2014 Maryland Patient Safety Center s Call for Solutions

Transcription

1 Improving Sepsis Outcomes Through Coordinated Early Recognition, Assessment, and Treatment UM-CRMC Sepsis Survival Rate 100% 95% 90% 89.5% CRMC 85% 85.3% 86.1% 86.2% 81.8% 82.3% 85.7% 84.7% 86.1% MD Statewide 80% 79.7% 75% CY 2010 CY 2011 CY 2012 Q Q Maryland Patient Safety Center s Call for Solutions CHARLES REGIONAL MEDICAL CENTER PAGE 1 OF 23

2 BACKGROUND, DESCRIPTION AND GOALS BACKGROUND: The Board, Medical Staff, Clinical Leadership, and Management of University of Maryland Charles Regional Medical Center (UM CRMC) are committed to fostering a culture of quality and patient safety. As part of the hospital s overall quality efforts, total mortality is routinely monitored by the Board-level Quality Council. As shown in the table below, total inpatient mortality at UM CRMC has historically averaged approximately 2%. Quarter Mortality Rate Jan-Mar % Apr-Jun 2.17% Jul-Sep 2.07% Oct-Dec 2.11% Jan-Mar % Apr-Jun 1.91% Jul-Sep 1.66% Oct-Dec 1.80% Jan-Mar % Apr-Jun 1.34% Jul-Sep 1.39% Oct-Dec 2.02% Source: HSCRC Inpatient Database When members of the Quality Council reviewed the 2.70% mortality statistic for the January to March 2011 quarter, they found a long running trend had been exceeded and requested an analysis. That analysis revealed Septicemia and Disseminated Infections [APR-DRG 720] constituted the leading cause of death at the hospital. As described by Sutton and Friedman: Septicemia, commonly referred to as sepsis, is a serious blood infection that produces systemic inflammation and may lead to organ failure, shock, and even death. Most often caused by bacteria or bacterial toxins in the blood stream (bacteremia with sepsis), more than one million cases of septicemia are reported in the United States each year. Costs of septicemia treatment are high, with total hospital costs estimated to be more than $24 billion in Despite resources incurred in treatment, an estimated 25 to 50 percent of patients succumb to this condition, making septicemia the tenth leading cause of death in the United States. (Source: Healthcare Cost and Utilization Project (HCUP), Trends in Septicemia Hospitalizations and Readmissions in Selected HCUP States, 2005 and 2010, Janet P. Sutton, Ph.D. and Bernard Friedman, Ph.D). CHARLES REGIONAL MEDICAL CENTER PAGE 2 OF 23

3 For FY 2011, Septicemia and Disseminated Infection [hereafter sepsis] accounted for 58 deaths or 35.4% of total deaths at UM CRMC. Although sepsis was also the leading cause of death at Maryland Hospitals in FY 2011, it accounted for 22.5% of deaths. This difference in sepsis mortality between UM CRMC and the State of Maryland was identified as a priority for improvement. Further analysis brought to light the fact the sepsis morality rate was not only a state-wide concern, but represented the leading cause of death in our hospital. The following were the top 5 mortal conditions in Maryland hospitals and at UM CRMC for FY 2011: Maryland FY 2011 UM CRMC FY % Septicemia and Disseminated Infections % Pulmonary Edema and Respiratory % Heart Failure % Respiratory System Diagnosis with Ventilator % CVA and Precerebral Occlusion with Infarct % Septicemia and Disseminated Infections % Pulmonary Edema and Respiratory % Major Respiratory Infections % Tracheostomy with long term ventilator % Heart Failure Source: HSCRC Inpatient Database DESCRIPTION: A Patient Safety Team was established to develop evidence-based guidelines for the prompt identification and early management of patients with severe sepsis. The goals set by the Team were as follows: GOALS: 1. Provide early recognition, assessment, and treatment of patients with sepsis. 2. Provide evidence-based care to patients with sepsis. 3. Evaluate effectiveness of care provided to patients with sepsis by monitoring process measures and outcomes. 4. Improve survival rates for patients with sepsis. CHARLES REGIONAL MEDICAL CENTER PAGE 3 OF 23

