AHA/HRET HEN 2.0 SEPSIS WEBINAR: TIPS & TRICKS FOR SEPSIS RECOGNITION, BUNDLES & DATA. July 26 th, :00 a.m. 12:00 p.m. CDT

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1 AHA/HRET HEN 2.0 SEPSIS WEBINAR: TIPS & TRICKS FOR SEPSIS RECOGNITION, BUNDLES & DATA July 26 th, :00 a.m. 12:00 p.m. CDT 1

2 WELCOME AND INTRODUCTIONS Mallory Bender, MA, LCSW, Program Manager, HRET 11:00am 11:05am 2

3 SUMMARY DISCLOSURE & ACCREDITATION STATEMENT HRET HEN 2.0 Sepsis: Recognition, Bundles & Data Online Live Webinar July 26, 2016 The planners and faculty of the HRET HEN 2.0 Surgical Site Infections webinar have indicated no relevant financial relationships to disclose in regard to the content of this presentation. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical education through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and Health Research & Education Trust (HRET). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. ABQAURP is an approved to provide continuing education for nurses. This activity is designated for 1.0 Nursing Contact Hours through the Florida Board of Nursing, Provider #

4 WEBINAR PLATFORM QUICK REFERENCE Mute your computer audio Download today s slides and resources 4

5 Tips & Tricks for Sepsis Recognition, Bundles & Data July 26, 2016 Virtual 11:00 am 12:00 pm CDT 11:00-11:05 AM Welcome and Introductions Open and housekeeping information, including review of relevant HRET HEN resources, change packages and Listserv. Mallory Bender, MA, LCSW Program Manager, HRET 11:05-11:10 AM HEN Data Update Topic-specific data update including national percent reduction and percent reporting for sepsis measures. Paul Cholod, MS Data Analyst, HRET 11:10-11:15 AM Easy Strategies to Get Started Brief sepsis overview and beginning strategies to reduce sepsis mortality. 11:15-11:30 AM Process Matters! Hospital story that describes the focus on 3 hour bundle process measures and the impact on sepsis mortality reduction 11:30-11:45 AM Enhance Your Sepsis Data Extraction Hospital story that will highlight tools to enhance data extraction and an explanation of how to use the data to drive quality improvement at your hospital. Maryanne Whitney RN, MSN, CNS Improvement Advisor Cynosure Health Suzanne Fletcher BSN, RN, CMSRN Sepsis Coordinator Quality and Infection Prevention Wesley Healthcare Sara Briggs Assistant Vice President St. Elizabeth Healthcare 11:45-11:55 AM Recognizing Sepsis In the Inpatient Setting & Reflection Ideas for finding sepsis in the inpatient setting and discuss what your peers are trialing. Maryanne Whitney, RN, MSN, CNS Steve Tremain, MD Improvement Advisors Cynosure Health 11:55 AM-12:00 PM Bring it Home Action items and tying together of didactic, hospital-level and improvement science information. Mallory Bender, MA, LCSW Program Manager, HRET 5

6 SEPSIS CHANGE PACKAGE Cha Sepsis driver diagrams and change ideas Example PDSA cycles Descriptions and guidance on how to use change package effectively Referenced appendices 6

7 ENCYCLOPEDIA OF MEASURES (EOM) Catalogued measure information available on the HRET HEN website HEN Core Topics (evaluation measures) HEN Core Process Measures HEN Additional Topics 7

8 SIGN UP TODAY: SEPSIS LISTSERV Sepsis Analytics Listserv is available for: Sharing of: HRET Resources Publicly Available Resources Best Practices Learnings from Subject Matter Experts Troubleshooting for Data Reporting and Analysis 8

9 HEN DATA UPDATE Paul Cholod, MS, Data Analyst, HRET 11:05am 11:10am 9

10 SEPSIS DATA SUBMISSION Measure N Expected Baseline Post-operative sepsis rate (per 1,000 surgical discharges 1,007 43% 29% 29% 31% 25% 21% 20% 19% Overall sepsis rate (per 1,000 discharges) 1,282 28% 19% 19% 19% 19% 16% 12% 10% 10

11 SEPSIS OVERALL RATE 11

12 SEPSIS POST-OPERATIVE RATE 12

13 Sepsis Overview Maryanne Whitney RN,CNS,MSN, Improvement Advisor, Cynosure Health 11:10am 11:15am 13

14 Sepsis is the Killer in Our Midst

15 SEVERE SEPSIS: A SIGNIFICANT HEALTHCARE CHALLENGE Hospitalizations have doubled Most costly reason for hospitalization in billion in aggregate hospital cost 1 out of 23 patients in hospital had septicemia Major cause of morbidity and mortality worldwide Leading cause of death in non-coronary ICU 10th leading cause of death overall In the US, more than 700 patients die of severe sepsis daily (1.6 million new cases per year) 1 DEATH EVERY 2 MINUTES

