HCA Sepsis Nonsense.

[RustedFox]

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I'm working at an HCA shop for the first time in a long time.

Can anyone give me the rundown as to how I should be cognitively approaching this sepsis logic bomb so I don't lose my job?

 

[Porfirio]

One SIRS criteria with triage vitals and any CC that is infection related = they want rocephin/cultures/lactic acid

It is as simple as that. Don’t worry about if they will be admitted or not. Don’t worry if it is CHF vs COPD vs pneumonia vs PE. Just order the sepsis work up and move on - this is what they want.

Added bonus if you give 500 cc to 1 L bolus up front before getting the lactic acid back or one BP measurement of systolic <90.

 

[Tenk]

You just order big order sets and turn off your brain.

If you’re worried about the patient getting 6000 ml of fluid with an EF of 15% you can document why you didn’t give 30 ml/kg bolus or why you’re using ideal body weight.

 

[robellis]

Why are you working at HCA those for profit bastards

 

[RustedFox]

Why are you working at HCA those for profit bastards

Small stepping stone.
I'm not going to be there forever; that's for sure.

 

[RustedFox]

One SIRS criteria with triage vitals and any CC that is infection related = they want rocephin/cultures/lactic acid

It is as simple as that. Don’t worry about if they will be admitted or not. Don’t worry if it is CHF vs COPD vs pneumonia vs PE. Just order the sepsis work up and move on - this is what they want.

Added bonus if you give 500 cc to 1 L bolus up front before getting the lactic acid back or one BP measurement of systolic <90.

Yeah, that's what bothers me.
Seeing as how 90 BPM (which is me after a cup of coffee) now counts, this is 90% of visits.
Plus, triage tends to write things like : "I'm dying" and "multiple complaints" as the chief complaint, so that's not helpful.

 

[turkeyjerky]

Why are you working at HCA those for profit bastards

Lack of options? Because many of us don't have many.

 

[bravotwozero]

Lack of options? Because many of us don't have many.

Plus believe it or not some HCA gigs actually pay well…

 

[Rekt]

Plus believe it or not some HCA gigs actually pay well…

For now... they're salivating at the impending oversupply.

 

[southerndoc]

Embrace the sepsis czar.

 

[deleted836128]

I once had one of my cases go to our hospital’s quality improvement meeting because I ordered a 2500 cc bolus for a septic patient and should have ordered 2700….

 

[Porfirio]

Yeah, that's what bothers me.
Seeing as how 90 BPM (which is me after a cup of coffee) now counts, this is 90% of visits.
Plus, triage tends to write things like : "I'm dying" and "multiple complaints" as the chief complaint, so that's not helpful.

You have to see the patient to get the true CC before ordering. So hop to it (<10 min door to doc time at some places).

I tell people all the time that I did a HCA fellowship out of residency. They just laugh. But it is true. I rarely get admin emails - compared to my peers.

 

[Brigade4Radiant]

Sepsis bundle needs to be ordered with 1 hour. Also you need to give people IM rocephin if the nurse is having trouble with IVs.

If it’s alcohol withdrawal do the sepsis bundle. Also you must order the bundle not individual orders or you failed.

Also don’t let the door to doc time get low. If you are coding a patient ask the nurse to get you the computer and sign up to stop the clock.

Admin doesn’t care Envision credintials two docs per doc working so they can quickly replace you

 

[Siggy]

One of the stupid things to remember is that CMS has defined septic shock as being a lactic >4 as well.

This all comes down to the Golden Rule... he who has the gold (CMS) makes the rules.

By the way, I did my fellowship at a Tenet facility and the critical care team was getting hit with all of the SEP1/sepsis core measures non-sense.

 

[miacomet]

LOL hilarious they are obsessed with sepsis yet refuse to mandate vaccination. It was never about patient safety.

 

[thegenius]

It's all fudging nonsense.
Manny Rivers showed more than thirty years ago that protocoling sepsis resuscitation was better than physician gestalt. Now that protocoling is de facto standard of care, has all this new surviving sepsis been shows to markedly improve outcomes over physician gestalt?

