The Kaiser Sunnyside Sepsis Story Care Improvement from EGDT through ProCESS and Beyond. Why the focus on Sepsis?

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1 The Kaiser Sunnyside Sepsis Story Care Improvement from EGDT through ProCESS and Beyond Lauren Bridge, RN, MN NEA-BC Why the focus on Sepsis? Mortality, Intensity of Resources, Risk of Readmission Compared to Acute Myocardial Infarction Nearly five times as many admissions More than ten times as many hospital deaths: 35-50% 30-50% of Septic patients require Critical Care while in the hospital Sepsis leads to high rates of acute-care readmission, as well as increased need for facility-based care after the hospitalization. 2 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. Kaiser Northwest Sepsis Care Improvement KP Northern California effort to reduce hospital mortality Initiation of Early Goal Directed Therapy as Standard of Care Stratifying Risk and Expansion of a Reliable Care Model Adaptation to a Continually Developing Evidence Base Innovations and Recommendations 3 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. 1

2 KP Northern California Initiative Was an ED-presentation-focused effort beginning in 2008 Established EGDT, per the Rivers Protocol, as standard of care Partnership between ED s and ICU s, Clinicians and Operations Multidisciplinary workgroups in each hospital developed workflows Key processes: Find and Name It: Expectation to draw and test lactate levels along with each and every blood culture drawn on ED patients Stratify Risk: Identification of top severity factors Lactate and BUN levels Treat aggressively at every level of risk 4 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. Risk Stratification for Severe and Moderate Sepsis Study of 20,000-patient database by Dr. Gabriel Escobar, Dept. of Research, KP Northern California Using statistical software, established a correlation between Lactate and BUN levels together to predict in-hospital mortality risk in the pre-egdt population 5 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. Commitment to Learning Knowledge Standardization Consistency 6 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. 2

3 Creation of Reliable Process and Consistency of Approach Kaiser Sunnyside partnered with Northern California s efforts to adopt EGDT for all severely ill, ED-presenting patients Collaboration between ED, ICU, and Laboratory operations and clinicians Education of ED physicians, ED and Critical Care Nurses Focus on Standardized care for patients with Intermediate Lactate ( ) on presentation began in MSPCU (step-down unit) became Center of Excellence Education module for PCU RN s; Socialization of Hospitalists to admit there Established expectation of Antibiotics within 2 hours, Repeat Lactate in <8 hrs. Initiated RRT Rounding on Intermediate patients and an RRT protocol for workup on inpatients with concerning signs/symptoms 7 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. Innovation Beyond Early Goal Directed Therapy Why not do EGDT? From our doctors Lactate may not be due to sepsis Patients looked too good for CVC/EGDT From the literature Serial lactates may be substituted for ScvO2 Falling lactate predicts good outcome Highest adherence failure rate From our case reviews Many patients did fine w/o invasive EGDT! 8 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. If not EGDT, then what? In the Non-Invasive Pathway: ED retests lactate to determine consult and admission destination If MSPCU, Hospitalist does admission 9 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. 3

4 Non-Invasive Pathway Outcomes Key to consistent standards: Collaboration between ED and the Receiving Units, and a Triumvirate of Champions: ED Physician, Intensivist, and Hospitalist Protocol Results In 3 years: 21 patients developed hypotension in ED and admission was changed to ICU; only 10 pts dropped BP later and then transferred up to ICU Cost savings included ICU per-day charges, CVC kits and clinician time, additional transfer at end of ICU stay 10 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. Mortality and Admission Rates - Kaiser Sunnyside Hospital 11 January 7, 2016 Next Steps Refining Risk Assessment Organ Failure Indications and Admission Decisions Another Next Step will be a protocol for management of patients with Sepsis presenting or worsening while in-house Organ failure indications are based on Surviving Sepsis Guidelines with modifications for info accessible in ED 12 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. 4

5 Kaiser Sunnyside Key System Innovations Non-Invasive Pathway RRT Rounding RN Staff Development Based on clinician experience plus evidence base Continually refined for indications of right candidates Utilizes MSPCU and Hospitalist expertise with Intermediate population to avoid ICU stays 13 January 7, Kaiser Foundation Health Plan, Inc. For internal use only. Expanded focus of care initiative to non- ICU population Valuable source of mentoring expertise for front-line RN s Serves as safety net for patients in non-critical care settings Situational awareness tool Specialized MSPCU training was expanded into a monthly class for RN s new to KP at all care levels Promotes greater collaboration between RN s during handovers and transfers of care level Thank you! Lauren Bridge, RN, MN NEA-BC Nurse Executive Lauren.M.Bridge@kp.org (503) January 7, Kaiser Foundation Health Plan, Inc. For internal use only. 5