sepsis reduction through technology and process improvements

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Sepsis Reduction through Technology and Process ImprovementsSession #36, March 6, 2018Amanda Logue, MD, Chief Medical Informatics Office, LGHTaylor Hargrave, BSN, RN, CIC, Infection Prevention Supervisor, LGH

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Amanda Logue MDTaylor Hargrave BSN, RN, CIC

Has no real or apparent conflicts of interest to report.

Conflict of Interest

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Agenda• Our system, population, and journey• Review baseline sepsis statistics• Project plan and governance• Methods of Health IT utilized to address sepsis• Value derived and future considerations

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Learning Objectives• Recognize the impact of integrated system monitoring and early

interventions into the EHR on helping prevent patients from developing sepsis

• Identify key processes, workflows, and resources to be involved in revamping care processes for potentially septic patients

• Evaluate quality measures that are impacted by sepsis prevention measures

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Our missionThe mission of Lafayette General Health is

to restore, maintain and improve health

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Lafayette General HealthWho we are

7 Inpatient facilities (incl. Academic)

43 Ambulatory sites: 18 specialties

1 Ambulatory surgery center

4,275 FTEs

59 Employed Physicians

1,700 Non-Employed Medical Staff

Our patients

29,000 Admissions

180,000 ED visits

23,000 Surgical cases

335,000 Outpatient visits

Fiscal Year 2017 (Oct 2016 – Sept 2017)

Acute HIMSS Level 6 (LGMC & UHC)

Top Service lines:

¾ Cardiology

¾ Neurology

¾ Orthopedics

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LGH Patient Population

Centers for Disease Control and Prevention. (2017). Nutrition, Physical Activity, and Obesity: Data, Trends and Maps. Retrieved from https://www.cdc.gov/nccdphp/dnpao/data-trends-maps/index.html

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2011 2012 2013 2014 2015

Per

cent

of p

opul

atio

n

Year

Percent of adults aged 18 years and older who have obesity †

Louisiana National Linear (Louisiana)†Obese is defined as body mass index (BMI) ≥ 30.0; BMI was calculated from self-reported weight and height (weight [kg]/ height [m²). Respondents reporting weight < 50 pounds or ≥ 650 pounds; height < 3 feet or ≥ 8 feet; or BMI: <12 or ≥ 100 were excluded. Pregnant respondents were also excluded.

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LGH Patient Population

U.S. Department of Labor, Bureau of Labor Statistics. (2017). Retrieved fromhttps://www.bls.gov/data/#unemployment

0

2

4

6

8

10

12

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Per

cent

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ent

Lafayette Metro vs. U.S. National Average Unemployment Rate

Lafayette Metro National Linear (Lafayette Metro)

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Information Systems Journey

CPOE, Documentation, ED, Pharmacy, Revenue Cycle

2003

System re-install, Surgery, Cerner

Patient Accounting, Quality Alignment

2012

Remote Hosting

2014

Women’s Health, Care Management, Registries,

CommonWell, EPCS, HealthyLink clinics

2016

Radiology, PACS,

Laboratory

2006

Ambulatory ASP, Oncology

2013

Integrated Ambulatory, Sepsis, PS-15 process, New

CDI software

2015

H o s p i t a l s a c q u i r e d :

EDW, HealthyLinkHospitals, Palm

Scanning, Patient Observer

2017

Sepsis2017 Nicholas E. Davies Enterprise Award of Excellence

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33.13% of overall mortality rates attributed to Sepsis• Previous workflow:

– Reviewed current symptoms vs. early detection– Identification only considered Temperature, HR, and Systolic BP (Rules of 100s)– When patient's vital signs met criteria a sheet was automatically printed on the

ICU printer– The Rapid Response Team nurse went to patient's unit and spoke with the

primary nurse, assisted with patient assessment if appropriate

• Problems:– No specificity or exclusion critieria– Duplicates were treated with less urgency– No qualifiers for the patient’s clinical status or illness– Inefficient– Only available at main campus

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Sepsis Mortality Rate and Incident Count

Diagnosis group Mortality RateMonthly Average

LGMC Mortality 2.13%

Overall Sepsis† 16.54%

Sepsis 7.28%

Severe Sepsis 18.92%

Septic Shock 33.33%

% of mortality attributed to sepsis 33.13%

Data Source: LGMC Cerner EHR database

†Overall Sepsis includes Sepsis, Severe Sepsis, and Septic Shock casesTime period: Nov. 2014 – Nov. 2015

