surviving sepsis: how health it saves one life per week · 1 surviving sepsis: how health it saves...
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Surviving Sepsis: How Health IT Saves One Life Per Week
Session #272, February 14, 2019
Devin Horton, MD, Hospitalist and Assistant ProfessorMatt Sanford, MBA, Senior Value Engineer
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Devin Horton, MD
Matt Sanford, MBA
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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• About University of Utah Health
• Understanding sepsis and why it’s a challenge for every
hospital
• Background on our approach using Lean Six Sigma
principles and process mapping
• How we measured before and after to determine effect
• The results, including how we reduced sepsis mortality rate
for patients with MEWS Scores 7-11 by 20%, costs by 10%
Agenda
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• Explain why sepsis poses a unique challenge to hospitals and the
imperative to improve the way it is recognized and treated
• Define the process and resources required to successfully
redefine sepsis recognition and treatment workflows hospital-wide
• Demonstrate how your EHR and communication technology can
leverage interoperability to deliver sepsis alerts to the right
caregivers
• Illustrate the real-world results University of Utah Health was able
to accomplish and apply them at your own organization
Learning Objectives
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About University of Utah Health
• Located in Salt Lake City
• 4 hospitals
• 10 community clinics
• 1,400 physicians
• 5,000 employees
• 200+ specialties
• Epic EHR
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Value Equation
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Value Stream: A Siloed Perspective
Wait
Wait
Wait
Pro
cess C
Pro
cess A
Pro
cess B
Pro
ce
ss F
Pro
cess E
Pro
cess H
Pro
cess G
Pro
cess D
Wait Wait
Wait Wait
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Patient’s Perspective Value Stream
Pro
cess A
Pro
cess B
Pro
ce
ss F
Pro
cess E
Pro
ce
ss H
Pro
cess G
Pro
cess C
Pro
ce
ss D
Patient’s Value Stream
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Value Stream Assignment
10TRUE NORTH = Perfection
Quality Improvement ApproachWhy PDSA (Plan, Do, Study, Act)
Learning from informed action
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Top patient safety issue for virtually every hospital
1 in 3patients who die
while hospitalized
have sepsis
>250,000patient deaths each year
$24 billionspent annually on treatment
50%mortality rate for
septic shock
Keehan SP, Cuckler GA, Sisko AM, et al.
2015;34(8):1407-1417.
Liu V, Lei X, Prescott HC, Kipnis P, Iwashyna TJ, Escobar
GJ. 2014;9(8):502-507.
Understanding Sepsis
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Plan• Motivation
• Define the problem
• Get baseline data
• Build a team
Do• Design the project
• Education
• Implement change
Study• What is the effect?
• Feedback
Act• Change process to
address problems
• Implement changes
• Redefine scope
Plan Study
ActDo
Quality Improvement Approach
http://www.deming.org
Plan Study
ActDo
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Seeing decompensation throughout the
hospital
Realizing residents and sometimes providers
couldn’t define what they were seeing
ACP 2014
No process in place (no “campaign”)
Anecdotally seeing delay
Motivation
Plan Study
ActDo
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What is happening at
the U?
How does sepsis affect our mortality?
What is the gold standard for treatment?
How good are we at treating
sepsis?
Can our nurses and residents
recognize a patient with
sepsis?
Plan: Define the Problem
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Severe Sepsis is #1Cause of Death
#1
University of Utah
MortalitySepsis upon
Admission
Sepsis mortality
TransferredAffects all our
Patients
Phil Dellinger, ACP Internal Medicine 2014
Plan Study
ActDo
26%42%
46%
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Crit Care Med 2013; 41:580-637.
Measure lactate level
Obtain blood cultures prior to administration of antibiotics
Administer broad spectrum antibiotics
Administer 30 ml/kg crystalloid for hypotension or lactate ≥4 mmol/L
The administration of
effective intravenous
antimicrobials within the first
hour of recognition of septic
shock (grade 1B) and
severe sepsis without septic
shock (grade 1C) should be
the goal of therapy.
