sepsis resuscitation bundle compliance journey - california

Arrowhead Regional Medical Center- Quality Leaders Awards 2013

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CHECKLIST OF MATERIALS INCLUDED:

**NOTE: You application will not be considered complete without items 1 – 3**

1. _X___ This cover sheet with CEO (or designee) approval

2. _X__ Description of improvement (use the attached Narrative Description form)

3. _X__ 3-5 digital photos depicting improvement in action (send to [email protected])

4. _X__ SNI Program form, if applicable (see explanation)

5. _X__ Supplemental materials (optional)

2013 CAPH|SNI Quality Leaders Awards Application Cover Sheet and CEO Approval Form

Title of Improvement/Entry: ARMC Sepsis Resuscitation Bundle Compliance Journey

CAPH Member Institution: Arrowhead Regional Medical Center

Name of contact person for this entry: Victoria Ogunrinu, RN, MPH, MSN / Carol Lee, M.D

Contact person’s title/job description: Assist Hosp Administrator/Emergency Physician

Phone number for contact person: 909-580-6246/ 909-580-6370

Email for contact person: [email protected] /[email protected]

Triple Aim Categories (you may check more than one):

___ Improving the Patient Experience

_X__ Improving the Health of Populations

_X__ Value and Cost Containment

CEO or designated hospital administrator: Please sign below to indicate your approval of submission of this entry. I certify that this entry has been reviewed and approved by hospital/health system administration.

Name/title: Patrick Petre, Chief Executive Officer Signature: Date:

mailto:[email protected]


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Narrative Description of ARMC Sepsis Resuscitation Bundle Compliance Journey


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□ Please check here if you DO NOT want this application shared on the SNI website. Please answer the following questions with detailed, but succinct answers. (Answers should total no more than three pages)

1) Please summarize your improvement/project in 200 words or less. Include the start and end dates, and indicate what your team aimed to achieve through this effort, and by when?

Arrowhead Regional Medical Center

Arrowhead Regional Medical Center(ARMC) embarked on the Sepsis Resuscitation Bundle Compliance Journey in 2011 along with our mission statement to provide quality health care to the community. In preparation for the improvement, ARMC leadership committed to drive and sustain improved outcomes for patients with sepsis. A Multi-Disciplinary Sepsis Task force was formed to manage the process. Surviving Sepsis Campaign began throughout the campus. Initially, 6month Sepsis Bundle Baseline was 38.1% and DY7 compliance was 50%. Mortality rate was 35.4%. A target of 65% was set for DY8 to improve compliance with the bundle. Within 18 months ARMC observed a phenomenal result attributable to effective coordination and strong partnerships among the ED, Critical Care and Medical-Surgical units. Resident physicians, nurses training and education were pivotal to the success of the project including daily rounding of the sepsis abstractor in the ED. The application of LEAN methodology showed a significant cost saving as well. To improve compliance with sepsis antibiotics, the task force recommended combining generic antimicrobial and sepsis order form. Our total DY8 bundle compliance was 75%, 10% above our target. DY8 mortality was 29.9% down from DY7 of 35.4%. ARMC has made great strides in improving outcomes for sepsis patients.

2) What is the problem that the improvement was designed to address and what was the organizational context? What

there a business case driving the decision to address this issue? In June 2011, our sepsis bundle compliance was 19.4% with mortality rate of 32.3%. The improvement was designed to increase the Sepsis Resuscitation Bundle compliance rate and decrease the mortality rate. ARMC started on the Sepsis campaign journey with the inception of DSRIP. The concerted effort was embraced by leadership and the Sepsis Task Force. ARMC vision statement of improving the health of the community, and the poor sepsis bundle compliance rate were the driving forces in addressing the complexity of the issue as an organization. The goal is to improve staff ability to identify sepsis early in ED and raise general awareness of sepsis resuscitation bundle.

3) Who were the intended customers /stakeholders and what was the impact on them?

The patients with sepsis and the population of the community of San Bernardino are the intended customers. Stake holders are Physicians, Staff, Leadership of the ARMC and Board of Supervisors. Our efforts had resulted into early detection and management of sepsis and reducing harm to the patients while increasing their survival rate.

