Northwell Sepsis Collaborative Evidence Based Best Practice

Northwell Sepsis Collaborative Evidence Based Best Practice M. Isabel Friedman, DNP, MPA, RN, BC, CCRN, CNN, CHSE Director of Clinical Initiatives Department of Clinical Transformation Nicholas DaCosta, MBA Program Manager Department of Clinical Transformation

Agenda 1.Sepsis - The Northwell Experience 2.History of the Collaborative 3.Treatment Goals 4.Treatment Tools 5.Collaboration and Education 6.The Collaborative Model 7.Supporting resources 8.Results 9.Lessons Learned 10.Questions 1

The Northwell Sepsis Experience 3

Northwell Sepsis Collaborative Timeline 2008 CEO Michael Dowling Prioritizes Sepsis as a organizationwide initiative 2010 Focus on ED Developed Northwell Sepsis Algorithm and Code Sepsis 2011 Taming sepsis Education Program (TSEP ) for nursing 2015 Primary Focus on Fluid Administration 2009 Northwell Health convenes the Sepsis Taskforce 2011 Partnership with IHI Focus on Inpatient units 2012 Taming sepsis Education Program (TSEP ) for Physicians 4

In the Beginning In 2008, President and CEO, Michael J. Dowling, prioritized sepsis as a Northwell Health, organizational-wide initiative. In 2009 Northwell Health convened an interprofessional group of clinicians from the emergency department (ED) and critical care to form the Northwell Health Sepsis Taskforce. The taskforce was charged with reducing Northwell Health s mortality by 50% in five years. Initial efforts started in the ICU 5

Focus on ED In 2010 Northwell hosted the Merinoff Symposium on Sepsis In 2010, the group developed triage criteria to screen emergency department patients for sepsis and began redesigning processes to accelerate bundle compliance. Development of the ED Code Sepsis and the development of the concept of Super SIRS The taskforce developed Sepsis algorithms, order sets and screening tools which was disseminated to all the emergency departments. 9

Goals for ED Treatment 1. Identify at Emergency Department triage, patients with a high probability of Severe Sepsis and identify at ESI level 1 or 2 2. Implement all resuscitation bundle elements for Severe Sepsis: - Lactate and Blood Cultures drawn within 30 minutes of T-0 - Blood Cultures drawn before antibiotics - Antibiotics within 60 minutes of Diagnosis of Severe Sepsis - Fluid Bolus administration initiated within 30 minutes of Diagnosis of Severe Sepsis - Fluid bolus administration of crystalloid at 500 ml q 15 min to total volume of 30 ml/kg - Initiate six hour bundle if lactate still > 4 or hypotension persist after fluid bolus Prevent worsening sepsis by early detection and prompt treatment 11

Super SIRS Definition created by Northwell Health to identify very sick patients who would benefit from early interventions. The goal was to bring resources to the patients who would benefit from early intervention regardless of the diagnosis. It can be noted that Super SIRS criteria is similar to qsofa Systolic BP < 100 mm/hg Respiratory rate > 22 Altered Mental Status Criteria Temp > 101 F or < 96.8 F OR Recent Fever, OR Clinical suspicion of Infection. SBP < 90 OR in SBP > 40 mm Hg from baseline, OR MAP < 65 Pulse > 120 bpm Respiratory rate > 24 / min New Unexplained Altered Mental Status 2

Code Sepsis Developed code sepsis for patients who meet super SIRS criteria or who are in severe sepsis/ septic shock Bring more resources to the bedside to facilitate prompt treatment and accurate documentation Mandatory for EDs throughout the organization 13