16 Severe Sepsis vs. Current Care Priorities Care Priorities U.S. Incidence # of Deaths Mortality Rate AMI (1) 900, ,000 25% Stroke (2) 700, ,500 23% Trauma (3) (Motor Vehicle) 2.9 million (injuries) 42, % Severe Sepsis (4) 751, ,000 29%

17 THE PIECES YOU NEED Early Recognition Change the Culture Burden of proof it s not sepsis Make Early Treatment Easy Automate Leverage Technology

18 START SCREENING! Screen Every Emergency Patient Screen All Seriously Ill Adult Inpatients Prioritize infections most frequently associated with sepsis UTI, pneumonia, abdominal Use the EMR for prompts and alerts Treat all Elderly Patients as High Risk May have atypical signs- altered MS, afebrile

19 POSITIVE SEPSIS SCREEN 3HR BUNDLE (TO BE COMPLETED WITHIN 3 HOURS OF PRESENTATION) Measure lactate level not a send out Obtain blood cultures prior to administration of antibiotics Administer broad spectrum antibiotics Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L

20 HYPOTENSION OR LACTATE > OR = 4 6HR BUNDLE (TO BE COMPLETED WITHIN 6 HOURS OF SEPTIC SHOCK PRESENTATION TIME) Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) 65mmHg Re-assess volume status and tissue perfusion and document findings In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was 4 mmol/l, Re-measure lactate if initial lactate elevated

21 RE-ASSESS VOLUME STATUS AND TISSUE PERFUSION AND DOCUMENT FINDINGS BY. EITHER: Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings. OR TWO OF THE FOLLOWING: Measure CVP Measure ScVO2 Bedside cardiovascular ultrasound Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

22 SO.PUTTING IT ALL TOGETHER Screen every patient in triage or evaluation. Screen inpatients every shift. Bundle blood cultures with lactate. Administer antibiotics within an hour. Clear and consistent actions after a positive sepsis screen. Outcomes will follow.

23 HOSPITAL STORY: PROCESS MATTERS Suzanne Fletcher BSN, RN, CMSRN, Market Sepsis Coordinator, Wesley Healthcare, Wichita, KS 11:15am 11:30am 23

24 WESLEY HEALTHCARE- WICHITA, KS Wesley Medical Center- 548 beds Wesley Medical Center ER- Level 1 Trauma Center Wesley Pediatric ER The Only Level 2 Pediatric Trauma Center in Kansas Wesley Woodlawn Hospital and ER- 82 beds, NICHE Certified Wesley Children s Hospital- To Open in the Fall of 2016 Wesley Birth Care Center Wesley West ED Wesley Derby ED- Fall of

25 TESTS OF CHANGE & WHAT WE LEARNED Began with an active sepsis team Ultimate Downfall- No Sepsis Coordinator Sepsis Coordinator Sepsis Champion Class Sepsis Screening Tools in EMR ED Sepsis alerts In-house Sepsis Alerts Provider order Sets Case Review State Wide Education Treat Before Transfer Forms 25

26 TESTS OF CHANGE & WHAT WE LEARNED Began with an active sepsis team Ultimate Downfall- No Sepsis Coordinator Sepsis Coordinator Sepsis Champion Class Sepsis Screening Tools in EMR ED Sepsis alerts In-house Sepsis Alerts Provider Order Sets Case Review State Wide Education Treat Before Transfer Forms 26

27 BARRIERS AND HOW WE RESOLVED Even Disbursement of Champions Continuing Education of those Champions Complicated Steps with Assessment Screens Physicians not Using Order Sets Changes Needed for Sepsis Alerts Provider Push-Back Transfers from Outlying Hospitals State Wide Education Informing Providers of Fall-outs with CMS Treat Before Transfer Forms not Available for Providers 27

28 MEASURES WHAT & HOW Implemented Process Measurement included: a) Ease of Workflow b) Provider and Nurse Feedback c) Concurrent Data Collection d) Retrospective Data Collection e) Mortality Rate Analysis Bundle Measurement Data & Mortality Rate Data Shared: a) Physician Medical Executive Meetings b) Quality and Patient Safety Meetings c) Critical Care Meetings d) OB Meetings e) Pediatric Meetings f) Monthly Sepsis Collaborative 28

