embedded research quality improvement initiative · –collects all sirs, investigative and...

Embedded

Research

Quality

Improvement

Initiative

Amith Shetty

Objectives

Embedded research

Shoe stringing

Background

Background

Research to Evidence based practice – delays

Capturing the effects of practice change – are we really doing better

Quality initiatives –

Usually very focused

System targets

Intended and unintended consequences

SEPSIS KILLS program:reduce preventable harm to patients with sepsis

RECOGNISE:

Risk factors, signs and symptoms of sepsis and inform senior clinician

RESUSCITATE:

With rapid antibiotics and IV fluids within one hour

REFER:

To specialist care and initiate retrieval if needed

Sepsis Bundle

– Oxygen

– Lactate

– Monitor

– Empirical Antibiotics

– Blood Cultures

– Intravenous Fluids

Sepsis Kills

Embedded research

Shoe stringing

Sepsis Pathways

Pathways guide clinicians to THINK about sepsis

NOT prescriptive ……clinical judgement is KEY

SEPSIS KILLS results

NSW hospital sepsis mortality

10

12

14

16

18

20

22

2009-2011 2012 2013 2014 2015

De

ath

s w

ith

an

d w

ith

ou

t A

uto

psy

(%

)

Principal only P+4 Comor P+5 Comor P+25 Comor P+50 Comor MJA - Comor 1-5

SMEDSA

– Sydney Multicentre Emergency Department Sepsis Archive

– Retrospective chart review populated sepsis registry approved at 5

Western Sydney EDs patients placed on the sepsis pathway

– Patients identified through clinician reported EMR alert for sepsis

based on CEC SIRS criteria or senior clinician suspicion

– Collects all SIRS, investigative and in-hospital outcome data for

identified patients

What we can already do!

Track and trigger

Self reported Time to antibiotics

Data reports

Research outcomes

At state level – CEC sepsis register – Broad coarse system level data

At district level – Multicentre data-rich Sepsis archive

Lactate in Suspected sepsis –

CEC sepsis register

ED Lactate levels risk

stratificationLactate group (mmol/L) Age median (IQR) Total, n (Died n/%)

[p]*

AE

n (%) [p]*

0 to <1 66.7 (48.1-79.4) 847 (37/4.37)

[NA]

54 (6.38)

[NA]

1 to <2 72.1 (57-82.1) 3531 (181/5.13)

[0.36]

244 (6.91)

[0.58]

2 to <3 73.1 (60.3-83) 1922 (145/7.54)

[0.0003]

198 (10.3)

[<0.0001]

3 to <4 74.3 (61.9-83.5) 897 (105/11.71)

[0.0003]

135 (15.05)

[0.0003]

≥ 4 74.1 (60.9-84) 1113 (283/25.43)

[<0.0002]

352 (31.63)

[<0.0002]

Total 72.6 (58.1-82.6) 8310 (751/9.04) 983 (11.83)

*p-values calculated for proportion difference against group below lactate group

Data learning to guideline

translation

State Level

– Time to antibiotics target extended to 120 minutes

– Lactate trigger for high degree of adverse outcome risk ≥ 2 mmol/L included

Registry data

– SIRS algorithms performance

– Broad spectrum antibiotic usage and AMS initiatives

– Multicentre data validation of qSOFA and SOFA sepsis definitions

What more have we done?

– Large dataset evaluation of sepsis algorithms in state-wide datasets

– Over 4 million events in NSW

– Cerner alert, Severe sepsis alert and qSOFA – sensitivity and specificity compared

– Multicentre ED data-sharing for validation and improvement of qSOFA

– 12555 events across multiple EDs in Australia and the Netherlands

– qSOFA – sensitivity 47.6% Specificity 89.1%

– LqSOFA(2) – sensitivity 65.5% Specificity 81.5%

Why do QI Research

Lessons learnt

– Clinician leadership locally critical

– Engagement carrots!

– Sustainability crucial

– Reproducibility

– DATA DATA DATA

– Implementation science – guidelines, knowledge generation, reflection,

adaptation and reimplementation + monitoring

Future challenges

– Clinician decision support versus Clinician Automation

– How do we track clinicians’ behaviour and suspected infection cohorts?

– Triaging patients in ED

– Tracking clinician test ordering

– What is acceptable test performance statistics?

Acknowledgements

– Dr Harvey Lander, Malcolm Green, Mary Fullick and CEC Sepsis kills team

– All NSW ED QI and staff – data in data out

– ED clinician leads at various sites and many others