Surviving Sepsis Legacy Meridian Park Medical Center Legacy Mount Hood Medical Center May 5, 2011 Maria Kulla RN, BSN, CCRN, ICU Nurse Sarah Barsotti RN, BSN, ICU Nurse
Project Teams Legacy Mount Hood (LMH) Le Rupp RN Maria Kulla RN Laura Vanderwerff M.D. Ross Bryan M.D. Marcia Soderling RN Molly Schmitz BS Aaron Kabb M.D. Madeline Carpenter PharmD Nancy Hara RN Legacy Meridian Park (LMP) Connie Kelty RN Sarah Barsotti RN Elizabeth Decker RN Kristin Hartley RN Chris Wenger RN Lesley Bobeck M.D Jordan Fein M.D Josh Leibovitz M.D. Sue Ellison RN Molly Schmitz BS Larry Cirotski PharmD Nancy Hara RN
Aims Decrease mortality and hospital length of stay of patients with sepsis by: Improved early recognition Consistent application of evidence based sepsis bundles at Legacy Meridian Park and Legacy Mount Hood.
Objectives More rapidly identify septic patients presenting to the Emergency Department. More rapidly identify patients developing sepsis in intensive and acute care units. Improve compliance with the 6 and 24 hour sepsis bundles across all patient care areas.
Measures Outcome Measures Mortality rate of patients with sepsis LMH Target is 16% reduction LMP Target is 5% (target) - 10% (stretch) reduction Length of stay for patients with sepsis LMH Target is 10% reduction LMP Target is 5% (target) - 10% (stretch) reduction
Measures Process Measures Compliance with 6-hr bundle (6 elements) LMH & LMP Target is 90% Compliance with 24-hr bundle (4 elements) LMH & LMP Target is 90%
Tests of Change Common Strategies for Both Sites Implemented sepsis screening tool Implemented Critical Care sepsis order set Implemented Emergency Department and Acute Care sepsis order set Added sepsis protocol to Rapid Response Team protocols
Tests of Change Legacy Mount Hood Created sepsis packet Place all sepsis tools in yellow colored folders to act as a visual prompt Promoted sepsis as a time sensitive illness through Group and 1:1 education, case studies, poster, and video presentations, badge cards Placed appropriate antibiotics in Pyxis on acute care units Implemented SBARQ script and printed it on back of sepsis screening tool Placed sepsis tools at triage for ease of accessibility and to promote use
Tests of Change Legacy Meridian Park Completed nursing education (100%) on sepsis screening tool and 6hr & 24hr bundles Skills day presentation Newsletter to identify nursing specific practice related to sepsis followed by case study with post-test 1:1 presentation with every critical care nurse Provided physician education on pre-printed orders/process Physician meetings and Electronic newsletter Place sepsis tools at triage for ease of accessibility and to promote use Implemented SBARQ script and printed it on back of sepsis screening tool Implemented screening tool for steroids and Xigris Concurrently audit to identify opportunities and success Feedback to those doing well and those with opportunity for improvement
Results Legacy Mount Hood Outcomes Data Mortality Rate in Sepsis Patients Length of Stay Avg. w/sepsis Patients Baseline: March 2010 17.45 Current: March 2011 16.01 Analysis: 8% Reduction Baseline: March 2010 8.6 Days Current: March 2011 6.1 Days Analysis: 29% Reduction
Results Legacy Mount Hood Bundle Compliance LMH Sepsis 6hr Bundle Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Serum Lactate Blood Cultures ABX w/in 1 hr. MAP > 65mm Hg CVP SCVo2/SVo2 at Goal CVC/PICC Placement Indicator Jan Feb Mar 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% LMH Sepsis 24hr Bundle Compliance Steriod Use Eval for Xigris Glucose Control IPP Management Indicator Jan Feb Mar
Results Legacy Meridian Park Outcomes Data Mortality Rate in Sepsis Patients Length of Stay Avg. w/sepsis Patients Baseline: March 2010 22.90 Current: March. 2011 19.20 Analysis:16%Reduction Baseline: March. 2010 7.7 days Current: March 2011 6.9 days Analysis: 12% Reduction
Results Legacy Meridian Park Bundle Compliance LMP Sepsis 6hr Bundle Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Serum Lactate Blood Cultures Abx w/in 1 hr. MAP > 65mm Hg CVP SCVo2/SVo2 at Goal CVC/PICC Placement Indicator Jan Feb March LMP Sepsis 24hr Bundle Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Steroid Use Eval for Xigris Glucose Control IPP Management Indicator Jan Feb March
Next Steps Legacy Mount Hood Further analysis of time study data to identify other causes of delay and improvement strategies in antibiotic administration Fine tune the sustainability plan for oversight, recognition, and monitoring bundle compliance (concurrent audits). Create sepsis newsletter that identifies evidenced best practices in care of septic patients
Next Steps Legacy Meridian Park Perform concurrent audits and give real time feedback ongoing Maintain monthly sepsis committee Develop surgeon engagement strategy Work diligently with physicians and pharmacy with screening tool for Xygris and steroids Investigate outcomes related to intensivist vs. hospitalist management of septic patients
Lessons Learned Must have physician buy-in of order sets and 6 and 24 hour bundles ED requires focused educational effort The majority of sepsis patients enter the hospital through the ED Nurses need support to approach physicians regarding the initiation of sepsis orders Chart abstraction for bundle compliance is resource intensive Medical/Surgical nurses need education and encouragement to call Rapid Response Team for septic patients An education plan that addresses initial education as well as on-going education is needed