Northwell Sepsis Treatment Tools 14

ISPOSITION DISPOSITION INTERVENTION INTERVENTION ARRIVAL AND EVALUATION ARRIVAL AND EVALUATION Northwell Health ED Sepsis/Severe Sepsis Management Patient with suspected significant infection (i.e. possible admission) POSSIBLE SEPSIS PLUS Probable Severe Sepsis Two of the following: SIRS Criteria: Two of the Temp > 101 F or < 96.8 F OR Recent following: Fever, OR clinical suspicion ofinfection. Temp > 101 F or < 96.8 F SBP < 90 or in SBP > 40 mm Hg from Pulse > 90 bpm baseline, or MAP < 65 Resp Rate > 20/min Pulse > 120 bpm T-0= WBC > 12K, < 4K or Bands > 10% Resp rate > 24 / min Triage New Unexplained Altered Time Mental Status Clinician evaluates patient and suspects early sepsis; orders labs (must include lactate/ BCs X 2). Code SEPSIS Northwell Health Inpatient Sepsis/Severe Sepsis Management Patient with known or suspected significant infection) PLUS SEPSIS SIRS Criteria: Two of the following: Temp > 101F or < 96.8 F Pulse > 90 bpm Resp Rate > 20/min WBC >12K, <4K or Bands>10% Clinician evaluates patient and suspects early sepsis; orders labs (must include lactate/ BCs X 2). SEVERESEPSIS 1. Two RNs to bedside if possible. 2. Place 18 G IV, Ask MD re: 2 nd Line & Foley 3. Draw Labs for Sepsis Panel in < 30 min. 4. Prepare for Fluid Bolus, Alert X-Ray tech 5. Source Control as appropriate 6. Consider transfer to a higher level of care T-0 = Lactate SEPSIS ACTIVATE Code Sepsis Order 1. Activate Code Sepsis in ED 2. Two RNs to bedside if possible. 3. Place 18 G IV, Ask MD re: 2 nd Line & Foley 1. Document Accurate Blood Culture 4. Draw Labs for Sepsis Panel in < 30 min. and Lactate draw times 5. Prepare for Fluid Bolus, Alert X-Ray tech 2. Repeat Vital Signs in 30 minutes 6. Source Control as appropriate 3. Source Control as appropriate Severe Sepsis ResuscitationElements Lactate draw < 30 min and result < 90min Sepsis Resuscitation Elements BCs X 2 ordered and drawn before Antibiotic (Unless clinically contraindicated) Antibiotics < 60 min of Code Sepsis Lactate ordered and resulted < 90 min IVF bolus started < 30 min of Code Sepsis BCs X 2 ordered and drawn before Abx Fluids: NS 500 ml boluses q 15 min to total Abx < 3 hrs of arrival 30mL/kG of actual body weight IV fluids consider NS 1-2 L over 2 hrs Repeat lactate approximately 30-60 min s/p Repeat lactate if initial lactate is elevated fluid bolus completion Monitor, document VS < q 60 min Cont. monitoring, document VS q 15 min x 90 minutes, then q 60 minutes DURING ED COURSE Severe Sepsis DxCriteria met (Dx SS) if: YES Code Repeat Lactate > 4 or Lactate > 2.0OR SEPSIS SBP < 90, or in SBP Persistent SBP < 90 > 40 mm Hg from NO YES baseline, OR MAP < 65 NEW End Organ Monitor VS, Septic Shock Bundle Severe Sepsis VS Dysfunction mental status, Consider Additional NS criteria met OR PaO2/FiO 2 ratio< 300 etc boluses and/or New End Organ Increasing O2 demand StartVasopressor Norepinephrine (0.05 Dysfunction (SEE BOX) to maintain sat > 90% micrograms/kg/min NO Cr > 2.0 or> 50% increase from known Path Complete Repeat Lactate level Continue monitoring VS, baseline Document approximately 30-60 mental status, etc. Urine Output< 0.5 Primary Dx: min s/p fluid bolus ml/kg/hr for > 2 hrs Severe Sepsis completion Bilirubin >2.0 mg/dl Secondary Dx: Clinical volume Platelet Count < 100K Suspected reassessment within Path Complete INR > 1.5, Source 6 hrs Document PTT > 60 sec Primary Dx: Sepsis, Newonset altered Path Complete 1. Document Accurate Blood Culture and Lactate draw times 2. Repeat Vital Signs in 30 minutes 3. Source Control as appropriate Sepsis Resuscitation Elements (Unless clinically contraindicated) Lactate ordered and resulted < 90 min BCs X 2 ordered and drawn before Abx if not already drawn within past 48 hrs Initiate or confirm Abx < 3hrs IV fluids consider NS 1-2 L over 2 hrs Repeat lactate if initial lactate is elevated Severe Sepsis Dx Criteria met (Dx SS) if: SBP < 90, or in SBP > 40 mm Hg from baseline, OR MAP < 65 New End Organ Dysfunction (SEEBOX) Lactate > 2.0 NO Continue monitoring VS, mental status, etc. Path Complete Document Primary Dx: Sepsis, Secondary Dx: SuspectedSource YES NEW(otherwise unexplained) End Organ Dysfunction PaO2/FiO 2ratio <300 Increasing O 2 demand to maintain sat > 90% Cr > 2.0 or > 50% increase from known baseline Urine Output < 0.5 ml/kg/hr for > 2hrs Bilirubin > 2.0 mg/dl Platelet Count < 100K INR > 1.5, PTT > 60 sec New onset altered Mental Status Lactate > 2.0 Severe Sepsis Resuscitation Elements Lactate draw < 30 min and result < 90 min BCs X 2 ordered and drawn before Antibiotic if not already drawn within past 48 hrs Initiate or confirm appropriate Antibiotics < 60min IVF bolus started < 30 min of Severe Sepsis recognition Fluids: NS 500 ml boluses q 15 min to total 30mL/kG of actual body weight Repeat lactate approximately 30-60 min s/p fluid bolus completion Cont. monitoring, document VS q 15 min x 90 minutes, then q 60 minutes NO Monitor VS, mental status, etc Path Complete Document Primary Dx: Severe Sepsis SecondaryDx: Suspected Source Repeat Lactate > 4 or Persistent SBP < 90 YES Septic Shock Bundle Consider Additional NS boluses and/or Start Vasopressor Norepinephrine (0.05 microgram/kg/min) Repeat lactate approximately 30-60 min s/p fluid bolus completion Clinical volume reassessment within 6 hrs Path Complete Document Primary Dx: Septic Shock, Secondary Dx: SuspectedSource Consultation, disposition, and transfer of care can occur at any point in the above care map. Hand off communication is critical and must include discussion of incomplete and complete elements. 15

