sepsis mortality reduction challenges, successes ... ... sepsis mortality reduction challenges,...

Sepsis Mortality Reduction Challenges, Successes & Outcomes of a Quality

Improvement Project Beacon Northern California Council

Patient First Safety Luncheon & Education Program Marci Hoze, RN, BSN, MPA

March 19, 2013

Presenter Presentation Notes Hien call to order Goals looks at process, moving change forward attached to agenda, directory – whom, why,, LSS methodology

End: Ideas for directory

Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Program Objects • Describe a strategy to reduce sepsis mortality through early

identification and goal directed therapy optimizing the electronic health record.

• Implementing a sepsis screening process • Implementing standardized severe sepsis treatment (EGDT)

• Identify challenges to varied data sources and reporting methods

• Developing a means for abstracting and reporting data

• Recognize the need for a quality improvement infrastructure to advance and sustain quality improvement projects

• Managing organizational change.

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Presenter Presentation Notes JIM

Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

University of California Davis

• 619 Bed Acute Care Hospital • Serves 33 Counties, 65,000 sq mile area • Level 1 Trauma Center • Burn Center • Children’s Hospital • Medical & Nursing School • 12,000 Faculty & Staff • 61,037 ER Visits • 888,632 Office Visits • 31,450 Admissions

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

UC Davis Goals • Reduce Sepsis Mortality by 15%

• Identify Patients Early • Evidence Based Timely Early Goal Directed

Therapy (EGDT) • Screen Severe Sepsis and Septic Shock Patients with a

Lactate Acid • Blood cultures prior to antibiotic administration • Antibiotics within 60 minutes • IV Fluid bolus of 20mg/kg within 3 hours • Vasopressors for refractory hypotension • Goal directed fluids to correct SVO2 or MAP

• Leverage EMR • Engage Frontline Nursing Staff

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Presenter Presentation Notes MARCI

Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Advantages

• Executive Leadership/Support • Gordon & Betty Moore Foundation Grant • DSRIP • Formation of Multidisciplinary Collaborative • Highly Developed Electronic Heath Record

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Challenges • Deciding on a sepsis screening tool – SIRS BPA • Negotiating bundle measures • Orchestrating organizational change

• Increasing use of lactates in differential • Reducing time from blood culture order to draw • Reducing time to antibiotics • Hardwiring rate, amount, and timing of fluids

• Data abstraction • Determining mortality – Coding vs Clinical • Defining “time of presentation” • Determining bundle compliance

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Presenter Presentation Notes MARCI

Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Diagram Present/Future State

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Presenter Presentation Notes MARCI I think this is a slide you are using to show how you mapped out where you needed to go and what you needed to do. I wonder if you could use this slide to talk about how you formulated a team, identified key stakeholders, developed a map for where you needed to go, etc. – describe the whole starting process.

Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Tools

 Best Practice Alert

 Standardized Protocol

 Screening Orders

 Treatment Orders

 Reassessment Views

 Reassessment Orders

 Professional Exchange Report

SEPSIS IMPROVEMENT COLLABORATIVE

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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ADULT SEPSIS ANTIBIOTIC COMPATIBILITY - Y-SITE

Drug name Amikacin Ampicillin Azithromycin Aztreonam Cefepime Ceftriaxone Clindamycin Gentamicin Meropenem Metronidazole Vancomycin

Amikacin I I C C I C C C C

Ampicillin I ? C C I C I ? C C

Azithromycin I ? I I I I I I C ?

Aztreonam C C I C C I I

Cefepime C C I C I C I

Ceftriaxone I I I I I C I

Clindamycin C C I C C I C ? ?

Gentamicin I I C I I C C C C

Meropenem C ? I ? C C C

Metronidazole C C C I C C C C C

Vancomycin C C ? I I I ? C C C

I = incompatible C = compatible ? = no information, avoid mixing

inappropriate combination

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

UC Davis Measuring “EGDT Compliance” Measures 2, 5, & 6

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Sepsis Mortality

Year Patient

Population Numerator Denominator

UCDMC SIC Mortality Rate

Rate of Patient Population

Increase (From Baseline)

Expected Deaths

O/E Ratio Potential Lives

Saved

2009* SIC Population 179 492 36.4% - - - - 2010 SIC Population 194 640 30.3% 30.1% 233 0.83 39 2011 SIC Population 176 632 27.8% 28.5% 230 0.77 54 2012** SIC Population 180 658 27.4% 33.7% 239 0.75 59

463 0.80 152 * Baseline

** CY 2012 YTD (Jan-12 to Nov-12)

SIC Population Breakout

Year Patient

Population Numerator Denominator

UCDMC SIC Mortality Rate

Rate of Patient Population

Increase (From Baseline)

Expected Deaths

O/E Ratio Potential Lives

Saved

Septic Shock 112 257 43.6% - - - - Severe Sepsis 67 235 28.5% - - - - SIC Population 179 492 36.4% - - - - Septic Shock 121 310 39.0% 20.6% 135 0.90 14 Severe Sepsis 73 330 22.1% 40.4% 94 0.78 21 SIC Population 194 640 30.3% 30.1% 233 0.83 39 Septic Shock 113 321 35.2% 24.9% 140 0.81 27 Severe Sepsis 63 311 20.3% 32.3% 89 0.71 26 SIC Population 176 632 27.8% 28.5% 230 0.77 54 Septic Shock 123 333 36.9% 29.6% 145 0.85 22 Severe Sepsis 57 325 17.5% 38.3% 93 0.62 36 SIC Population 180 658 27.4% 33.7% 239 0.75 59

* Baseline ** CY 2012 YTD (Jan-12 to Nov-12)

2011

2012**

TOTAL

2009*

2010

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

UC Davis Average Length of Stay

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Presenter Presentation Notes MARCI

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

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Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Lessons Learned • Anticipated hospital areas where the SIRS alert may be

problematic

• Reports highlight units and services where SIRS is very common / expected

• Allowed for lock out times to be determined clinically

• Training is key to ensuring alerts are being evaluated appropriately

• Mandatory 15 minute eLearning for nursing • Follow-up in-service on each unit

• Institutional Support is key to buy-in

• If workflow is dependent on timely entry of vital signs, track how timely vitals are entered.

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Presenter Presentation Notes MARCI/JIM DEPENDING ON IF THESE ARE SEPARATE OR TOGETHER. We can trade off or ??

Sepsis Improvement Collaborative A HEALTHIER WORLD THROUGH BOLD INNOVATION

Lessons Learned -EGDT • Physician education is key

• Because of constant turnover in physician housestaff, nurses also must be educated

• Rapid response team is critical to maintaining consistency in process

• Bundle should be done prior to transfer of patient to another unit