Sepsis: Overcoming Common Barriers...Code Sepsis ED ID Project Tools Predictive Analytics (EPIC...
Transcript of Sepsis: Overcoming Common Barriers...Code Sepsis ED ID Project Tools Predictive Analytics (EPIC...
Sepsis:Overcoming Common Barriers
Dr. Jim Frazier, MD, System VP of Medical Affairs
&
Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC
Clinical Nurse Specialist
Norton HealthcareLouisville, Kentucky
• 5 Acute Care Hospitals
– 1,837 licensed beds
• 7 Outpatient Centers
• 13 Norton Immediate Care Centers
• Nearly 14,000 employees
• Approximately 1,000 Employed Medical Providers
Objectives
Recognize the intricacy of the SEP-1 Core Measure
Compare state of the environment pre- and post-interventions implementation
Describe strategies to influence project management and system change for common barriers
SEP-1 Core Measure
• National standards of care and treatment processes for common conditions
– Proven to reduce complications and lead to better patient outcomes
– SEP-1 introduced October 2015
• All measures must be met to be compliant
SEP-1 Core Measure, continued
• Two main definitions of interest:
– Severe Sepsis
– Septic Shock
• Multiple criteria must align to “start the clock” for presentation time
• Provider documentation of severe sepsis or septic shock overrides criteria in most cases
Interventions
Processes
Code Sepsis
ED ID Project
Tools
Predictive Analytics
(EPIC tool)
Sepsis Screening Tool
Accountability
Facility sepsis meetings
Notification to RNs and
Providers
Failure Analysis Tool Development
Standardized tool to categorize misses and develop interventions
Operational definitions of categories defined
System and site lead both categorize misses and compare results
Interventions reviewed monthly
MonthPatient
ID Who What Why When Where How [to fix] Additional Comment
December APRN Late IVF A ED/ICU
STAR technique. Additionally
removing 250ml bolus from
standing orders will decrease the need to
recalculate the total fluid amount
ED NP saw a "bolus" was ordered and then ordered additional amount to meet total 30mL/kg bolus requirement. First bolus however was only 250mL, not 1L.
December MDwrong abx A ED Order sets
MD dx sepsis. Ordered abx to cover intra-abdominal infx however these abx don't meet SEP-1 guidelines
December MDinitial lactate UA ED
heightened awareness of
infection criteria
Criteria met: HR, RR, Cr, perf bowel. Additional note, IP ordered lactate however it was ordered as routine 0400
0
20
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60
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120
DI LOHT A UA O DI LOHT A UA O DI LOHT A UA O DI LOHT A UA O DI LOHT A UA O
Nu
mb
er o
f O
ccu
rre
nce
s Failure Category
NAH NBH NH NWCH SYSTEM
NHC System Sepsis Timeline
Noted Improvements
Jan17-Dec17*Norton System
Common Barriers: Bolus
Educate!
• Bolus only has to be initiated within 3 hours
• Lactate >=4 or 2 low BPs in 6 hour timeframe before or after time zero
Ideal Body Weight
Patient/decision maker can always refuse after appropriate provider
conversation
Focused exam can be completed after
initiation of bolus up to six hours after
presentation time
30mL/Kg IVF Bolus
Common Barriers: Repeat Lactate
Order sets – 2 lactates, second within 4 hours of
first
Exploring a reflex order if initial is
>2.0
Common Barriers: Documenting “Sepsis”
Show the dataGive the why
• Fixed payment based on DRGs
• Longer GMLOS for sepsis (compared to UTI, etc)
• Better representation of truly septic patients when officially coded and discharged
Common Barriers: Finding Your Champions
Ask for volunteers
Invest your time
Focus on high population areas
first
• ED, ICU, then IP and specialty services
• Don’t turn away any engagement!
Future Implications
Mentoring Leaders
Celebrating successes
Recognizing unique contributions
Improve accountability
References
• CMS Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-18 through 06-30-18, manual version 5.3
• Santistevan, Jamie (2016). Sepsis CMS Core Measure (SEP-1) Highlights. American College of Emergency Physicians. www.acep.org