Welcome and Overview. Sepsis Mortality Reduction Boot Camp 3/20/ PDF Free Download

Welcome and Overview Sepsis Mortality Reduction Boot Camp 3/20/2014

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AHA/HRET (HEN) Sepsis Mortality Reduction Boot Camp-Day 1 repeated Virtual Meeting Summary Disclosure & Accreditation Statement March 20, 2014 The planners and faculty of the AHA/HRET (HEN) Sepsis Mortality Reduction Boot Camp have indicated no relevant financial relationships to disclose in regard to the content of this activity with the following exception. Kathleen Vollman indicated she receives honorarium from Sage Products, Eloquest Healthcare & Hill-Rom. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical education through the joint sponsorship of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and Health Research & Education Trust (HRET). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AHA/HRET (HEN) Sepsis Mortality Reduction Boot Camp-Day 1 repeated Virtual Meeting Summary Disclosure & Accreditation Statement March 20, 2014 The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is an approved provider with the Florida Board of Nursing to provide continuing education for nurses. ABQAURP designates this activity for 3.75 Nursing Contact Hours through the Florida Board of Nursing, Provider # 50-94. 6640 Congress St. New Port Richey, FL 34653 Toll Free 800.998.6030 Telephone 727.569.0190 www.abqaurp.org

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Develop an understanding of the impact of sepsis on hospital mortality Understand implementation of sepsis screening in the ED and the inpatient departments Learn how best to collect data and how to drive improvement Today s Objectives

Polling Question 1: Who is participating today?

Polling Question 2: Time Zone?

Polling Question 3: What size is your facility?

Impact of Sepsis Kathleen M Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Consultant ADVANCING NURSING LLC SEPSIS SOLUTIONS INTERNATIONAL Detroit MI 48168

Disclosures

Overview Significance of the problem Define the continuum Process for development of a hospital wide sepsis program: The Power of the Pyramid o Organizational support o Early Recognition Screening/triggers o Implementation/protocols o Measurement/CI

Severe Sepsis: A Significant Healthcare Challenge Hospitalizations have increased by 32% from 2005-2010*** Most costly reason for hospitalization in 2009** o 15.4 billion in aggregate hospital cost 1 out of 23 patients in hospital had septicemia** Rank in the top 4 most costly for all 4 payer groups*** Sixth most common inpatient diagnosis*** Major cause of morbidity and mortality worldwide o Leading cause of death in noncoronary ICU (US) 1 o 10th leading cause of death overall (US) 2 * In the US, more than 700 patients die of severe sepsis daily (1.6 million new cases per year)

Severe Sepsis: A Significant Healthcare Challenge * Based on data for septicemia Reflects hospital-wide cases of severe sepsis as defined by infection in the presence of organ dysfunction 1 Sands KE, et al. JAMA 1997;278:234-40. 2 National Vital Statistics Reports. 2005. 3 Angus DC, et al. Crit Care Med 2001;29:1303-10. **AHRQ Healthcare cost & Utilization Project October 2011 **AHRQ Healthcare cost & Utilization Project October 2011 *** Torio CM, Andrews RM (AHRQ). HCUP Statistical Brief #160. August 2013, AHRQ, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.pdf

Severe Sepsis vs. Current Care Priorities U.S. Care Priorities # of Deaths Mortality Rate Incidence AMI (1) 900,000 225,000 25% Stroke (2) 700,000 163,500 23% Trauma (3) 2.9 million 42,643 1.5% (Motor Vehicle) (injuries) Severe Sepsis (4) 751,000 215,000 29% Source: (1) Ryan TJ, et al. ACC/AHA Guidelines for management of patients with AMI. JACC. 1996; 28: 1328-1428. (2) American Heart Association. Heart Disease and Stroke Statistics 2005 Update. Available at: www.americanheart.org. (3) National Highway Traffic Safety Administration. Traffic Safety Facts 2003: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System. Available at http://www.nhtsa.dot.gov/. (4) Angus DC et al. Crit Care Med 2001;29(7): 1303-1310.

A Sepsis Pilot Recognizes trouble before it starts Follows standard operating procedures (SOP) for managing sepsis. Does not take little things for granted. Understands the consequences: Immediate Long term Holds everyone accountable takes personal responsibility for outcomes.

Time Sensitive Diseases Changing the Paradigm of Practice AMI Stroke Trauma < 10% 8-25% < 5%

4-Tier Process for Severe Sepsis Program Implementation Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively SEPSIS SOLUTIONS INTERNATIONAL 2006

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(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify Sepsis Coordinator 6. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting 7. Begin to define action plan and timeline for program development and implementation 24

1. Define Sepsis Goal: Develop Project Team Charter

Economic Implications of an Evidence-based Sepsis Protocol: Can We Improve Outcomes and Lower Costs? Objective To determine financial impact of a sepsis protocol designed for use in the ED in a Academic, tertiary care hospital in US Design Analysis of results from recent prospective study comparing outcomes in patients with septic shock before and after initiation of sepsis protocol Adults (n=120) who sequentially presented to ED with septic shock, specifically o o o At least two systemic inflammatory response syndrome (SIRS) criteria Known or suspected infection (based on radiologic imaging and clinical suspicion) Shock requiring both fluid resuscitation and vasopressor administration ED = Emergency Department Shorr AF et al. Crit Care Med. 2007;35:1257 1262. 26

Summary of Results Post-protocol, savings of ~$6,000/patient observed Translated into total cost difference of $573,000 between the two groups Post-protocol, ICU costs reduced by ~35% (p=0.026) and ward costs fell by 30% (p=0.033) Protocol resulted in a reduction in overall hospital LOS of 5 days (p=0.023) 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.

