Kansas Heart and Stroke Collaborative

Transcription

1 Sepsis in the Long Term Care Facility Aligning with Requirements of Participation Dr. Bob Moser, MD F.A.A.F.P Executive Director, Kansas Heart & Stroke Collaborative University of Kansas Health System University of Kansas School of Medicine Kansas Heart and Stroke Collaborative Overview of QI and Performance Improvement In Action 1

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3 MI/Stroke Issues in Rural Kansas Inconsistent adoption of current EB guidelines with Time Critical Diagnoses KS hospitals data showed Heart Cath rarely performed within 90 minutes of First Medical Contact Less than 3% of eligible patients with ischemic stroke received thrombolytic therapy Higher mortality rates in rural Kansas Higher hospital readmissions in rural Kansas >75% of patients arrive by private vehicle, not EMS Kansas Heart & Stroke Collaborative Model Acute Care Focus Improve outcomes for heart attacks and stroke and reduce total cost of care. EB Guideline protocols/order sets adoption with local realities Local education for staff, EMS and LTC around protocols Utilization of telemedicine support of original CAH s to improve standardization across providers and support local systems of care Data collection and assistance with performance improvement Identified need for protecting peer review in QAPI work Identified additional tools to assist with improving timely interventions ipads in ER to capture photo of EKG Communication Sheet to summarize patient condition for consult call EMTALA Plus Form for improved communication on patient transfers 3

4 Kansas Heart & Stroke Collaborative Model Transitions of Care Focus Improve transitions of care and care coordination and reduce readmissions Utilized Regional Transitional Care Managers TCM (APRN s) with original group in NW Kansas Accomplished through home visits with consenting patients Able to test concept of CareCar Utilized TCM s to capture and bill for new CMS service Transitional Care Management Expanded participating sites included training and incorporating local TCM s Kansas Heart & Stroke Collaborative Model Care Coordination Focus Local Health Coaches to improve care coordination Improve patient engagement/education and self management skills. Trained Health Coaches to provide and bill for Chronic Care Management (CCM) CCM Intake includes screening for social determinants Partnered with Cerner s HealtheCare Module to prioritize clients and document Using ehealth Coach & Home Monitoring via Windsor Place for communities with limited personnel 4

5 Kansas Heart & Stroke Collaborative Model Population Health Focus Move to Clinical Care QAPI Goal to Reduce incidence and mortality of MI and Stroke Developed Clinic Registries and Performance Dashboards Focus on Post MI/Stroke, hypertension, hyperlipidemia and tobacco cessation Community education and stakeholder engagement BP Measurement Technique; Tobacco Use Screening Ask & Act Program Outcomes with KHSC Model Now common practice participating sites have EB guidelines in use and tracking data More common for MI patients to be transferred out from CAH within 30 minutes to Heart Cath lab 30%+ reduction in rates of MI in NW Kansas >18% of eligible stroke patients receiving thrombolytics Reduction in total cost of care for MI and Stroke Expanded model into Sepsis, Heart Failure, Palliative Care, and Trauma 5

6 Kansas Heart & Stroke Collaborative Model New Model to Advance Standards of Care This model demonstrates ability to move EB Guidelines into current practice quicker than past trends EB Guideline protocols/order sets adoption with local realities Local education for staff, EMS and LTC around protocols Data collection and assistance with performance improvement Now a recognized Patient Safety Organization Care Collaborative PSO which addressed challenges to address QAPI gaps between providers and facilities Requirements of LTCF s Where Does the Sepsis Program Align? Infection Prevention and Control Program Antibiotic Stewardship Infection Preventionist QAPI Program Performance Improvement Project (PIP) Opportunities with KUHS Care Collaborative on a Sepsis PIP Education at your facility Tools Data Collection CONTACT Nicole Palmer at npalmer@kumc.edu 6

7 UNDERSTANDING AND RECOGNIZING SEPSIS FOR NURSING HOME/LTC FACILITIES Value of Sepsis Recognition and Action Protocols for LTCF with New ROP s Kansas Delivery System Reform Incentive Payment (DSRIP) at The University of Kansas Health System in cooperation with the Kansas Clinical Improvement Collaborative, and the Kansas Sepsis Project 13 What is Sepsis? Infection is the invasion of the body by disease causing agents (generally bacteria, viruses, parasites, or fungi) Sepsis is a complication of infection It is an overwhelming and life threatening response to an infection which can lead to tissue damage, organ failure, and death. 14 7