4) How was the improvement effort staffed and what was each team member’s role? How often did the team meet? Initially, Sepsis management at ARMC was not protocol driven hence the need to recognize implementation of Surviving Sepsis Campaign along with DSRIP mandate. Earlier efforts were initiated with the available staff with


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some results. The initial focus was on standardization of the process. Later on, an LVN was hired for sepsis abstraction and rounding in ED as well as responding to Rapid Assessment Team (RAT) calls on the med/surg units. While there is a need for a sepsis coordinator, the role has been shared among the Quality Management staff and the DSRIP administrator. The multidisciplinary task force meets monthly and the Sepsis working committee meets prior to the task force meetings to review the fallouts. The team comprises of the Sepsis abstractor, ED physician, ED educator and DSRIP Administrator. The Sepsis Task Force comprises of Physicians from ED, ICU, Infectious diseases, Family Practice, Nurse Educators, Unit Nurse Managers, PI staff and DSRIP Administrator.

5) If a formal improvement methodology was used, please describe. (e.g. IHI’s Model for Improvement/PDSA cycles, Lean, etc.) The Sepsis order set underwent PDSA cycles to identify issues and opportunities. The forms were revised a few times. In addition, Sepsis LEAN was also implemented. LEAN identified issues with labeling of the blood culture tubes and use of sepsis antibiotics form. Necessary strategies were implemented to improve the process. Representatives from each department relay the information and changes to their own department. LEAN Data analysis of Sepsis patients for 2012 revealed an increase in average length of stay for patients with unsuccessful Sepsis bundle compliance. Average length of stay for a successful bundle patient was 19 days (9 ICU days, 10 Med/Surg) for a total room cost of $17,900.97 per patient. The average length of stay for an unsuccessful patient was 25 days (11 ICU days, 14 Med/Surg) with a total room cost of $22,729.94. Successful bundle completion stayed 6 days less (2 ICU days, 4 Med/Surg) and generated a $4,828.98 room cost savings per patient. ARMC cared for a total of 264 Septic patients in 2012, with 102 unsuccessful bundle compliance patients (61.4% bundle compliance) with total room cost of $492,555.55. Meeting a goal of 75% bundle compliance on the same 264 patients in CY 2012 would have produced 66 unsuccessful bundle patients at a total room cost of $318,712.42. The potential room cost savings between 102 patients versus 66 patients equals $173,843.14.

6) What activities or changes took place through the improvement effort?

Several activities took place in our organization which we believe contributed to sepsis improvement efforts. We

Developed the sepsis order set

Trained all staff, physician, residents and nursing staff

Lean Study

PDSA cycles

New Resident Physician orientation skit

Standardize order set for sepsis

Sepsis Order set available electronically in Resident physicians tool

Daily Rounding in ED

Posting results in ED and the units on continuing progress being made.

Revised the antimicrobial order form for the organization.

Collaboration with IT, laboratory and respiratory departments

Sepsis Task Force committee meetings

ARMC leadership support The team efforts by implementation of all the above had a huge impact on the outcome of our Sepsis program.

7) What are the results from this effort? How do you know your improvement project made an impact? Please include

the quantitative measures and baseline/outcomes data demonstrating the success of your efforts. The organization experienced better compliance with the sepsis resuscitation bundle and a decline in sepsis mortality rate. With the initiation of the sepsis LEAN our projected cost savings is $173,843.14 per year. The data below clearly depicts the impact of our improvement efforts. Our 18 month journey has achieved a goal of 82% by June 2013, increase of 62.6%, and mortality rate decreased by 5% to 27.3%. ARMC has made great strides in improving outcomes for sepsis patients.