Who here is giving 30 ml / kg and broad spectrum antibiotics for the 19 yo old who comes in with symptomatic, uncomplicated strep throat?

 

[bravotwozero]

It's all fudging nonsense.
Manny Rivers showed more than thirty years ago that protocoling sepsis resuscitation was better than physician gestalt. Now that protocoling is de facto standard of care, has all this new surviving sepsis been shows to markedly improve outcomes over physician gestalt?

Who here is giving 30 ml / kg and broad spectrum antibiotics for the 19 yo old who comes in with symptomatic, uncomplicated strep throat?

What people also don’t realize about manny rivers is that the guy created and patented his own central venous catheter to measure central venous pressure, thereby creating a massive financial incentive for him to promote his ‘protocol’.

Conflict of interest anyone?

 

[Porfirio]

It's all fudging nonsense.
Manny Rivers showed more than thirty years ago that protocoling sepsis resuscitation was better than physician gestalt. Now that protocoling is de facto standard of care, has all this new surviving sepsis been shows to markedly improve outcomes over physician gestalt?

Who here is giving 30 ml / kg and broad spectrum antibiotics for the 19 yo old who comes in with symptomatic, uncomplicated strep throat?

19 yr old with BP <90 or lactic acid >4.0 and they only have strep?

As for the antibiotics, clearly this is going home. HCA only cares about sepsis for the admits.

I do not agree with flooding the world in rocephin.

 

[wholeheartedly]

Any influence of the task force report that came out on this this year for reducing some of this? I thought of you guys and threads like this when it first came out.

Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report

Using a format that addresses common steps in the initial emergency care of adults with suspected sepsis, this report summarizes the task force's assessment of current knowledge and recommendations. The task force focused this work on adult sepsis diagnosis and management given recent...

www.idsociety.org

 

[AlmostAnMD]

You just order big order sets and turn off your brain.

If you’re worried about the patient getting 6000 ml of fluid with an EF of 15% you can document why you didn’t give 30 ml/kg bolus or why you’re using ideal body weight.

Don't listen to him, he's just trying to get a bigger share of the money pot by giving you advise that dings your charting. You need to not only give 6,107 mL of fluid (6,106 is a FAILURE) you need to give it as fast as possible. If the EF < 15%, my distributively shocked patient gets the full bolus of actual body weight 30 mg/kg as a traditional bolus. If the EF % > 15%, he goes to the trauma bay and I use the MTP tubing and lines to dump it in. That's because another trick is constantly changing times on when the full bolus needs to be administered by. The safest thing to do is to prepare for the 5 or 15 minute sepsis bundles and keep rechecking lactates until either lactate is undetectable or the patient is undetectable, whichever happens first.

 

[Tenk]

Don't listen to him, he's just trying to get a bigger share of the money pot by giving you advise that dings your charting. You need to not only give 6,107 mL of fluid (6,106 is a FAILURE) you need to give it as fast as possible. If the EF < 15%, my distributively shocked patient gets the full bolus of actual body weight 30 mg/kg as a traditional bolus. If the EF % > 15%, he goes to the trauma bay and I use the MTP tubing and lines to dump it in. That's because another trick is constantly changing times on when the full bolus needs to be administered by. The safest thing to do is to prepare for the 5 or 15 minute sepsis bundles and keep rechecking lactates until either lactate is undetectable or the patient is undetectable, whichever happens first.

Damn you caught me

 

[RustedFox]

Don't listen to him, he's just trying to get a bigger share of the money pot by giving you advise that dings your charting. You need to not only give 6,107 mL of fluid (6,106 is a FAILURE) you need to give it as fast as possible. If the EF < 15%, my distributively shocked patient gets the full bolus of actual body weight 30 mg/kg as a traditional bolus. If the EF % > 15%, he goes to the trauma bay and I use the MTP tubing and lines to dump it in. That's because another trick is constantly changing times on when the full bolus needs to be administered by. The safest thing to do is to prepare for the 5 or 15 minute sepsis bundles and keep rechecking lactates until either lactate is undetectable or the patient is undetectable, whichever happens first.

