BREAKOUT SESSION Improving Sepsis Outcomes · BPH • ED triage VS: 139/104, 98, 30, 100.3 ® wbc...

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B R E A K O U T S E S S I O N

Improving Sepsis Outcomes Through Best Practices and Data Transparency

Assistant Vice President, Medical & Surgical Services, Valley Health System, Ridgewood, New Jersey

Bettyann Kempin DNP, NP-C, MS-HCM, CCRN-K, NEA-BC, FACHE

PRESENTED BY

Vice President, Quality Solutions Healthgrades

Debra Gradick MD, FACEP


Learning Objectives

•  Implementing process and organizational changes to improve sepsis outcomes

•  How to align providers to create clinical and organizational change

•  Using data and chart review to corroborate clinical change

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Ridgewood, New Jersey Valley Health System


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Ridgewood, New Jersey Valley Health System


Hospital Inhospital Mortality

Star Performance Cases Actual Predicted

Sepsis

Valley Health System, Ridgewood, NJ 1717 22.25% 19.37% ★"

Five-Star Requirement 1717 18.05% 19.37% ★★★★★"

National Average 472 17.18% 17.25% ★★★"

State Average 714 20.43%

Hospital A 1154 18.80% 16.87% ★" "Hospital B 1715 20.82% 23.59% ★★★★★"

Hospital C 894 19.02% 15.54% ★"

Hospital D 1931 19.68% 21.15% ★★★★★" "Hospital E 726 22.87% 16.47% ★"

Benchmarks & comparative data (medpar 2011-2013) Sepsis – 2015 data table (prior outcomes)

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Why Healthgrades Quality Solutions?

•  Partnership dates back to 2006

•  Quality Rating Assessments in:

•  Cardiac, Orthopedics, GI, Vascular, Pulmonary, Critical Care, etc.

•  Intimate knowledge of the organization and its performance

•  Team members committed to the effort

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Solution: Engaged Healthgrades Quality Solutions group

Quality assessment and improvement plans for sepsis

•  Assessed efficacy of clinical structure and processes

•  Identified opportunities for improvement based on current best practices

•  Customized solutions

•  Assessed documentation and coding

•  Identified metrics for success

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Strategy for innovation

•  Formation of a sepsis subcommittee

•  Monthly review of data

•  Frequent on-site meetings

•  Reports to (and engagement from) C-suite executives on progress

•  Accountability (internally and at HG) for making requisite changes

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Focus on Multidisciplinary Approach Teamwork

•  Healthcare providers from:

•  EMS

•  ED

•  Inpatient/CC

•  Informatics

•  Quality

•  Community Education

•  Medical Records

•  Healthgrades


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Process changes: Emergency medical services

•  July 1, 2013 — pre-hospital sepsis protocol in effect utilizing SIRS criteria

•  Mandatory EMS sepsis education

•  Criteria developed in conjunction with ED physicians and EMS medical control

•  Patients meeting criteria receive specific clinical interventions


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Process changes: Emergency department

•  SWAT nurses

•  Real-time triage flag for VS consistent with sepsis

•  Sepsis tracker

•  Electronic checklist for seamless transition of care

•  ED sepsis order set

•  Lactic acid reflex order


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ED Sepsis tracker and checklist


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Process changes: Inpatient

•  Sepsis order set – inpatient

•  Sepsis surveillance board

•  RRT real-time notification paging system

•  Lactic acid reflex order in EMR

•  Nurse-driven lactic acid order

•  Process for repeat focused exam


Surveillance Board

Indicator Public Tracker

Multiple ways to monitor sepsis electronically Informatics: Checks and balances

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Palliative care pathway in the ICU Process changes: ICU

•  Robust multidisciplinary rounds

•  Patient criteria for palliative care

•  Nurse-driven palliative consult

•  Day 3-5: Have family meeting to establish goals of care


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Process changes: Technology

•  Worked with Registration to ensure accurate capture of admission source

•  Collaboration between HIM and providers to establish appropriate documentation for capture of palliative care

•  Templates developed (with the aid of Informatics) to accurately document repeat focused exams at 3/6 hours


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Process changes: Quality department

•  Creation of data collection tool — Sepsis Dashboard

•  Shared drive

•  Physician communication — feedback to providers on opportunities identified in case reviews