8 LCTF Infection Risk Aging Population Est. >20% population >65 by 2030 Characteristics of LTCF population Increasing complexity of care Variety of comorbid conditions and who have functional limitations in mobility and dependence in activities of daily living Residence in group quarters Increased incidence of MDRO Adverse Events from Tx for infections Critical Facts on Sepsis Sepsis is the leading cause of death in U.S. hospitals mortality increases 7.6% every hour that treatment is delayed 62% of people hospitalized with sepsis are re hospitalized within 30 days As many as 92% of sepsis cases originate in the community More than 1.6 million people in the U.S. are diagnosed with sepsis each year one every 20 seconds Sepsis survivors have a shortened life expectancy, are more likely to suffer from impaired quality of life 16 8

9 Types of Sepsis Sepsis causes fever, rapid heart rate/breathing, and an increased white blood cell count. Severe Sepsis is when there are also signs and symptoms which indicate an organ may be failing Septic Shock is the presence of severe sepsis, plus extremely low blood pressure that doesn t respond to fluid replacement 17 Detecting Sepsis Early Systematic Inflammatory Response Syndrome (SIRS) The Systematic Inflammatory Response Syndrome (SIRS) are not specific to sepsis, but offer objective indicators that sepsis may be developing. SIRS is not always related to infection and not always present with infection SIRS Criteria include: 1. Body temperature less than 36C (96.8F) or greater than 38C (100.4F) or greater than 2 above baseline 2. Heart rate greater than 90 beats per minute 3. Tachypnea (high respiratory rate), with greater than 20 breaths per minute 4. White blood cell count less than 4000 cells/mm³ or greater than 12,000 cells/mm³; or the presence of greater than 10% immature neutrophils (band forms). 18 9

10 The Front Line of Sepsis NURSING AIDES Nursing aides represent the sepsis watch team Watch for the initial signs and symptoms of sepsis (i.e. change in vital signs) Look for 2 or more SIRS Criteria Notify nursing staff when SIRS suspected NURSES Nurses represent the sepsis warning team Look for the possible source of infection Notify the provider of possible sepsis Contact EMS to transfer to hospital, if necessary for Severe Sepsis and Septic Shock 19 Sepsis Watch Team: SIRS Criteria If two or more SIRS Criteria present, notify nurse 1. Temperature > or < Heart rate > 90 beats per minute 3. Respirations > 20/min 4. White blood cell count > 12,000 or < 4000 or 10% Bands on differential

11 Sepsis Warning Team: Signs and Symptoms of Sepsis If previous criteria met + any ONE of the following = Sepsis Notify provider immediately and implement Sepsis Response Protocol (or transfer Productive to hospital Cough depending on protocol) Fever, chills, rigors Diarrhea Non prophylactic AB Treatment Recent hospitalization Open wound Recent flu/viral illness Recent Surgery/Invasive Procedure Indwelling Device Other Immunosuppression 21 Signs and Symptoms of SEVERE SEPSIS If sepsis criteria met + any ONE of the following signs that Organ Dysfunction is present: Decreased Perfusion (capillary refill greater than 3 seconds, mottled skin, cold extremities) Acute Mental Status Changes SBP < or equal to 90mmHg or dropped 40mmHg from baseline O2 Sat less than 90% Even in the absence of SIRS, organ dysfunction indicates severe sepsis if likely source of infection is present. TRANSFER TO HOSPITAL or IMPLEMENT SEVERE SEPSIS PROTOCOL IMMEDIATELY 22 11

