Sepsis Reduction through Technology and Process Improvements

Sepsis Reduction through Technology and Process Improvements Session #36, March 6, 2018 Amanda Logue, MD, Chief Medical Informatics Office, LGH Taylor Hargrave, BSN, RN, CIC, Infection Prevention Supervisor, LGH 1

Conflict of Interest Amanda Logue MD Taylor Hargrave BSN, RN, CIC Has no real or apparent conflicts of interest to report. 2

Agenda Our system, population, and journey Review baseline sepsis statistics Project plan and governance Methods of Health IT utilized to address sepsis Value derived and future considerations 3

Learning Objectives Recognize the impact of integrated system monitoring and early interventions into the EHR on helping prevent patients from developing sepsis Identify key processes, workflows, and resources to be involved in revamping care processes for potentially septic patients Evaluate quality measures that are impacted by sepsis prevention measures 4

Our mission The mission of Lafayette General Health is to restore, maintain and improve health 5

Lafayette General Health Who we are 7 Inpatient facilities (incl. Academic) 43 Ambulatory sites: 18 specialties 1 Ambulatory surgery center 4,275 FTEs 59 Employed Physicians 1,700 Non-Employed Medical Staff Acute HIMSS Level 6 (LGMC & UHC) Our patients 29,000 Admissions 180,000 ED visits 23,000 Surgical cases 335,000 Outpatient visits Top Service lines: Cardiology Neurology Orthopedics Fiscal Year 2017 (Oct 2016 Sept 2017) 6

LGH Patient Population Percent of population 40 35 30 25 20 15 10 5 Percent of adults aged 18 years and older who have obesity 0 2011 2012 2013 2014 2015 Year Louisiana National Linear (Louisiana) Obese is defined as body mass index (BMI) 30.0; BMI was calculated from self-reported weight and height (weight [kg]/ height [m²). Respondents reporting weight < 50 pounds or 650 pounds; height < 3 feet or 8 feet; or BMI: <12 or 100 were excluded. Pregnant respondents were also excluded. Centers for Disease Control and Prevention. (2017). Nutrition, Physical Activity, and Obesity: Data, Trends and Maps. Retrieved from https://www.cdc.gov/nccdphp/dnpao/data-trends-maps/index.html 7

LGH Patient Population 12 Lafayette Metro vs. U.S. National Average Unemployment Rate Percent Unemployment 10 8 6 4 2 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Lafayette Metro National Linear (Lafayette Metro) U.S. Department of Labor, Bureau of Labor Statistics. (2017). Retrieved from https://www.bls.gov/data/#unemployment 8

Information Systems Journey 2003 2012 2014 2016 CPOE, Documentation, ED, Pharmacy, Revenue Cycle System re-install, Surgery, Cerner Patient Accounting, Quality Alignment Remote Hosting Women s Health, Care Management, Registries, CommonWell, EPCS, HealthyLink clinics Hospitals acquired: Radiology, PACS, Laboratory Ambulatory ASP, Oncology Integrated Ambulatory, Sepsis, PS-15 process, New CDI software EDW, HealthyLink Hospitals, Palm Scanning, Patient Observer 2006 2013 2015 2017 9

Sepsis 2017 Nicholas E. Davies Enterprise Award of Excellence

33.13% of overall mortality rates attributed to Sepsis Previous workflow: Reviewed current symptoms vs. early detection Identification only considered Temperature, HR, and Systolic BP (Rules of 100s) When patient's vital signs met criteria a sheet was automatically printed on the ICU printer The Rapid Response Team nurse went to patient's unit and spoke with the primary nurse, assisted with patient assessment if appropriate Problems: No specificity or exclusion critieria Duplicates were treated with less urgency No qualifiers for the patient s clinical status or illness Inefficient Only available at main campus 11

Sepsis Mortality Rate and Incident Count Diagnosis group LGMC Mortality 2.13% Overall Sepsis 16.54% Sepsis 7.28% Severe Sepsis 18.92% Septic Shock 33.33% % of mortality attributed to sepsis 33.13% Time period: Nov. 2014 Nov. 2015 Overall Sepsis includes Sepsis, Severe Sepsis, and Septic Shock cases Data Source: LGMC Cerner EHR database 12 Mortality Rate Monthly Average