What's even funnier about this is that Tenk and I know each other in real life. He was a med student when I was a junior resident, and was an intern when I was a senior.

 

[lymphocyte]

It's all fudging nonsense.
Manny Rivers showed more than thirty years ago that protocoling sepsis resuscitation was better than physician gestalt. Now that protocoling is de facto standard of care, has all this new surviving sepsis been shows to markedly improve outcomes over physician gestalt?

Who here is giving 30 ml / kg and broad spectrum antibiotics for the 19 yo old who comes in with symptomatic, uncomplicated strep throat?

Rivers was very likely wrong (ProCESS, ARISE, and ProMISe, all great RCTs). I say "very likely" and not "definitively," because some data suggest certain septic phenotypes might actually benefit from EGDT (in one of my favourite articles of the past decade), but that's way out into the weeds. I also don't want to say "fraudulently," but he'll unfortunately have that suspicion lingering over him for the rest of his career.

Seymour CW, Kennedy JN, Wang S, et al. Derivation, validation, and potential treatment implications of novel clinical phenotypes for sepsis. JAMA. 2019;321(20):2003.

 

[RustedFox]

Rivers was very likely wrong (ProCESS, ARISE, and ProMISe, all great RCTs). I say "very likely" and not "definitively," because some data suggest certain septic phenotypes might actually benefit from EGDT (in one of my favourite articles of the past decade), but that's way out into the weeds. I also don't want to say "fraudulently," but he'll unfortunately have that suspicion lingering over him for the rest of his career.

Seymour CW, Kennedy JN, Wang S, et al. Derivation, validation, and potential treatment implications of novel clinical phenotypes for sepsis. JAMA. 2019;321(20):2003.

Yeah, I read thegenius' comment and my first thought was "uhh, we did this in journal club as residents. No."

 

[turkeyjerky]

Rivers was very likely wrong (ProCESS, ARISE, and ProMISe, all great RCTs). I say "very likely" and not "definitively," because some data suggest certain septic phenotypes might actually benefit from EGDT (in one of my favourite articles of the past decade), but that's way out into the weeds. I also don't want to say "fraudulently," but he'll unfortunately have that suspicion lingering over him for the rest of his career.

Seymour CW, Kennedy JN, Wang S, et al. Derivation, validation, and potential treatment implications of novel clinical phenotypes for sepsis. JAMA. 2019;321(20):2003.

I'm of the thought that the real implications of the Rivers trial are widely recognized but poorly delineated. It was basically a randomized trial of early intensive care and aggressive resuscitation in sepsis. This was in an era when dynamic indicies of fluid status and actions targeted at increasing DO2 were still thought to be best practice. The followup studies showed that protocolizing care to a specific bundle was unncessary, as long as you still gave thoughtful early care. Andromeda showed that trending lactate is either unnecessary or counterproductive. Unfortunately, SEP-1, and especially the HCA bastardization of it, doesn't equal early aggressive, but thoughtful, resuscitation and we're probably moving back to the type of care given in the control arm of rivers.

 

[thegenius]

19 yr old with BP <90 or lactic acid >4.0 and they only have strep?

As for the antibiotics, clearly this is going home. HCA only cares about sepsis for the admits.

I do not agree with flooding the world in rocephin.

No...the point is that there are patients with SIRS / Sepsis that don't need anything but antibiotics. They don't need labs and lactate.

 

[thegenius]

Rivers was very likely wrong (ProCESS, ARISE, and ProMISe, all great RCTs). I say "very likely" and not "definitively," because some data suggest certain septic phenotypes might actually benefit from EGDT (in one of my favourite articles of the past decade), but that's way out into the weeds. I also don't want to say "fraudulently," but he'll unfortunately have that suspicion lingering over him for the rest of his career.

Seymour CW, Kennedy JN, Wang S, et al. Derivation, validation, and potential treatment implications of novel clinical phenotypes for sepsis. JAMA. 2019;321(20):2003.