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Sepsis Length of Stay

Diagnosis LOS: Days Monthly Average

Hospital Wide 4.5Overall Sepsis 9.35

Sepsis 8.61Severe Sepsis 7.25Septic Shock 12.21

Data Source: LGMC Cerner EHR databaseTime period: Nov. 2014 – Nov. 2015

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Sepsis Core Measure1

1Measure Set: Sepsis Set Measure ID #: SEP-1 Performance Measure Name: Early Management Bundle, Severe Sepsis/Septic Shock Description: This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. As reflected in the data elements and their definitions, the first three interventions should occur within 3 hours of presentation of severe sepsis, while the remaining interventions are expected to occur within 6 hours of presentation of septic shock. Rationale: The evidence cited for all components of this measure is directly related to decreases in organ failure, overall reductions in hospital mortality, length of stay, and costs of care.

The Joint Commission. (2016) Specifications Manual for National Hospital Inpatient Quality Measures v.5.2a (applicable 1/1/2017 - 12/31/2017). https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx

Data Source: LGMC Cerner eQualityCheck

LGMC pre-go live

compliance 2.44%

Time period: Oct. 2015 – Feb. 2016

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LGMC baseline cost per case by DRG

DRG Cost per DRG8723 “Sick” $7,434.458712 “Sicker” $11,902.188701 “Sickest” $27,669.24

Data Source: Premier Quality Advisor

1SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS2SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC3SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W/O MCC

Time period: Mar. 2015 – Feb. 2016

DesignImplementation

Governance

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Governance• Governance:

– Executive Sponsor: CMIO– Clinical Transformation Committee– Medical Executive Committee

• Project team:– Quality department– IT analysts– Nursing subject matter experts (ICU, Med-Surg, RRT, ED)– Clinical pharmacists – Cerner Quality Reporting

• Goals/Anticipated outcome: – Increase early detection and prevention of Sepsis– Decrease mortality associated with Sepsis

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Design and Build

• Project Timeline:• 14 months

• Algorithm monitoring and modification:• Alert initially built in “silent mode”• Project team audited and validated alert population and

frequency• Excluded:

• CV surgery for the initial 24 hours post-op• Active laboring population for 24 hours • Comfort measures only patients for duration of stay• NICU, Nursery, Pediatrics

Design & build

Training plan

Support plan Adoption

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Design and Build, cont.

• Decisions:• Who to alert• Frequency of alert

• Every patient will only alert once Q24 hours. • Alerts are suppressed for extended time (72 hours) if a sepsis

order set is active or if a sepsis diagnosis is in place• When to call physician• Additional FTE added to Rapid Response Team (LGMC)

• Repeat lactate orders: • If any lactate result is > 2.0, then an automatic timed lactate is

ordered for 5 hours after the original lab was ordered

Design & build

Training plan


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3028

26

20

8

2 1

26.1%

50.4%

73.0%

90.4%97.4%

99.1% 100.0%

0%

20%

40%

60%

80%

100%

120%

0

5

10

15

20

25

30

35C

ount

of A

lerts

SIRS or Sepsis Alerts by Infectious EtiologyMay 2015

Count of Alerts Cumulative %

22

16 15

108 7 6 6 5 5 5 4

1 1 117.8%

34.4%45.6%

54.4%62.2%

68.9%75.6% 81.1% 86.7% 92.2% 96.7% 97.8% 98.9%100.0%

0%

20%

40%

60%

80%

100%

120%

02468

1012141618

Cou

nt o

f Ale

rts

SIRS or Sepsis Alerts by Non-Infectious EtiologyMay 2015

Count of Alerts Cumulative %

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• 1 month prior to go-live: all nurses assigned module via LMS training on alert workflow

• Infection Prevention (IP) attended hospitalist meetings to explain the core measure– Quick reference laminated pocket cards were provided to

physicians

• Education provided to physician residents via LSU education platform

• IP attended Women's Services staff meetings to discuss core measures; information included in department newsletter

Design & build

Training plan


See Sepsis Appendix for sample training materials

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• Infection Prevention quarterly review of all Sepsis patients• Synopsis of all core measure passes and misses sent to those

involved in care of patient at the time of event• Thank you card sent to physicians responsible for passes• Opportunity letter sent to physicians responsible for misses• Synopsis of passes and misses sent to each leader monthly

