QA Septic Shock

• See Septic Shock Guideline article

Purpose

Kendiss Olafson & the QA team are monitoring performance and appropriate interventions for Septic Shock in the ICUs in the Winnipeg Region.

Data Collection Method

For the first episode of Septic Shock (admit or complication) of any ICU patient, the following two entries must be made in the TMP, L_TmpV2 file.

First SBP<90

Date and Time that the blood pressure (BP) criteria is met for the first time as per Septic Shock Blood Pressure Guideline guideline.

First low BP may be prior to ICU admission.

If a patient with existing septic shock is transferred from one ICU to another, for next ICU transferred into code Item: First BP <90 with no date/time and enter transfered from previous ICU with DX of shock already coded as the comment.

• Project: QASeptic
• Item: First SBP<90
• Date and Time: dt/tm of first low BP as per above unless transferred from other ICU
• Comment: only in case of transfer from other ICU, enter transfered from previous ICU with DX of shock already coded

Question: Encounter number still required?

• integer variable: we would like you to add a counter for each incident of Shock you have and antibiotic start date. For example if --TOstryzniuk 14:39, 11 December 2009 (CST)
  • Julie, encounter number in integer var, has not been implemented yet. Do you need it?--User:TOstryzniuk|TOstryzniuk]] 14:41, 4 February 2010 (CST)

First NEW Antibiotic

The time of antibiotics is the date and time antibiotics are given for sepsis. This may occur prior to the development of shock or after.

If the person then goes into septic shock and the antibiotics are not changed the time is that of original antibiotic coverage.

If the antibiotics are changed in response to the new shock state then the time of Antibiotics is the date/time that the new antibiotics were given.

If the patient does not receive Antibiotics (e.g. DC treatment) provide a reason in the comment section of the "First Antibiotic" entry.

• Project: QASeptic
• Item: First Antibiotic
• Date and Time: Date/Time as discussed above
• Comment:
  • note reason if an antibiotic was not given
  • any other comments requested/required? Ttenbergen 16:07, 8 February 2010 (CST) Template:Discussion

Study Run Times

Start date: October 8, 2009

Every qualifying patient sent after this date will need to have a temp entry, not only patients admitted after this date.

Review Date

Dec 22.09-Cancel

(~75 days after start) - meeting booked with Kendiss and Trish for 2009 Dec 22. Meeting cancelled. Review rescheduled to Feb.2.10. --TOstryzniuk 18:21, 21 December 2009 (CST)

Feb 2,2010

• completed. Data is showing some good trends for ICU's in the Region. Dr. Kendiss Olafson from the ICU QI team will present at the data collection team meeting in April 2010.--TOstryzniuk 16:30, 2 February 2010 (CST)--TOstryzniuk 16:30, 2 February 2010 (CST)
  • see: Feb 2.2010 Review Meeting

May 4 ,2010 from 1100-1200 hrs

• meeting request sent out Feb 2.10 by TOstryzniuk 22:21, 2 February 2010 (CST)

End Date

• Preliminary End Date: (6 months after start) - April 8, 2010.
• REVISED to December 31.2010---TOstryzniuk 17:04, 8 February 2010 (CST)
  • (set in ccmdb.mdb consistency checks)See: | See:change request log

Consistency Checks

Tmp Checker will check for the following:

Date or Comment

Every entry for project QA Septic must have either a date or a time.

Dx but no tmp

L_Tmp entry is required if:

• a DX of Septic shock exists
• program is "CC"

(implemented by s_tmp_QASeptic_Dx_no_tmp)

Tmp but no dx

A diagnosis must exist if:

• a "QASeptic" entry is present in L_Tmp
• program must be "CC"

(implemented by s_tmp_QASeptic_tmp_no_dx)

Send mode

Data for all patients meeting requirements for this study, including patients you are not sending this batch, will be sent every time complete patients are sent.

Discussion

• I just entered my first pt into this study, and ran into a bit of a snag. The pt had been transfered to us from another ICU. I was able to find the first low BP, but had to take the first AB from the in and out record. I don't have any copies of MAR or any of the ER charting....so I took the first antibiotic given after the low BP. Had it not been recorded on the I&O record, I wouldn't have had anything else to get info from. So, my question is...is this good enough? Does it actually provide the info that you are looking for? BDeVlaming 12:10, 7 October 2009 (CDT)
  • Yes this is good enough. Please put a note in your "COMMENT" section in TMP for First antibitic start. "Date and time of antibitic obtained from I & O sheet. No medication record from other center".--TOstryzniuk 11:55, 20 October 2009 (CDT)

• Another issue: There are instances where the patient may already be on antibiotics for an infection and then later develops septic shock anyway. Sometimes a new antibiotic is started and in this case the new antibiotic is the one to use in our tmp file. Occasionally, though, a new antibiotic may not be started. We need to know what to do in these cases. Putting a start date of an antibiotic that is likely not the right one would not help. I have one patient like this right now. The patient was on two antibiotics for pneumonia, copd exac. Developed septic shock 2 days later. No new antibiotics started yet. I will keep watching to see if new antibiotics are started as this patient likely has a bug that is not covered by the antibiotics he is on. --LKolesar 15:20, 7 October 2009 (CDT)
  • if the patient had new antibiotics started for THIS infection, put that date and time of the antibiotic start. In another words antibiotic start may be PRIOR to the onset of shock.
  • If they where aready on an antibotic and they develop new sepsis/infection, the antibiotic date should be left blank and in the COMMENT section state patient already on antibitic and there were no antibiotic changes made.TOstryzniuk 11:33, 20 October 2009 (CDT)

• Here is another scenario for you: A patient develops septic shock in a community hospital and is coded by the data collector, then a few days later the patient is transferred to a tertiary ICU for continued care. The data collector in the second hospital needs to code septic shock because it is still ongoing. Should she use the same times of low BP and antibiotic start as the first presentation of septic shock at the first hospital? We cannot always derive this information from the bits of chart that the sending hospital copies for us. The only way to be sure of getting the same times would be to email the first data collector and obtain the times from her. Is this the correct process to follow?? --LKolesar 11:08, 16 October 2009 (CDT)
  • The data collector in the second hospital needs to code in the Admit Diagnosis septic shock because it is still ongoing however, if a patient comes from an ICU with a previous onset of septic shock and the data has already captured in the previous ICU admission TMP file, there is no need to enter the same start date of onset of shock in the next ICU admission TMP file. We don't want to double count same episode of septic shock.
    • INSTRUCTION: for next ICU transfered into, in the TMP file select ITEM: First BP <90, don't put a date however in the COMMENT section type in the following: transfered from previous ICU with DX of shock already coded.

Update: Feb 2.2010 Review Meeting

Collection guide has been updated under Instruction above in regards to collecting antibiotics.--TOstryzniuk 14:44, 4 February 2010 (CST)

• Brenda Kline and Kendiss Olafson have audited at a few septic shock charts. They found a couple charts that they disagreed with in regards to the date/time of antibiotics. Below are their findings and suggestion for clarifying data collection guidelines:

*Most of the errors are due to the following situation.

• • Someone is on antibiotics (could be for days….) Their clinical situation deteriorates and in response NEW antibiotics are ordered (this may be prior to shock onset or just before). If new antibiotics are not ordered immediately after septic shock onset then We want the time the antibiotics were last changed….
• We found that if antibiotics were not changed after septic shock that the data collectors are reporting when the person was FIRST started on antibiotics rather then the last time prior to shock that NEW antibiotics were initiated.I hope that makes sense. Dr. Kendiss Olafson.