Gold Standard
Plan Study
ActDo
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0
5
10
15
20
25
30
AIM HCH HCICU MICU OTSS SICU SSTUABX
Ryan Bender, Josh Marr, Nathan Cook
University of Utah Health Average
9 Hours
LactateHours
AntibioticHours
IVF Bolus7.5 9.5
Plan Study
ActDo
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3.6
11.7
NURSES RESIDENTS
21 QUESTIONS | AVERAGE SCORE
Administered by Chief Medical Residents 2014-2015
Clinician Sepsis Knowledge
17%
56%
Plan Study
ActDo
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Physicians
Nursing
Education
Pharmacy
Information
Technology
Rapid Response
Team
Value Engineers
ARUP
Pulmonary Lab
Quality
Build a Team
Plan Study
ActDo
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Gemba = Japanese translated to “the real place”
Translated to English = Where the work happens
Going to the Gemba
Purpose
• Gain understanding of what actually happens
• Engage those doing the work
• Humble Inquiry = respect people
-Fujio Cho
Leaders must spend time on the
plant floor (not just walk through
or take a tour).
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Japanese for “actual place”
http://www.lean.org
HCA takes vital signs
Writes them down, sees next patient
Enters information into
Epic
Nurse sees abnormalities
Pages providerNurse waits for
responseProvider calls
backRN / MD
discussion
Orders lactate, fluids,
antibiotics
Pharmacy approval
Antibiotics sent Nurse
administration
GEMBAPlan Study
ActDo
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Difficult for hospital staff to identify early stages of sepsis
Step-intensive process with multiple opportunities for
human error
No forced function – no universally accepted threshold
ChallengesPlan Study
ActDo
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Plan• Motivation
• Define the problem
• Get baseline data
• Build a team
Do• Design the project
• Education
• Implement change
Study• What is the effect?
• Feedback
Act• Change process to
address problems
• Implement changes
• Redefine scope
Plan Study
ActDo
Quality Improvement Approach
http://www.deming.org
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Why Process Mapping
Steps in the processOwner
• Bring clarity to the entire value stream
• Define gap between current and future state
• Pinpoint origins of defects
Change in Ownership
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Early Stages
Plan Study
ActDo
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Final Process MapPlan Study
ActDo
9 different owners must
work in harmony for
recommended care
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Strong
Weak
Forced functions and constraints
Automation and computerization
“nudge to do the right thing”
Standardization and protocols
Checklists
Rules and policies
Education and information
“Be more careful”
https://www.ismp.org/newsletters/ambulatory/archives/200602_4.asp
Designing a System
Plan Study
ActDo
28Journal of Hospital Medicine pages S5-S10, 2 NOV 2016 DOI: 10.1002/jhm.2653
http://onlinelibrary.wiley.com/doi/10.1002/jhm.2653/full#jhm2653-fig-0001
Likelihood of death
or major post-
discharge morbidity
Capability for self-
care and likelihood
of preventing
deterioration using
limited therapies
Early Detection, Prevention, and Mitigation of Critical Illness Outside Intensive Care Settings
Plan Study
ActDo
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SIRS vs. mEWS
Developed using vital signs from nearly 35,000 patients
Evaluated test performance for mortality
Resuscitation 2010; 81(8): 932-937
Early Warning ScorePlan Study
ActDo
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Building the Intervention
PLA
N
STUD
Y
ACTDO
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0 1 2 3 4 5 6 7 8 9 10 11
mEWS Score
Distinct patients
450
400
350
300
250
200
150
100
50
0
Data analysis by Dan Findley, M.B.A.
Sept. 2015 to
Sept. 2016
In-hospital mortality
for patients at max
mEWS score
All patients had an
ICD-9/10 code for
sepsis
Developing Measurement Tools
Plan Study
ActDo
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Information
technology /
forced function
Reliable
communications
Education
Multi-faceted Approach
Plan Study
ActDo
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34
0
5
10
15
20
Nurses ResidentsPRE POST
60%56%
39%
CMRs 2015-2016
17%
Survey: Sepsis KnowledgePlan Study
ActDo
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Patient vitals entered in Epic
are outside normal range
Alert triggered, sent to the
primary team / rapid response
team’s device
Primary/Rapid response team
begins intervention right away
Nurse validates vitals and
elevated mEWS score
ABX
MEWS WorkflowPlan Study
ActDo
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Clinical Decision Support Advisory – Smith, Jane
You have entered vital signs that are concerning for the safety of
your patient; mEWS 5-7* Click ACCEPT if the vital signs you entered are correct. This will trigger an automatic page to
the Charge RN
* Click CANCEL to re-enter vital signs.