Hard to say that Rivers was "wrong" when the standard of care prior to his protocol was to stick septic patients in the corner of the ER and not do anything. He showed an 16% absolute survival benefit.

It turns out that Rivers protocol was too broad and complicated...all patients really need is BP support (via fluids or vasopressors) and antibiotics as soon as possible. So I wouldn't consider him wrong. He was better than what was happening prior to him.

 

[thegenius]

I'm of the thought that the real implications of the Rivers trial are widely recognized but poorly delineated. It was basically a randomized trial of early intensive care and aggressive resuscitation in sepsis. This was in an era when dynamic indicies of fluid status and actions targeted at increasing DO2 were still thought to be best practice. The followup studies showed that protocolizing care to a specific bundle was unncessary, as long as you still gave thoughtful early care. Andromeda showed that trending lactate is either unnecessary or counterproductive. Unfortunately, SEP-1, and especially the HCA bastardization of it, doesn't equal early aggressive, but thoughtful, resuscitation and we're probably moving back to the type of care given in the control arm of rivers.

?? Did Andromeda come out very recently?

This is the first I heard of this. I clearly remember stud(ies) showing lactates trending down in early treatment of sepsis improved outcomes.

EDIT:
Oh yea I remember comparing capillary refill time (CRT) to lactate reduction. Came out in 2019.
Interesting stuff. This capillary refill time stuff is not spoken of at my institution at all.

 

[elanmorin]

What's even funnier about this is that Tenk and I know each other in real life. He was a med student when I was a junior resident, and was an intern when I was a senior.

Hopefully you were kind to your interns, then.

 

[Siggy]

Hard to say that Rivers was "wrong" when the standard of care prior to his protocol was to stick septic patients in the corner of the ER and not do anything. He showed an 16% absolute survival benefit.

It turns out that Rivers protocol was too broad and complicated...all patients really need is BP support (via fluids or vasopressors) and antibiotics as soon as possible. So I wouldn't consider him wrong. He was better than what was happening prior to him.

Basically this. The key to understanding sepsis and sepsis protocols is that the protocols are likely wrong... however they're significantly better than the historical standard of care of doing jack all until the patient died. The thing with all the newer studies like ProCESS is that the standard of care has changed... so instead of getting 30 ml/kg of fluids and rapid antibiotics, they're getting 20 ml/KG and rapid antibiotics. That's still a lot more than doing nothing.

 

[RustedFox]

Hopefully you were kind to your interns, then.

I was hard on them.
It made Tenk great.

Don't confuse "intern who knows that he needs to learn and wants to learn" with "PLP that doesn't know that they need to learn and doesn't want to learn".

Addendum: I got a call from PLP at "OldJob" last month to ask how I was doing at NewJob.
She thanked me for being so hard on her right out of PLP school.
I apologized; but she told me not to.

A few years back on here; I posted about how much I sucked as an intern. It was in a thread about how my scribes were unservicably bad. I should find that post. It was a good "development" story.

 

[southerndoc]

@RustedFox Remind me what PLP means again? I think of Peace Love & Pizza (a fabulous pizzeria here).

 

[bravotwozero]

Pretend Level Provider. Also interchangeable with LLP - low level provider…

 

[Dred Pirate]

can't comment on HCA - but I was part of our adoption of the sepsis plan at our hospital.
1. Ya - we give broad spectrum abx for everybody and pains me as I know we are going to see a huge increase in abx resistance. So part of me actually commends HCA for doing rocpehin - we only do rocephin for Urosepsis pt's. Otherwise it is cefepime (+/- flagyl) + vanc.
2. Everybody qualifies as a septic pt now it seams with the SBP <90 (slight over exaggeration)
3. you can do 30ml/kg on idea weight as long as you document you are doing it on ideal weight.
4. The fluid in the abx counts towards the fluid - which for a vanc is often 500ml (depending on the dose)

 

[turkeyjerky]

Hard to say that Rivers was "wrong" when the standard of care prior to his protocol was to stick septic patients in the corner of the ER and not do anything. He showed an 16% absolute survival benefit.