Sepsis Length of Stay Diagnosis Hospital Wide 4.5 Overall Sepsis 9.35 Sepsis 8.61 Severe Sepsis 7.25 Septic Shock 12.21 LOS: Days Monthly Average Time period: Nov. 2014 Nov. 2015 Data Source: LGMC Cerner EHR database 14

Sepsis Core Measure 1 LGMC prego live compliance 2.44% Time period: Oct. 2015 Feb. 2016 1 Measure Set: Sepsis Set Measure ID #: SEP-1 Performance Measure Name: Early Management Bundle, Severe Sepsis/Septic Shock Description: This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. As reflected in the data elements and their definitions, the first three interventions should occur within 3 hours of presentation of severe sepsis, while the remaining interventions are expected to occur within 6 hours of presentation of septic shock. Rationale: The evidence cited for all components of this measure is directly related to decreases in organ failure, overall reductions in hospital mortality, length of stay, and costs of care. The Joint Commission. (2016) Specifications Manual for National Hospital Inpatient Quality Measures v.5.2a (applicable 1/1/2017-12/31/2017). https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx Data Source: LGMC Cerner equalitycheck 15

LGMC baseline cost per case by DRG DRG Cost per DRG 8723 Sick $7,434.45 8712 Sicker $11,902.18 8701 Sickest $27,669.24 Time period: Mar. 2015 Feb. 2016 1 SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS 2 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC 3 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W/O MCC Data Source: Premier Quality Advisor 16

Design Implementation Governance

Governance Governance: Executive Sponsor: CMIO Clinical Transformation Committee Medical Executive Committee Project team: Quality department IT analysts Nursing subject matter experts (ICU, Med-Surg, RRT, ED) Clinical pharmacists Cerner Quality Reporting Goals/Anticipated outcome: Increase early detection and prevention of Sepsis Decrease mortality associated with Sepsis 18

Design and Build Design & build Training plan Project Timeline: 14 months Algorithm monitoring and modification: Alert initially built in silent mode Project team audited and validated alert population and frequency Excluded: CV surgery for the initial 24 hours post-op Active laboring population for 24 hours Comfort measures only patients for duration of stay NICU, Nursery, Pediatrics 19 Support plan Adoption

Design and Build, cont. Design & build Training plan Decisions: Who to alert Frequency of alert Every patient will only alert once Q24 hours. Alerts are suppressed for extended time (72 hours) if a sepsis order set is active or if a sepsis diagnosis is in place When to call physician Additional FTE added to Rapid Response Team (LGMC) Repeat lactate orders: If any lactate result is > 2.0, then an automatic timed lactate is ordered for 5 hours after the original lab was ordered 20 Support plan Adoption

SIRS or Sepsis Alerts by Infectious Etiology May 2015 35 120% 30 30 28 26 90.4% 97.4% 99.1% 100.0% 100% Count of Alerts 25 20 15 10 26.1% 50.4% 73.0% 20 8 80% 60% 40% 5 2 1 20% 0 0% Count of Alerts Cumulative % 21

Count of Alerts 18 16 14 12 10 8 6 4 2 0 16 15 17.8% SIRS or Sepsis Alerts by Non-Infectious Etiology May 2015 10 8 7 54.4% 45.6% 34.4% 62.2% 68.9% 6 6 96.7% 97.8% 98.9%100.0% 92.2% 86.7% 81.1% 75.6% 5 5 5 4 1 1 1 120% 100% 80% 60% 40% 20% 0% Count of Alerts Cumulative % 22

Design & build Training plan Support plan Adoption 1 month prior to go-live: all nurses assigned module via LMS training on alert workflow Infection Prevention (IP) attended hospitalist meetings to explain the core measure Quick reference laminated pocket cards were provided to physicians Education provided to physician residents via LSU education platform IP attended Women's Services staff meetings to discuss core measures; information included in department newsletter See Sepsis Appendix for sample training materials 23

Infection Prevention quarterly review of all Sepsis patients Synopsis of all core measure passes and misses sent to those involved in care of patient at the time of event Thank you card sent to physicians responsible for passes Opportunity letter sent to physicians responsible for misses Synopsis of passes and misses sent to each leader monthly 24

