LVHN Sepsis Quality Improvement Project Matthew McCambridge, MD, MS Chief Quality Officer 2015 Lehigh Valley Health Network Don Levick, MD, MBA Chief Medical Information Officer
LVHN Sepsis Quality Improvement 93 Providers 30 Nurses 12 Tech Partners 20 RRT 17 Physicians 14 Therapists (PT, OT, Speech) 119 Blood Products 48 PRBCs 6 FFP 29 Platelets 36 Cryoprecipitate 2
Reduce Sepsis Mortality The Local Problem 3
Sepsis Quality Improvement 4
Mortality Index # of Patients Who Died Sepsis Quality Improvement LVHN* Mortality Index According to Calendar Year Quarter 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0.00 0.85 238 Q3 2013 (n= 13,882) Deaths Mortality Index LVHN Benchmark Linear (Mortality Index) 0.95 0.99 278 Q4 2013 (n= 13,833) 292 Q1 2014 (n= 13,986) 0.93 1.01 256 260 Q2 2014 (n= 13,817) Q3 2014 (n= 13,996) 1.15 1.07 317 315 Q4 2014 (n= 14,032) Q1 2015 (n= 13,470) 0.90 0.91 259 Q2 2015 (n= 13,578) 152 Jul/Aug 2015 (n= 8,903) 500 450 400 350 300 250 200 150 100 50 0 Numerator: Number of deaths observed Demoninator: Number of deaths expected according to UHC 2014 AMC Risk Adjustment Model *LVH-H data in not included 5
Sepsis Quality Improvement 6
Reduce Sepsis Mortality Design and Implementation 7
Sepsis Quality Improvement Task Forces Present on Admission ED Protocols Order Sets Early Resuscitations Pharmacy ED Physicians & Residents Hospitalists Enterprise Analytics Pathology Blood Bank Internal Medicine ED Nurse EMS Lean & Quality Education Non-Present on Admission Med/Surg/ICU Rescuing Resuscitation Patients who develop sepsis in-house Pharmacy ED Physicians & Residents Hospitalists Enterprise Analytics Clinical Quality Infection Control Nursing Surgeons - General SPPI Internal Medicine Pulmonary Clinical Informatics 8
Sepsis Quality Improvement POA Sepsis Subcommittees Group 1 A Physical & Operational Changes in the ED Flow Diagram, Sepsis Order Set Lab/Pharmacy, Sepsis Response Team Group 1 B Sepsis Education Transition of Care, Residents Pharmacy Physicians Nursing Enterprise Analytics Quality Physicians Nursing Education Quality PCS Group 1 C Reporting / Feedback Group 1 D Education for EMS Staff for Pre-Hospital Arrival Physicians Quality PCS / PCM Quality Physicians Nursing EMS Quality 9
Sepsis Mortality Improvement Task Force Timeline January 2016 through April 2016 DEC 23 JAN 07 JAN 27 FEB 10 FEB 17 FEB 24 FEB 25 FEB 26 MAR 02 MAR 03 MAR 14 MAR 16 MAR 17 MAR 18 MAR 22 APR 06 APR 07 High Sepsis Mortality Recognized 1 st Sepsis Task Force Meeting 1 st Non-POA Sepsis Sub- Committee Meeting Begin Monthly Sepsis Mortality Review Design Sepsis Info Graphic 1 st POA Sepsis Sub- Committee Meeting BPA Planning Meeting Begin Weekly Sepsis Rounding Education 2 nd Non-POA Sepsis Sub- Committee Meeting Sepsis Order Set Planning Meeting Lab / Pharmacy Planning Meeting Update Antibiotic List with Pharmacy 2 nd POA Sepsis Sub- Committee Meeting POA Reporting Feedback Sub- Committee Meeting POA Operational Changes in ED, Order Set, Flow Diagram, Labs, Task Force Sub- Committee POA Meeting Education for EMS Staff for Pre- Hospital Arrival Sub- Committee Meeting POA Sepsis Education, TOC, Residents Sub- Committee Meeting Sepsis Care Coordination Between ED / Inpatient Units Quarterly Sepsis Task Force Meeting 10
Reduce Sepsis Mortality How Healthcare Information Technology was Utilized 11
The Sepsis Pathway Severe Sepsis Non-Invasive Protocol SIRS + confirmed infection + one organ system dysfunction 2 LB IV 30 cc/kg NSS over 1 3 hours Blood Culture Antibiotics Admit to ICU Sepsis transition SmartText 12
Epic Sepsis Initiation Order Set 13
Epic Sepsis Initiation Order Set 14
Epic Sepsis Initiation Order Set 15
Epic Sepsis Initiation Order Set 16
Epic Sepsis Initiation Order Set 17
Reduce Sepsis Mortality LVHN Tableau Sepsis Reporting 18
LVHN Sepsis Clinical Analytics Model Use to monitor LVHN s performance in managing patients with Sepsis Developed over 4 months Built in Tableau and fed by data from Epic EHR 79 different clinical metrics Model has over 5 million rows of data Design based on Best Evidence, reporting requirements, and ability to review data from many perspectives Can drill from Tableau down into actual Patient record in Epic EHR as relevant
