Sepsis Initiative Gap Analysis

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* 1. Facility:

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* 2. Contact Name:

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* 3. Contact Email:

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* 4. Do you have a sepsis screening tool/system?

Yes

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* 5. Screening for sepsis, severe sepsis, and septic shock is performed at our hospital in the following departments:

	Yes	No
Emergency Department	Emergency Department Yes	Emergency Department No
Medical/Surgical Department	Medical/Surgical Department Yes	Medical/Surgical Department No
Intensive Care Unit	Intensive Care Unit Yes	Intensive Care Unit No
Other (explain in "other" comment field)	Other (explain in "other" comment field) Yes	Other (explain in "other" comment field) No

Other Departments (please specify)

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* 6. Screening Frequency:

	Yes	No
We screen every adult patient during triage in the Emergency Department	We screen every adult patient during triage in the Emergency Department Yes	We screen every adult patient during triage in the Emergency Department No
We screen every adult patient once a shift in the inpatient department	We screen every adult patient once a shift in the inpatient department Yes	We screen every adult patient once a shift in the inpatient department No

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* 7. Have an "Alert" mechanism to provide for prompt escalation and action from care providers with defined roles and responsibilities.

Yes

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* 8. Have a standard sepsis order set or protocol

Yes

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* 9. Our hospital consistently performs the following within 3 hours

	Yes	No
Measure lactate level	Measure lactate level Yes	Measure lactate level No
Obtain blood cultures prior to administration of antibiotics	Obtain blood cultures prior to administration of antibiotics Yes	Obtain blood cultures prior to administration of antibiotics No
Administer broad spectrum antibiotics	Administer broad spectrum antibiotics Yes	Administer broad spectrum antibiotics No
Administer 30 mL/kg crystalloid for hypotension or lactate ≥4mmol/L	Administer 30 mL/kg crystalloid for hypotension or lactate ≥4mmol/L Yes	Administer 30 mL/kg crystalloid for hypotension or lactate ≥4mmol/L No

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* 10. Our hospital performs the following within 6 hours

	Yes	No
Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mmHg	Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mmHg Yes	Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mmHg No
In the event of persistent hypotension after initial fluid administration (MAP < 65 mmHg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1 (below for reference)	In the event of persistent hypotension after initial fluid administration (MAP < 65 mmHg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1 (below for reference) Yes	In the event of persistent hypotension after initial fluid administration (MAP < 65 mmHg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1 (below for reference) No
Remeasure lactate if initial lactate was elevated	Remeasure lactate if initial lactate was elevated Yes	Remeasure lactate if initial lactate was elevated No

TABLE 1: Reference
DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH:

Either:
-Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner 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

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* 11. Cultures are obtained before antimicrobial therapy is initiated if such cultures do not cause significant delay (>45 minutes) in the start of antimicrobial(s) administration.

Yes

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* 12. Have broad spectrum antibiotics in a dispensing system which permits antibiotics administration within one hour in the following locations:

	Yes	No
Emergency Department	Emergency Department Yes	Emergency Department No
Inpatient Department	Inpatient Department Yes	Inpatient Department No

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* 13. Use a "time zero" method that displays visual cues for health care team for timing of interventions for sepsis bundle (identification time)

Yes

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* 14. Does your hospital track clinician adherence to the sepsis resuscitation bundle?

Yes

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* 15. How often do you have meetings between the ED and ICU to discuss sepsis related activities?

More than once a month

Approximately once a month

Approximately once a quarter

We do not currently have these meetings

Other (please specify)

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* 16. Are these meetings specifically for sepsis review?

Yes

No, but they are a part of a larger committee (e.g. Critical Care, Quality, etc)

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* 17. Goals of care and prognosis are being discussed with patients (if conscious and able to understand) and families

Yes

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* 18. Goals of care are being incorporated into treatment and end-of-life planning, utilizing palliative care principles where appropriate

Yes