How Health IT was Utilized

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How Health IT was Utilized• Cerner St. John Sepsis Agent:

– Gathers and combines patient information and vital signs from EHR– Fires alert in EHR when signs for SIRS or organ dysfunction are detected

• Electronic alerts based on algorithm• Orders/tasks to drive action• Evidence-based electronic order sets

– Sepsis quality measure compliant– Improve antibiotic use identification

• Core measure reporting

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St. John Sepsis Agent Algorithm

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Sepsis Inpatient Workflow

Green boxes = Health IT utilization

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Sepsis Alert• At least 2 SIRS criteria and 1 organ dysfunction criteria• Alert for the patient who meets criteria for the Sepsis Security Rule should display

as shown• Date and Time appear prior to the clinical event in the alert• Includes a link to the patient’s chart in the message

Screenshot from Cerner EHR

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Alert order placed on patient’s chart with nursing task


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Decision Tree

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Provider Notification FormIf deemed clinically necessary, nurse will contact provider and document communication in EHR


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ED Workflow

Green boxes = Health IT utilization

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ED Tracking Board icon


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Sepsis Order Sets


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Sepsis Quality Measures Order• Triggers the sepsis core measure component on the summary level MPages• Allows the clinician ability the track real time what care has been provided and

what still needs to be provided in relation to the Sepsis core measure


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Sepsis Severity Identification Order• Completed by physician to identify the type of sepsis being treated and

suspected source of infection• Drives electronic documentation for the Sepsis core measure and helps with the

establishment of time zero


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Early Warning Alerts Flowsheet


Value Derived

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Decreased Sepsis Mortality Rate

2.13%

16.54%

7.28%

18.92%

33.33%

1.89%

12.69%

6.29%9.41%

28.77%

0%

5%

10%

15%

20%

25%

30%

35%

Hospital MortalityRate

Overall SepsisMortality Rate

Sepsis MortalityRate

Severe SepsisMortality Rate

Septic ShockMortality Rate

LGMC Mortality Rate Data

Baseline (Nov. 2014 - Nov. 2015) Outcome (Mar. 2016 - Feb. 2017)


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Decreased Sepsis Mortality Rate

Diagnosis Group Monthly Average(Nov. 2014 – Nov.

2015)

Monthly Average (Mar. 2016 – Feb.

2017)

Percent changein Mortality Rate

Hospital Mortality 2.13% 1.89% -11.17%Overall Sepsis 16.54% 12.69% -23.26%

Sepsis 7.28% 6.29% -13.66%Severe Sepsis 18.92% 9.41% -50.26%Septic Shock 33.33% 28.77% -13.68%

% of mortality attributed to sepsis 33.13% 31.2% -5.83%


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Improved Sepsis Core Measure Compliance by 949.48%

2.46%

25.86%

0%

5%

10%

15%

20%

25%

30%

Pre-go live compliance (Oct. 2015 - Feb. 2016) Post-go live compliance (March. 2016 - Feb.2017)

LGMC Sepsis Core Measure Compliance

Data Source: LGMC Cerner eQualityCheck

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Increased Incident Count/Coding


5.42

38.08

9.83

23.67

12.25

50.08

12.42

22.83

0

10

20

30

40

50

60

SIRS Sepsis Severe Sepsis Septic Shock

Change in Incident Coding by Diagnosis Group

Baseline Monthly Average (Nov. 2014 - Nov. 2015)Outcome Monthly Average (Mar. 2016 - Feb. 2017)

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Decreased Cost Per Case• How decreased cost:

– Diagnosing sooner impacts progression of disease– Coded more patients with sepsis diagnosis codes– Decreased mortality and improved outcomes– Improved efficiencies to care for patient – lowered cost to provider, patient, and

payerDRG Cost per DRG

Baseline(Mar. 2015 –Feb. 2016)

Cost per DRGOutcome(Mar. 2016-Feb. 2017)

Number of Cases (Mar. 2016 –Feb. 2017)

Cost Savings (Mar. 2016 –Feb. 2017)

870 “Sickest” $27,669.24 $27,633.68 29 $1,031.24

871 “Sicker” $11,902.18 $11,413.57 424 $207,170.64

872 “Sick” $7,434.45 $6,618.30 116 $135,480.90

Total cost savings $343,682.78

Data Source: Premier Quality Advisor

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39.84 Lives Impacted/SavedOverall Sepsis Lives Impacted/Saved Analysis