Sepsis Order Sets 16

Sepsis Screening and Documentation Sepsis Screen Treatment Documentation 17

Collaboration and Education In 2011, The Taming sepsis Education Program (TSEP ) was developed as a comprehensive system-wide nursing sepsis education in four specialty areas. 2011 Partnership with IHI to assist with developing the collaborative structure and introduce PDSA methodology. In 2012, TSEP was available for physicians in four distinct specialties. 18

Nationwide collaboration Provided education on improvement science methodology IHI - PDSA Joint Commission, - Robust Process Improvement (RPI) HVHC/Dartmouth institute Lean Help establish collaborative frame work Northwell modified the IHI model and adapted to fit organizational needs Facilitates sharing of best practices 19

Taming Sepsis Education Program (TSEP ) Methodology Multimodal educational modality Online and live simulation Pre and post tests Specialized for Critical Care, ED, medical surgical, and pediatric Case studies developed by clinical content experts Expanded to include Physician modules Implementation Developed by Northwell s Center for Learning and Innovation supported by funds from HRSA grant award* Copyright obtained Part of onboarding process for physicians and nurses Has educated over 9,000 nurses and 300 physicians since 2011 Incorporated Sepsis Education into annual mandatories 20

Current Focus In 2015 to the present, Fluid administration is the primary focus of improvement efforts In 2016, secondary focus on repeat lactate levels was site specifically added Currently our goal is to reduce mortality in Northwell Health to single digits 21

The Collaborative Model 22

Collaborative Philosophy The Collaborative Model is a methodology of implementing large-scale process changes in segments small enough to understand. The impact of each small change can be easily evaluated, and best practices identified The Collaborative relies on the collective knowledge of participants, support from internal faculty, experts, and information from current literature and evidence-based guidelines The Collaborative will provide facilities a strong framework for taking action to achieve, sustain, and disseminate breakthrough improvements Teams will benefit from interaction with clinical experts and collaborative learning, and build on the progress and experience of other facilities Senior Leadership support is critical to success 23

Collaborative Structure Sepsis Faculty Executive Director Executive Sponsor Team Lead Team Identify the goals and aims of the Collaborative Participate as Core Faculty Drive Collaborative through education and support Identify Executive Sponsor Support project throughout the facility Identify team members and help select Team Lead Support and mentor facility team Address and resolve concerns and project issues Share success with site Leadership Manage meeting calendar and guide team in Process Improvement (PDSA) Point of contact for site Participate in Taskforce and Collaborative Calls Provide progress updates to Executive Sponsor Plan, design, and enact PDSAs Report outcomes to Collaborative Design follow up PDSAs to develop reliable processes Identify challenges and areas for future improvement 24

Collaborative Expectations Each Northwell Facility has at least one Sepsis Team (Emergency Department and/or Inpatient) Teams have monthly site meetings to discuss their challenges and devise solutions, which are tested using improvement science methodology (PDSA) PDSAs are uploaded monthly to a Team Shared Site. The PDSAs are reviewed by the improvement science mentor and clinical chair and feedback is given to the team lead All teams present their Improvement Science work at a monthly Collaborative Call where there is a sharing of challenges and best practices 25