4 PROCESS(ES) IMPLEMENTED Goal: Provide early recognition, assessment, and treatment of patients with sepsis. Goal: Provide evidence-based care to patients with sepsis. The Surviving Sepsis Campaign is a joint collaboration of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine committed to reducing mortality from severe sepsis and septic shock worldwide. UM CRMC utilizes Surviving Sepsis Campaign evidence-based severe sepsis assessment criteria. The following Severe Sepsis Guidelines and Flow Diagram outlines the coordinated hospital-wide approach to early recognition, assessment and treatment of severe sepsis for patients in the Emergency Department, Medical-Surgical units, and Intensive Care Unit (ICU). CHARLES REGIONAL MEDICAL CENTER PAGE 4 OF 23

5 SEVERE SEPSIS GUIDELINES FLOW DIAGRAM SEPSIS ASSESSMENT CRITERIA SEPSIS = 1 Infection criteria + 2 SIRS criteria SEVERE SEPSIS = 1 Infection criteria + 2 SIRS criteria + 1 Organ Dysfunction criteria INFECTION: Symptoms like dysuria, wound drainage, foul smell, cough, fever, unexpected postop pain Pneumonia documented by x-ray or symptoms? [fever, cough, crackles auscultated, tachypnea] Documented or suspected positive urine, blood, wound, sputum cultures Receiving antibiotic/anti-fungal agent WBCs present in normally sterile fluid Suspicion of a perforated hollow organ SYSTEMIC INFLAMMATORY RESPONSE [SIRS]: Temperature > F Temperature < 96.8 F Heart Rate > 90 Respiratory Rate > 20 WBC > 12,000 WBC < 4,000 ORGAN DYSFUNTION: SBP < 90 or MAP under 70 >1 hr despite fluid resuscitation Arterial hypoxemia: PaO2/FIO2 less than 300 Urine output < 0.5 ml/kg/hr > 2 hrs despite fluid resuscitation Creatinine > 2.0 mg/dl [176.8 mol/l] INR > 1.5 or PTT greater than 60 seconds Platelets < 100,000 Bilirubin > 4 mg/dl [70 mol/l] Lactate > upper limits of normal Altered consciousness; reduced Glasgow Coma Scale. Skin mottling Ileus EMERGENCY DEPARTMENT ICU INPATIENT & RAPID ASSESSMENT [RA] TEAM ASSESSMENT When sepsis suspected, ED staff calls CODE SEPSIS, assesses patient utilizing ED SEVERE SEPSIS SCREENING TOOL. ASSESSMENT SEPSIS patient admitted from ED or transferred from other unit. ASSESSMENT As part of RA Team response, nurse assesses patient for possible sepsis utilizing RA Team Sepsis Screening Tool & Protocol. SEPSIS CRITERIA When criteria met, ED SEVERE SEPSIS ORDER SET initiated through CPOE. SEPSIS CRITERIA Nurse confirms criteria met & notifies Physician to obtain additional orders. SEPSIS CRITERIA When criteria met, RA nurse notifies Physician of positive Sepsis Screening. TREATMENT PRIORITIES TREATMENT PRIORITIES TREATMENT PRIORITIES Implement ED SEVERE SEPSIS ORDER with focus on timely: Fluid resuscitation Hemodynamic stability Blood cultures Lactate level Antibiotics Oxygenation/airway management Disposition: Consider admission to ICU when Lactate 2 or greater Implement SEVERE SEPSIS ICU ADULT ORDER SET with focus on timely: [if not previously done] Fluid resuscitation Hemodynamic stability & monitoring Blood cultures Lactate level Antibiotics Oxygenation/airway management VTE/DVT & GI Prophylaxis Implement Protocol interventions with focus on timely: Fluid resuscitation Lactate level Transfer to ICU, if appropriate CHARLES REGIONAL MEDICAL CENTER PAGE 5 OF 23