12 Signs and Symptoms of SEPTIC SHOCK If severe sepsis criteria met + any ONE of the following: SBP < or equal to 90mmHg or dropped 40mmHg from baseline O2 Sat less than 90% Septic Shock defined as SBP less than 90, MAP < 65, or SBP decrease of greater than 40 from patient baseline, despite adequate fluid challenge (30ml/kg of crystalloid). Vasopressor support will be required so if SNF able to implement IVF s, must be at 30cc/kg over 1 hour (minimum of 2 IV sites) and vasopressors administered centrally, not via peripheral IV 23 SIRS Suspected Source of Infection SEPSIS SIRS or SEPSIS= Notify Nurse & notify provider SEPSIS Acute Organ Dysfunction Severe Sepsis SEVERE SEPSIS = Notify provider and set up transfer to hospital Severe Sepsis Tissue Hypoperfusion Septic Shock SEPTIC SHOCK = Transfer to Hospital 24 12

13 If Sepsis is Suspected 1. Notify unit nurse who should confirm SIRS + likely source of infection and implement facility sepsis protocol 2. Prepare to transfer to appropriate facility depending on local realities 3. Notify receiving facility the patient likely has sepsis so they can activate their sepsis response team 4. Early Sepsis If possible, obtain labs at facility (consistent with antibiotic stewardship policies) and report to provider within 1 hr 5. DO NOT delay transfer waiting to obtain lab or lab results, especially if signs of organ dysfunction are present (confusion, poor output, low oxygen sats) 25 Septic Shock: Timing of Antibiotics Fraction 1.00 % Survival % Total receiving antibiotics 14 ICUs; n = 2, Only.60 50% of patients in Septic Shock received antibiotics w/in 6 hrs Time, hrs Kumar Crit Care Med

14 When to Transfer Immediate transfer to hospital is advisable UNLESS facility has the following: 1. Physician or Advanced Practice Nurse in house 2. Nurses trained in acute care 3. Ability to draw blood (lactate, blood cultures, Urine Analysis, CBC) 4. Access to relevant laboratory results within 3 hours 5. Immediate availability of broad spectrum IV antibiotics 6. Staff proficient in and equipment administration of IV fluid boluses 27 LTCF Considerations in Decision to Transfer 1. Preferences of resident and family 2. Overall condition of resident 3. Life expectancy 4. Awareness of determining patient DNR status and preferences for level of intervention 5. Transfer to a hospital 28 14

15 Additional Considerations Palliative treatment is always required if resident is not transferred for acute treatment Timing is imperative Sepsis is a medical emergency that requires urgent attention and mortality increases 7.6% every hour that treatment is delayed 29 Impairments After Sepsis Many people who survive sepsis recover completely and their lives return to normal. However, older people, people who have suffered more severe sepsis, and those treated in an intensive care unit are at greatest risk of longterm problems, including suffering from post sepsis syndrome

16 Impairments After Sepsis COGNITIVE Persons 65 and older who survive severe sepsis are at triple the odds of experiencing moderate to severe cognitive impairment FUNCTIONAL Severe sepsis may be associated with 1.5 new functional limitations in persons with no, mild, or moderate pre existing functional limitations Once people have sepsis they are more likely to develop it with subsequent infections. 31 Symptoms of Post sepsis Patients will need time to heal their body and mind in order to get better. They may experience the following physical symptoms: General to extreme weakness fatigue Breathlessness General body pains or aches (difficulty moving around) Difficulty sleeping Weight loss, lack of appetite, food not tasting normal Dry, itchy skin that may peel (brittle nails) and hair loss 32 16

17 LTC/NF Sepsis PIP as part of your QAPI Program AIM Statement We will reduce the percentage of residents transferred to hospital with Septic Shock. Identify Baseline Number of residents transferred to hospital with Dx of Sepsis in a defined timeframe divided into that group with Dx of Septic Shock in same timeframe x 100 Examine Process and Engage Staff (Adopt Sepsis Protocols from Stop Sepsis Campaign) Process for early sepsis identification and intervention Tools to assist recognition, documentation, communication and data collection Examples of measurement (data) include a process measure like compliance rates for use of the Early Warning Tool or SBAR/CUS tools Education of Staff, Residents, and Family/caregivers Monitor and Sustain Collect your data and compare outcomes to your goal targets and view your trend graphs Analyze for performance improvement opportunities 34 17