Sepsis Collaborative Process Improvement Strategy The PDSA Methodology will be used by teams to measure performance of process redesign goals Plan Plan Develop the plan based on a needs assessment Act Do Do Study Execute the plan Collect data and review performance indicators Study Act Adjust, adopt or abandon 26

Overview of Meetings Meeting Purpose Who Frequency Availability Faculty Meeting 1. Governing Body for the Collaborative 2. Address issues and ideas put forth by sites 3. Discuss regulatory changes/requirements 4. Ensure health system policy is in line with Evidence based practice Sepsis Faculty Monthly Web Ex/ Inperson Learning Sessions 1. Enhance understanding and applications of evidence 2. Gather new skills to accelerate improvement 3. Get connected to colleagues to share stories & best practices 4. Make solid plans for taking action immediately All Members Bi-annually In-Person Taskforce Meeting 1. Provide a forum for discussion between members and the faculty 2. Display System/site metrics All Members Monthly Web Ex/ Inperson Collaborative Call 1. Provide teams an opportunity to present their PDSA to the collaborative 2. Provide site with expert feedback from Improvement science advisors All Members Monthly Web Ex/ Inperson 27

Supporting Resources 28

Data Organization-wide Database Created for Reliability 29

Reports 30

Report Notes: Sepsis, Severe Sepsis & Septic Shock discharges based on the following secondary ICD-9 codes: 99591 (Sepsis). 99592 (Severe Sepsis). 78552 (Septic Shock) is a subset of 99592 and is included in this report. The following ICD-10 codes for Sepsis, Severe Sepsis & Septic Shock are included after September 2015: 'A400', 'A401', 'A403', 'A408', 'A409', 'A4101', 'A4102', 'A411', 'A412', 'A413', 'A414', 'A4150', 'A4151', 'A4152', 'A4153', 'A4159', 'A4181', 'A4189', 'A419','A427','A5486', 'A021','A227','A267','A327','B377','R6520','R6521'. Excludes patients under 18 years of age and discharges to the Hospice service. 31 Copyright 2017 Krasnoff Quality Management Institute. Data Source: Hospital Billing. Data as of 9/13/2017.

Sepsis SharePoint Site 32

Site Lessons Learned Pyxis in ED stocked with Sepsis appropriate antibiotics Pharmacist responds to all Code Sepsis called VBG Lactate done in ED to improve turn around time to results RRTs called on inpatient units (similar to code sepsis concept) Sites created a Sepsis Toolkit Lime green Sepsis alert labels created to facilitate lab accessioning of Sepsis blood work Sepsis stickers with the bundle requirements put on ED patient charts Super SIRS criteria developed for ED use and now transferred to the inpatient units Chief Residents or their designee carry a Sepsis beeper and are charged with answering all Code Sepsis/RRT and all necessary follow up of bundle element compliance Initiation of fluids within 30 minutes of recognition of Severe Sepsis 33

Northwell Health Lessons Learned Strategic Initiative Corporate infrastructure and support Transparent non-punitive environment Need Site Support and buy in Dedicated Team Lead Site Champions and team members Sharing of best practices Learning from other site s challenges 34

References Leisman, D., Wie, B., Doerfler, M., Bianculli, A., Ward, F., Akerman, M., D Angelo, J., & D Amore, J. (2016). Association of fluid resuscitation initiation within 30 minutes of severe sepsis and septic shock recognition with reduced mortality and length of stay. Annals of Emergency Medicine, 68,(3): 298-311. doi.org/10.1016/j.annemergmed.2016.02.044 Leisman, D., Doerfler, M., Ward, M.F., Masick, K.D., Wie, B., Gribben, J., Hamilton, E., y Klein, Z., Bianculli, A.R., Akerman, M., D Angelo, J., & D Amore, J. (2017). Survival benefit and cost savings from compliance with a simplified 3-hour sepsis bundle in a series of prospective, multisite, observational cohorts. Society of Critical Care Medicine, 45(3):395-406. doi: 10.1097/CCM.0000000000002184 Seymour, C., Gesten, F., Prescott, H., Friedrich, M., Iwashyna, J., Phillips, G., Lemeshow, S., Osborn, T., Terry, K., & Levy, M. (2017) Time to treatment and mortality during mandated emergency care for Sepsis. The New England Journal of Medicine 376:2235-2244. DOI: 10.1056/NEJMoa1703058 35

Questions? Thank You