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(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify Sepsis coordinator 6. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting 7. Begin to define action plan and timeline for program development and implementation 28

The Role of Executive Sponsorship 1. Sponsors are executive leaders explicitly tied to a process being improved. 2. Sr. executives round regularly (q week, q 2 weeks) on process aims, goals, targets, outcomes with the frontline team. o o Informative, not punitive. Accountable, not in trouble 3. Sponsors remove barriers to progress.

Role of Executive Sponsor Review project plans Review results from first team meeting Identify anticipated barriers that senior leader can help address Enlist support and help AND ASK for a sponsor to be assigned to the project

Baseline Data Collection Process: Defining Current State Pick time period for medical record query Sample size: minimum of 20 pts per ICU Query strategies: o ICD 9 codes: 785.52 and 995.92 o 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 Select Data Collection Elements o Outcome: mortality, cost per case, LOS o Process 31

The Team Is KEY! Can Be Major Barrier If Not Functioning Well Must have nurse and physician champions from ED and ICU (need at least one physician at all meetings) Must be linked in the organization s quality or operational structure Are you linked? Must meet at least 1-2 times per month 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? MUST have bedside nurses on team provide reality check and best knowledge of barriers Do you? 32

Tier I: Organizational Consensus and Support Milestones and Checklist Complete Team Charter Sepsis Goals aligned with organizational goals Identify sepsis coordinator/resource(s) for program Develop sepsis team(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting Collect Baseline Data essential step Begin to define action plan and timeline for program development and implementation

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 34

Tier 1: Challenges and Barriers Scheduling meetings and consistent attendance Time Skipping key steps---charter, communication plan, align team/program within organization Baseline data 35

4-Tier Process for Severe Sepsis Program Implementation Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively SEPSIS SOLUTIONS INTERNATIONAL 2006

Screening for Sepsis and Performance Improvement 1. 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) 2. Performance improvement efforts in severe sepsis should be used to improve patient outcomes (UG) Dellinger RP, et al. Crit Care Med. 2013;41580-637

Severe Sepsis: Defining a Disease Continuum Infection Systemic Manifestations of infection Sepsis Severe Sepsis Adult Criteria A clinical response arising from a nonspecific insult, including 2 of the following: Temperature:> 38 C or < 36 C Heart Rate: > 90 beats/min Respiration: > 20/min WBC count: > 12,000/mm 3, or < 4,000/mm 3, or > 10% immature neutrophils Altered mental status BG >140 (non diabetic) SIRS = Systemic Inflammatory Response Syndrome Bone et al. Chest.1992;101:1644-1654. Systemic Manifestations of infection with a presumed or confirmed infectious process Sepsis with 1 sign of organ dysfunction, hypoperfusion or hypotension. Examples: Cardiovascular (refractory hypotension) Renal Respiratory Hepatic Hematologic Unexplained metabolic acidosis Shock

Signs & Symptoms of Sepsis Chills Alteration in LOC Tachypnea Unexplained metabolic acidosis Heart rate Altered blood pressure Platelets Bands Skin perfusion Urine output Skin mottling Poor capillary refill Hyperglycemia Purpura/petechia Levy M, et al. Crit Care Med 2003;31:1250-6.

Definitions Sepsis: presence of infection (suspected or confirmed) with systemic manifestations of infection Severe Sepsis: Sepsis-induced tissue hypoperfusion or organ dysfunction Septic Shock: Hypotension that persists despite adequate fluid resuscitation

Why Do You Need to Have a Screening Process? TIME IS TISSUE!! o Similar to trauma, AMI, or stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcomes. 1 To screen effectively, it must be part of the nurses daily routines i.e., part of admission and shift assessment Must define a process for what to do with the results of the screen If you don t screen you will miss patients that may have benefited from the interventions 1. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327.

Screening for Severe Sepsis Yes Positive Screen for Severe Sepsis? No Surviving Sepsis Guidelines Monitor frequently whether on the ward or ICU Standard care

Tier II: Screening for Severe Sepsis Milestones and Checklist Develop screening process for ED, rapid response team and ICU (eventually housewide) Develop audit process to evaluate compliance and effectiveness Ensure screening process has clear next steps defined for nursing staff

Tier III: Sepsis Bundle Implementation Milestones and Checklist Develop easy to use order sets (ED and ICU should be the same), organized by bundle Order sets approved by appropriate medical and nursing leadership/committees Identify resistance and barriers to bundle implementation and develop solutions o Ex: ability to get lactate quickly Identify equipment needs and make capital requests Develop triggers/processes to alert staff when time to move from first 3 hrs to shock bundle Define educational plan for all staff Develop implementation plan

Tier III: Develop and Implement the Education Plan o o o Content: (present to physicians, nurses and RTs) o Significance of problem o Sepsis continuum o Pathophysiology of severe sepsis o Prevention and management (share the evidence) o Case studies for staff to practice with bedside tools Methods: o Self learning modules o Classroom and/or small groups of staff on unit o Web-based: IE:ICU-USAPRO Ongoing: o build into orientation, o monthly for residents, o every 6 months for all staff, o one-on one during rounds