How Health IT was Utilized

How Health IT was Utilized Cerner St. John Sepsis Agent: Gathers and combines patient information and vital signs from EHR Fires alert in EHR when signs for SIRS or organ dysfunction are detected Electronic alerts based on algorithm Orders/tasks to drive action Evidence-based electronic order sets Sepsis quality measure compliant Improve antibiotic use identification Core measure reporting 26

St. John Sepsis Agent Algorithm 27

Sepsis Inpatient Workflow Green 28 boxes = Health IT utilization

Sepsis Alert At least 2 SIRS criteria and 1 organ dysfunction criteria Alert for the patient who meets criteria for the Sepsis Security Rule should display as shown Date and Time appear prior to the clinical event in the alert Includes a link to the patient s chart in the message Screenshot from Cerner EHR 29

Alert order placed on patient s chart with nursing task 30 Screenshot from Cerner EHR

Decision Tree 31

Provider Notification Form If deemed clinically necessary, nurse will contact provider and document communication in EHR Screenshot from Cerner EHR 32

ED Workflow 33 Green boxes = Health IT utilization

ED Tracking Board icon Screenshot from Cerner EHR 34

Sepsis Order Sets Screenshot from Cerner EHR 35

Sepsis Quality Measures Order Triggers the sepsis core measure component on the summary level MPages Allows the clinician ability the track real time what care has been provided and what still needs to be provided in relation to the Sepsis core measure Screenshot from Cerner EHR 36

Sepsis Severity Identification Order Completed by physician to identify the type of sepsis being treated and suspected source of infection Drives electronic documentation for the Sepsis core measure and helps with the establishment of time zero Screenshot from Cerner EHR 37

Early Warning Alerts Flowsheet Screenshot from Cerner EHR 38

Value Derived

Decreased Sepsis Mortality Rate 35% 30% LGMC Mortality Rate Data 33.33% 28.77% 25% 20% 15% 10% 5% 2.13% 1.89% 16.54% 12.69% 7.28% 6.29% 18.92% 9.41% 0% Hospital Mortality Rate Overall Sepsis Mortality Rate Sepsis Mortality Rate Severe Sepsis Mortality Rate Septic Shock Mortality Rate Baseline (Nov. 2014 - Nov. 2015) Outcome (Mar. 2016 - Feb. 2017) Data Source: LGMC Cerner EHR database 40

Decreased Sepsis Mortality Rate Diagnosis Group Monthly Average (Nov. 2014 Nov. 2015) Monthly Average (Mar. 2016 Feb. 2017) Percent change in Mortality Rate Hospital Mortality 2.13% 1.89% -11.17% Overall Sepsis 16.54% 12.69% -23.26% Sepsis 7.28% 6.29% -13.66% Severe Sepsis 18.92% 9.41% -50.26% Septic Shock 33.33% 28.77% -13.68% % of mortality attributed to sepsis 33.13% 31.2% -5.83% Data Source: LGMC Cerner EHR database 41

Improved Sepsis Core Measure Compliance by 949.48% LGMC Sepsis Core Measure Compliance 30% 25% 20% 15% 10% 5% 0% 2.46% Pre-go live compliance (Oct. 2015 - Feb. 2016) 25.86% Post-go live compliance (March. 2016 - Feb. 2017) Data Source: LGMC Cerner equalitycheck 42

Increased Incident Count/Coding Change in Incident Coding by Diagnosis Group 60 50 50.08 40 38.08 30 23.6722.83 20 10 5.42 12.25 9.83 12.42 0 SIRS Sepsis Severe Sepsis Septic Shock Baseline Monthly Average (Nov. 2014 - Nov. 2015) Outcome Monthly Average (Mar. 2016 - Feb. 2017) Data Source: LGMC Cerner EHR database 43

Decreased Cost Per Case How decreased cost: Diagnosing sooner impacts progression of disease Coded more patients with sepsis diagnosis codes Decreased mortality and improved outcomes Improved efficiencies to care for patient lowered cost to provider, patient, and payer DRG Cost per DRG Baseline (Mar. 2015 Feb. 2016) Cost per DRG Outcome (Mar. 2016- Feb. 2017) 44 Number of Cases (Mar. 2016 Feb. 2017) Cost Savings (Mar. 2016 Feb. 2017) 870 Sickest $27,669.24 $27,633.68 29 $1,031.24 871 Sicker $11,902.18 $11,413.57 424 $207,170.64 872 Sick $7,434.45 $6,618.30 116 $135,480.90 Total cost savings $343,682.78 Data Source: Premier Quality Advisor