18 Steps to Reach Sepsis QA Goals 1. Education of staff on Sepsis looking at patient, risk factors, and vitals as a whole. Important especially for CNA s and others who do vitals 2. Apply criteria and protocols Consider tools/apps to help guide Redivus App Pilot available through KUHS 3. Early activation of response key on need for early decision regarding consultations, evaluation, initial treatment and/or transfers depending on local realities 4. Goal directed therapy through use of the order sets 5. Data collection for performance improvement opportunities 35 Infection Control ( ) Key Requirements Infection Prevention and Control Program The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum the following elements: A system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases For all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement Based upon the facility wide assessment and the following national standards; 18

19 Infection Control ( ) Key Requirements Infection Prevention and Control Program Written standards, policies, and procedures for the program, which must include, but are not limited to: A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; When and to whom possible incidents of communicable disease or infections should be reported; Infection Control Key Requirements Standard and transmission based precautions to be followed to prevent spread of infections; When and how isolation should be used for a resident The type and duration of the isolation A requirement isolation should be the least restrictive possible for the resident under the circumstances. The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and The hand hygiene procedures to be followed by staff involved in direct resident contact. 19

20 Infection Control Key Requirements An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. A system for recording incidents identified under the facility s IPCP and the corrective actions taken by the facility. Infection Preventionist The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who is responsible for the facility s IPCP. Antibiotic Stewardship Programs and activities that promote the appropriate selection and use of antibiotics. Activities include limiting the use of antibiotics when they are not needed, and minimizing the frequency, duration, and number of antibiotics prescribed. Stewardship can improve the outcomes for residents who need antibiotics and prevent the unintended consequences of antibiotic use such as side effects, the development of antibiotic resistant bacteria, and the replacement of normal bacteria with those which cause infections, such as C. difficile. Many residents with C. difficile infection (CDI) have had exposure to antibiotics within 28 days prior to the onset of symptoms. CDI risk increases with taking multiple antibiotics or taking long courses of an antibiotic. Antibiotic stewardship can be an effective prevention strategy for the reduction of CDI. 20

21 Infection Control Key Requirements The IP must Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; Is qualified by education, training, experience or certification; Works at least part time at the facility; Has completed specialized training in infection prevention and control. IP must be a member of the facility s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis. Resources: Medline University online courses: Infection Prevention in Long Term Care Settings (1 Contact Hour) QIS: Infection Prevention and Control (for Administrators) (1.25 Contact Hours) Infection Control Key Requirements Linens Personnel must handle, store, process, and transport linens so as to prevent the spread infection; Annual review The facility will conduct an annual review of its IPCP and update their program, as necessary. 21

22 Infection Control Key Requirements The facility must develop influenza and pneumococcal immunization policies and procedures. Influenza Before offering the influenza immunization, each resident or the resident s representative receives education regarding the benefits and potential side effects of the immunization Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period The resident or the resident s representative has the opportunity to refuse immunization; and The resident s medical record includes documentation indicating the following; That the resident or resident s representative was provided education regarding the benefits and potential side effects of influenza immunization That the resident either received the influenza immunization or did not receive it due to medical contraindications or refusal Infection Control Key Requirements The facility must develop influenza and pneumococcal immunization policies and procedures. Pneumococcal Disease Before offering the pneumococcal immunization, each resident or the resident s representative receives education regarding the benefits and potential side effects of the immunization Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized The resident or representative has the opportunity to refuse, and The resident s medical record includes documentation indicating the following; The resident or the resident s representative has the opportunity to refuse immunization; and The resident s medical record includes documentation indicating the following; That the resident or resident s representative was provided education regarding the benefits and potential side effects of influenza immunization That the resident either received the pneumococcal immunization or did not receive it due to medical contraindications or refusal 22

23 Infection Control Key Requirements Implementation Deadlines Infection Control Phase 1: November 28, 2016 Phase 2: November 28, 2017 The links to the Facility Assessment and the Antibiotic Stewardship Phase 3: November 28, 2019 Infection Preventionist (IP) and the IP participation on QAA Committee Infection Control and Antibiotic Stewardship Resources clinicians choose the rightantibiotic/toolkit1 working with a lab.html elements antibiotic stewardship.pdf elements antibiotic stewardshipappendix a.pdf elements antibiotic stewardshipappendix b.pdf termcare/resources/facilities/ptsafety/index.html SHEA Surveillance Definitions of Infections in Long Term Care Facilities: Revisiting the McGeer Criteria Oct

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