Implementation Hospital resources often focus on planning phase and then back off after implementation. The implementation phase is the most critical. Frequent rounds by project champion recommended on unit to support staff and answer questions. Defined resources for bedside nurse: o Project champion has pager to be available 24/7 initially o Clinical nurse champions identified on each ICU unit and ED to be resources to bedside staff (these staff should be members of the sepsis team/committee from the beginning)

TIER III: Develop Implementation Plan Identify who will oversee the implementation and the expectations of that person(sepsis nurse or program coordinator) Define ICU/ED resources for staff that they can call at any time for questions and assistance Create rounding schedule and process o Should begin as daily in the ICU and ED o Keep master list of all patients who go on the bundles (and those who should have but didn t if possible) o Do real time interventions to ensure patients get the evidence based practices o Define follow up process for review and evaluate missed opportunities

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 order sets/work through committees 9. Identify resistance and barriers to bundle implementation and develop solutions 10. Develop & implement an educational plan for all staff: 11. Develop an implementation plan 49

4-Tier Process for Severe Sepsis Program Implementation Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively SEPSIS SOLUTIONS INTERNATIONAL 2006

Tier IV: Measurement Milestones and Checklist Define outcome and process data elements that will be collected Develop and implement a data collection process Revise and update goals and action plan as needed Execute implementation plan

Data Collection Patient Log o o Define how will find all patients that receive the bundles Real time data collection is optimal then used as checklist to ensure patient receives all appropriate interventions Outcome o o o Process o Mortality (ICU and Hosp) Hosp LOS Cost per case (total and direct) SSC database o Data elements that measure process achievement of the 3 & 6 hour bundles & outcome measures of the 6hrs

Strategies for Keeping Sepsis Front and Center Align team with clinical and quality structures in organization Sepsis program/goals part of hospital quality plan Reporting progress and data quarterly to executive leadership Report to hospital board annually Standing agenda item on department meetings Communication plan---includes flyers, newsletters, postings in units etc. Code sepsis Real time data measurement and feedback 54

Seize the Opportunity The Power of The Pyramid Can Make a Difference in Implementing a Sepsis Program while Saving Lives & Money

Questions

Polling Question 3: Where is your team? Where is your organization on the sepsis climb? o Just started getting our team together o We have an order set o Almost to the top of the summit o Stuck on the mountain side and setting up camp o Moving along with a great team and we know where we are headed?

Optimizing Care for Patients with Severe Sepsis and Septic Shock Sean R. Townsend, MD VP Quality & Safety, California Pacific Med. Ctr. Clinical Assistant Professor University of California, San Francisco March 2014 This presenter has nothing to disclose.

Our Work Funded By:

Time Sensitive Interventions AMI Door to PCI o Focus on the timely return of blood flow to the affected areas of the heart. Stroke Time is Brain o The sooner that treatment begins, the better are one s chances of survival without disability. Trauma The Golden Hour o o Requires immediate response and medical care on the scene. Patients typically transferred to a qualified trauma center for care.

Mortality Increasing with Successive Organ Failures Mortality Rate # of Organ Dysfunctions 21.2% 1 44.3% 2 64.5% 3 76.2% 4 Source: Angus DC et al. Crit Care Med 2001;29(7):1303-1310.

National Hospital Discharge Database

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012 R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Crit Care Med 2013; 41:580-637 Intensive Care Medicine 2013;..

Screening for Sepsis and Performance Improvement 1. 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 and allow implementation of early sepsis therapy (Grade 1C). 2. Performance improvement efforts in severe sepsis should be employed to improve patient outcomes (UG).

Initial Resuscitation 1. We recommend the protocolized, quantitative resuscitation of patients with sepsisinduced hypoperfusion (defined as hypotension persisting after initial fluid challenge or blood lactate concentration 4 mmol/l). This protocol should be initiated as soon as hypoperfusion is recognized and should not be delayed pending ICU admission. During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of a treatment protocol: Central venous pressure (CVP): 8 12mm Hg Mean arterial pressure (MAP) 65mm Hg Urine output 0.5mL.kg 1.hr 1 Superior vena cava oxygen saturation (ScvO2) or mixed venous oxygen saturation (SvO2) 70% or 65%, respectively. (Grade 1C)

Initial Resuscitation 2. We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (grade 2C).

Antibiotic therapy 1. We recommend that intravenous antimicrobial therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (grade1c). Remark: Although the weight of evidence supports prompt administration of antibiotics following the recognition of severe sepsis and septic shock, the feasibility with which clinicians may achieve this ideal state has not been scientifically validated.

Antibiotic therapy 4. We suggest the use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who appeared septic, but have no subsequent evidence of infection (grade 2C).

123

Surviving Sepsis Campaign: Data Analysis 2005-2008 First analysis: 2 years 15,000 pts January 2005-December 2006 Current analysis: 4 years 28,150 pts January 2005-December 2008

Hospital Mortality by Time to Antibiotics

Source control 1. We recommend that a specific anatomical diagnosis of infection requiring consideration for emergent source control (e.g., necrotizing soft tissue infection, peritonitis, cholangitis, intestinal infarction) be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the first 12 hr after the diagnosis is made, if feasible. (Grade 1C).

