 2 groups:
1. Pre-Intervention Data ( April-July 2014)
2. Post-Intervention Data (August 2014-Jan 2015
 Data collected for 3 parameters: Sepsis, Severe Sepsis,
and Septic Shock
 Bundle compliance was measured for all parameters.
 Intravenous fluids was measured for Sepsis, however,
was not required.

62. Outcome Outcome Measurement
Comparison…..
 To measure the difference
in bundle compliance pre
and post intervention, data
from the first time period
was compared to data from
second time period
What was the initial
Infection?
 Data from the initial
infection was measured
separately to determine
source of infection

63. The Sources of Infection for Patients Diagnosed with
Sepsis during Pregnancy
Sutter Medical Center Sacramento
April 2014-January 2015
Frequency (N=99) Percent (%)
Chorioamnionitis 45 46.4
Pyelonephritis 14 14.4
Endometritis 5 5.2
Urinary Tract
Infection
5 5.2
Unknown 29 29

64. Frequency of Sepsis, Severe Sepsis and Septic Shock
Sutter Medical Center Sacramento
April 2014-January 2015*
* Deliveries ~4000

65. Results
Bundle Compliance Indicators in Patients with Sepsis, Severe
Sepsis, and Septic Shock in Pre-and Post-Intervention
Numb.
(N)
Draw
Lactate
Blood
Culture
Fluid
Bolus
Broad
Spectrum
ATB
Bundle
Met
Repeat
Lactate
Sepsis 31
66
74%
90.9
38.7%
43.9
64.5%
73
77.4%
95.4
38.7%
45.5
79%
79
Severe
Sepsis
13
34
100%
97.1
46.2%
55.9
76.9%
73.5
76.9%
97.1
53.8%
52.9
69.2%
82.4
Septic
Shock
3
4
100%
75
66.7%
75
66.7%
100
66.7%
100
66.7%
100
66.7%
100

66. Weighted Cross Tabulations for Patients with Sepsis
Lactate
Drawn
(yes)
Broad-
Spectrum
Antibiotic
Administered
(Yes)
Repeat
Lactate
Drawn
(yes)
Pre-
Intervention
23(74.2%) 24 (77.4%) 18(58.1)
Post-
Intervention
60(90.9%) 63 (95.5%) 52 (78.8%)
p Value (<.05) .029 .006 .034
Statistical
Significance
Achieved

67. Broad
Spectrum
Antibiotic
Administered
(No)
Broad
Spectrum
Antibiotic
Administered
(Yes)
P Value
p<.05
Pre-
Intervention 4 (25%) 12 (75%) .010
Post-
Intervention 1 (2.6%) 37 (97.4%)
Weighted Tabulations for
Broad-Spectrum ATB
Administered
In Patients with Severe Sepsis or
Septic Shock
Statistical
Significance
Achieved

68.  Statistical significance for effect of education & perinatal
sepsis order on bundle compliance:
Draw Lactate
Administer Broad Spectrum ATB
Draw Repeat Lactate
 Adjusted SIRS criteria for Maternal Sepsis is accepted!
 Physician & RN champions instrumental
 Antibiotic Type & timely administration
 Perinatal staff must be educated in early recognition and
management of maternal sepsis
Key Points

69. Sutter Health
Maternal Sepsis
Recommendations
Looking at the impact of implementing a
project regionally.

70. SMCS Sepsis Data

71. SIRS Criteria

72. Organ Dysfunction Criteria

73. Chart Data

74. Sepsis Screening Criteria for Non-OB adults vs. OB
Screening Tool - adjusted for the physiological
effects of pregnancy
Adult Screening Criteria
• Temp > 38°C (100.4°F) or < 36°C
(96.8°F)
• HR > 90
• Resp Rate> 20
• WBC >12,000, < 4,000 or >10%
Bands
• New mental status change
• Blood glucose > 140 mg/dl in the
absence of diabetes
Perinatal Screening Criteria Adjustments
• Temp > 38°C (100.4°F) or < 36°C
(96.8°F)
• HR > 110
• Resp Rate > 24
• WBC > 15,000 or < 4,000 or
> 10 % immature neutrophils
• Altered Mental Status present
• Blood glucose > 140 mg/dl in absence
of diabetes

