Stopping Sepsis in Virginia Hospitals and Nursing Homes Hospital Webinar #2

Stopping Sepsis in Virginia Hospitals and Nursing Homes Hospital Webinar #2 - Tuesday, March 21, 2017

Welcome and Introductions Today s objectives: Introduce Sepsis Practice Collaborative Model Tier 1 Understanding the need for organizational consensus on sepsis management Discuss your data Your sepsis team Review Sepsis Gap Analysis and Sepsis Program Action Plan Redefine screening (if time allows) Update on Box and project updates 2

Your Sepsis Support Team Deborah Smith MLT(ASCP), BSN, CIC, CPHQ Improvement Consultant Candy Hamner RN, BA, MA Improvement Consultant Betsy Cole Archer, MS, ASCP Director, Performance Improvement Wanda Clevenger BSN, RN, MBA Director, Performance Improvement Kathleen Vollman, MSN,RN, CCNS, FCCM, FAAN Sepsis Content Expert 3

Sepsis Practice Collaborative Model Tier 1: Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively Kathleen M. Vollman RN, MSN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING LLC Sepsis Solutions International LLC kvollman@comcast.net Northville, Michigan www.vollman.com 4 Sepsissolutionsinternational LLC 2017

Sepsis Practice Collaborative Model 4 Tier Process for Program Implementation Measuring Success CQI 1 Implementation of the Sepsis Bundles Early Screening with Tools and Triggers Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively VAE (VAP) Bundle Hand Washing CAUTI Infection Prevention BSI Adapted from: Sepsis Solutions International Documentation Improvement ~ Accurate Coding 1 Continuous Quality Improvement

Organizational Consensus and Support Milestones and Checklist 1. Define Sepsis Program Goal and align with organizational goals 2. Identify Executive sponsor 3. Collect Baseline Data essential step 4. Develop sepsis team(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting a. Create a sepsis coordinator position to oversee program 6. Begin to define action plan and timeline for program development and implementation

7 Polling Question

8 Polling Question

9 Project Team Charter /Policy

Building the Why

Economic Implications of an Evidence-based Sepsis Protocol: Can We Improve Outcomes and Lower Costs? Objective a. To determine financial impact of a sepsis protocol designed for use in the ED of a Academic, tertiary care hospital in US Design a. Analysis of results from recent prospective study comparing outcomes in patients with septic shock before and after initiation of sepsis protocol Population a. Adults (n=120) who sequentially presented to ED with septic shock, specifically: a. At least two systemic inflammatory response syndrome (SIRS) criteria b. Known or suspected infection (based on radiologic imaging and clinical suspicion) c. Shock requiring both fluid resuscitation and vasopressor administration ED = Emergency Department Shorr AF et al. Crit Care Med. 2007;35:1257 1262.

Summary of Results a. Post-protocol, savings of ~$6,000/patient observed a. Translated into total cost difference of $573,000 between the two groups b. Post-protocol, ICU costs reduced by ~35% (p=0.026) and ward costs fell by 30% (p=0.033) c. Protocol resulted in a reduction in overall hospital LOS of 5 days (p=0.023) d. Pre-protocol, 28-day mortality rate was 48.3% vs. 30.0% following protocol initiation (p=0.040) ICU, intensive care unit; LOS, length of stay Shorr AF et al. Crit Care Med. 2007;35:1257 1262.

Sepsis is #1 Cause of Inpatient Deaths

Sepsis Impact on Mortality in Hospitals 1 out of 2-3 Deaths r/t Sepsis, Most POA In KPNC 2012 subset, patient meeting criteria for EGDT comprised 32.6 percent of sepsis deaths & patients with sepsis, normal BP & lactate < 4 comprised 55.9% of sepsis deaths Liu V, et al. JAMA,2014:May 18 th, online.

Proportion & Cost of Unplanned 30 day Readmissions after Sepsis (2013 Nationwide Readmission Database) Mayr FB, et al. JAMA, 2017, Jan 22 nd published online

18 http://www.cdc.gov/nchs/data/databriefs/db62.pdf

Common Causes of Hospitalization Adults aged 85 and over: U.S. 19 Levant S, Chari K, DeFrances CJ. Hospitalizations for patients aged 85 and over in the United States, 2000 2010. NCHS data brief, no 182. Hyattsville, MD: National Center for Health Statistics. 2015.

Discharge Disposition After Sepsis Septicemia or sepsis Other diagnoses Disposition Percent Routine 39 79 Transfer to other short-term 6 3 care facility Transfer to long-term care 30 10 institution Died during the 17 2 hospitalization Other or not stated 8 6 Total 100 100 1 Difference is statistically significant at the 0.05 level. SOURCE: CDC/NCHS, National Hospital Discharge Survey, 2008. 20

Tier I: Organizational Consensus and Support Milestones and Checklist 1. Define Sepsis Program Goal and aligned with organizational goals 2. Identify Executive sponsor 3. Collect Baseline Data essential step; understand your current process 4. Develop sepsis team(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting 6. Begin to define action plan and timeline for program development and implementation

22 Polling Question

23 Polling Question

Role of Executive Sponsor a. Review project plans b. Review team meeting minutes c. Identify anticipated barriers that senior leader can help address d. Give voice to organizational sepsis work to C-suite and maintain alignment

