COMPREHENSIVE EARLY GOAL DIRECTED THERAPY IN SEPSIS ROCHESTER GENERAL. Sepsis Treatment Order Sets Sepsis Treatment Order Sets

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1 Publication Year: 2013 COMPREHENSIVE EARLY GOAL DIRECTED THERAPY IN SEPSIS ROCHESTER GENERAL Summary: An organized accepted approach to sepsis recognition, early management in the ED including specific antibiotic choice, EMR integration, rapid transfer to the ICU. Hospital: Location: Rochester General Rochester, New York Contact: Bryan Gargano, MD, FACEP, Medical Director Category: A: Arrival B: Bed Placement C: Clinician Initial Evaluation & Throughput D: Disposition E: Exit from the ED Key Words: Care Transitions Communication Consults Continuity of Care Information Systems Sepsis Hospital Metrics: Annual ED Volume: 119,837 Hospital Beds: 528 Ownership: Not-For-Profit Trauma Level: None Teaching Status: Yes Tools Provided: Sepsis Treatment Order Sets Sepsis Treatment Order Sets Clinical Areas Affected: Ancillary Departments Emergency Department Inpatient Units ICU Pharmacy Staff Involved: Consult Services ED Staff IT Staff Nurses Pharmacists Physicians Copyright Urgent Matters 1

2 Innovation Comprehensive sepsis care management: An organized accepted approach to sepsis recognition, early management in the ED including specific antibiotic choice, EMR integration, rapid transfer to the ICU, and analysis of these metrics with ED Physician compensation adjusted depending on their adherence to these expectations. Varied practice patterns resulted in increasing sepsis mortality and increasing challenges of bringing critical patients to the ICU. The result was increased ED care of critically ill patients that then prevented ED resources to be directed to the incoming patients. In 2011, ED occupancy exceeded capacity on 250 days and over 113,000 patients were seen. This was an increase of approximately 26% over ED patients seen in This contributed to delays in transfer of critically ill patients to the various ICUs and increased ED boarding. The ED and MICU nurses and physicians recognized they were integral to the transfer process and took ownership. Through transformational leadership and strong bedside nursing care the teams from both departments demanded better quality outcomes. These sickest of patients are dependent on the skills and knowledge of both the ED and MICU nurses working in collaboration. The optimal and timely transfer of the patient is paramount to a successful patient outcome. Innovation Implementation Initially education through CME for physician and midlevel providers regarding early goal directed therapy in sepsis was performed. This was then integrated into Morbidity and Mortality meetings. Next, came nursing education and then patient care technician education through critical care classes. The team needed to overcome fears regarding both increased IV fluid resuscitation, dispelling the myth that all the patients would develop pulmonary edema. It was also important for the team to accept that multiple rapidly delivered antibiotics are in our septic patients best interests and will not cause C. Difficile colitis after one dose. Intensivitsts, Infectious disease specialists, surgeons, Medical hospitalists, and ED providers had to review and agree on what antibiotics are appropriate for each general indication. This included what the recommended agents given our institutions resistance patterns and in compliance with CMS Pneumonia regulations. This group also had to make recommendations for antibiotic choices for each indication if the patient is penicillin allergic. Subsequently, these antibiotic bundles by indication had to be built into the EMR and stocked in the ED in a manner that nursing may give the first antibiotic as a bolus. Subsequently the antibiotics were then bundled so it was not possible for the provider to order only 1 of the potentially 2 or 3 antibiotics recommended within the indication (see Sepsis Treatment Order Sets). Sepsis evaluation order sets had to be constructed and implemented into the EMR. The nursing documentation of a sepsis screen had to be constructed. Given that nursing missed completing this when they were performing bedside nurses it was then moved to part of the triage navigator and compliance increased. Given this increased triage work load a benefit for nursing was needed. The sepsis screen was updated to populate a warning flag on the general patient list to alert any and all ED staff that an individually triaged patient may be septic and require immediate attention. This was then also used to create an EMR alert to the provider who opens this record that this patient may be septic, prompting a response - that includes a single click that will open the sepsis treatment order set to rapidly ensure compliance with evaluation goals. Patient flow was another huge part of this initiative. The ICU teams accepted the goal of any admitted patient from the ED arriving to the ICU within 60 minutes of admission. ICU nursing changed their staffing patterns to ensure an available nurse to retrieve patients and coordinate their care. The Attendings covering the ICU acknowledged that in a frankly septic patient waiting for all the labs to result delayed care. It was agreed that a patient could be admitted to the ICU once imaging is completed, labs sent, airway secured as needed, and appropriate vascular access obtained. The Intensivists and Medical Hospitalists changed their staffing to ensure they could rapidly accept these patients when called, communicate the need for the patient to arrive to ICU nursing, and accept that they will have the ongoing burden in initial evaluation and resuscitation. Perhaps most importantly, the Medical Hospitalists ensured they would be able to accept a patient out of the ICU in an ongoing "bed ahead" process to ensure ICU bed availability. Practices and reports were put in place to ensure that times in ICU transfer as well as compliance with accepted sepsis treatment and evaluation practices were measured. These reports initially required significant manual extraction but with EMR optimization and report service assistance is currently more automated. Copyright Urgent Matters 2