75. Obstetrical Sepsis Management Pathway
New or
suspected
infection
Evaluate for 2 or more
SIRS Criteria
Temp > 100.4°F (38°C)
HR > 110
RR > 24
WBC > 15,000, < 4,000 OR >
10% immature neutrophils
Altered mental status
Blood glucose > 140 mg/dL in
absence of diabetes
Interventions for Simple Sepsis
✓Draw Lactate,
 CBC, CMP, PT, PTT, INR, Serum creatinine
☐ U/A
 Blood Cultures (2 sets prior to antibiotics)
✓ IV Access
✓Give Antibiotic (considering source of infection)
Chest XRAY
✓Rapid Response Team: RRT confirms + Sepsis Screen & initiates
STAT labs (standardized proc)
√ RRT RN initiates SEPSIS ALERT!
Consider Source of Infection
SEPTIC SHOCK
MORTALITY 40-60%
Clinical features are the same as severe
sepsis
 Distinguishing Feature: Profound
Hypotension BP Systolic <90, MAP<65
despite fluid resuscitation!
☐ LACTATE > 3.9 MMOL/L
Interventions for Septic Shock
√ RRT calls Code Sepsis
✓Broad spectrum antibiotics
✓Call Rapid Response Team
✓ICU admission
✓Anesthesia at bedside
✓IV Fluids Normal Saline bolus 30 ml/kg NOW for
lactate > 3.9 mmol or hypotensive
✓Consider Central Venous Access
Any 1 or more features of acute organ
dysfunction
Lactate > 2 mmol/L
SBP < 90 mmHG or MAP < 65
☐ SBP decrease < 40mmHG from baseline
☐Bilirubin > 2mg/dl
New (or increased) oxygen requirement to maintain
SP O2 > 92%
 Urine output < or equal to 30 ml/hr for 2 hours
Platelet count < 100,000
Coagulopathy (INR >1.5 or PTT >60 sec
Interventions for Severe sepsis
✓Consider IV Fluids N/S for Lactate >2 mmol/L
✓CALL RAPID RESPONSE TEAM
✓Repeat lactate every 4-6 hours until Lactate < 2
✓SpO2 and oxygen per protocol
√Call MD to initiate OB severe Sepsis Order Set
SEPSIS
SEVERE
SEPSIS
Sepsis
Screen
SEPTIC
SHOCK
Yes
Yes
Yes
Yes





76. Sepsis Standard Work
Sepsis Recognition and Sepsis Care Should
Be Standard For All Inpatients –
Including Perinatal Patients

77. Early Recognition
What is Standard Work?
• Standard Work is a method used to complete nearly identical processes in
a uniform way (used in manufacturing, Toyota)
• Improvement teams have adopted this approach in healthcare in attempts
to
1) reduce variation in care (“No fluid bolus needed, she’ll just
be in pulmonary edema”)
2) errors of omission (“I forgot to order a repeat lactate”)
• Typically standard work identifies a task, the operator to complete the
task, the equipment required, the time frame for completion
• Though there are limits to standardization in work, there is much work
that can be standardized
77

78. Perinatal Sepsis Standard Work
Create Protocols with Adjusted SIRS criteria for Maternal Sepsis
Early intervention implemented for all patients who screen
positive for sepsis
Arrival of Rapid Response Team followed by physician/
intensivist evaluation
78

79. Documentation and Reports
Sepsis Summary Flowsheets
Sepsis Screen
Sepsis Overview Report
Sepsis Sidebar Report

80. 80
Vitals, lab, I/O
will populate here
from other
flowsheets and
results so that a
complete sepsis
assessment
(screen can be
done)
Sepsis
Summary
Flowsheet
YOU MUST
COMPLETE
ALL 4
QUESTIONS

81. 1. Is an infection suspected?
Symptoms patient
may have that
indicate Potential
Infection
Sepsis Screen

82. 2. Identify 2 or more NEW signs of SIRs
Sepsis Screen
Axillar
y
Temp

83. 3. Identify new signs of organ dysfunction
Sepsis Screen

84. 4. Pt meets criteria for Positive Screen?
84
Note: the criteria to be used when answering this question

85. Action Taken
Rows and groups display if answer
to Question 4 is “Yes.”

86. Sepsis Start Time: TIME ZERO

87. 87
Severe Sepsis and Septic Shock
Bundle Elements
This
documentation
populate the
sepsis overview
to the specific
bundle
completionIf YES, patient meets criteria for Code
Sepsis / 6 hour bundle