29 ADVICE FOR OTHERS Process Implementation a) Problem Identification b) PDSA for Small Change c) Driver Diagram for Large Scale Changes d) Chose your Team Members e) Appeal to Those Team Members in a Meaningful Way f) Collaborate g) Educate h) Implement i) Study j) Revisit Don t Wait for Perfection in Your Plan Implement and Determine What Changes are Needed 29

30 EXAMPLE: TREATING BEFORE TRANSFER Problem: Patients arriving from outlying hospitals with no sepsis interventions initiated 7.6% mortality increase with every hour without broad spectrum antibiotics Wesley Healthcare experiencing increase in mortality rates Plan: a) Help outlying hospitals by providing recommended interventions b) Create a form for transfer center to fax when call is received 30

31 Do: a) Collaborate with ED Medical Director, Hospitalist Champion and Infectious Disease Pharmacist for recommendations b) Create form c) Submit to all involved for final approval d) Ask transfer center to implement Study: Act: a) What happened after implementation? b) Did everything go as planned? c) What changes were made? a) Implement Changes 31

32 DOCUMENT FOR TRANSFER CENTER 32

33 TREAT BEFORE TRANSFER FORM 33

34 OUR PROGRESS 34

35 WRAP UP AND NEXT STEPS Changes in Our Own In-House Sepsis Care Transferring Hospitals Initiating Recommended Treatment Possible City-Wide Collaborative with Standardized Order Sets Finalization of EMS Collaboration Fine Tuning Existing Processes Continued Provider and Nurse Education Continued Site Visits and Outreach Continued Education to other Hospitals In Kansas and Iowa Through LISTSERV 35

36 QUESTIONS? Suzanne Fletcher BSN, RN, CMSRN Quality and Infection Prevention Market Sepsis Coordinator- Wesley Healthcare 550 N. Hillside Wichita, Kansas Office

37 HOSPITAL STORY: ENHANCE DATA ABSTRACTION Sara Briggs, MSN, RN, NEA-BC, Assistant VP Care Coordination and Patient Logistics, St. Elizabeth Healthcare, Edgewood, KY 11:30am 11:45am 37

38 38 Sepsis Quality Initiative July 2016

39 St. Elizabeth Healthcare About Us: - 7 facilities & over 1200 licensed beds serving the NKY/Greater Cincinnati Region - Services including: - Orthopedic Institute - Heart and Vascular Institute - Diagnostic and therapeutic catheterization - Cancer center - Birthing center with a Level III nursery - Behavioral health center - Business health center - Sports medicine - Cardiac rehabilitation center - Women s wellness and breast center - Family practice residency program

40 EMR Workflow Integration A sepsis screening tool will fire in EPIC to the RN & MD once it identifies a patient with: One manifestation of organ dysfunction The Best Practice Advisory will then request verification of suspected infection (the 3 rd criteria for identification of Severe Sepsis or Septic Shock)

41 Nurse Screening BPA View Automatically populates recent lab values here. BPA is a Screening Tool only *Nurse will gather data/use clinical judgment *MD will diagnose & prescribe If no evidence to suspect infection, RN must click RN: No documented/ suspected infection, & the checkmarks for orders will disappear. These will populate as nursing orders per protocol (slide 14), once BPA accepted. Check next to the applicable criteria to justify presence of 2 or more SIRS and 1 or more Organ dysfunction.

42 Physician Screening BPA View BPA is a Screening Tool only MD will still need to diagnose & prescribe Automatically populates recent lab values & vitals here. You can add Severe Sepsis or Septic Shock to your problem list from the BPA If no evidence to suspect infection, MD must click I certify no current Sepsis. the checkmarks for the orders & criteria below will disappear.

43 Nursing Protocol Order Set Allows the nurse to initiate some of the time sensitive lab orders. Nurse must immediately call MD & pull up EPIC orders to obtain orders for Severe Sepsis or Septic Shock.

44 Nursing Protocol Sepsis Bundle

45 CONCURRENT REVIEW The following is a brief review procedure for concurrent review of Sepsis cases. Core Measure reviewer receives s of all Sepsis BPA s During QM office hours the review nurse will review the case and if additional orders or actions are needed the review nurse will call the nurse taking care of the patient and recommend needed action. [example: blood culture needs to be drawn by time. The reviewer will look at all available data sources in Epic including at times the BPA s that fired. 45