6 LESSONS LEARNED/CHALLENGES/SOLUTIONS Lessons Learned / Challenges Baseline data obtained prior to implementation of severe sepsis guidelines indicated the need to mobilize resources to meet key process and outcome measures. Solution #1: Code Sepsis With a wealth of research confirming the value of early goal-directed therapy, it became clear the Emergency Department would play an essential role. The initiative began with education and awareness. However, it quickly became clear that although education and awareness was a good foundation, improved outcomes would not come from the will of individuals. It would require process changes developed and implemented by the Emergency Department, including a standardized electronic sepsis screening tool, evidence-based orders initiated through computerized provider order entry, and swift deployment of needed resources through Code Sepsis. Once announced overhead, Code Sepsis delivers an ED physician, 2 ED nurses, an ED technician, and a phlebotomist to the patient s bedside. Care tasks then proceed in tandem rather than sequentially. Early recognition of sepsis, combined with prompt, leading-practice, intervention has resulted in dramatic and sustained improvement in the timeliness of key process measures related to lactate levels, blood cultures, IV fluid resuscitation, and antibiotic administration, as well as in patient survival. EMERGENCY DEPARTMENT ASSESSMENT When sepsis suspected, ED staff calls CODE SEPSIS, assesses patient utilizing ED SEVERE SEPSIS SCREENING TOOL. SEPSIS CRITERIA When criteria met, ED SEVERE SEPSIS ORDER SET initiated through CPOE. TREATMENT PRIORITIES Implement ED SEVERE SEPSIS ORDER with focus on timely: Fluid resuscitation Hemodynamic stability Blood cultures Lactate level Antibiotics Oxygenation/airway management Disposition: Consider admission to ICU when Lactate 2 or greater CHARLES REGIONAL MEDICAL CENTER PAGE 6 OF 23

7 The following screenshots from our electronic medical record explain the steps of Code Sepsis, as well as how the process has been hard-wired into the Emergency Department s workflow. CODE SEPSIS Step #1 Early Recognition Early sepsis recognition is achieved by utilizing the Sepsis Screening Tool at the first point of contact [Triage] CODE SEPSIS Step #2 Mobilization When criteria met, CODE SEPSIS is paged to alert staff to respond to the patient s location. Responders include 2 ED nurses, ED physician, ED tech, and phlebotomist. CHARLES REGIONAL MEDICAL CENTER PAGE 7 OF 23

8 CODE SEPSIS Step #3 Sepsis Order Set Sepsis orders are initiated through Computer Provider Order Entry [CPOE] which standardizes evidence-based diagnostics and interventions. CHARLES REGIONAL MEDICAL CENTER PAGE 8 OF 23

9 Solution #2: Sepsis Assessment At Every Rapid Assessment Team Call On the inpatient units, the Rapid Assessment Team [Hospitalist, ICU Nurse and Respiratory Therapist] routinely evaluates patients for possible sepsis utilizing evidence-based criteria. The assessment is documented by the Rapid Assessment Team and is a permanent part of the patient s medical record. If criteria are met, the Rapid Assessment Sepsis Protocol is initiated. This process has assisted in the early identification of inpatients having signs or symptoms of sepsis. INPATIENT & RAPID ASSESSMENT [RA]TEAM ASSESSMENT As part of RA Team response, nurse assesses patient for possible sepsis utilizing RA Team Sepsis Screening Tool & Protocol. SEPSIS CRITERIA When criteria met, RA nurse notifies Physician of positive Sepsis Screening. TREATMENT PRIORITIES Implement Protocol interventions with focus on timely: Fluid resuscitation Lactate level Transfer to ICU, if appropriate The Rapid Assessment Team Screening Tool and patient care Protocol used at UM CRMC follow. CHARLES REGIONAL MEDICAL CENTER PAGE 9 OF 23