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8) Please describe your plans for sustaining the improvements made. Describe the challenges or opportunities with maintaining success over time. ARMC sepsis project has a multidisciplinary approach for continuing sustainability. The standardized protocol for bundle compliance, education and ongoing training of ARMC new members will help to maintain the standards and compliance. Some of the challenges we have encountered are related to our hybrid electronic system. Some of the departments are still using paper charting. The Sepsis Task Force continues to focus on improving our process and reviewing each elements of the bundle. Fallouts are promptly addressed by each department. Since over 70% of ARMC sepsis patients present in ED, the PI staff will continue to round in ED twice a day to remind ED staff about sepsis bundle compliance. The electronic version of the sepsis was placed in the resident tools for easy access for the physicians. We also identified blood culture labeling as an issue; a LEAN project was initiated to address the improvement project. This effort resulted in significant improvement in the process that can be sustained. Compliance with Sepsis antibiotics was an issue, so we combined our generic antimicrobial order form with sepsis antibiotic form. Sepsis screening is now embedded in the nursing shift assessment and the sepsis panel order is now computerized as well as in the paper charting in ED. Finally, as a teaching hospital, new resident physician come on board every June. We have added new residents’ orientation to Sepsis management. We also included a flash card for to carry along with them. With continuing leadership support and effective oversight by the ever so committed Task Force, Staff ownership of the project, ARMC Sepsis Resuscitation Bundle compliance project will continue to be effectively sustained. These are the pillars behind our success.

9) Is there anything else you would like to report?

ARMC has created a Sepsis PowerPoint education for doctors and nurses. The sepsis flash card is also available for staff as a reminder for the sepsis bundle. This has been presented at the Leadership council as well. Our Sepsis improvement journey has been shared at the Sepsis/CLABSI collaborative and made available on the DSRIP portal for other organizations. The application of LEAN to our sepsis management also contributed to the improved outcomes. Overall, ARMC staff has a sense of ownership of our sepsis bundle program and can articulate all the elements of the sepsis resuscitation bundle. The goal of the Sepsis rounding in ED is to hardwire the process completely.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2011 Sepsis Compliance Bundle 19% 26% 47% 47% 50% 61% 40%

2012 Sepsis Compliance Bundle 42% 63% 45% 58% 57% 74% 50% 61% 69% 63% 81% 77%

2013 Sepsis Compliance Bundle 70% 78% 86% 88% 90% 82%

2011 Mortality Rate 32% 35% 16% 53% 25% 28% 35%

2012 Mortality Rate 42% 38% 41% 35% 39% 26% 25% 22% 41% 19% 50% 36%

2013 Mortality rate 30% 30% 43% 25% 19% 27%

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100%ARMC Sepsis Resuscitation Bundle Compliance and Mortality Rate


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ARMC Digital Photos

Depicting Improvement in

Action


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Sepsis Abstractor ED Rounding Septic Patient Initial Screening

by Triage RN

Sharing Sepsis Report with ARMC Leadership New Resident Physicians’ Orientation

ED Physician orienting Resident Physician to

Sepsis Screening Forms and Sepsis order set


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Supplemental Questions for Incentive Program or SNI

Initiative (not required for all entries)

If your Quality Leaders Award entry is related to existing work towards achieving your hospital system’s Incentive Program milestones, or is part of an SNI-run program, such as SNI’s CG-CAHPS Improvement Network or Sepsis/CLABSI Collaborative, please answer these three additional questions for your program. Attachments are welcome.

1) Accelerated Results: How has your system exceeded the goals of your Incentive Program milestones, or those of your SNI program? Please demonstrate what factors contributed to these goals being surpassed.

Include data to support this.

ARMC has exceeded the initial goals set in 2011. Not only have we met the goals for 2013, DY 8, we have surpassed the DY9 as well. Initially, DY7 mortality rate was 35.4%, and the Sepsis resuscitation bundle compliance was 50%. Our 18 month journey has achieved a goal of 82% of bundle compliance by June 2013. Total DY8 of 75% shows an increase of 25% from DY7. DY8 mortality was 29.9% from DY7 of 35.4%. Several factors contributed to the success of the ARMC Sepsis program with outstanding achievement. We started out with great leadership support that gave us the capacity to translate our vision into reality. We believe that our organization is defined by results. This ignited our enthusiasm to critically look inward and implement a sustainable change. We embarked on the Surviving Sepsis Campaign education throughout the organization. With the support of the Safety Net Institute and the Sepsis and CLABSI Collaborative we were able to achieve and surpass our goals. We were able to instill the “think bundle concept” in our clinician. All elements of the bundle is addressed and given equal weight. We monitor bundle compliance in real time by rounding in ED where over 70% of our patients present initially. Early recognition and management of the sepsis patient is crucial, the Performance Improvement staff responds to RAT calls (Rapid Assessment Team). This allows us to monitor and provide real time feedback. The Sepsis Task Force meets regularly to review performance report and address fallout with each department and providers. Several members of ARMC attend the collaborative meeting and return highly energized and motivated to share their new knowledge among staff on their respective units. As a teaching hospital, new resident physician come on board every June. We have added new resident physicians’ orientation to Sepsis management. We also included a flash card for residents to carry along with them. We collaborated with our IT department to add sepsis screening to the nursing assessment. Collaboration with the laboratory department to prioritize resulting of the serum lactate and respiratory for ABG with lactate in a timely manner were essential. As a team, we have been able to achieve success and sustain the upward trend in sepsis bundle compliance with downward trend in mortality rate. Our most powerful message is “Think Bundle”. There are no other magic formula to Surviving Sepsis Campaign other than implementing all the sepsis bundle elements for early detection and timely management. With sepsis, the clock is ticking and time is of essence.

