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

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Embedded Research Quality Improvement Initiative Amith Shetty

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Page 1: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Embedded

Research

Quality

Improvement

Initiative

Amith Shetty

Page 2: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Objectives

Embedded research

Shoe stringing

Page 3: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Background

Page 4: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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

Page 5: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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

Page 6: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Sepsis Bundle

– Oxygen

– Lactate

– Monitor

– Empirical Antibiotics

– Blood Cultures

– Intravenous Fluids

Page 7: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Sepsis Kills

Embedded research

Shoe stringing

Page 8: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Sepsis Pathways

Pathways guide clinicians to THINK about sepsis

NOT prescriptive ……clinical judgement is KEY

Page 9: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

SEPSIS KILLS results

Page 10: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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

Page 11: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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

Page 12: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

What we can already do!

Page 13: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Track and trigger

Page 14: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Self reported Time to antibiotics

Page 15: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Data reports

Page 16: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Research outcomes

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

At district level – Multicentre data-rich Sepsis archive

Page 17: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Lactate in Suspected sepsis –

CEC sepsis register

Page 18: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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

Page 19: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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

Page 20: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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%

Page 21: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Why do QI Research

Page 22: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

Lessons learnt

– Clinician leadership locally critical

– Engagement carrots!

– Sustainability crucial

– Reproducibility

– DATA DATA DATA

– Implementation science – guidelines, knowledge generation, reflection,

adaptation and reimplementation + monitoring

Page 23: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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?

Page 24: Embedded Research Quality Improvement Initiative · –Collects all SIRS, investigative and in-hospital outcome data for identified ... Research outcomes At state level –CEC sepsis

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