6/4/2018. Focusing on Early Sepsis: An RN Driven Approach

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1 Focusing on Early : An RN Driven Approach Alice Ferguson MSN, RN, CPHQ Virginia Mason Strategic Plan Virginia Mason Mason Medical Medical Center Center 1

2 Virginia Mason Everything Else 53% 47% 2276 deaths Kaiser by Coding by Review Other 44% 37% 48% 35% 19% 17% KPNC 480K pts : 14K deaths NIS 6.5M pts : 143K deaths Liu Et. Al. JAMA May

3 Why focus on low grade sepsis? Septic Shock Hypotension [CATE GORY NAME] [PERC ENTA GE] 33% 1817 Kaiser Permanente Northern CA Liu Et. Al. JAMA July The Virginia Mason Bundle Recognize Initiate Bundle SIRS + Possible Infection SIRS any 2 TEMP > 38.0, < 36.0 HR > 90 RR > 20 WBC > 12, < 4 > 10% bands Severe + Injury: Lactic Acid Creatinine Delirium Septic Shock Hypotension < 1 hour 2L NS Bolus Start Abtcs Check Draw Blood Cxs 6 3

4 The Virginia Mason Bundle Recognize Initiate Bundle SIRS + Possible Infection SIRS any 2 TEMP > 38.0, < 36.0 HR > 90 RR > 20 WBC > 12, < 4 > 10% bands Severe + Injury: Lactic Acid Creatinine Delirium Septic Shock Hypotension < 1 hour 2L NS Bolus Start Abtcs Check Draw Blood Cxs 7 Why RN Initiated? RN Suspects Sent Read Created Assessment Travel to Bedside Orders Placed in EHR Nurse Review of Orders Initiated 8 4

5 Why RN Initiated? RN Suspects Sent Read Created Assessment Travel to Bedside Orders Placed in EHR Nurse Review of Orders Initiated 9 Power Hour: Nurse Leads RN Work: < 30mins Identify Check within 10 min Check Blood Cultures Start 500cc fluid bolus MD Work: < 60mins Confirm Start Antibiotics Complete fluid bolus Pharmacy Work: Prioritize Antibiotics Dose and Prepare STAT Hand-Deliver to patient 5

6 Why RN Initiated? RN Suspects Sent Power Hour Initiated Assessment Read Sent Created Orders Placed in EHR Continued 11 Results 100% 80% Element and Bundle Compliance 93% 94% Power Hour Baseline 60% 48% 40% 36% 20% 0% Bolus 12 6

7 Results LACTATE RESULT 3-4 9% >4 4% % < 2 71% 13 Results OUTCOMES No New Intervention 22% Antibiotics Initiated 41% Non- Acute Treatment Initiated 25% Treatment Expanded for Existing 12% 14 7

8 Outcomes No reported adverse effects Reduction in BOTH deaths per sepsis discharge 12.5 to 8.4 (p<0.001) deaths per hospital discharge 1.05 to 0.78 (p=0.015) 15 But what about?!? But your whole process is based on SIRS!!!! What about qsofa??????? How much fluid do you give???? 16 8

9 But what about?!? Power Hour is a process intervention Focuses on team-based delivery of high quality care New evidence can be integrated into the existing structure at any time Critical elements (leveraging nurse expertise, team-based care, early initiation & treatment) remain the same 17 The Virginia Mason Bundle Recognize Initiate Bundle SIRS + Possible Infection New Improved SIRS any 2 Criteria TEMP > 38.0, < 36.0 HR > 90 RR > 20 WBC > 12, < 4 > 10% bands Severe + Injury: Lactic Acid Creatinine Delirium Septic Shock Hypotension < 1 hour 2L NS Bolus Start Abtcs Check Draw Blood Cxs 18 9

10 Thank You Don t Wait Initiate! Power Hour 10