39.84 Lives Impacted/Saved Overall Sepsis Lives Impacted/Saved Analysis Month Sepsis Mortality Total Sepsis Sepsis Mortality Count Encounters Rate Baseline 12.54 75.15 16.54% -- Mar-16 8 74 10.81% 4.24 Apr-16 9 96 9.38% 6.87 May-16 12 77 15.58% 0.74 Jun-16 8 84 9.52% 5.90 Jul-16 13 85 15.29% 1.06 Aug-16 11 74 14.86% 1.24 Sep-16 9 87 10.34% 5.39 Oct-16 10 75 13.33% 2.41 Nov-16 14 97 14.43% 2.04 Dec-16 7 85 8.24% 7.06 Jan-17 13 96 13.54% 2.88 Feb-17 17 100 17.00% 0.00 TOTAL 39.84 Monthly Average 45 Lives Impacted/Saved* 3.32 *Lives impacted/saved calculated by multiplying the change in mortality rate from baseline and the number of sepsis encounters per month

Future considerations ED physician note often started without a sepsis diagnosis Create standard nursing documentation that would assist in supporting time zero. Involve clinical pharmacy with real-time alerting to identify insufficient use of appropriate antibiotics. Identify opportunities to reduce duplicate alerts Higher utilization of problem list and order sets. Focus more effort on the SIRS alerts and appropriateness of those predicting sepsis. Consider soft alerts to physicians for SIRS to consider earlier and more aggressive care. 46

Questions Taylor Hargrave, tahargrave@lgh.org Amanda Logue, aclogue@lgh.org, @Logue4Logue Please complete online session evaluation 47

The VAP Bundle: A Story of Data Driven Process Improvement Session #36, March 6, 2018 Tawanna McInnis-Cole, System Director Infection Prevention, MS, BSN, RN, CIC Jocelyn Thomas, Regional Manager of Infection Prevention MPH, CIC, CSSGB 48

Conflict of Interest Tawanna McInnis-Cole MS, BSN, RN, CIC Jocelyn Thomas MPH, CIC, CSSGB Has no real or apparent conflicts of interest to report. 49

Agenda Overview of Memorial Hermann Health System The VAP Bundle and why it is Important Initial Paper and Electronic Implementations Impact of Implementations: Bundle Compliance and VAP Rates VAP Bundle Upgrade - using data to drive Health IT Results from a Decade of Bundle Use Lessons Learned 50

Learning Objectives Describe how Memorial Hermann increased the utilization of ventilator bundles to reduce the occurrence of VAP. Explain how governance can drive accountability and compliance to improve patient outcomes. Discuss how the utilization of data can drive the incidence of VAP downwards, towards a rate of zero. 51

Memorial Hermann Health System Woodlands Sugar Land TMC Katy Memorial City Southeast Total hospitals: 15 (11 acute, 2 rehab, 1 children s, 1 orthopedic) Inpatient admissions: 158,241 Annual emergency visits: 595,611 Annual deliveries: 25,146 Employees: 25,040 Beds (acute licensed): 4,016 Medical staff members: 5,708 Fellowship programs: 48 Greater Heights Northeast Cypress Pearland Children s Southwest TIRR 52 Katy Rehab MHOSH

Our Network of Care 292 Care Delivery Sites 53

Memorial Hermann Recent Accolades Quality A competitive advantage for Memorial Hermann 15 Top Health Systems; Top 5 Large Health Systems (2012 & 2013) John M. Eisenberg National Patient Safety & Quality Award (2012) National Quality Forum National Quality Healthcare Award (2009) TIRR Memorial Hermann No. 2 in rehabilitation hospitals Texas Hospital Association Bill Aston Quality Award (2011) America s #1 Quality Hospital for Overall Care (2011 & 2012) Healthcare s 100 Most Wired 12 th consecutive year America s 50 Best Hospitals (2010-2014) 54 The Joint Commission Top Performer (2012), Heart Attack, Heart Failure, Pneumonia, Surgical Care 2011 Texas Healthcare Foundation Quality Improvement Awards (9 Memorial Hermann Campuses) 2015 Houston Business Journal (HBJ) No. 3 Best Places to Work