It turns out that Rivers protocol was too broad and complicated...all patients really need is BP support (via fluids or vasopressors) and antibiotics as soon as possible. So I wouldn't consider him wrong. He was better than what was happening prior to him.

Except that's not what they studied--control patients got lined, bolused, and pressed as well...

I just think that with all these unnecessary sepsis alerts, we're obviously not able to give proper attention to the actual septic patients. So we've moved back to the old standard 'put em in the corner' except now they get 30 ml/kg and a bunch of checkboxes clicked.

 

[xaelia]

?? Did Andromeda come out very recently?

This is the first I heard of this. I clearly remember stud(ies) showing lactates trending down in early treatment of sepsis improved outcomes.

EDIT:
Oh yea I remember comparing capillary refill time (CRT) to lactate reduction. Came out in 2019.
Interesting stuff. This capillary refill time stuff is not spoken of at my institution at all.

If you look at the new surviving sepsis guidelines, cap refill gets a shout out as a reasonable metric for assessing peripheral perfusion and titrating resuscitation.

Doubt it'll catch on in U.S. because it's too difficult to audit – easy to see someone's weight and how much fluid they've received.

Side note:
Let me just tell you how many sepsis alerts I've encountered over the past year: zero

It's glorious.

 

[southerndoc]

If you look at the new surviving sepsis guidelines, cap refill gets a shout out as a reasonable metric for assessing peripheral perfusion and titrating resuscitation.

Doubt it'll catch on in U.S. because it's too difficult to audit – easy to see someone's weight and how much fluid they've received.

Side note:
Let me just tell you how many sepsis alerts I've encountered over the past year: zero

It's glorious.

What's even more impressive is despite not having sepsis alerts, sepsis mortality is better in NZ than in the US.

 

[RustedFox]

What's even more impressive is despite not having sepsis alerts, sepsis mortality is better in NZ than in the US.

I'm sure at least part of that reason is that the average septic Kiwi doesn't have 8-13 other chronic, generally calorie related ailments.

 

[southerndoc]

I'm sure at least part of that reason is that the average septic Kiwi doesn't have 8-13 other chronic, generally calorie related ailments.

Probably. I also think they don't emphasize fluid boluses... just emphasis on early antibiotics and to bolus as they deem necessary. Maybe @xaelia can comment.

 

[Dred Pirate]

I'm sure at least part of that reason is that the average septic Kiwi doesn't have 8-13 other chronic, generally calorie related ailments.

We had this discussion at work - americans aren't overweight - we are just under tall, if we all were 7 feet 2 inches, we would be at our ideal weight - we just have to figure out how to grow taller.

 

[RustedFox]

We had this discussion at work - americans aren't overweight - we are just under tall, if we all were 7 feet 2 inches, we would be at our ideal weight - we just have to figure out how to grow taller.

It sickens me. Really does.
The whole "fatshaming" and "fatphobic" nonsense that I hear bandied about in common parlance is just pathetic.
We used to be a nation that would overcome anything. Everything. Because we could.
But now, its "I can't because I have ______ (euphemism for zero dedication to maintaining physical fitness)."

 

[BoardingDoc]

It sickens me. Really does.
The whole "fatshaming" and "fatphobic" nonsense that I hear bandied about in common parlance is just pathetic.
We used to be a nation that would overcome anything. Everything. Because we could.
But now, its "I can't because I have ______ (euphemism for zero dedication to maintaining physical fitness)."

To preface: I am in no way supporting people who whine about their health defects which are solely related to their only form of exercise being bicep curls of fork to mouth. That said, I think the "good old days" idea doesn't really work here. If we had the same cheap, calorie dense food back in 1930 that we do today, I think we would have become a nation of fatty fat fats a lot sooner than we did.

I'm not saying this is an excuse. I just think that people on the whole were as lazy 100 years ago as they are today. The social/political/economic/agricultural/etc dynamics were simply different then.