•  Intensivist review of outlier cases


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Collect process and timing metrics along with labs, palliative care, and EMS alerts

Sepsis dashboard example

Arrival DateArrival Time

Inpatient Sepsis

Order Set Utilized

Inpatient Sepsis

Order set-Time

Ordered

Sepsis Diagnosis

Date

Sepsis Diagnosis

Time

First Order By Intensivist

DateFirst Order By

Intensivist TimeCC

Physician

Serum Lactate

Measured (Y/N)

Date & Time Lactic

OrderedLactic Result

Serum Lactate

Repeated to

Monitor Fluid

Resusitation (Y/N)

Blood Cultures Obtained Prior to

Antibiotic Administr

ation

Broad Spectrum Antibiotics

administered within 3 hrs

of ED Admission

(Y/N)

Date & Time Abx Ordered

(Administered)

Broad Spectrum Antibiotic

s Administ

ered Within 1 Hour Of

ICU Admission (Y/N)

Initial Bolus 30 ml/kg of

Crystalloid or

Colloid Equivalen

t (Y/N)

Patient Respondi

ng To Fluid

Did Patient

Get Started

On Vasopres

sors

Date & Time

Pressors Ordered

8/10/2016 1810 N N/A 8/21/2016 1852 8/21/2016 1408 Suffin Y 8/10/2016@1921 1.9 N Y N8/11/2016@0316 N/A N N Y

8/21/2016@1950

8/24/2016 2250 Y8/25/2016@0105 8/25/2016 0131 8/24/2016 2355 Jacoby Y 08242015@2335 7.3 Y N Y

8/25/2016@0109 N/A Y(notgiven) N Y

8/24/2016@2332


Sepsis review example Chart review

Patient ID/Age/Sex

Admit Date

LOS Presenting Symptoms

Comorbidities Hospital Course

MRN XXXX 80 / M

9/5/XX arrival: 1550 Seen by ED MD: 1609

2 Sent in from SAR with fever, AMS, and SOB CXR -> RLL PN BIB Valley EMS Sepsis Alert in the field

Recent hip fx- s/p repair, Dementia, DVT, Parkinson’s, BPH

•  ED triage VS: 139/104, 98, 30, 100.3 ® wbc 7.1, SCr 1.9, lactate 6.5, CXR->bilat infiltrates

•  Given ceftriaxone and Zithromax in the ED; 500cc IVF and admitted to med/surg for PN/dehydration

•  Developed AF with RVR and became hypotensive

•  Transferred to ICU; Amiodarone started and Zosyn added.

•  9/6- Cardiology consulted for management of AF;

•  Palliative Care involved to help establish goals of care-> patient made DNR/DNI

•  O2 sat now 88%; BiPAP started

•  9/7- Still hypotensive despite IVF boluses; pt. taken off pressors at family’s request; transitioned to comfort care and expired

Considerations: Initial volume resuscitation not as per EGDT; admission to non-ICU bed Exceptional Care: Sepsis alert by EMS; Early involvement of Palliative Care

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2017 Valley Health System Sepsis Outcomes

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2012-2017 Healthgrades award years

Valley Health System Healthgrades outcomes (Medicare)

Cohort 2017 2016 2015 2014 2013 2012

Sepsis ««««« ««« « « « « Stroke ««««« ««« « « « « Resp. Failure ««««« ««« « « « «

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2013-2016 (All payer data) Improvement in sepsis outcomes

19.95% 15.93% 16.96%

16.93%

26.90%

21.06%

33.45%

29.23%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Year 1 Year 2 Year 3 Year 4 (Q3 15 - Q2 16)

Actual

Predicted

18% reduction in mortality rates since 2013!!!

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-5.40 -5.07

-2.87

0.56

2.99

-6.00

-5.00

-4.00

-3.00

-2.00

-1.00

0.00

1.00

2.00

3.00

4.00

Medicare Data

2017 Healthgrades outcomes – Sepsis for Valley Health System

5 star in 2017!!!

2012 2013 2014 2015 2016 2017

1 1 1 1 3 5!!!

Z score by year 2013-2017

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BREAKOUT SESSION Improving Sepsis Outcomes · BPH • ED triage VS: 139/104, 98, 30, 100.3 ® wbc...

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