Fluid therapy 1. We recommend crystalloids be used in the initial fluid resuscitation of severe sepsis (Grade 1B). 2. We suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (Grade 2C). Delaney AP, Dan A, McCaffrey J, et al: The role of albumin as a resuscitation fluid for patients with sepsis: A systematic review and meta-analysis. Crit Care Med 2011; 39:386 391 3. We recommend against the use of hydroxyethyl starches (HES) for fluid resuscitation of severe sepsis and septic shock (Grade 1B). (This recommendation is based on the results of the VISEP, CRYSTMAS, 6S and CHEST trials. The results of the recently completed CRYSTAL trial were not considered).

Fluid therapy 4. Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated lactate) with suspicion of hypovolemia to be a minimum of 30ml/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid, may be needed in some patients (Grade 1C). 5. We recommend a fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (e.g. change in pulse pressure, stroke volume variation) or static (e.g., arterial pressure, heart rate) variables (UG).

Vasopressors 1. We recommend that vasopressor therapy initially target a mean arterial pressure (MAP) of 65 mm Hg (grade 1C). 2. We recommend norepinephrine as the first choice vasopressor (Grade 1 B). 3. We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain blood pressure (Grade 2B). 4. Vasopressin.03 units/min can be added to norepinephrine with the intent of raising MAP to target or decreasing or decreasing norepinephrine dosage (UG). 5. We suggest dopamine as an alternative vasopressor agent to norepinephrine in highly selected patients at very low risk of tachyarrhythmias and with relative or absolute bradycardia. (Grade 2C).

Vasopressors 1. Phenylephrine is not recommended in the treatment of septic shock except: Norepinephrine associated with serious arrhythmias Cardiac output is known to be high and blood pressure persistently low As salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target (grade 1C).

Goals of Care and Communication of Prognosis 1. We recommend that goals of care and prognosis be discussed with patients and families (Grade 1B). 2. We recommend that these communications should be incorporated into treatment and endof-life care planning, utilizing palliative care principles where appropriate (Grade 1B). 3. We suggest that goals of care be addressed as early as feasible, but no later than within 72 hrs of ICU admission (Grade 2C).

NQF BUNDLE: Sepsis 0500 TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION : 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L time of presentation is defined as the time of triage in the Emergency Department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements severe sepsis or septic shock ascertained through chart review.

NQF BUNDLE: Sepsis 0500 TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION: 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) 65mmHg) 6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36mg/dl): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO2)* 7. Remeasure lactate* * Targets for quantitative resuscitation included in the guidelines are CVP of 8 mm Hg, ScvO2 of 70% and lactate normalization

Change in Compliance Over Time Levy MM et al. CCM 38(2):367-374, February 2010.

Change in Mortality Over Time Levy MM et al. CCM 38(2):367-374, February 2010.

Mortality: Site Quarter Mortality over 4 year study period 36.7% to 27.5% ARR: 9.2% RRR: 25.0% P=0.005

Intermountain: SS & Shock

Intermountain: Shock Only

Questions?

Establishing an Emergency Department Sepsis Screen Phelan Bailey, RN, CEN Emergency Department Nurse Manager St. Claire Regional Medical Center Kentucky

About Us St. Claire Regional Medical Center is a 159-bed rural hospital centrally located between Lexington and Ashland, in Morehead, Kentucky. The emergency department has approximately 30,000 yearly visits, which accounts for for more than 70% of the admissions to the hospital. Nursing and physician leaders in the emergency department work closely together to advance the care of patients. 60

Case Study 62 year old male presenting from long-term care facility o paraplegic, bed-ridden o indwelling urinary catheter. Complaint: deteriorating mental status. Vital signs: blood pressure 80/50, heart rate 119, respiratory rate 23, temperature 98.5 C, spo 2 95% on 2 liters per minute via nasal cannula. Treatment is initiated. 61

Case Study (cont.) The patient remains in emergency department for several hours with limited IV fluids and a single antibiotic agent administered. The patient is admitted to the ICU and received a central line, arterial line, several boluses of IV fluids, additional antibiotics, and vasopressors. Why weren t these interventions initiated in the emergency department? 62

Discovering a Need Chart reviews of patients with primary diagnosis of sepsis for the months of January- March 2012. o 42 patients with primary diagnosis of sepsis. o 21 patients met SIRS criteria at triage o 13 of those 21 patients met SIRS criteria based on vital signs alone. o Only 3 of those 21 patients had the established sepsis order set initiated. 63

The Next Step Sepsis screening tool created and added into ED triage assessment. Performed on every adult patient upon arrival to emergency department. If patient meets the criteria, the Triage Sepsis order set is initiated by the nurse and the patient is flagged on the tracker.