10 SEPSIS ASSESSMENT CRITERIA INFECTION: Does patient have any ONE of the following? Yes Symptoms such as dysuria, wound drainage, foul smell, cough, fever or unexpected post-op pain? Yes Pneumonia documented by x-ray or symptoms such as fever, cough, crackles auscultated, and/or tachypnea? Yes Documented or suspected positive urine, blood, wound or sputum culture results? Yes Currently receiving an antibiotic or anti-fungal agent? Yes WBCs present in normally sterile fluid? Yes Suspicion of a perforated hollow organ? SYSTEMIC INFLAMMATORY RESPONSE [SIRS]: Does patient have any TWO of the following? Yes Temperature greater than F or less than 96.8 F? Yes Heart rate greater than 90? Yes Respiratory rate greater than 20? Yes WBC greater than 12,000 or less than 4,000? ORGAN DYSFUNCTION: Does patient have any ONE of the following? Yes Systolic BP under 90 or MAP under 70 for over 1 hour, despite fluid resuscitation? Yes Arterial hypoxemia: PaO2/FIO2 less than 300 Yes Urine output less than 0.5 ml/kg/hr greater than 2 hours despite fluid resuscitation Yes Creatinine greater than 2.0 mg/dl [176.8 mol/l Yes INR greater than 1.5 or PTT greater than 60 seconds Yes Platelets less than 100,000 Yes Bilirubin greater than 4 mg/dl [70 mol/l] Yes Lactate greater than the upper limits of normal Yes Altered consciousness or reduced Glasgow Coma Scale Yes Skin mottling Yes Ileus Sepsis Rapid Assessment Team Screening Tool & Protocol SEPSIS = 1 Infection criteria + 2 SIRS criteria SEVERE SEPSIS = 1 Infection criteria + 2 SIRS criteria + 1 Organ Dysfunction criteria Yes No Does patient meet SEPSIS criteria? If YES, initiate interventions 1-5 Yes No Does patient meet SEVERE SEPSIS criteria? If YES, initiate interventions Notify physician of positive screen and patient status 2. STAT CBC, CMP, and Lactate Level 3. Continuous pulse oximetry. Initiate oxygen at 2 LPM; titrate to keep SpO 2 equal or greater than 94% 4. For systolic blood pressure under 90, infuse 1 liter 0.9% Sodium Chloride BOLUS over 30 minutes 5. Vital signs every 10 minutes during event 6. STAT ABG 7. Consider Intensivist consult 8. Evaluate patient for transfer to ICU CHARLES REGIONAL MEDICAL CENTER PAGE 10 OF 23

11 Solution #3: Expanded Physician Staffing In The ICU And Developed A Severe Sepsis Order Set As part of the hospital s commitment to improving the timeliness of care for patients with sepsis and other conditions, UM CRMC expanded physician staffing in the ICU to 24/7/365. Having around the clock physician staffing in the ICU was an important element in the optimal coordination of care for severe sepsis patients. ICU ASSESSMENT SEPSIS patient admitted from ED or transferred from other unit. SEPSIS CRITERIA Nurse confirms criteria met & notifies Physician to obtain additional orders. TREATMENT PRIORITIES Implement SEVERE SEPSIS ICU ADULT ORDER SET with focus on timely: [if not previously done] Fluid resuscitation Hemodynamic stability & monitoring Blood cultures Lactate level Antibiotics Oxygenation/airway management VTE/DVT & GI Prophylaxis CHARLES REGIONAL MEDICAL CENTER PAGE 11 OF 23

12 A multidisciplinary team developed the following ICU Adult Severe Sepsis Order Set. CHARLES REGIONAL MEDICAL CENTER PAGE 12 OF 23

13 MEASURABLE OUTCOMES Goal: Evaluate effectiveness of care provided to patients with sepsis by monitoring process measures and outcomes. UM CRMC has achieved outstanding improvement in all key measures when compared to baseline data collected prior to implementation of Severe Sepsis Guidelines in June 2012 and the Code Sepsis Team in January CHARLES REGIONAL MEDICAL CENTER PAGE 13 OF 23

14 Obtaining Blood Cultures prior to administration of antibiotics increased from a baseline of 86% and has exceeded 95% overall. Feedback is provided to staff for any deficiencies. 100% 75% ED MEASURE: % Blood Culture Before Antibiotic 100%100%100%100% 100%100%100% 100% 100% 100%100% 97% 91% 92% 92% 86% 50% 25% Sepsis Guidelines Implemented Code Sepsis Initiated 0% Improvement in the timeliness of initial Lactate Level has been shown, from baseline data of 202 minutes [2012 Q1] to significantly less than the 90 minutes performance target, for the last eight consecutive months Sepsis Guidelines Implemented ED MEASURE: Average # of minutes ED Arrival to Lactate Measured Code Sepsis Initiated Performance Target: <90 mins Favorable Trend 0 CHARLES REGIONAL MEDICAL CENTER PAGE 14 OF 23