Also, FWIW, I can't imagine the challenges of being an FP in this regard. I see tons of obese people who come in for their back pain that just won't get better. I don't have to fix that crap though. It's not an emergency. I would dread having to constantly explain to people that their joints hurt because Scotty says that their structural integrity field has been running at 300% and he can't hold it together much longer.

 

[RustedFox]

To preface: I am in no way supporting people who whine about their health defects which are solely related to their only form of exercise being bicep curls of fork to mouth. That said, I think the "good old days" idea doesn't really work here. If we had the same cheap, calorie dense food back in 1930 that we do today, I think we would have become a nation of fatty fat fats a lot sooner than we did.

I'm not saying this is an excuse. I just think that people on the whole were as lazy 100 years ago as they are today. The social/political/economic/agricultural/etc dynamics were simply different then.

Also, FWIW, I can't imagine the challenges of being an FP in this regard. I see tons of obese people who come in for their back pain that just won't get better. I don't have to fix that crap though. It's not an emergency. I would dread having to constantly explain to people that their joints hurt because Scotty says that their structural integrity field has been running at 300% and he can't hold it together much longer.

I don't entirely disagree; but 90% of our leisure time back in "the good old days" was spent being physically active or doing something of substance. Now, that time is spent virtue signaling on social media and being a "foodie" (don't get me started on that term).

 

[Lexdiamondz]

It sickens me. Really does.
The whole "fatshaming" and "fatphobic" nonsense that I hear bandied about in common parlance is just pathetic.
We used to be a nation that would overcome anything. Everything. Because we could.
But now, its "I can't because I have ______ (euphemism for zero dedication to maintaining physical fitness)."

I read a comment on reddit the other day about a 24 year old, 200 lb woman being "not that big".

Muhammad Ali knocked out Sonny Liston at 210 lbs. The greatest heavyweight boxer of the 20th century is roughly the same weight as a typical childless mid 20s American woman in 2021.

In residency, we did our anesthesia rotation with the bariatrics service because our PD figured those were the tubes that would be most akin to what we'd see in the ED. Sad, yet highly accurate in retrospect.

 

[RustedFox]

I read a comment on reddit the other day about a 24 year old, 200 lb woman being "not that big".

Muhammad Ali knocked out Sonny Liston at 210 lbs. The greatest heavyweight boxer of the 20th century is roughly the same weight as a typical childless mid 20s American woman in 2021.

In residency, we did our anesthesia rotation with the bariatrics service because our PD figured those were the tubes that would be most akin to what we'd see in the ED. Sad, yet highly accurate in retrospect.

I'm so keeping this little nugget of data.

 

[xaelia]

Probably. I also think they don't emphasize fluid boluses... just emphasis on early antibiotics and to bolus as they deem necessary. Maybe @xaelia can comment.

Oh.

Uh.

We can't get sepsis alerts because paper.

For vital sign documentation and physician orders.

🙃

 

[bravotwozero]

Oh.

Uh.

We can't get sepsis alerts because paper.

For vital sign documentation and physician orders.

🙃

you're using paper charts....

lol wut

 

[xaelia]

you're using paper charts....

lol wut

Yep.

I'd say the NZ public system is about 15 years behind the U.S. for health IT, generally speaking.

For someone board-certified in clinical informatics, it's been frustrating.

NZ: low salaries and anachronistic computer systems vs. no night shifts, uncountable weeks of leave, and nice patients with realistic expectations of the ED.

Still feels to be in favor of NZ, for the moment.

 

[bravotwozero]

I actually don't mind paper charts, to be honest. Used paper t sheets in residency, would love to have that back.

 

[xaelia]

I actually don't mind paper charts, to be honest. Used paper t sheets in residency, would love to have that back.

We have a Frankenstein's monster of implementation.

ED is the last department on paper for nursing notes, vital signs, and lab + medication orders.

Radiology orders and lab results are in our core IT system.

And then the ED trackboard is another tenuously-connected piece.

It's a lovely tapestry of ageing legacy systems, all jerry-rigged together.