Month Sepsis Mortality Count

Total Sepsis Encounters

Sepsis Mortality Rate

Lives Impacted/Saved*

Baseline 12.54 75.15 16.54% --Mar-16 8 74 10.81% 4.24Apr-16 9 96 9.38% 6.87May-16 12 77 15.58% 0.74Jun-16 8 84 9.52% 5.90Jul-16 13 85 15.29% 1.06Aug-16 11 74 14.86% 1.24Sep-16 9 87 10.34% 5.39Oct-16 10 75 13.33% 2.41Nov-16 14 97 14.43% 2.04Dec-16 7 85 8.24% 7.06Jan-17 13 96 13.54% 2.88Feb-17 17 100 17.00% 0.00TOTAL 39.84

Monthly Average 3.32

*Lives impacted/saved calculated by multiplying the change in mortality rate from baseline and the number of sepsis encounters per month

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Future considerations

• ED physician note often started without a sepsis diagnosis – Create standard nursing documentation that would assist in supporting

time zero.• Involve clinical pharmacy with real-time alerting to identify

insufficient use of appropriate antibiotics.• Identify opportunities to reduce duplicate alerts

– Higher utilization of problem list and order sets.• Focus more effort on the SIRS alerts and appropriateness of those

predicting sepsis.– Consider “soft alerts” to physicians for SIRS to consider earlier and more

aggressive care.

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Questions• Taylor Hargrave, [email protected]• Amanda Logue, [email protected], @Logue4Logue

• Please complete online session evaluation

mailto:[email protected]


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The VAP Bundle: A Story of Data Driven Process ImprovementSession #36, March 6, 2018Tawanna McInnis-Cole, System Director Infection Prevention, MS, BSN, RN, CIC Jocelyn Thomas, Regional Manager of Infection Prevention MPH, CIC, CSSGB

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Tawanna McInnis-Cole MS, BSN, RN, CIC Jocelyn Thomas MPH, CIC, CSSGB

Has no real or apparent conflicts of interest to report.

Conflict of Interest

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Agenda

• Overview of Memorial Hermann Health System• The VAP Bundle and why it is Important• Initial Paper and Electronic Implementations• Impact of Implementations: Bundle Compliance and VAP Rates• VAP Bundle Upgrade - using data to drive Health IT • Results from a Decade of Bundle Use• Lessons Learned

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Learning Objectives

• Describe how Memorial Hermann increased the utilization of ventilator bundles to reduce the occurrence of VAP.

• Explain how governance can drive accountability and compliance to improve patient outcomes.

• Discuss how the utilization of data can drive the incidence of VAP downwards, towards a rate of zero.

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Memorial HermannHealth System

Woodlands Sugar Land TMC Katy Memorial City Southeast

Greater Heights

Northeast

TIRR Katy Rehab

Children’s Southwest

• Total hospitals: 15 (11 acute, 2 rehab, 1 children’s, 1 orthopedic)

• Inpatient admissions: 158,241• Annual emergency visits: 595,611• Annual deliveries: 25,146

• Employees: 25,040• Beds (acute licensed): 4,016• Medical staff members: 5,708• Fellowship programs: 48

PearlandCypress

MHOSH

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Our Network of Care

292 Care Delivery Sites

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Memorial HermannRecent Accolades

15 Top Health Systems; Top 5 Large Health Systems

(2012 & 2013)

National Quality Forum National Quality

Healthcare Award (2009)

TIRR Memorial Hermann No. 2 in rehabilitation

hospitals

2011 Texas Healthcare Foundation Quality

Improvement Awards (9 Memorial Hermann

Campuses)

Healthcare’s “100 Most Wired” 12th

consecutive year � America’s 50 Best Hospitals (2010-2014)

Texas Hospital Association

Bill Aston Quality Award (2011)

America‘s #1 Quality Hospital for Overall

Care (2011 & 2012)

John M. Eisenberg National Patient Safety &

Quality Award (2012)

2015 Houston Business Journal (HBJ) No. 3 Best Places to Work

The Joint Commission

Top Performer (2012), Heart Attack, Heart

Failure, Pneumonia,

Surgical Care

Quality – A competitive advantage for Memorial Hermann

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Our JourneyHigh Reliability Organization

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Commercial Aviation

Nuclear AircraftCarriers

Air Traffic Control

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High ReliabilityCertified Zero Award

1. Zero Events

2. 12 Consecutive Months

3. Certified Zero Category

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High Reliability 2011-2017Certified Zero Awards