15 Improvement in the timeliness of Antibiotic Administration has also been demonstrated, from baseline data of 420 minutes [2012 Q1] to significantly less than the 180 minutes performance target, for the last five consecutive months Sepsis Guidelines Implemented ED MEASURE: Average # of minutes ED Arrival to Antibiotic Administered Code Sepsis Initiated Performance Target: <180 mins Favorable Trend 50 0 Improvement in the timeliness of IV Fluid Resuscitation has been shown, from baseline data of 194 minutes [2012 Q1] to significantly less than the 120 minutes performance target, for the last 15 consecutive months Sepsis Guidelines Implemented ED MEASURE: Average # of minutes IV Fluid Resuscitation Code Sepsis Initiated Performance Target: <120 mins Favorable Trend 0 CHARLES REGIONAL MEDICAL CENTER PAGE 15 OF 23

16 Lack of consistency of VTE/DVT Prophylaxis was related to documentation. This documentation issue was corrected, and this measure has been 100% for last four consecutive months. ICU MEASURE: VTE/ DVT Prophylaxis or Doc. Contraindication 100% 100%100%100% 100%100% 100%100% 100%100%100%100% 80% 88% 89% 80%80% 60% 40% Sepsis Guidelines Implemented Code Sepsis Initiated Performance Target >90% 20% Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Lack of consistency of GI Prophylaxis was also related to documentation. This issue was corrected, and the measure has been 100% for the last eight consecutive months. ICU MEASURE: GI Prophylaxis or Doc. Contraindication 100% 100%100%100% 100% 100%100%100%100%100%100%100%100% 80% 83% 75% 60% 40% Sepsis Guidelines Implemented 67% Code Sepsis Initiated Performance Target >90% 20% Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 CHARLES REGIONAL MEDICAL CENTER PAGE 16 OF 23

17 Goal: Improve survival rates for patients with sepsis. Sepsis survival rates have improved significantly since the staff at UM CRMC initiated Code Sepsis in January UM CRMC sepsis survival rates have improved from 79.7% in 2010 to 89.5% in the second quarter of This 89.5% survival rate at UM CRMC exceeds the 86.1% survival rate for Maryland hospitals during the second quarter of UM-CRMC Sepsis Survival Rate 100% Sepsis Guidelines Implemented Code Sepsis Initiated 95% 90% 89.5% CRMC 85% 80% 85.3% 79.7% 86.1% 86.2% 81.8% 82.3% 85.7% 84.7% 86.1% MD Statewide Favorable Trend 75% CY 2010 CY 2011 CY 2012 Q Q CHARLES REGIONAL MEDICAL CENTER PAGE 17 OF 23

18 SUSTAINABILITY Sustainability has been achieved by hard-wiring our coordinated hospital-wide approach to early assessment and treatment of patients with sepsis, data collection and reporting. After the original Sepsis Patient Safety Team fulfilled its mission, it was disbanded in late The Critical Care Committee assumed responsibility for review of outcomes and needed action. Sepsis is a standing agenda item. Furthermore, key performance measures have been incorporated in the hospital s Quality and Safety Status Report. The Critical Care Committee has approved next steps to achieve continued improvement: Provide Sepsis Update CME in November 2013 at UM CRMC. Representatives from the Maryland Patient Safety Center have been invited to attend. Use this as an opportunity to celebrate and thank staff. Discuss challenges and what we did to address them. Discuss outcomes: What does our data show? How do we compare to our 2012 baseline? What is the impact of Code Sepsis? Develop a tool in the Electronic Medical Record for sepsis reassessment. Refine ICU Severe Sepsis Orders set and improve adoption. Share our improvements and lessons learned with others. CHARLES REGIONAL MEDICAL CENTER PAGE 18 OF 23