26 Polling Question

27 Polling Question

Baseline Data Collection Process a. Pick time period for medical record query b. Sample size: minimum of 20 pts per ICU c. Query strategies: a. ICD 9 codes: 785.52 and 995.92 or DRG 870, 871, 872---now also look at ICD-10 R65.20 and R65.21 b. Patients in ICU on 1-2 antibiotics, vasopressor (review charts to see if meet criteria for severe sepsis with lactate > 4 or septic shock before including in outcome data or process data) d. Select Data Collection Elements a. Outcome b. Process

How you Collect Data Impacts Use How is Data Used Prospective Concurrent Retrospective Anticipatory review of patient record (can impact current care) Data abstracted in real time or within 24 hours Serves as a prompt to execute bundle or the next phase of the bundle Recommended for new improvement teams Recommended for advanced improvement teams or those that have demonstrated success with process measures Yes No No Yes No Yes Yes No Yes Yes Surviving Sepsis Campaign, Society of Critical Care Medicine, website accessed 1/26/2017 29 No Yes

Tier I: Organizational Consensus and Support Milestones and Checklist 1. Define Sepsis Program Goal and aligned with organizational goals 2. Identify Executive sponsor 3. Collect Baseline Data essential step 4. Develop sepsis team/committee(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting a. Create a sepsis coordinator position to oversee program 6. Begin to define action plan and timeline for program development and implementation

32 Polling Question

33 Polling Question

The Team Is KEY! Can Be Major Barrier If Not Functioning Well a. Must have nurse and physician champions from ED and ICU (need at least one physician at all meetings) b. Must be linked in the organization s quality or operational structure Are you linked? c. Must meet at least 1-2 times per month d. Team members must be well educated on the evidence and armed with tools and knowledge to change behavior at the bedside Does the team need more education? e. MUST have bedside nurses on team provide reality check and best knowledge of barriers Do you? Consider developing nurse champions on each patient care unit and shift

35 Polling Question

36 Polling Question

Tier I: Organizational Consensus and Support Milestones and Checklist 1. Define Sepsis Program Goal and aligned with organizational goals 2. Identify Executive sponsor 3. Collect Baseline Data essential step 4. Develop sepsis team/committee(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting a. Create a sepsis coordinator position to oversee program 6. Begin to define action plan and timeline for program development and implementation

38 Polling Question

Sepsis Program Action Plan Item Responsibility Due Date Status 1. Assemble team 2. Identify executive sponsor 3. Educate team on evidence 4. Project Charter 5. Baseline data 6. Define screening tool and process for ED, ICU, Floor, RRT 7. Define screening audit process 8. Develop triggers/processes to alert staff when time to move from first 3 hrs to shock bundle 9. Develop & implement an educational plan for all staff: 10. Develop an implementation plan 11. Data measurement & feedback

How to Use the Gap Analysis Gap analysis sections represent what is needed for a Sepsis Practice Collaborative Model Sepsis Practice is not a project but a system for delivering care that ensures evidence based best practices are provided consistently Share Gap Analysis results with your executive leader for support and guidance 40

Don t Miss out on this Invitation!!! Did you receive your invitation to BOX in your email? 41

Set Up Your BOX Accounts BOX is a SECURE file replaces encryption You received invitation with a link from Sarah Helen or Deb Smith ACT immediately this invite expires in 7 days Detailed instructions with screen shots email from Deb Smith or Wanda Clevenger Linda Harris will be resending invites every 7 days 42

Where do you go for BOX HELP Trouble accessing BOX Sarah Helen 804-289-5320 sstudebaker@hqi.solutions Hospital data report questions 804-965-1202 wclevenger@vhha.com 43

Hospital Project Needs - Data Self Reported Sepsis Process Measure The Process Measure template entitled Self-Reported Data Template and instructions for opening and updating the file are available in your BOX folder. Start entering data into the template. You have the choice of submitting monthly or quarterly. To get the most benefit from this work, we encourage monthly submissions. 44

45 Self Report Data Template

Hospital Project Needs Hospital Site Visits Hospitals that have submitted their Gap Analysis and policies are being contacted to schedule on-site visits. Discuss Gap Analysis and Policy feedback and recommendations Review project outcome and process measure data Identify framework for collaborating with nursing homes Eight hospitals have not yet submitted requested Gap analysis and documents. Please submit ASAP. 46

Upcoming Stopping Sepsis Webinars April 25, 2017 - Cross setting (hospitals and nursing homes 4 th qtr. 2016 outcome data, building cross setting relationships and more. May 16, 2017 Hospital #3 Join Kathleen Vollman for Tier 2 Early Screening Tools with triggers May 23, 2017 Nursing Home Session 47

SSC Guidelines: Screening 2016: We recommend that hospitals and hospital systems have a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients (BPS). 2012: We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy (1C) Dellinger RP, et al. Crit Care Med. 2013;41580-637 Rhodes, A et al. Crit Care Med 2017 published online

Finding the Patients Redefining what a septic shock patient looks like Before Supine in bed Ventilator Fluids wide open Increasing vasopressors Minimally responsive NOW Sitting up in bed Nasal cannula IV boluses Weaning vasopressors Awake Don t look sick enough to be in ICU or to have a central line Must correct this misperception

Contact Information Wanda Clevenger Director, Performance Improvement (804) 965-1202 wclevenger@vhha.com Kathleen Vollman Clinical Nurse Specialist/Consultant kvollman@comcast.net 51

Q & A This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network- Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI 11SOW 20170321-124035 52