ICU Central Line Associated Bloodstream Infections (18)ICU Catheter Associated Urinary Tract Infections (16)

Hospital-Wide Central Line Associated Bloodstream Infections (7)Hospital-Wide Catheter Associated Urinary Tract Infections (5)

Ventilator Associated Pneumonias (23)Retained Foreign Bodies (46) Iatrogenic Pneumothorax (24)

Accidental Punctures and Lacerations (3)Pressure Ulcers Stages III & IV (37)

Hospital Associated Injuries (7)Deep Vein Thrombosis and/or Pulmonary Embolism (2)

Deaths Among Surgical Inpatients with Serious Treatable Complications (1)Birth Traumas (16)

Obstetric Trauma in Natural Deliveries with Instrumentation (4)Serious Safety Events 1&2 (21)

Serious Safety Events 1 & 2 for 1000 Days (2)All Serious Safety Events (1)Early Elective Deliveries (9)

Manifestations of Poor Glycemic Control (21)

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263

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The VAP Bundle: A Story of Data Driven Process Improvement

20172017 Nicolas E. Davies Enterprise Award of Excellence

Nicholas E. Davies Enterprise Award of Excellence

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BundlesWhy are they important?

• Evidence based, interdisciplinary plans for patient care

• Focus on 3-6 interventions that significantly improve patient outcomes for a specific population

• Foundation in research and peer reviewed literature

• Regulatory and in house surveillance

• Drive process improvement and standardization

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• Up to 20% of vented patients develop VAP 1

• > 39% of pneumonia cases in acute care setting 1

• Increase in ventilator days, length of stay and antibiotic use 1

• Mortality may exceed 10% 1

VAPWhy Does it Matter?

Complications of Mechanical Ventilation:Ventilator Acquired Pneumonia (VAP) Ventilator Associated Events (VAE)

1. Coffin, Susan E., et al. “Strategies to Prevent Ventilator‐Associated Pneumonia in Acute Care Hospitals.” Infection Control and Hospital Epidemiology, vol. 29, no. S1, 2008, pp. S31–S40. JSTOR, JSTOR, www.jstor.org/stable/10.1086/591062.

http://www.jstor.org/stable/10.1086/591062

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VAP Financial Impact

• At least 20% may be preventable 2

• 52,543 cases per year 3

• VAPs make up 31.6% of the cost of the top 5 HAIs 4

• Estimated cost of $40,144 per case in 2012. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003;54:258-266

3. R. Douglas Scott II. The DirecT MeDical cosTs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention March 2009

4. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health Care–Associated InfectionsA Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039–2046. doi:10.1001/jamainternmed.2013.9763

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VAP Bundle (Adults)Nursing Bundle• Suction – 4 Hrs.• Oral Care – 4 Hrs.MD Bundle• Head of Bed – 4 Hrs.• SUD Prophylaxis – 24 Hrs.• VTE Prophylaxis

(Mechanical 4 Hrs./ Pharmaceutical 24 Hrs.)

• Sedation Holiday – 24 Hrs.

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Houston…..We Have a Problem

It was the year 2006.Data analysis showed the VAP rate was too high!!!

VAP rates to become focus for CMS

64VAP rate = count of VAPs per 1,000 vent days

System VAP Rate

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What Did We Do?We implemented our VAP Bundle because:

• Infection Control leadership believed we could reduce the VAP rate

• IHI and evidence based literature

• Standardize and monitor care across the system

Do No Harm

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VAP Bundle TimelineMajor Events

Continuous surveillance of

1. Clinical Outcomes

2. VAP Bundle Compliance

July 2017 VAP Upgrade Implemented

2016 Start VAP Bundle Upgrade

2013 CDC Changes VAP to VAE

Mar 2010 Electronic Abstraction

2008-2009 Conversion to EHR

May 2007 Implementation on Paper

2013 VAE Report Developed

Jan 2017 TheraDoc Infection Control

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Data Analysis• Paper forms

Weekly manual auditsExcelMIDAS database – focus studies

• Reporting at System & Nursing Unit Level:-Bundle Compliance (documentation audits)-Clinical Outcomes (VAP Rate)

May 2007 Implementation on Paper

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Data Analysis: VAP Rates

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• Facilities converted to EHR

• Daily reports manually processed and emailed to nursing

• Monthly Facility Compliance metrics published

• Monthly metrics reported to System Executives

2008-2009 Conversion to EHR

EHR

The Attack of the EHR

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Nursing Documentation in the EHR