Our Journey High Reliability Organization Commercial Aviation Nuclear Aircraft Carriers Air Traffic Control 55 5

High Reliability Certified Zero Award 1. Zero Events 2. 12 Consecutive Months 3. Certified Zero Category 56

High Reliability 2011-2017 Certified Zero Awards ICU Central Line Associated Bloodstream Infections (18) ICU Catheter Associated Urinary Tract Infections (16) Hospital-Wide Central Line Associated Bloodstream Infections (7) Hospital-Wide Catheter Associated Urinary Tract Infections (5) Ventilator Associated Pneumonias (23) Retained Foreign Bodies (46) 263 Iatrogenic Pneumothorax (24) Accidental Punctures and Lacerations (3) Pressure Ulcers Stages III & IV (37) Hospital Associated Injuries (7) Deep Vein Thrombosis and/or Pulmonary Embolism (2) Deaths Among Surgical Inpatients with Serious Treatable Complications (1) Birth Traumas (16) Obstetric Trauma in Natural Deliveries with Instrumentation (4) Serious Safety Events 1&2 (21) Serious Safety Events 1 & 2 for 1000 Days (2) All Serious Safety Events (1) Early Elective Deliveries (9) Manifestations of Poor Glycemic Control (21) 57 5

The VAP Bundle: A Story of Data Driven Process Improvement 20172017 Nicolas E. Davies Enterprise Award of Excellence Nicholas E. Davies Enterprise Award of Excellence 58

Bundles Why are they important? Evidence based, interdisciplinary plans for patient care Focus on 3-6 interventions that significantly improve patient outcomes for a specific population Foundation in research and peer reviewed literature Regulatory and in house surveillance Drive process improvement and standardization 59

VAP Why Does it Matter? Complications of Mechanical Ventilation: Ventilator Acquired Pneumonia (VAP) Ventilator Associated Events (VAE) Up to 20% of vented patients develop VAP 1 > 39% of pneumonia cases in acute care setting 1 Increase in ventilator days, length of stay and antibiotic use 1 Mortality may exceed 10% 1 1. Coffin, Susan E., et al. Strategies to Prevent Ventilator Associated Pneumonia in Acute Care Hospitals. Infection Control and Hospital 60 Epidemiology, vol. 29, no. S1, 2008, pp. S31 S40. JSTOR, JSTOR, www.jstor.org/stable/10.1086/591062.

VAP Financial Impact At least 20% may be preventable 2 52,543 cases per year 3 VAPs make up 31.6% of the cost of the top 5 HAIs 4 Estimated cost of $40,144 per case in 201 2. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003;54:258-266 3. R. Douglas Scott II. The DirecT MeDical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention March 2009 61 4. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health Care Associated InfectionsA Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039 2046. doi:10.1001/jamainternmed.2013.9763

VAP Bundle (Adults) Nursing Bundle Suction 4 Hrs. Oral Care 4 Hrs. MD Bundle Head of Bed 4 Hrs. SUD Prophylaxis 24 Hrs. VTE Prophylaxis (Mechanical 4 Hrs./ Pharmaceutical 24 Hrs.) Sedation Holiday 24 Hrs. 62

Houston.. We Have a Problem It was the year 2006. Data analysis showed the VAP rate was too high!!! VAP rates to become focus for CMS 63

System VAP Rate 64 VAP rate = count of VAPs per 1,000 vent days

What Did We Do? We implemented our VAP Bundle because: Infection Control leadership believed we could reduce the VAP rate IHI and evidence based literature Standardize and monitor care across the system Do No Harm 65

VAP Bundle Timeline Major Events May 2007 Implementation on Paper 2008-2009 Conversion to EHR Mar 2010 Electronic Abstraction 2013 CDC Changes VAP to VAE 2013 VAE Report Developed 2016 Start VAP Bundle Upgrade Continuous surveillance of 1. Clinical Outcomes 2. VAP Bundle Compliance Jan 2017 TheraDoc Infection Control July 2017 VAP Upgrade Implemented 66

May 2007 Implementation on Paper Data Analysis Paper forms Weekly manual audits Excel MIDAS database focus studies Reporting at System & Nursing Unit Level: -Bundle Compliance (documentation audits) -Clinical Outcomes (VAP Rate) 67

