Lessons Learned – Sepsis and Covid-19
One of the most popular educational offerings available to CHPSO members are the regularly scheduled Safe Table forums. Offered about two dozen times per year, these meetings are focused on safety and quality improvement topics, each with a specific clinical focus. As a members-only patient safety activity, these confidential forums occur within each participant’s patient safety evaluation system and provide a safe space in which to explore systematic concerns or issues and share lessons learned.
In August, CHPSO hosted a Safe Table related to a clinical topic at the forefront of everyone’s mind – COVID-19 – specifically the differential diagnosis and management of sepsis and COVID-19. For this discussion, we were pleased to host a panel of experts in a variety of related areas from one of our member organizations – UCLA Health. The panelists for this Safe Table included Dr. Russell Kerbel, MD, MBA, the Medical Director for Sepsis Prevention, a Hospitalist and Informaticist; Dr. Christopher Tymchuk, MD, PhD, a Hospitalist and Infectious Disease specialist; Dr. Kathryn Melamed, MD, who specializes in Critical Care and Pulmonary Disease, and Julie Gaspar, RN, who is a COVID-19 and Sepsis Educator.
These four highly skilled clinicians led the group through a discussion of a complex, hypothetical case derived from their combined real-world experiences. The case study prompted discussions around questions such as the appropriateness of starting empiric antibiotics for community acquired pneumonia in a febrile, hypoxic, tachycardic patient with several other co-morbidities and a pending COVID-19 polymerase chain reaction.
Additional discussion centered around when to re-screen for sepsis in patients who had been diagnosed with COVID-19 and for whom antibiotics had been discontinued. The team walked the group through a series of guidelines and best practices including general approaches to the management of COVID-19, whom to test and when, as well as other laboratory study recommendations such as baseline bloodwork and re-screening laboratory testing protocols.
The team also shared several electronic medical records (EMR)-based approaches to hardwiring the safe care and treatment of patients with sepsis, COVID-19, and/or both disease processes. These tools included a focused COVID-19 Summary Report page, which was based on the recommendations of the UCLA Hospitalists, Infection Disease specialists, Intensivists and Informaticists.
The goal of this page was to create a single tab in the summary section of the EMR with relevant clinical information regarding COVID-19. The design was taken from previous work on similar tabs that have worked well to guide focused review and assessments such as those designed to guide clinicians in the management of fevers, glucose, anti-coagulation, and diuresis. This COVID-19-focused tab includes relevant vital signs, lab tests, and medications all listed by time of test/administration. Specific sections of the tab include:
- Temperature graph and anti-pyrectics
- Vital signs
- Respiratory status
- COVID-19 labs
- COVID-19 therapeutics
- Chest imaging
- Blood type and blood products
- Interleukin-6, COVID-19 and Influenza results and orders
- COVID-19-related resource links such as facility specific resources, interfacility transfer guide and the county department of public health information page for health care providers
The discussion concluded with a review of several other important areas for consideration. These included the need for excellent communication between the physicians and the direct care/primary registered nurse (RN) caring for the patient. These patients can decompensate rapidly and the RN at the bedside is in the best position to see these changes. Prompt notification and response by the entire care team will ensure the best possible outcome for these patients.
Suggestions included ensuring that you maintain an open differential diagnosis – don’t let confirmation bias cloud your clinical judgment. Consider implementing MD/RN bedside rounding with representatives from infectious disease, pulmonology, hospitalist, case management/care coordination, and clinical trial teams (as appropriate for the patient and facility type). The UCLA team also encouraged physician and nursing leadership to solicit nursing perspective from a variety of care areas (e.g. emergency department, medical/surgical floor, and intensive care units) about how best to monitor these patients in the hospital.
CHPSO members can email firstname.lastname@example.org if they would like access to the members-only information related to this Safe Table topic. Please click here to see if you are a CHPSO member. If you would like information on becoming a CHPSO member, please check out the prospective members section of our website. Those interested in diving deeper into the differential diagnosis and management of COVID-19 and sepsis may find the following recently published article(s) on the topic to be of interest.
Furukawa, D., & Graber, C. J. (2020). Antimicrobial stewardship in a pandemic: picking up the pieces. Clinical Infectious Diseases. Available here.
Vaughn, V. M., Gandhi, T., Petty, L. A., Patel, P. K., Prescott, H. C., Malani, A. N., … & Flanders, S. A. (2020). Empiric Antibacterial Therapy and Community-onset Bacterial Co-infection in Patients Hospitalized with COVID-19: A Multi-Hospital Cohort Study. Clinical Infectious Diseases. Available here.