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VAP Bundle Automation in the EHRCustom Rules and Alerts for Adults

Syst

emN

ursi

ngR

espi

rato

ry

Ther

apy

<Fun

ctio

n>Pr

ovid

er Order for Mechanical

Ventilation for ADULT

VAP Rule #5

Sends tasks to Nursing

Nurse documents in PowerChart

Sends notifications to RT

VAP Rule #1

VAP Rule #4

VAP Rule #2

VAP Rule #3

Automatically orders VAP

Bundle, Sedation Holiday & Patient

Education

Orders SBT, Suction,

Notifies RT if vent orders entered in

order statusRT documents in

PowerChartSends tasks to RT

Order for Single Component of VAP Bundle

MD cancels or re-orders mechanical

ventilation

MD cancels ventilation orders

VAP Rule #6

Cancels orders and tasks to nursing

Cancels orders and tasks to RT

Checks for duplicate orders, alerts provider to cancel duplicate orders

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VAP Monthly ReportFinancial Number Attending Type of

Unit Facility Nursing Unit Midas ICU Code for CLIP & VAP

55555555 Dr House Adult MEMORIAL CITY - ACUTE MC - NEUROSCIENCE A (J4EC) MC - Neuroscience Unit

55555555 Dr Jekyl Adult HERMANN HOSPITAL - ACUTE HH - ICU MICU MEDICAL ICU (MICU)HH - ICU MEDICAL ICU

55555555 Dr Who Adult HERMANN HOSPITAL - ACUTE HH - ICU CCU CARDIAC CARE UNIT HH - CCU

Bundle elements = Yes or No EXCEPTSedation Holiday = Yes, No or N/A

Audit Date HOB up 30 deg Oral hygiene q4 Hrs. Suction q4 Hrs. DVT Prophylaxis SUD Prophylaxis Sedation weaning trial q24 hours

3/1/2014 Yes Yes Yes Yes Yes Yes

3/2/2014 No No No No No No

3/1/2014 Yes Yes Yes No Yes N/A

Mar 2010 Electronic Abstraction Begins

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In 2013, the CDC proposed a new algorithm for preventable events related to mechanical ventilation.

VAP was replaced by four broader surveillance tiers:1. Ventilator-Associated Conditions (VAC)2. Infection-related ventilator-associated complications (IVAC)3. Possible VAP4. Probable VAP

#3 and #4 later combined to become pVAP

2013 CDC Changes VAP to VAE

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Impact of VAE Report 2013

A Technology Improvement Story• Newly introduced surveillance for VAE required the

assistance of technology– Report was created and enabled the new

surveillance • Report simplified surveillance in a manner that allowed

IPs to be objective.• All pertinent factors were summarized in report which

lead to an overall efficient process for conducting surveillance.

• Initial surveillance showed unexpected FiO2 and PEEP fluctuations

• The technology prompted the analyses that improved patient care

– Allowed for process improvement

Multiple people were changing the

vent settings

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Clinical Event

Performed Date

APRV Vent Mode

Peep Min

FiO2 Min

Temp Min

Temp Max

WBC Min

WBC Max

ABX-Vancomycin

ABX -All

Others

ABX-Cefepime

09/23/2013 5 0 98 102.3 77.7 77.7 vancomycin Mero-penem

ABX-All Other Cephalosporins

Anti-fungal

Anti-influenza

Culture Order

Description

Micro Source

Organism Identified (Drawn Date)

Invasive Airway Type

Infection Control

Alert

Infection Control

Alert Response

Culture: Respiratory

w/Gram Stain

Sputum MRSAEndotracheal(Intubated)

2013 VAE Report Developed

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• Not at zero VAPS / VAEs• Compliance rates high• Review new evidence in the literature• Documentation drift• Data drift in compliance report• New medications• Use of single ventilation orders was leading to fallouts • Ventilator order set use was low• Order sets (MPPs) not aligned with VAP Bundle• Each MPP had different content

2016 Start VAP Bundle Upgrade

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How Did We Implement?People• VAP Bundle Workgroup created• Sponsored by HAI Steering Committee• Multi-disciplinaryProcess• Weekly meetings• Clinical stakeholders consulted• Design sessions• Complex approval process• Testing and validation

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How Did we Implement?