Data Analysis: VAP Rates 68

2008-2009 Conversion to EHR The Attack of the EHR Facilities converted to EHR Daily reports manually processed and emailed to nursing EHR Monthly Facility Compliance metrics published Monthly metrics reported to System Executives 69

Nursing Documentation in the EHR 70

VAP Bundle Automation in the EHR Provider Order for Mechanical Ventilation for ADULT Order for Single Component of VAP Bundle Checks for duplicate orders, alerts provider to cancel duplicate orders MD cancels or reorders mechanical ventilation MD cancels ventilation orders System VAP Rule #1 VAP Rule #2 VAP Rule #3 VAP Rule #4 VAP Rule #5 VAP Rule #6 Nursing Automatically orders VAP Bundle, Sedation Holiday & Patient Education Sends tasks to Nursing Nurse documents in PowerChart Cancels orders and tasks to nursing Respiratory Therapy Orders SBT, Suction, Sends tasks to RT RT documents in PowerChart 71 Notifies RT if vent orders entered in order status Sends notifications to RT Cancels orders and tasks to RT

Mar 2010 Electronic Abstraction Begins VAP Monthly Report Financial Number Attending Type of Unit Facility Nursing Unit Midas ICU Code for CLIP & VAP 55555555 Dr House Adult MEMORIAL CITY - ACUTE MC - NEUROSCIENCE A (J4EC) 55555555 Dr Jekyl Adult HERMANN HOSPITAL - ACUTE HH - ICU MICU MEDICAL ICU (MICU) 55555555 Dr Who Adult HERMANN HOSPITAL - ACUTE HH - ICU CCU CARDIAC CARE UNIT MC - Neuroscience Unit HH - ICU MEDICAL ICU HH - CCU Audit Date HOB up 30 deg Oral hygiene q4 Hrs. Suction q4 Hrs. DVT Prophylaxis SUD Prophylaxis Sedation weaning trial q24 hours 3/1/2014 Yes Yes Yes Yes Yes Yes 3/2/2014 No No No No No No 3/1/2014 Yes Yes Yes No Yes N/A Bundle elements = Yes or No EXCEPT Sedation Holiday = Yes, No or N/A 72

2013 CDC Changes VAP to VAE In 2013, the CDC proposed a new algorithm for preventable events related to mechanical ventilation. VAP was replaced by four broader surveillance tiers: 1. Ventilator-Associated Conditions (VAC) 2. Infection-related ventilator-associated complications (IVAC) 3. Possible VAP 4. Probable VAP #3 and #4 later combined to become pvap 73

Impact of VAE Report 2013 A Technology Improvement Story Newly introduced surveillance for VAE required the assistance of technology Report was created and enabled the new surveillance Report simplified surveillance in a manner that allowed IPs to be objective. All pertinent factors were summarized in report which lead to an overall efficient process for conducting surveillance. Initial surveillance showed unexpected FiO2 and PEEP fluctuations The technology prompted the analyses that improved patient care Allowed for process improvement 74 Multiple people were changing the vent settings

2013 VAE Report Developed Clinical Event Performed Date APRV Vent Mode Peep Min FiO2 Min Temp Min Temp Max WBC Min WBC Max ABX- Vancomycin ABX - All Others ABX- Cefepime 09/23/2013 5 0 98 102.3 77.7 77.7 vancomycin Meropenem ABX-All Other Cephalosporins Antifungal Antiinfluenza Culture Order Description Culture: Respiratory w/gram Stain Micro Source Sputum Organism Identified (Drawn Date) MRSA Invasive Airway Type Endotracheal (Intubated) Infection Control Alert Infection Control Alert Response 75

2016 Start VAP Bundle Upgrade Not at zero VAPS / VAEs Compliance rates high Review new evidence in the literature Documentation drift Data drift in compliance report New medications Use of single ventilation orders was leading to fallouts Ventilator order set use was low Order sets (MPPs) not aligned with VAP Bundle Each MPP had different content 76

How Did We Implement? People VAP Bundle Workgroup created Sponsored by HAI Steering Committee Multi-disciplinary Process Weekly meetings Clinical stakeholders consulted Design sessions Complex approval process Testing and validation 77

How Did we Implement? Process (continued) Clinical Stakeholders testing sessions Communication and education Pilot at one ICU System Go Live July 2017 Technology Online research, meetings, training & education Extensive data analysis 78

