SCPSF Collaborative

Sepsis Management Webcast

February 5, 2014

Welcome!

Julia Slininger

Vice President, Quality &

Patient Safety

HASC

515 South Figueroa Street

Suite 1300

Los Angeles, CA 90071-3300

TEL: (213) 538-0766

jslininger@hasc.org

How to Participate in Today’s

Web Seminar

How to participate in today’s

Webinar presentation

• At the telephone prompt, please be sure to enter your unique audio pin located in your Webinar audio pane.

• We will have time for Q&A at the end of the presentation.

• Submit your text question using the Questions pane

OBJECTIVES:

-Walk through Redlands’

Sepsis Management journey,

as a top priority, to improve

survival

-Progress to-date

-Overview of challenges and

lessons learned

REDLANDS COMMUNITY HOSPITAL

Coleen Thompson, BSN, RN, CPHQ

Quality & Pt Safety Manager

Ana Campos R.N.

ICU Manager

Becky Baldwin R.N.

ICU Charge Nurse

Sepsis

Redlands Community Hospital:

Our Journey to Improving

Survival

Ana Campos R.N., ICU Manager

Becky Baldwin R.N. ICU Charge Nurse

Coleen Thompson R.N., Quality & Pt Safety

An Inconvenient Truth

Outcome Measures

Mortality Rates

January – August 2011

Numerator/

Denominator Mortality

Rate

RCH Mortality Rate for Septic Shock 24/52 46.2%

RCH Mortality Rate for all Sepsis 61/232 26.3

AHRQ Sepsis Mortality Rate - 18.0

When Dashboard Data on Mortality Rates were

presented to the Medicine Collaborative, and we

were asked to drill down into the DRGs causing

our rate to be higher than expected, this is what

we found.

Support From the Top

The data was presented to Hospital

Administration and the Board of

Directors

Sepsis Management became a top

performance improvement priority

A team was commissioned

Our Sepsis Team

Intensivist

ICU Manager

ICU Charge Nurse

Emergency Dept Physician

Director of Critical Care Services (ICU/ED)

ED Nurse Manager

Pharmacy

Lab

Respiratory Therapy

Quality & Pt Safety Manager

Quality Data Coordinator

Plan of Attack

Data revealed that our greatest opportunity was

the Septic Shock population.

We defined the segment to begin our work as:

Patients presenting to the Emergency Dept with SIRS

criteria and admitted to the ICU.

Focus on the process measures, and the outcomes will

follow.

A Harsh Reality

Even though we had Sepsis Orders in

Place since 2006…

Even though we had educated Physicians,

& Nurses…

Even though we thought we were

practicing to the bundle…

Baseline Performance Measure Data

Indicator Jan 2012

Lactic Acid Drawn w/I 1 hr 11/15=72%

Blood Culture prior to Abx 12/15=80%

Abx started within 3 hrs 12/15=80%

Appropriate fluid resuscitation within 6 hr 13/13=100%

CVL placed within 6 hr 9/12=75%

Vasopressors after fluid resuscitation 8/9=89%

MAP 65 or more within 6 hrs 9/14=64%

CVP above 8 within 6 hrs 6/9=67%

ScVO2 at goal within 6 hrs 4/9=44%

Glucose below 150 within 24 hrs 9/15=60%

Low dose steroids within 24 hrs 12/12=100%

Inspiratory Plateau Pressure below 30 within 24 hr 4/4=100%

Point of Care Team: Gold Alert

Provides clinical support where the patient is “Critical Care is a need not a place”

Patient assessment, data interpretation and initiation of treatment plan concurrent with

“Sepsis Initial Orders”

Expedites transfer to ICU, if patient’s transfer is not required RAT nurse will follow up for further assistance and feedback.

Goal Directed Therapy

1st

Hour

Recognition – SIRS Criteria

• Challenge:

• Solution: Education, Badge Buddies, weekly then

monthly feedback to front line

Activate the Gold Alert:

• Challenge: EDMD Resistance “we are here, we don’t

need that”

• Solution: Data and Education “shed light not heat” IHI

Lactic Acid & Blood Cultures

• Challenge: Obtaining timely

• Solution: Add Lab Tech to Gold Alert Response Team

Goal Directed Therapy

Within 3 Hours

Administer Antibiotics:

• Challenge: Time from order written to

administration

• Solutions: Make sure omni cell has the abx

stocked and CPOE

Start Fluid Resuscitation:

• Challenge: Appropriate volume & CVL placement

• Updating the order set to make following the

guidelines easier

Goal Directed Therapy

Within 6 Hours

CVL Placed: • Challenge: Timely placement

• Solution: Dr Gil worked with ED Physicians

Pressors: Had to ensure adequate fluids first

MAP

CVP: Resolved with improved line placement & fluids

SCVO2 • Challenge: Sharing monitors with ICU

• Solution: Obtain VBG as part of the sepsis bundle 1st hour Labs

Goal Directed Therapy

Within 24 Hours

Glucose – • Challenge: The insulin orders were for diabetic pts not for

septic patients

• Solution: revised the insulin orders for septic patients to start the drip after 2 values >180

Low Dose Steroids • Challenge ordering them consistently, and then stopping

them when indicated

• Solution: Update to the order set, adding this to the role of the pharmacist during ICU rounds.

Inspiratory Plateau Pressure – Informed RT of what we were doing after baseline data collection. They have been 100% ever since.

Safety Net

Rapid Assessment Team

ICU RN and RT with an MD as needed

Medical Executive Committee approved

standardized procedure

Screen for SIRS criteria each time the

team is activated

Results

Indicator AUG 2013

Lactic Acid Drawn w/I 1 hr 7/7 = 100%

Blood Culture prior to Abx 7/7 = 100%

Abx started within 3 hrs 7/7 = 100%

Appropriate fluid resuscitation w/I 6 h 7/7 = 100%

CVL placed within 6 hr 5/5 = 100%

Vasopressors after fluid resuscitation 4/4 = 100%

MAP 65 or more within 6 hrs 7/7 = 100%

CVP above 8 within 6 hrs 5/5 = 100%

ScVO2 at goal within 6 hrs 3/3 = 100%

Glucose below 150 within 24 hrs 7/7 = 100%

Low dose steroids within 24 hrs 7/7 = 100%

Inspiratory Plateau Pressure below 30 within 24 hr 4/4 = 100%

GOLD ALERT ACTIVATED 6/7 = 86%

Impact on Mortality

Sepsis Mortality Index to Top 10% of Medium Sized Hospitals

0.000.00

2.14

0.55

1.40

2.35

1.39

2.00

1.49

0.40

1.86

2.33

1.391.74

1.77

1.19

1.751.92

1.681.751.62

1.77

1.12

0.76

1.320.96

0.92

0.00

0.50

1.00

1.50

2.00

2.50

2011 - Q2 2011 - Q3 2011 - Q4 2012 - Q1 2012 - Q2 2012 - Q3 2012 - Q4 2013 - Q1 2013 - Q2

Discharge Quarter

Mo

rta

lity

In

de

x

870 - SEPT/sev seps w MV 96+hr 871 - SEPT/seps s MV 96+ w MCC 872 - SEPT/seps s MV 96+ s MCC

Success!

Spread to

Tele

Next Steps

Improve performance to early goal directed performance measures for Non-ICU patients through recognition, activation of the protocol, meeting performance goals • Sepsis Orders for Telemetry

• Education to the Hospitalist Team

• Education to the Tele Nurses

• Adding Tele Dept staff and leaders to the team

• Continue data collection, data analysis, and focused performance improvements based on that data.

• Celebrate our successes!