Process (continued)• Clinical Stakeholders testing sessions• Communication and education• Pilot at one ICU• System Go Live July 2017

Technology• Online research, meetings, training & education • Extensive data analysis

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VAP Bundle UpgradeUse of Data to Drive Decisions

• Identified all documentation elements and compared with evidence based research

• Wrote custom reports to pull documentation data

• Analyzed each response in terms of volume, clinical content and alignment with Bundle elements

• Presented data to clinical stakeholders

• Used data to drive decision making for future state

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Vent Check by Nurse PowerForm Usage Dec 2015

841 visits

FacilityNumber of times PowerForm Signed

GH Greater Heights 1584HC Childrens 1594HH HERMANN 9044KM Katy 775MC Mem City 1180NE Northeast 845SE Southeast 1399SG Sugar Land 71SW Southwest 2304TR TIRR 30TW The Woodland 1283Grand Total 20,109

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Data AnalysisPUD Prophylaxis Documentation

Meds for prevention of PUD being administered 18,266Meds for prevention of PUD not being administered due to contraindications 288Physician order 287Exclusion exists 575Patient on enteral feeding 577Grand Total 19,993

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Data AnalysisFree text responses

Reason not Using Int. Compression Device

# of times documented

Other: lymphedema 72Other: heparin gtt 65Other: pt receiving anti-coagulant therapy 33Other: bath 25Other: pt oob 25Other: in chair 23Other: On heparin gtt 23Other: On Heparin 22Other: patient on heparin drip 22Other: up to chair 18Other: PVD 17Other: Heparin drip 16Other: on heparin drip 16Other: pt up in chair 16Other: angiomax gtt 15Other: DVT 15Other: pt recieving anti-coagulant therapy 15Other: Up in chair 15Other: HEPARIN 14Other: chair 13Other: IVC filter 13Other: pt up to chair 13Other: Comfort measures 11Other: disease process 11Other: pt recieivng anti-coagulant therapy 10Other: Betty said not to 1

Other: Betty said not to

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When Different Technologies Collide…

VAP Bundle

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VTE AdvisorWhat is it?

VTE Advisor• Cerner Clinical Decision Support tool• Used only by providers• Not viewed by nursing or RT• Helps assess individual risk of adult VTE• Includes orders for VTE prophylaxis

VAP Bundle vs the VTE Advisor• Memorial Hermann designed tool• Includes orders for DVT prophylaxis• Different terminology• Some overlapping content• Some different indications and contraindications

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Jan 2017 TheraDoc Infection Control

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Highlights from the Upgrade

• Increased accuracy of compliance data

• Order sets updated and integrated with VAP Bundle

• Increased order set use

• Automated communication from provider to nurse

• VAP Bundle integrated with VTE Advisor

July 2017 Upgrade Implemented

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• Increased documentation efficiency- 69% reduction in clicks for prophylaxis nursing PowerForm

- Reduced from 1,327,194 clicks/month to 422, 289

• Automated display of medication orders

• Automated display of medication administration

• Zero reported fallouts in CHG mouthwash orders

July 2017 Upgrade Implemented

88

Smarter DocumentationAutomated Data Flow From Physician to Nurse

89

Ventilation Order SetsIncreased Utilization

0

100

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May-17 Jun-17 Jul-17 Aug-17 Sep-17

Number of Times Adult Ventilation Order Sets Used

Ventilator Add On MPP

Ventilator High Frequency MPP

Ventilator Initiation/Bundle Orders MPP

Ventilator Non Invasive MPP

VAP Bundle Upgrade

90

VAP Bundle ComplianceAccurate data reveals opportunity to improve.

91

Our JourneyResults from a Decade of VAP Bundle Partnership

Maintaining Our VAP Rate

92

High Reliability!

23 Certified Zero Awards for VAP

93

Financial ImpactVAP Bundle

If we had done nothing…

Hospital expansion = more vent days1,200 extra VAP infections @ $40,144 per infection

Estimated lives saved = 100+

VAP Bundle projected cost avoidance = $48,172, 800

94

Lessons Learned

• Governance structure• Multidisciplinary, multi-level groups• Scheduled reviews• Clinical champions• Data Validation

- always examine and understand your data• Automation can decrease infections• Partnership is the building block of change

95

Moral of our VAP Story…

…the price of excellence is

eternal vigilance

96 THANK YOU!

Tawanna McInnis-Cole [email protected]

Jocelyn [email protected]

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sepsis reduction through technology and process improvements

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