Hospital-wide Implementation of Standardized Access to Peripheral Vasopressors for Sepsis

Background:

Patients with fluid refractory shock require prompt vasopressor support. Initiation of vasopressors may be delayed due to lack of central venous access. When administered properly, peripheral vasopressors are safe and effective. Between January 1, 2016 and January 9, 2018, our institution identified 758 cases of severe sepsis, with 208 (27%) cases requiring treatment with pressors. Thirty-six patients were treated without placement of central line, 17% of patients requiring pressors, and were the focus of our improvement effort. Our aim was to improve timely initiation of vasopressors for patients with fluid refractory shock by creating a standardized protocol for peripheral administration.

Methods:

A multidisciplinary team mapped the current state. A key driver diagram was created (Fig. 1).

Fig. 1.

Peripheral vasoactive-inotropic infusion key driver diagram. ED, Emergency Department; ICU, intensive care unit.

Results:

A standard protocol for delivery and monitoring of epinephrine, norepinephrine, and dopamine via peripheral IV was implemented (Fig. 2). To insure the safety of the protocol we required: low concentration of medication infusions, IV checks every 15 minutes, and a maximum duration of 6 hours. In addition, orders for rescue therapy with phentolamine were created and nurses were trained on phentolamine delivery. We aligned the electronic order set, pump library and policy documents, and integrated job aids in our septic shock pathway.

Fig. 2.

Peripheral vasoactive-inotropic infusion algorithm. CVL, central venous line; CLABSI, Central line associated bloodstream infection; ED, Emergency Department; IV, Intravenous; ICU, intensive care unit; KVO, keep vein open; MAP, mean arterial pressure; MIVF, maintenance intravenous fluid; PIV, peripheral intravenous line; VAS, vascular access service.

Conclusions:

Standardization led to a clear, safe process for staff to initiate vasopressors as early as clinically indicated regardless of patient vascular access. We are monitoring time to vasopressor initiation, use and duration of peripheral vasopressors, presence of a wound consult, and frequency of patient rescue events. Degree of fluid overload and duration of hypotension will be important clinical outcomes to measure in the future.