ARMC Sepsis Bundle Resuscitation Bundle Compliance Demonstration Year (DY) Goal:

DY8 DY9 DY10

Increase rate of sepsis resuscitation bundle com-pliance from a baseline of 38.1% to a target of 65%.

Increase rate of sepsis resuscitation bundle compliance from a DY8 target of 65% to a target of 75%.

Increase rate of sepsis resuscitation bundle compliance from a DY9 target of 75% to a target of 81%.


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Sepsis Resuscitation Bundle Element

Jun-11 DY7 DY8 Q1

total DY8 Q2

total DY8 Q3

total DY8 Q4

total DY8 Total

Sepsis Resuscitation Bundle Compliance

19.4% 50.0% 62.9% 72.3% 76.1% 87.0% 75.3%

6 31 123 246 39 62 47 65 51 67 67 77 204 271

DSRIP Goal Bundle Compliance

Baseline 38.1% 65%

Mortality Rate 32.3% 35.4% 32.3% 32.3% 32.8% 23.4% 29.9%

(exclusions removed) 10 31 87 246 20 62 21 65 22 67 18 77 81 271

For DY 7 ARMC Bundle compliance was 50% from a baseline of 38.1%.

For DY 8 ARMC target was 65% and we achieved compliance rate of 75.3%.

Target for DY 9 is 75% which we have achieved in DY8.

Target for DY 10 is 81%. We are hopeful that we would also surpass the DY10 goal with effective hardwiring of our process

2) Spread: How has this project helped your system spread the gains of the Incentive Program or SNI program to other parts of your organization that were NOT involved in the initial work of this program? [e.g., chronic disease self-management support initiated in one clinic was replicated in another]

Include data from the measurement of this spread of improvement.

Our initial education and intervention in ED and ICU provided slow yields. A phenomenal change occurred with the addition of nurse rounding in ED and providing education on Sepsis screening on an ongoing basis. A powerful Sepsis education board was visibly displayed in ED for continuous staff education. Since there is no other affiliated hospital, we have spread the concept to other programs within the hospital. The rounding in ED for sepsis has been replicated in CLABSI prevention, where we now round on the units providing ongoing education to staff on CLABSI prevention. Additionally, we have worked to promote “spread” by implementing a monthly DSRIP improvement meeting which began as 4 separate team meetings to share information and collaborate. Sometimes CLABSI and Sepsis nurses round together as well.

Badges for Rounding

ARMC CLABSI LOGO ARMC SEPSIS LOGO


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3) Integration: Have you been able to connect the work of the Incentive Program or SNI-led program to

your organization’s strategic goals in order to achieve maximum gains and sustainability? Describe this process and the level of integration you have achieved. [e.g., We used the Lean Core Measures Improvement Initiative to create a standardized work process for CHF orders]

Include data from the measurement of the integration gains.