Send message: Send this advisory via in Basket
AcceptAccept CancelCancel
Clinical Decision Support
Plan Study
ActDo
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Plan• Motivation
• Define the problem
• Get baseline data
• Build a team
Do• Design the project
• Education
• Implement change
Study• What is the effect?
• Feedback
Act• Change process to
address problems
• Implement changes
• Redefine scope
Plan Study
ActDo
Quality Improvement Approach
http://www.deming.org
Plan Study
ActDo
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Data
SourcesData
Warehouse
Metadata
Data Marts
ETL
Epic
ADT
Lab
X-ray
Billing
Reporting & Analytics
Web Applications
Registries
CMS
Predictive Models
Data
Consumption
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RESULTS
OCT 2016 – SEPT
2017
Plan Study
ActDo
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Blood cultures, lactate → antibiotics within 3 hours
30 ml/kg IVF if hypotension/shock
Pressors if hypotensive after fluid
CMS measure for severe sepsis and septic shock:
Sepsis Early Management Bundle
Plan Study
ActDo
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Data analysis by Polina V. Kukhareva M.S., M.P.H.
Odds of septic patients receiving ABX in
the first 24 hours after SIRS increased
31 % (95% CI, 1% to 70%; p=0.041)
Length of stay decreased by
10%(95% CI, -14% to -5%; p<.001)
Total direct cost decreased by
10%(95% CI, -15% to -5%; p<.001)
After Adjusting for Covariates
Plan Study
ActDo
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Data analysis by Matt Sanford, M.B.A.
Ma
y
June
July
Augu
st
Septe
mb
er
Octo
be
r
No
ve
mbe
r
De
ce
mbe
r
Janu
ary
Feb
ruary
Ma
rch
April
Ma
y
June
July
Augu
st
Septe
mb
er
Octo
be
r
No
ve
mbe
r
De
ce
mbe
r
Janu
ary
Feb
ruary
Ma
rch
April
Ma
y
June
July
Augu
st
Septe
mb
er
Octo
be
r
No
ve
mbe
r
De
ce
mbe
r
Janu
ary
Feb
ruary
Ma
rch
April
Ma
y
June
July
Augu
st
2014 2015 2016 2017
Total Direct Cost of Sepsis MS-DRG Cases
Baseline Mean
Post Implementation Mean
= 10% decrease in cost
(does not include capacity)
Baseline = May 2014 to Sept 2015
Post-Implementation = May 2016 to July 2017
Baseline and Implementation Parameters
Plan Study
ActDo
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Plan• Motivation
• Define the problem
• Get baseline data
• Build a team
Do• Design the project
• Education
• Implement change
Study• What is the effect?
• Feedback
Act• Change process to
address problems
• Implement changes
• Redefine scope
Plan Study
ActDo
Quality Improvement Approach
http://www.deming.org
Plan Study
ActDo
Plan Study
ActDo
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PDSA Cycles: mEWS of 7+ Mortality
ResultsPlan Study
ActDo
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Decrease in length of stay
Decrease in direct costs
Decrease in mortality rate for elevated MEWS scores
Results
10%
10%
20%
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Continued PDSA Cycles
ED version
2.0
Modify trigger
thresholds
Modify vital sign
thresholds
Blood cultures
helpful or not? Surgical
services
Modify RRT team and
cancer center
Modify snoozing capability
Plan Study
ActDo
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EHR + Clinical Communication
Plan Study
ActDo
Communication
Platform
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Educate your clinical organization on how to tap the potential
of your communication platform
Use your clinical platform to make your EHR better
Hardwire communication to automate notification and
speed response
Use multi-disciplinary teams to solve complex problems
Measure impact, adjust, and expand success throughout
the hospital
Communication and Improving Clinical Outcomes
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• Thanks for listening!
• Devin Horton, MD
• [email protected]• https://www.linkedin.com/in/devin-horton-2b219811b
• Matt Sanford, MBA
• [email protected]• https://www.linkedin.com/in/matthewnsanford
• Please remember to complete online session evaluation.
Questions