Triage Sepsis Order Set CBC CMP Magnesium PTT, PT/INR Lactate Troponin BNP Blood culture x 2 Includes the following: UAMC CXR - portable EKG IV initiation and normal saline bolus Bedside telemetry, noninvasive blood pressure, and continuous pulse oximetry monitoring

Post-Intervention Data Screening initiated on January 15 th, 2013. 235 positive screens from January 15 th,2013 through June 30 th, 2013. 113 (48% of patients with positive screen) met criteria for diagnosis of sepsis. Main sources: o Sepsis of urinary origin. o Sepsis of pulmonary origin. 66

What s Next? Establishment of sepsis risk screening for inpatient units. Sepsis education for all nursing staff. Development of protocols to decrease the risk of developing sources of infection: o Criteria for indwelling catheter insertion to decreased incidence of catheter-associated urinary tract infections (CAUTIs). o Ventilator-associated pneumonia (VAP) prevention. 67

QUESTIONS? 68

Mortality Reduction Through Timely Identification of Sepsis on the Floors: the MOST Protocol Mary Ann Barnes-Daly RN BSN CCRN DC Regional Clinical Initiative Lead Sutter Health Sacramento, CA March 2014

About Us Sutter Amador Hospital Sutter Auburn Faith Hospital Sutter Davis Hospital Sutter Medical Center, Sacramento Sutter Roseville Medical Center Sutter Solano Medical Center Sacramento, California

About Our Project Pilot center in 2010 Regional in 2011 Sutter Amador Hospital Sutter Auburn Faith Hospital Sutter Davis Hospital Sutter Medical Center, Sacramento Sutter Roseville Medical Center Sutter Solano Medical Center Sacramento, California

Funding for the Project

Overview- Scope of project Continue quality improvement in ED and ICU Develop a process for identification of severe sepsis and early initiation of treatment for patients on the floors MOST units = o Medical o Oncology o Surgical o Telemetry

Why MOST? This cohort of patients is important because they tend to have a higher likelihood to die than patients who go from ED to ICU In other words patients who go directly from ED to ICU, although presumably sicker, survive more than patients who go from MOST to the ICU later. * *SSC data and our own showed the same trends

ICU admits from ED vs. transfer from inpatient units (severe sepsis and septic shock)

Mortality Rate Summary SRMC 2010 Patients Admitted to ICU from SRMC ED o Mortality rate = 21.4% Patients transferred to ICU from MOST* Units Mortality rate = 25.2% Conclusion: patients transferred from inpatient unit were 15% higher likelihood to die than patients admitted from ED to ICU directly *MOST= Medical Oncology Surgical Telemetry combined

Screening and Identification Strategies Step One: o Standardize the screening criteria-regional approach ISO = Infection SIRS - Organ Failure o Some screens lacked full list of SIRS criteria o Some screens lacked full list of organ failure criteria o Modifications such as replacing the P/F ratio with increasing O2 requirements to maintain SaO2 >90%

Screening and identification strategies continued Step Two: Educate and retrain including: o the pathophysiology of systemic inflammation and organ failure o how and when to screen o how to use the chain of command when challenges arise

Screening on the floors Step Three: o roll out screening with superusers/auditors/mentors Step Four: o Measure compliance with screening o Outcome metric for the grant

Now what? Your patient has a positive sepsis screen Process and resources for appropriate response to a new positive screen for severe sepsis Standardize the right response 24/7 Create hand-off specific for sepsis status Response for simple sepsis o Notify MD, ask for initial and serial lactates o Increase screening to twice per shift

Call RRT Response to screen positive for severe sepsis o RRT (ICU RN and RCP) arrives and interfaces with RN and validates screen o If incorrect-educate and coach RRT validates o If positive call SEPSIS ALERT o Initiate standing orders for ABG, Lab, Fluid bolus o Additional personnel include Lab tech, IVT, Nursing supervisor, Intensivist either live or on phone

Response to screen positive for severe sepsis If the patient is stable initiation of the 3 hour bundle can occur on MOST unit Most severe sepsis patients were quickly transferred to the ICU for resuscitation, observation and a quick turn-around (6-24 hours) No longer waiting for septic shock to occur Patient flow impact

Trend Line Shows Significant Reduction in Mortality for MOST Units

2011 Mortality Data ICU Patients combined severe sepsis and septic shock

Data Summary 2010-2011 ED mortality reduction from 21.4% to 12.0% MOST units mortality reduction from 25.2% to 12.3% Overall ICU mortality reduction from 22.8% to 12.1%

Data Summary 2010-2011 ED mortality now 12.0% MOST mortality now 12.3%

Overall improvements More patients going from ED directly to ICU ED mortality reduction Less patients transferred from MOST to ICU MOST mortality reduction Overall ICU severe sepsis and shock mortality reduction No impact on ICU bed availability

Thank you - barnesm4@sutterhealth.org

Got Lactate??? Karin Molander, MD Sepsis Physician Champion, Mills Peninsula Health Services Burlingame, CA

Mills Peninsula Health Services Mills-Peninsula Health Services o General medical and surgical hospital in Burlingame, CA, 393 licensed beds, includes: o SNF o Behavioral Health o Family Birth Center 44,738 ED visits 2012. 14,819 admissions 3444 inpatient surgeries

MPHS Sepsis Mortality At Sutter hospitals severe sepsis and septic shock are the leading cause of death. Since 2006 we have been developing protocols on early recognition and rapid treatment of Severe Sepsis & Septic Shock. In 2007 MPHS Sepsis mortality was greater than 35%

PACE (Partners Advancing Clinical Excellence) Gordon and Betty Moore Foundation awarded Sutter a multi-million dollar grant to improve mortality in patients identified with Severe Sepsis (in addition to 5 other outcome measures) Involved 6 Sutter facilities RN and MD involvement Monthly call in meetings 2006-2012