46 RETROSPECTIVE REVIEW The following is the process for retrospective review of Sepsis Core Measures. Cases are selected based on coding. Sepsis cases qualify nightly in the Midas Care Management system from interface feeds from hospitals ADT/DAB [Epic]. Based on qualifying conditions, cases are placed on Core Reviewers worklist and Core detail profile. Sepsis Core focus studies [data collection form] are automatically generated in Midas for cases that qualify. Demographic data automatically populates in Midas from interface [example: pt age, insurance etc.]. Core Reviewer reviews chart in Epic abstracts and enters appropriate information into Midas A 2 nd validation review occurs in all sepsis cases. Reports are generated from Midas. Data is harvested from Midas for reporting to CMS, TJC. 46

47 METRICS for Success Mortality Length of Stay Core Measure Compliance Readmission Rates Cost Per Case

48 SEPSIS QUALITY INITIATIVE 8 Sepsis Length of Stay 7.8 October Sepsis Initiative Begins Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 48

49 SEPSIS QUALITY INITIATIVE Sepsis Readmissions HW Readmissions Sepsis Readmissions October Sepsis Initiative Begins 30% 25% 20% 15% 10% 5% Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 0% 49

50 SEPSIS QUALITY INITIATIVE Sepsis Mortality October Sepsis Initiative Begins Sepsis Mortality Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun

51 SEVERE SEPSIS/SEPTIC SHOCK CORE MEASURE COMPLIANCE Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr-16 Early Management Sepsis Bundle Goal 2nd Quarter 2016 Data collection incomplete and subject to change

52 SEVERE SEPSIS/SEPTIC SHOCK CORE MEASURE COMPLIANCE Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar-16 Apr-16 EDG FLO FTT Grant 2nd Quarter 2016 Data collection incomplete and subject to change

53 QUESTIONS? Sara Briggs MSN, RN, NEA-BC St. Elizabeth Healthcare 53

54 Recognizing Sepsis in the Inpatient Setting & Reflection Maryanne Whitney RN,CNS,MSN, Steve Tremain MD, Improvement Advisors, Cynosure Health 11:45am 11:55am 54

55 Inpatient Sepsis Detection Screen for sepsis every shift and at transfers Use the EMR Develop Alerts Optimize Rapid Response Team involvement 55

56 LEVERAGE TECHNOLOGY Use EMR for inpatient screening Best Practice Alerts Prompts for Interventions Contact MD or RRT Request lactate because one has not been drawn in 4 hours Request blood culture because they have not been drawn N/A pt. does not have suspected or known infection

57

58

59 BEST PRACTICE ALERTS

60 MODIFIED EARLY WARNING SCORING SYSTEM

61 Mobilize resources What are they? Mobilize experts Who are they? Consensus in diagnosis Allow for clinical decisions Time sensitive Create action Antibiotics Labs Fluids RRT Can they be involved?

62 SEPSIS SURPRISES IN THE LITERATURE Highest Mortality Sepsis diagnosed on the floors Lactate >2 mmol/l but < 4 mmol/l Bundle Compliance Worst on the floor Hospitals with RRT/Sepsis Alert as resource saves most lives

63 REFLECTIONS 63

64 BRING IT HOME Mallory Bender, Program Manager, MA, LCSWHRET 11:55am- 12:00pm 64

65 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Review your facility s sepsis mortality data. Review the current sepsis order-sets and protocols. What are you going to do in the next month? Participate in development/ update of sepsis protocols and order-sets. Create or update the vision for your organizations sepsis program. 65

66 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Communicate sepsis mortality data to department. Identify a department to begin inpatient sepsis screening What are you going to do in the next month? Participate in the development in hand off tools Develop PDSA tests of change to address process failures 66

67 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Review sepsis mortality data. Ensure inpatient department leaders are represented on the sepsis committee. What are you going to do in the next month? Provide support to the development of EMR sepsis detection and data abstraction tools. Assign an executive sponsor from the C-suite to support the improvement team by providing necessary support and removing barriers. 67

68 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Speak with a Rapid Response Team member to understand their role in sepsis mortality reduction. What are you going to do in the next month? Work with advisory board to develop sepsis education for patients and families. 68

69 CONTINUING EDUCATION CREDITS Launch the evaluation link in the bottom left hand corner of your screen. If viewing as a group, each viewer will need to submit separately through the CE link 69

70 UPCOMING EVENTS AHA/HRET HEN 2.0 Data Webinar July 28, :00am - 12:00pm (CST) Register here! AHA/HRET HEN 2.0 VAE Webinar August 2, :00am - 12:00pm (CST) Register here! AHA/HRET HEN 2.0 Falls Webinar August 4, :00am - 12:00pm (CST) Register here! Register Now! 70

71 THANK YOU! Find more information on our website: Questions/Comments: 71

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