Organization: Solution Title: Sinai Hospital of Baltimore Sepsis Mortality - A Four-Year Improvement Initiative Program/Project Description:What was the problem to be solved? How was it identified? What baseline data existed? What were the goals how would you know if you were successful? IDENTIFIED PROBLEMS 1. High mortality rate for DRG 416 /DRGs 870, 871, and 872 Sepsis, Severe Sepsis and Septic Shock. 2. Silo approach with focus on the inpatient services when analyzing the factors affecting the sepsis mortality.rate. 3. Inability to verify compliance with IHI Sepsis Resuscitation &/or Sepsis Management Bundles. BARRIERS TO EARLIER IDENTIFICATION: 1. Silos in care 2. Lack of evidence-based practice among the clinical services while caring for possible and/or ocnfirmed sepsis patient. BASELINE SEPSIS MORTALITY RATES 2005 21% 2006 20% 2007 20% GOALS 1. Decrease sepsis mortality rate by 10% for CY 2009 discharges with yearly decreases by providing evidencebased care for all patients with suspected and/or confirmed sepsis. 2. Identify system issues affecting the timeliness of diagnosis and medical intervention. 2. Deploy and activate an integrated Emergency Department and Inpatient medical staff-approved CPOE Early Goal-Directed Therapy order set. 3. Identify medical staff-approved sepsis indicators for monitoring compliance with evidence-based sepsis management. BASELINE SEPSIS INDICATOR RESULTS (January 2010) 1. Serum lactate obtained when three SIRS criteria met - 60% 2. Two sets of blood cultures ordered and obtained in the ED when three SIRS criteria met - 92% 3. IV Antibiotics ordered and given within 4 hours of presentation and/or symptom presentation - 68.4% 4. IV fluid resuscitation - 75% Process:What methodology or process was used to develop the Solution? A multidisciplinary team that included Nursing and Medical Staff representatives from the ICU, Emergency Department, Pharmacy, and the Chief of Internal Medicine was convened in August 2007 to develop an Early Goal-directed Therapy CPOE order set. The team reviewed the recommended Sepsis Resuscitation and Sepsis Management Bundles from the Institute of Healthcare Improvement and the 2008 International Guidelines for Management of Severe Sepsis and Septic Shock from AHRQ. Medical Staff approval of the Early Goal--directed Therapy order set in Cerner--occurred in October 2008. The approved order set and nursing protocol were
activated and made available in CPOE in February 2009. In November 2009, a computerized alert (see attached) prompted by vital sign measurements or the white blood count meeting three of the four SIRS criteria was deployed. The alert was designed to appear next to the patient's name within the ED physician's Cerner patient tracking list.and in the Patient Alert section in the patient's Cerner electronic medical record. The alert was designed as an order and would remain in the alert section of the electronic record and pop-up once every 24 hours when the record was opened until the "order" was discontinued by a physician. Solution:What Solution was developed? How was it implemented? 1. Created a CPOE order set for Early Goal-directed Therapy for Sepsis. 2. Created an electronic Sepsis alert prompt/order activated by any three of the vital signs and/or white blood cell count meeting three SIRS criteria.(see attached) 3. Identified four sepsis indicators for monitoring: Serum lactate ordered and obtained when three SIRS criteria met; Blood culture(s) obtained before IV antibiotic(s) administered; IV antibiotic(s) ordered and given within 4 hours of ED presentation when three SIRS present at presentation and/or within 4 hours of symptom presentation; and IV fluid resuscitation. 4. Serum lactate critical value (prompting call to the ED physician from the lab) changed from 4.9 to 4.0. 5. Decreasing the complications in patients with sepsis by requiring the use of ultrasound-guidance for central line insertions in the fall of 2009, following the IHI central line insertion bundle, and restricting insertion of Foley catheters to RNs only in November 2009. Measurable Outcomes:What are the results of implementing the Solution? Provide qualitative and/or quantitative results to data. (Please include graphs, charts, or tools as attachments.) Sinai Hospital has experienced a yearly decrease in the combined sepsis DRGs mortality rate since 2007. The 2010 combined DRGs sepsis mortality rate was 15.94%. Since beginning the sepsis initiative in August 2007, Sinai Hospital has achieved a 63.65% decrease in the combined sepsis DRGs mortality rate. The combined sepsis DRGs mortality rate for January 2011 through June 2011 is 12.73%. Since implementing sepsis specific indicator monitoring in CY 2010, compliance has improved in all of the Emergency Department sepsis management indicators.please see attached chart Sustainability:What measures are being taken to ensure that results can be sustained and spread? 1. The Emergency Department's Performance Dashboard and the Physician Contracted Service are linked to compliance with evidence-based practice. 2. Continued monitoring and providing compliance results timely on the established indicators. 3. Required reporting of the sepsis indicators by the ED at the Sinai Hospital's Performance Management Committee semiannually. 4. When greater than 95% compliance was consistently achieved for administering IV antibiotics within 4 hours of symptoms presentation in 2009, electively decreasing the time frame for administering IV antibiotics to 3 hours of symptom presentation in 2010. Role of Collaboration and Leadership:What role did teamwork and collaboration play in the Solution? What partners and participants were involved? Was the organization s leadership engaged and did they share the vision for success? How was leadership support demonstrated? Improvement required the cooperation of Information Services, Medical and Nursing leadership in the Emergency Department, the Emergency Department Advanced Practice Nurse, the ED Clinical IS Coordinator, the Respiratory Care Department, the Laboratory, the Pharmacy, Medical Leadership in the ICU, the Case Management Systems Administrator, and the Performance Improvement/Risk Management Department. The ED Medical Director and
the ED Advanced Practice Nurse were active participants in the development and deployment of the CPOE Early Goal-directed Therapy Order Set and the Sepsis Alert. The Chairman of the Emergency Department and the ED Advanced Practice Nurse addressed each case with a variation with the involved medical provider and/or nurse. Innovation:What makes this Solution innovative? What are its unique attributes? Use of technology to provide evidence-based practice thus creating an environment where the staff can do the right thing for "Every Patient - Every Time." Contact Person: Suzanne Butterbaugh Title: Performance Improvement/Risk Management Coordinator Email: sbutterb@lifebridge Health.org Phone: 410-601-9733
ANNUAL MORTALITY RATE 2005 2006 2007 2008 2009 2010 January - June 2011 Combined Septicemia DRGs Mortality Rate 20% 20% 19% 13.6%* 16.5% 15.94% 12.73% * Significant increase in the total DC coded with Sepsis as a principle diagnosis compared to CY 2005, 2006, and 2007. EMERGENCY DEPARTMENT SEPSIS PERFORMANCE INDICATORS BASELINE 2008 CY 2010 JANUARY - JUNE 2011 Obtaining Serum Lactate with 3 SIRS present 45% 60% 91.9% Blood cultures before IV antibiotics 92% 92% 98.1% Antibiotics given within 4 hours of presentation Not available 82.4% Antibiotics given within 4 hours of presentation 87.6% IV fluid bolus given as indicated for systolic blood pressure < 90 Not available 73.4% 100%