We are members of the SNI Lean Learning Community. Applying Lean Methodology enabled us to standardize work processes for Sepsis, HAPU prevention, providing Stroke education, and improving errors related to the collection of blood cultures prior to antibiotic administration in the ED. Measures have maintained improvements and results for minimum of 3 months since implementation. HAPU incidence rates showed a 69% gain upon initial implementation, improving from 3.9% to 1.2%. Providing Stroke patient education produced a 9 % gain, improving from 91.7% to 100%. Utilizing Lean Methodology in the ED enabled us to reduce errors related to blood cultures prior to antibiotics from 16.3% to 0.9%. Improving this process positively impacted Sepsis bundle compliance rates, and Pneumonia Core Measures. In many ways, we have incorporated shared learning from SNI Sepsis/CLABSI Collaborative. We also presented our sepsis program at one of the collaborative meeting where we received useful feedback. This cheered us on and also gave us opportunity to improve on the gains. The PDSA cycles also helped us to identify and successes and failures. While our bundle compliance soared, the decline in sepsis mortality rate has not been so dramatic. This is now our focus. We have set up a sepsis mortality review panel to look into each case as we move forward. We celebrate achievement of each department with no bundle fallout at the sepsis taskforce meetings.


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Supplemental Materials


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Last July 2013, Sepsis Screen has been placed LIVE into Meditech PCS. The changes were to reflect “Normals” in the Sepsis Screen, specifically – No Documented Infection, No Suspected Infection, Vital Signs WNL & BP WNL. Also a message reminder for a “Positive Sepsis Screen” to notify the physician and order a Sepsis Panel per physician Orders (CPOE).


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ARMC SEVERE SEPSIS/SEPTIC SHOCK REPORT 2011-2013

Sepsis Bundle Compliance Sepsis Mortality

Month *Num *Den % Compliance **Num **Den Rate

Jun-11 6 31 19% 10 31 32%

Jul-11 6 23 26% 8 23 35%

Aug-11 9 19 47% 3 19 16%

Sep-11 7 15 47% 8 15 53%

Oct-11 6 12 50% 3 12 25%

Nov-11 11 18 61% 5 18 28%

Dec-11 8 20 40% 7 20 35%

Jan-12 8 19 42% 8 19 42%

Feb-12 10 16 63% 6 16 38%

Mar-12 13 29 45% 12 29 41%

Apr-12 15 26 58% 9 26 35%

May-12 16 28 57% 11 28 39%

Jun-12 14 19 74% 5 19 26%

Jul-12 6 12 50% 3 12 25%

Aug-12 11 18 61% 4 18 22%

Sep-12 22 32 69% 13 32 41%

Oct-12 17 27 63% 5 27 8%

Nov-12 13 16 81% 8 16 50%

Dec-12 17 22 77% 8 22 36%

Jan-13 21 30 70% 9 30 30%

Feb-13 18 23 78% 7 23 30%

Mar-13 12 14 86% 6 14 43%

Apr-13 21 24 88% 6 24 25%

May-13 28 31 90% 6 31 19%

Jun-13 18 22 82% 6 22 27%

*NUM = (numerator) total no. of patients who comply the severe sepsis bundle. *DEN= (denominator) total population of patients positive for severe sepsis/septic shock. COMPLIANCE% = numerator/denominator

**NUM = (numerator) total no. of patients died of severe sepsis/septic shock. **DEN = (denominator) total population of patients positive for severe sepsis/septic shock. MORTALITY % = numerator/denominator


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Graph 1 shows the levels of compliance to sepsis bundle implementation. Since 2011, there has been an increase of 63% in compliance from June 2011 to June 2013.

Graph 2 displays down line trending of sepsis mortality rate beginning June 2011 to June 2013.

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ANTIMICROBIAL ORDER FORMAT (For Parenteral Therapy Only)

DIAGNOSIS __________________________________________________________________________________

INFECTIOUS DISEASE DIAGNOSIS ________________________________________________________________

Gram Stain (Source and Results) _________________________________________________________________

Culture(s) (Source and Results) __________________________________________________________________

Are antibiotics being used prophylactically? □ No □ Yes

If yes, discontinue after (check one) □ One dose only □ Two doses

ALLERGIES __________________________________________________________________________________

BUN ___________________________ CREATININE ______________________ WEIGHT __________________

ANTIMICROBIAL ORDERS

Antibiotics for Severe Sepsis / Septic Shock - “1” + “2” + “3” (Renal dose adjustment after the 1st dose per Pharmacy) 1st dose of Antibiotics to be administered STAT - after Blood Cultures