88. Sepsis Best Practice Alert
• Two new Best Practice Alerts
1. Simple Sepsis
2. Severe Sepsis (Organ Dysfunction)

89. Applying what we have learned
Case Scenarios
89

90. Case Scenario #1
Preterm with PPROM X 8 days
• 0848- T-97.8, BP 115/62, P-100, 98%, FHR 160
• 1110-MD here to consent for C/S
• 1200-C/S, Apgar 1/8. Baby to NICU
• 1230. OBRR- Temp 101.8, P-120, SOB. 88/40. RRT
called. CBC, blood culture, lactate drawn. IV Fluids 2 L
given. Zosyn started.
• 1300- Lactate 9. Urine output < 30ml/hr. Bleeding at
incisional site. NS 2 L given on way to ICU. BP 88/44,
p-122. Coags drawn in ICU. Extended stay for mother
due to septic shock.

91. Questions
• At what point did she meet SIRS criteria?
• What signs of organ dysfunction did she have?
• List the standard work that was done in response.
91

92. Scenario #2
2nd stage of Labor
• 0900-Twin gest 38.1 weeks, pushing in 2nd stage of labor.
No other risk factors. Temp spiked to 102.1, P-130, R-22.
Pt screened positive for sepsis. RN called MD in which
MD gave orders to follow sepsis protocol.
• 0940-Lactate 5.6. WBC 26. LR 2 Liter bolus NS given,
Zosyn ordered and administered.
• 0955,0958-patient delivered healthy twins. Health care
team decided to manage care in L&D for recovery. Orders
to redraw lactate at 1200. RN’s did not want to separate
the mom-baby couplet. BP stable, P-110, Temp 100.1, R-
20.
• 1130- Lactate drawn (1200)-3.9, 1 liter of NS given.
Lactate drawn every 6 hours until lactate <2.

93. Questions
• At what point did she meet SIRS criteria?
• What signs of organ dysfunction did she have?
• List the standard work that was done in response.
• List the standard work that was not done.
• Does lactate increase during labor and increase with
length of pushing?
93

94. 8/3/13 @2216
 Pt presented L&D Triage with R sided flank pain,
fever of 101, and vomiting X2.
OB Hx:
 No risk factors; GA: 24 weeks, G-1, P-0
Vital Signs:
 HR=120, bp-103/58, FHR 165-170.
Labs:
 UA: 2+ nitrites, Pos for leukocyte esterase, 1+ protein, 2+
ketones, >100 WBC 4 RBC, 4+ bacteria
Outcome:
 Macrobid and D/C home.
 T-99.8,FHR=165 MD would call pt when UA culture returns in
48 hrs. Culture…………Cx results: E.Coli >100,000
Leanna presents to Triage at 24
weeks…..

95. 8/4@1900
Pt returns with fever, R sided flank pain, aches, N&V, chills,
feeling dizzy, SOB..POSITIVE SEPSIS SCREEN
VS
 P=130, BP 85/52, Map 64. O2 sat 99%
 FHR=140’s.
Treatment
 Ampicillin 2 gm given, 1 Liter LR given, RRT At bedside,
serial lactates, NS bolus. Gentamicin given.
Response:
 55 minutes later: T-98.2, P=102, BP101/61, O2 Sat 100,
lactic Acid-1.6. Patient transferred to HRM
LeeAnna……

96. 6 hours later:
Pt shivering, C/O SOB, o2 at 3L, o2 sat 95%,
T=99.2, P=114, BP100/61. Remains SOB. Lactic
Acid 2.6
6 1/2 hrs:
 RRT at BS. Clammy, O2 sat 94%, required O2
administration
7 hrs:-
Orders to transfer to ICU. Central line placed.
12 hrs –
chest Xray indicated fluid overload/interstitial edema
LeeAnna……

97. 17 hours:
 pt intubated and sedated, VSS; CRP-264.7; albumin
1.8, WBC-21.1, Hgb 7.8
Day 3
 R nephrostomy tube, foley catheter. VSS. Transferred
to HRM
Day 5
 Central line d/c; D/C home at 1230!
LeeAnna……
continued

98. 3 months later
 Admitted for SROM
 Nephrostomy tube in place.
 On Cipro 500mg Q12h
 11/22@1430-delivered healthy baby girl!
LeeAnna……
Day of Delivery….

99. LeeAnna Septic Shock Survivor……

100. Let’s Begin the Campaign to promote Early
Recognition & Management of Maternal Sepsis
100