Severe Sepsis/Septic Shock Diagnosis CBC Blood Cultures Source Cultures Lactate Radiographic studies Treatment Antibiotics within 1 hour of dx of Septic Shock Antibiotics within 3 hours of dx of Severe Sepsis Source control EGDT

Causes of Elevated Lactate Shock Post cardiac arrest Regional tissue ischemia DKA Thiamine deficiency Liver failure Malignancy Mitochondrial disease Drugs/toxins Alcohol, cocaine, CO, cyanide Pharmacologic agents metformin, epinephrine, linezolid, propofol Anaerobic muscle activity Seizure Heavy exercise

Lactate Elevated lactate associated with increased mortality if cause is due to hypoperfusion (Broder and Weil Science 1964; 143) Noted to be a predictor of mortality in ED patients presenting with suspected infection (Shapiro et al Ann Emerg Med 2005; 45)

RN Sepsis SIRS Protocol Allows ED triage RN to initiate work-up on patient presenting with suspected infection and positive SIRS screen. o CBC o Blood Cultures o Lactate o Saline lock

4Ts W Sugar Thought Tachypnea Tachycardia Temperature WBC Glucose > 120 (based on case study by Maureen D. Raynor)

Positive Sepsis Screen 2 of the following criteria and suspected infection: o T > 38 or < 36 o RR > 20 o HR > 90 o Confusion o WBC > 13 or < 4 or > 10% bands

Positive Sepsis Screen Other risk factors o Age > 60 o o o o Immunocompromised (recent chemo, steroids, HIV+) History of diabetes, liver disease, chronic renal disease Altered Mental Status Current use of antibiotics o Systolic BP < 100

Screening patients Developed badge cards for RN/MDs Nurse Protocols Best Practice Alert within EHR Mandatory Screen performed at triage and each shift Goal: develop automated BPA to prompt as laboratory and VS data entered into EHR

Best Practice Alert Prompt within Electronic Health Record Activated if Blood cultures are ordered Then prompts to order lactate, yes or no. Initially ran silently within EHR to verify low incidence of false alert Initially only activated in ED Now facility-wide

Lactate Audit 2/18/13 9/6/13 Utilize daily Epic workbench report to audit all lactates 2.0 for last 24 o in ED, critical care, med/surg. Chart review for MD identification of sepsis, severe sepsis, septic shock Total of pts with lactate 2 577 # pts with lactate 2 and sepsis, severe sepsis or septic shock 441 # not septic 130 % sepsis 76.4 % not sepsis 23.6

Lactate Audit 2/18/13 9/6/13 37% of patients with a lactate 2.0 and sepsis had a normal WBC (4 WBC 12) Normal WBC and Sepsis # pts with lactate 2 and sepsis 441 # pts with lactate 2, normal WBC and sepsis 168 % pts with sepsis and normal WBC 38.1

Septic Shock Jun 2012 - Sept 2013 Severe Sepsis/Septic Shock Oct 2013 - Jan 2014 First Lactate value 0-1.9 2.0-3.9 4.0-5.9 > 6.0 Mortality numerator 22 44 19 25 147 182 86 47 Mortality denominator 169 226 105 72 mortality rate 13.0% 19.5% 18.1% 34.7% percent of total # pts 29.5% 39.5% 18.4% 12.6% First Lactate value 0-0.9 1.0-1.4 1.5-1.9 Mortality numerator 7 6 9 44 50 53 Mortality denominator 51 56 62 mortality rate 13.7% 10.7% 14.5%

MPHS Mortality 45.0% MPHS Septic Shock and Severe Sepsis Mortality 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% EHR Go Live Series1 10.0% 5.0% 0.0% ED RN SIRS Protocol Hospital-wide RN SIRS Protocol

MPHS Mortality reduction Individual feedback to RN/MD using Sepsis Bundle Compliance Audit Tool Monthly Sepsis Team meetings (RNs, MDs, pharmacists, Quality, ED scribes, Management, C suite) Daily Lactate audits POC lactate on RRT

MPHS Sepsis Team Members MPHS Sepsis Committee members accepting Patient Safety First award at November 2013 Beacon conference for reducing sepsis mortality by > 30% for > 6 months

Break Don t go far! We will begin again at the top of the hour!

Sepsis Mortality Reduction Journey Jonathan Kling, MBA, RN, CCRN Associate Chief Nursing Officer NCH Healthcare System Naples, Florida

Sepsis Mortality Reduction Journey The Highs and the Lows

About Us Non profit, multifacility Healthcare System in Naples, Fl. 715 total beds; 2 hospital system. Alliance of 650 physicians & medical facilities. throughout Collier County and SW Florida. Extensive inpatient and outpatient services. Member of the Mayo Clinic Network 37,284 admissions; 87,100 emergency room visits; 3,033 births; 416 open heart surgeries; 11,282 surgical procedures & 3,000employees. 2012, 2013 Most Wired. ANCC Pathways Designated, July 2013. 143

Goal: The Pre-Journey IHI Reducing Sepsis Mortality Collaborative October 09 to September 10 o Reduce sepsis mortality by 10% in ED to Critical Care admitted patients. o Bundle component compliance > 85%. Action: Created ED Sepsis Alert to ID potential sepsis patients sooner. 40% 35% 30% 25% 20% 15% 10% 5% 0% Sepsis Mortality Rate 34% 10% 24%