3 Early data was frequently used to help trouble shoot and optimize individual aspects of care. Currently data is predominantly used for recognition and motivation. Data is reported at daily huddles, posted in the Department, and discussed at monthly team meetings. ED Physician contracts were amended such that quarterly productivity incentive bonuses were decreased directly based on their compliance with sepsis guidelines to ensure both quantity (RVU Productivity) and quality of care. The mantra of pay for performance is alive and well in modern healthcare and currently the hospital included compliance with accepted sepsis evaluation and management as part of a third party payor agreement encouraging administrative support of a widely clinical initiative. Initially nursing used data to counsel and coach individual low performing nurses. However, as the system was optimized to support nursing needs outliers became more random and sporadic. The need to celebrate high achievers became paramount and individual caricatures of team members who perform outstandingly at certain aspects of sepsis care now adorn cartoon super hero bodies at team meetings and poster celebrations. Timeline Three years from planning, through initial evaluation, and into initiation has been a full year of management, data analysis, and roll out to our Newark Wayne Community Hospital data at Newark Wayne was tracked but starting in 2013 the data was increasingly brought to the staff and improvement projects for the ED providers initiated. There continues to be adjustments and improvements. In March 2013 the nursing sepsis screen was moved to the triage nursing screen with results populating visible flags on the track board to ensure ED team members recognize a septic patient in a timely manner. At that time a prompt for the ED Nurse to document critical care time was also implemented. In May of 2014 a public recognition of our superheroes from each team was began involving the team members face being superimposed on comic book heroes and posted at team meetings and other public sites for recognition. As of July 2013 there is active review of the sepsis order sets as the resistance to Aztreonam has risen and there will likely be antibiotic updates in August of Results Using the new processes we have maintained the average length of time from ED Admit to ICU transfer at less than 60 minutes since initiation. Dramatically increased compliance with early goal directed therapy measures for provider ordering practices, nursing practices, and patient flow. Please see the attached data graphs for this information. There was also a noticeable reduction in overall hospital mortality rate of about 30% in 2012 that was attributed to these initiatives. Hundreds of hours of physician, nursing, and administrative time was spent in meetings, collaborative discussion, rounding, leading huddles, EMR updates, and of course data collection and distribution. There was no single purchase or expenditure and hours of labor cost on multi-year projects are challenge to calculate. Estimates would be around $300,000. The return on investment in freeing up ED bed capacity alone as well as increased ED capacity allowing volume growth has been over $1 million. Advice and Lessons Learned Change must be objectively measured with open feedback, reward, and punishment as necessary in a continuous and ongoing fashion. Your electronic medical record can be a benefit to your change if you build intuitive system improvements for your team. All team members must be aligned with the goal, celebrated for their individual and group success, and unified by a single sense of purpose for there to be lasting success. Sustainability A significant ongoing contribution of clinical and administrative staff time was required to start up the innovation. Initially it required physician champions in each ICU and the ED to lead the provider teams and align the work. Then Copyright Urgent Matters 3

4 individual meetings for each Department involved had to agree to participate and subsequently engage their teams. EMR improvements needed to be planned, written, tested, and implemented. Standing reports had to be written, validated, and optimized to ensure ongoing data collection. Physician contracts had to be negotiated to include sepsis care in the incentive package and a mechanism set in place to ensure it impacts their quarterly incentive payments. At this time to sustain the new processes there is currently one midlevel that performs routine data extraction and analysis. This work is optimized by specially written reports from the EMR. One physician oversees and collates data and interfaces with administration to adjust physician incentive compensation. One clinical nurse leader and several nurses maintain ongoing feedback to nursing staff and help organize recognition. The project is discussed routinely at standing ICU and Patient Flow meetings but is not a large part of the agenda. The team included: Keith Grams, ED Chief, Bryan Gargano, ED Medical Director, Shari McDonald, ED Nursing Director, Diana Blauw, MICU Nurse Manager, Dan Demilio, ED QA PA, Data Analysis, Mary Mahler, ED Nursing, Todd Sheppard, ICU Director, Anil Job, Hospitalist Jonathan Scott, SICU PA, Debbie Lester, ICU Nursing, Robin Covey, ED Pharmacist, Alexandra Yamshchikov, ID Specialist, Wende Tefel, Nursing Education and many others including those who participated in the ED/MICU Process Flow team, ICU Meetings, Hospital Flow, and many other meetings. Tools to Download Sepsis Treatment Order Sets Related Resources Sepsis NW Thru June 2013 Sepsis RGH Thru June 2013 MICU Outcome Graphs MICU Transfer Time Chart Copyright Urgent Matters 4

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