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  • 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

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