VAP Bundle Upgrade Use of Data to Drive Decisions Identified all documentation elements and compared with evidence based research Wrote custom reports to pull documentation data Analyzed each response in terms of volume, clinical content and alignment with Bundle elements Presented data to clinical stakeholders Used data to drive decision making for future state 79

Vent Check by Nurse PowerForm Usage Dec 2015 Facility Number of times PowerForm Signed GH Greater Heights 1584 HC Childrens 1594 HH HERMANN 9044 KM Katy 775 MC Mem City 1180 NE Northeast 845 SE Southeast 1399 SG Sugar Land 71 SW Southwest 2304 TR TIRR 30 TW The Woodland 1283 80 Grand Total 20,109 841 visits

Data Analysis PUD Prophylaxis Documentation Meds for prevention of PUD being administered 18,266 Meds for prevention of PUD not being administered due to contraindications 288 Physician order 287 Exclusion exists 575 Patient on enteral feeding 577 Grand Total 19,993 81

Data Analysis Free text responses Reason not Using Int. Compression Device # of times documented Other: lymphedema 72 Other: heparin gtt 65 Other: pt receiving anti-coagulant therapy 33 Other: bath 25 Other: pt oob 25 Other: in chair 23 Other: On heparin gtt 23 Other: On Heparin 22 Other: patient on heparin drip 22 Other: up to chair 18 Other: PVD 17 Other: Heparin drip 16 Other: on heparin drip 16 Other: pt up in chair 16 Other: angiomax gtt 15 Other: DVT 15 Other: pt recieving anti-coagulant therapy 15 Other: Up in chair 15 Other: HEPARIN 14 Other: chair 13 Other: IVC filter 13 Other: pt up to chair 13 Other: Comfort measures 11 Other: disease process 11 Other: pt recieivng anti-coagulant therapy 10 Other: Betty said not to 1 82 Other: Betty said not to

When Different Technologies Collide VAP Bundle 83

VTE Advisor What is it? VTE Advisor Cerner Clinical Decision Support tool Used only by providers Not viewed by nursing or RT Helps assess individual risk of adult VTE Includes orders for VTE prophylaxis VAP Bundle vs the VTE Advisor Memorial Hermann designed tool Includes orders for DVT prophylaxis Different terminology Some overlapping content Some different indications and contraindications 84

Jan 2017 TheraDoc Infection Control 85

July 2017 Upgrade Implemented Highlights from the Upgrade Increased accuracy of compliance data Order sets updated and integrated with VAP Bundle Increased order set use Automated communication from provider to nurse VAP Bundle integrated with VTE Advisor 86

July 2017 Upgrade Implemented Increased documentation efficiency - 69% reduction in clicks for prophylaxis nursing PowerForm - Reduced from 1,327,194 clicks/month to 422, 289 Automated display of medication orders Automated display of medication administration Zero reported fallouts in CHG mouthwash orders 87

Smarter Documentation Automated Data Flow From Physician to Nurse 88

Ventilation Order Sets Increased Utilization Number of Times Adult Ventilation Order Sets Used 900 800 VAP Bundle Upgrade 700 600 500 400 300 200 Ventilator Add On MPP Ventilator High Frequency MPP Ventilator Initiation/Bundle Orders MPP Ventilator Non Invasive MPP 100 0 May-17 Jun-17 Jul-17 Aug-1789 Sep-17

VAP Bundle Compliance Accurate data reveals opportunity to improve. 90

Our Journey Results from a Decade of VAP Bundle Partnership Maintaining Our VAP Rate 91

High Reliability! 23 Certified Zero Awards for VAP 92

Financial Impact VAP Bundle If we had done nothing Hospital expansion = more vent days 1,200 extra VAP infections @ $40,144 per infection Estimated lives saved = 100+ VAP Bundle projected cost avoidance = $48,172, 800 93

Lessons Learned Governance structure Multidisciplinary, multi-level groups Scheduled reviews Clinical champions Data Validation - always examine and understand your data Automation can decrease infections Partnership is the building block of change 94

Moral of our VAP Story the price of excellence is eternal vigilance 95

Questions? Tawanna McInnis-Cole Tawanna.McInnis-Cole@memorialhermann.org Jocelyn Thomas Jocelyn.Thomas@memorialhermann.org Please complete online session evaluation 96 THANK YOU!