The Pre-Journey Thomson Reuter Sepsis Team September 10 August 11 Goal: Reduce Sepsis mortality by 10% within 6 months Action: Built additional sepsis PowerPlans for med/surg and critical care Results Mortality Index 2.5 2.0 1.5 1.0 0.5 0.0 1.9 1.8 10% 1.0 Q2-Q3'10 Q4'10-Q1'11 Top Decile

The Pre-Journey 35% 30% 25% 20% 15% 10% 5% 0% Mortality % August 2010 - September 2011 Mortality = Patients with Primary MS-DRG of Sepsis who Died Total # of Patients with Primary MS-DRG of Sepsis

The Real Journey Begins Problem Identified Fall of 2011 Sepsis Mortality Rate of 32% Initial Goal: To reduce severe sepsis mortality rate of NCH inpatient population by 10% (from 32% to 22%) by 12/30/12 and maintain < 22%* mortality rate for 6 months. * CRG med 22.2 benchmark expected comparative for top deciles of large community hospital. 147

The SEPSIS Journey Select/Form Interdisciplinary Team o Physician Champion, Nurse Leaders, bedside RNs, IP, Pharmacy Employ Evidence-Based Practice (EBP) o Sepsis bundle, early identification & intervention, alert system Plan/Pilot Spread Implement/Monitor/Evaluate Sustain

The SEPSIS Journey Select/Form Team Employ EBP Plan/Pilot: ED and Critical Care (CC) o Raise awareness, SOS o Bundle compliance, sepsis alerts, PowerPlans, Spread: to non-cc, Hospitalists, NPs, PAs o Expand alerts to fire to RNs o RN escalation process/rapid response team Implement/Monitor/Evaluate Sustain

The SEPSIS Journey Select/Form Team Employ EBP Plan/Pilot Spread Implement/Monitor/Evaluate o Comprehensive raise awareness and education campaign o Sepsis Committee monthly review of stats, case studies, opportunity identification Sustain

The Journey 70% 60% Severe Sepsis Mortality July 2011 March 2012 2011-12 50% 40% 30% 20% 10% 0% Jul Aug Sep Oct Nov Dec Jan Feb Mar

The Journey: SOS S.O.S. = Suspect Onset of Sepsis 152

The Journey Badge Cards for Non-Critical Care, Critical Care and Emergency Department Personnel 153

The Journey: SOS Documented or Suspected Infection And 2 or more = SIRS/Systemic Inflammatory Response Syndrome Heart Rate>90 BPM Temperature <36 C(96.8 F) or >38.3 C (101 F) Respiratory Rate > 20 BPM White Blood Cell Count >12,000 And 1 or more s/s hypoperfusion and/or organ dysfunction: SBP <90 or MAP <70 or drop of 40 from baseline Lactate > 4 mmol/l (on ABG or LA) Worsening Hypoxemia Worsening altered mental status Decreased urine output (<30ml/hr x 4 hrs) Creatinine increase > 0.5 mg/dl above baseline INR > 1.5 or PTT > 80 Platelet count < 100,000 Bilirubin > 2mg/dL

The Journey: SOS If your patient presents with s/s of Severe Sepsis: Immediately notify the physician to obtain orders to initiate the Sepsis Critical Care Power Plan which includes: Obtain Serum Lactate (ABG or draw Lactic Acid stat) Obtain Blood Cultures (peripheral & IV access device prior to Abx) Administer IV Broad Spectrum Antibiotic(s) within 1 hour In the event of Hypoperfusion or Lactate > 4 mmol/l Administer IV Fluid Bolus (20 ml/kg/hr) Apply Vasopressors for hypotension not responding to initial Fluids (SBP>90 or MAP> 65 mmhg) Control Glucose Levels >70 but < 150 (begin IV insulin protocol prn) Central Line Placement Measure CVP goal 8-12 mmhg

The Journey 50% 45% 40% 2012 46% Sepsis Mortality 2012-2013 38% % Expired 35% 30% 25% 20% 15% 10% 5% 32% 17% 31% 24% 2013 25% 23% 17% 17% 16% 29% 13% 8% 14% 11% 19% 7% 24% 13% 33% 10% 21% 14% 0% 156

The Journey Continues 50% Sepsis Mortality 2012-2014 40% 2012 2013 2014 30% 20% 10% 0%

Impact of Sepsis Improvements $3.7 m cost avoided. 172 lives saved 40 35 30 25 20 15 10 5 0 Actual # Mortalities Projected # Mortalities

Sepsis Actual vs. Baseline 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Actual Sepsis Mortality Rate Linear (Actual Sepsis Mortality Rate) Baseline / Proj Rate

The Journey Continues Select/Form Employ EBP Plan/Pilot Spread Implement/Monitor/Evaluate Sustain the Gain

Surviving Sepsis Campaign data collection to drive improvement Christa Schorr RN,MSN, FCCM Program Director of Critical Care Clinical Trials and Faculty for the Surviving Sepsis Campaign Cooper University Hospital, Camden, NJ

Past Present 6 & 24 hour bundle Previous Chart Review Database Version 3 162

Aggregate data 15,000 patients

Mortality results

New SSC database Enter new patient record; view/select records Built-in reports Export to local file and transmit to central site at SCCM 165

www.survivingsepsis.org Inside the data collection tool

Monthly - Quarterly Reports

Data collection & feedback Adequate resources for data collection and analysis Consistency in data entry Clear understanding of sepsis and data elements Timely feedback Process to display aggregate results Instrument to provide individual clinician feedback