1 Choose ONE from the following:

□ Piperacillin + tazobactam 4.5 mg IVPB every 4 hours

□ Meropenem 2 g IVPB every 8 hours (patient with recent

antibiotic exposure)

□ Aztreonam 2 g IVPB every 6 hours + Metronida-

zole 500 mg IVPB every 6 hours (patient with Penicillin allergy)

2 PLUS □ Vancomycin __________mg (20mg/kg) IVPB

every 12 hours

3 PLUS □ Tobramycin __________mg (5mg/kg) IVPB every

24 hours

OR □ Amikacin __________mg (15mg/kg) IVPB every

24 hours (for patient with recent antibiotic exposure)

With community acquired pneumonia:

ADD □ Levofloxacin 750mg IVPB every 24 hours

With health-care associated infections:

ADD □ Micafungin 100mg IVPB every 24 hours

With community acquired bacterial meningitis only:

□ Ceftriaxone 2 g IVPB every 12 hours + Vancomycin

__________mg (20mg/kg) IVPB every 12 hours

ADD □ Ampicillin 2 g IVPB every 4 hours (if the patient is

50+ years old or immunocompromised)

DATE: _____________________________________ TIME ________________________________________ Physician’s Signature _____________________________________________ Pager No. ____________________

Patient Identification

ARROWHEAD REGIONAL MEDICAL CENTER

ANTIMICROBIAL ORDER FORM


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Arrowhead Regional Medical Center PDCA Cycle (LEAN SEPSIS) Project: Lean Sepsis - ED Blood Culture (PDCA Cycle #2) Date: 6-26-13

Process Owner: ED Nurse Manager

Executive Sponsor: Assist Hosp Administrator

Team Members: PI, IT, Staff Nurses, Nurse Epidemiology, Laboratory

PLAN

Error correction of ED blood cultures by ED nurse

Daily specimen labeling error rate tracking

DO

Action Who Due Date / Freq.

Blood Culture specimen transportation from ED to Lab Telemetry Techs Q2hours

Telemetry Tech Transport Log - for error rate tracking Telemetry Techs Q2hours

Notification of specimens with missing date/time/initial:

Telemetry Tech to contact the ED Charge RN at x04356 for error correction

Corrected Specimens to be picked up on next transport

Telemetry Techs Upon receipt of specimen with no date/time/initial

ED Charge RN to notify patient’s nurse of unlabeled specimen

ED Charge Nurse Upon Tele Tech notification

Patient’s nurse to correct specimen label and sign Error Correction Log. **Specimen will not be transported until error is corrected**

Patient’s Nurse Upon notification from Charge

Nurse

Educate ER Staff of change in process ED Nurse Manager 7-12-13

Educate Telemetry Techs of change in process Lean Team Completed

PDCA Cycle duration: 1 month -------------- 7-15-13 to Early August (TBD)

CHECK

Action Who Frequency

Telemetry Tech Transport Log Telemetry Techs Q2hours

ED Blood Culture Pilot Study Report LEAN Coordinator Qweek

ED Asst. Manager to follow up with ED Charge Nurses on error corrections on fall outs

ED Nurse Manager Qweek

ACT Action Who Date / Frequency

Follow-up Meeting

Next Steps / Countermeasures

LEAN Coordinator Early August

Goal: 2 weeks = 0% errors Reward: ED department Pizza Party from Nursing Ad-min

Assist Hosp Admin Upon achieved goal


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New Resident Physician Training and Orientation to ARMC Sepsis Management


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ARMC Leadership excited about the Sepsis Improvement Report


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ARMC ED Triage Nurse Checking In of suspected Sepsis Patient


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PI Nurse rounding in ED and reviewing Sepsis patient’s chart for Bundle Compliance


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ED Physician orienting Resident Physician to Sepsis Order set


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ED Physician inserting a Central line


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Sepsis Skit for Staff and Physician Training


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ICU Nurse orienting a new Nurse to Sepsis Screening

in Meditech


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ED SEPSIS EDUCATION BOARD

sepsis resuscitation bundle compliance journey - california

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