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
Reduce Sepsis Mortality Value Derived 28
LVH Mortality Index 29
LVH Muhlenberg Mortality Index 30
LVH Sepsis Mortality 31
LVHN Muhlenberg Sepsis Mortality Index 32
Total inpatient 12 th / 140 Post-surgical 11 th / 140 Urology tied 1 st / 135 OB tied 1 st / 124 Gynecology tied 1 st / 133 Gyn Onc tied 1 st / 116 HIV tied 1 st / 110 Burn 5 th / 57 Cardiac Surgery 7 th / 118 Medical Oncology 8 th / 134 LVHN Vizient Current Rankings 2017 Q1 33
Reduce Sepsis Mortality Work in progress to make further improvements 34
Next Clinical Phase - Sepsis BPA for Hospital Acquired Sepsis Next Phase for LVHN Sepsis care management Real-time Sepsis reporting EHR alert terminology update 35
Sepsis Best Practice Advisory Inpatient Nurse BPA Inpatient nurse BPA Alerts based on LVHN-developed, modified SIRS criteria Alerts at File of vital signs, or chart opening Algorithm hyperlink included Acknowledge Reasons assist in tracking compliance 36
Sepsis Best Practice Advisory Inpatient Provider BPA Inpatient provider BPA Alerts based on LVHN-developed, modified SIRS criteria Alerts at chart opening Algorithm hyperlink included Sepsis initiation order set automated to open Acknowledge reasons assist in tracking compliance Lock-out period to avoid over-alerting 37
Next Economic Phase - Linking Clinical with Claims Data Sepsis Cohort Profile For the 253 patient/members who had a sepsis diagnosis in December 2016, 87 of them were in one of LVHN s accountable care (at risk) contracts Some non-surprising highlights 84 of these patient/members are classified as very high risk The PMPM for these members of $7,427 is extremely high This cohort had 343 ER visits There were 343 readmissions, with a 53% readmission rate per 1,000 members - extremely high 66 of these members are age 65+ Summary on next slide - example patient cohort summary Created with Epic EHR data loaded to Optum One where claims data was integrated Detailed clinical and economic data about this patient/member cohort This type of analytics is critical to understand the underlying economics of providing care, especially in a world of value based purchasing where providers absorb risk 38
Initial Findings: Sepsis Clinical and Claims Summary Sepsis patients are clinically complex patients with multiple conditions: Very high risk stratification 95% of patients have chronic conditions, most prevalent chronic conditions include Diabetes, Ischemic Heart Disease, COPD, CHF and Hypertension 18% of members have no PCP continuity (No PCP visits in the past year) These complex patients can benefit from better care coordination with PCP involvement Largest cost drivers throughout the care continuum after the index admission are readmissions and skilled nursing care 32% of episodes result in readmission and 30% include Skilled Nursing Facility care Readmissions result from various clinical conditions with the largest contributors being cardiac, respiratory and gastrointestinal related conditions Most skilled nursing care is provided outside of LVHN so there is a need for better care coordination with these non-lvhn SNF s There are Outmigration opportunities (care rendered outside of LVHN) for Sepsis patients after the index admission More care rendered inside LVHN would enable better care coordination between providers More effective care coordination should result in lower cost and improved clinical outcomes 39
Clinical and Claims Profile from Epic EHR and Optum 40
Pathway Overview Dashboard Deeper insight into Sepsis care delivery throughout the continuum of care Reflects both reimbursement and associated cost pathways extended to Sepsis episode patients 41
Readmission Analysis Understanding Sepsis Readmissions 42
Triple Aim Drives LVHN Strategy and Goals LVHN Mission: We heal, comfort and care for the people of our community by providing advanced and compassionate health care of superior quality and value supported by education and clinical research. Better Health, Better Care, Better Cost Berwick, D., Nolan, T., Whittington, J. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs 27:3. 43