19 ROLE OF COLLABORATION AND LEADERSHIP What role did teamwork and collaboration play in the Solution? Team work was essential for this organization-wide patient safety initiative. Collaboration made it possible to fully understand the roles of the various departments and how each works interdependently to achieve optimal goals. Emergency Department Leadership developed and implemented Code Sepsis. Nursing Leadership worked collaboratively to assure the smooth transition of care from the Emergency Department, Inpatient Units, and the Intensive Care Unit. Intensivists were key drivers in the development of sepsis order sets and were assisted by Clinical Pharmacy in drug selection, including antibiotics. The Medical Staff sponsored a Sepsis CME to launch the new sepsis guidelines. Emergency Department s Nurse Educator developed Sepsis module education in HealthStream. The physician led Performance Improvement Committee as well as the Critical Care Committee promoted these major patient safety efforts and closely monitored the outcomes. The Performance Improvement department developed the ongoing monitoring and reporting process for sepsis outcomes. What partners and participants were involved? The Board of Directors, Administration, Emergency Medicine, Critical Care, Infectious Disease, Nursing, Pharmacy, Infection Prevention, and Performance Improvement were major stake holders. Was the organization s leadership engaged and did they share the vision for success? Leadership launched this clinically significant patient safety initiative. Relevant data were presented indicating an opportunity for improvement. The Board of Directors, Medical Staff, and Executive Team established this organizational priority and sanctioned the Sepsis Patient Safety Team. James Burke Mark Dumais, MD, FACP Richard Ferraro, MD Debbie Shuck-Reynolds, RN Ashebir Woldeabezgi, MD Julie Shores, RN Maggie Eller, RN Darin Mann, DO Abbas Omais, MD Sharon Kiessling, RN Philippa J. Sumlin, RN Carina Blumer, RN Gabe Abiola, PharmD Mary Harman, RN Chair, Quality Council of the Board Administrative Sponsor, Chief Medical Officer Advisor/ Chief of Emergency Medicine Advisor/Emergency Department Manager Advisor/Infectious Disease Team Leader, ICU Manager Team Facilitator, PI Coordinator Emergency Medicine Intensivist/ICU Medical Director Emergency Department Intensive Care Unit Intensive Care Unit Pharmacy Infection Prevention CHARLES REGIONAL MEDICAL CENTER PAGE 19 OF 23

20 How was leadership support demonstrated? Leadership demonstrated clear support for the initiative, from its inception to present day. UM CRMC s Chief Medical Officer served as the Administrative Sponsor for the project, keeping Leadership informed of the team s progress as well as needed resources for successful implementation. Leadership support resulted in: Approving the expansion of the Intensivist Program 24/7/360. Approving new medical equipment. ICU purchased two EV 1000 clinical platform monitors for $120,000. They provide continuous measurement of central venous oxygen saturation and automatically calculate stroke volume and cardiac output. These monitors are an important diagnostic tool in the identification and treatment of sepsis. Requiring clinical staff to complete mandatory sepsis education annually since April 2012, when the Sepsis module was originally developed in HealthStream. The sepsis module has been completed 470 times by 297 clinical staff. This represents approximately a $12,000 investment in staff development. Adding Procalcitonin testing in the Laboratory. Procalcitonin is a good biological diagnostic marker for sepsis, severe sepsis, or septic shock. CHARLES REGIONAL MEDICAL CENTER PAGE 20 OF 23

21 INNOVATIVE ATTRIBUTES Development and implementation of CODE SEPSIS An innovative SEPSIS acronym was also developed to educate staff about the warning signs of sepsis. It is included in the hospital s Screensavers, posted on nursing units, and incorporated in the Sepsis mandatory annual education for clinical staff. SEPSIS Warning Signs Shifting WBC up or down Elevated or low temperature Pressure -- BP is low Speedy heart rate [>90] Infection Speedy respiratory rate [>20] RELATED TOOLS AND RESOURCES The Patient Safety/Performance Improvement Department conducts retrospective reviews utilizing the Severe Sepsis and Septic Shock Outcomes data collection tool for patients meeting criteria. Criteria were developed by member hospitals of the University of Maryland Medical System. Results are summarized in a PDCA [Plan-Do-Check-Act] report and distributed to appropriate departments/committees for staff feedback and needed action. A copy of the data collection tool follows. CHARLES REGIONAL MEDICAL CENTER PAGE 21 OF 23

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