Where do we start? 169

6 Hour Sepsis Resuscitation Bundle Compliance 100 90 80 70 60 50 40 30 20 10 0 Serum lactate within 6 Hrs 2005 Baseline Data 2006 2007 2008 Blood Culture before Antibiotics Antibiotic Compliance Fluids and Vasopressors for hypotension or elevated lactate CVP>=8mm Hg within 6 Hrs for shock or elevated lactate ScvO2>=70% or SvO2>=65% within 6 Hrs for shock or elevated lactate All applicable elements of the resuscitation bundle

Severe sepsis 6 hour resuscitation bundle compliance 100 90 80 70 60 50 40 30 20 10 0 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 Serum lactate within 6 Hrs Antibiotic Compliance 171

Time (hours) to antibiotic delivery Source of Infection Present Not Present p value Pneumonia* n=62 2.50 ± 2.31 3.35 ± 2.31 0.01* UTI n=83 2.94 ± 2.13 3.21 ± 2.29 0.4 Abdomen* n=34 3.87 ± 2.66 2.95 ± 2.12 0.03* Meningitis n=4 1.55 ± 1.15 3.14 ± 2.24 0.16 Skin n=18 2.42 ± 1.25 3.17 ± 2.29 0.17 Bone n=3 3.22 ± 4.07 3.10 ± 2.21 0.92 Wound n=7 1.80 ± 1.19 3.15 ± 2.25 0.11 Catheter n=11 2.89 ± 1.63 3.12 ± 2.25 0.74 Endocarditis n=3 3.17 ± 2.65 3.11 ± 2.23 0.96 Device n=2 1.68 ± 1.31 3.12 ± 2.23 0.36 Other n=39 3.01 ± 2.16 3.55 ± 2.50 0.17 172

AUDIT & FEEDBACK

Dashboard reporting ICU Benchmarks per Surviving Sepsis Database BM 79% BM 78% Goal is 100% Goal is within 6 hr of present ation Goal is 100% 6 HR SEVERE SEPSIS RESUSCITATION BUNDLE Number of charts Serum lactate within 6 hr Median time to serum lactate measure Blood cultures collected before antibiotics 4 Q 10 1 Q 11 2 Q 11 3 Q 11 4 Q 11 1 Q 12 2 Q 12 3 Q 12 4 Q 2012 36 50 38 31 30 26 30 26 24 100% 36/36 96% (48/50) 97% (37/38) 94% (29/31) (30/30) 100% (26/26) 100% 97% (30/29) 96% (25/26) 96% (23/24) 1 hr 1 hr 1 hr 1 hr 1hr 1hr 1 hr 1 hr 1hr 94% 34/36 90% (45/50) 87% (33/38) 87% (27/31) 97% (29/30) 88% (23/26) 90% (27/30) 96% (25/26) 83% (20/24) Data example reflects previous 6 & 24 bundles

Dashboard reporting ICU BM 68% Goal is 100% GOAL IS 3 hr for ED admits, or 1 hr for non- ED admits 6 HR SEVERE SEPSIS RESUSCITATION BUNDLE Antibiotic compliance Median time to antibiotic administration 4 Q 10 1 Q 11 2 Q 11 3 Q 11 4 Q 11 1 Q 12 2 Q 12 3 Q 12 69% 25/35 58% (29/50) 63% (24/38) 74% (23/31) 70% (21/30) 73% (19/26) 83% (25/30) 65% (17/26) 4 Q 2012 62% (15/24) 2 hr 3 hr 3 hr 2 hr 2hr 2hr 2 hr 2 hr 2hr Data example reflects previous 6 & 24 bundles

Provider Report Card - example Chart review date Clinican team: nurse physician NP/PA resident fellow other name Date of service: Patient medical record # Indicator # Criteria to be completed with 3 hours of severe sepsis 1 Measure lactate Indicator compliance Elaspsed time to meet indicator NOTES: 2 Obtain blood culture prior to administration of antibiotics 3 Administer broad spectrum antibiotics 4 Administer 30 ml/kg crystalloid for hypotensionor lactate 4 mmol/l # applicable indicators # indicators met 3 hour bundle compliance Criteria to be completed within 6 hours of severe sepsis 5 Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg Team comments: In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/l (36 mg/dl): 6 Measure central venous pressure (CVP) 7 Measure central venous oxygen saturation (Scvo2) 8 Remeasure lactate if initial lactate was elevated 9 Hospital Mortality (if known at time of report) # applicable indicators # indicators met 6 hour measured bundle compliance Achieve central venous pressure (CVP) 8 mm Hg Achieve central venous oxygen saturation (Scvo2) 70% Remeasure lactate if initial lactate was elevated 6 hour achieved bundle compliance

SSC-provider level feedback Clinical team Severe Sepsis Report Card Clinical team: nurse physician NP/PA resident fellow other name 3 hour bundle

Summary Importance of data collection Significance of drilling down to details Value of audit and feedback

Where do you start? Where will you look to improve?

Wrap Up Next Steps & CEU Instructions

Tune in tomorrow! Learn additional strategy and tools for sepsis mortality reduction SAME BAT TIME & CHANNEL

Welcome and Overview. Sepsis Mortality Reduction Boot Camp 3/20/2014