UMMS Sepsis Program
Transcript of UMMS Sepsis Program
UMMS Sepsis Program
June 2021 | Edition 1
NEWSLETTER
Dr. Tom Scalea
Physician in Chief
Shock Trauma
Sepsis Program
Executive Sponsor
For more information contact:
Dorsey Dowling, Program Facilitator | [email protected]
“We want to reiterate the magnitude of the problem. These
statistics represent individual patients that die.
We want to highlight the power of harnessing all of the
expertise available locally to hone down on this particular
disease.
We want to thank all the individuals at the UMMS
institutions for their past and future cooperation.
We want to highlight the need to use accurate data of the
highest quality and accuracy.
Buckle your seatbelts, here we go!!!”
Sepsis at UMMS hospitals remains a significant cause of mortality. In our first program
newsletter, we are highlighting our most recent efforts to identify barriers, compare practice and
improve processes. We believe we can make great strides by focusing on a consistent methods
for decreasing morbidity and mortality secondary to sepsis.
Three system subgroups have been formed to explore barriers and opportunities by:
establishing a better understanding of when and how clinician’s diagnose sepsis; a Tableau
Dashboard to aid interrogation of data for promoting timely antibiotic administration; and related
diagnostic processes aimed to reduce the time from blood culture order to bacterial identification
and antimicrobial susceptibility results. We will continue to grow our program and expand our
interventions as we continue to learn lessons from our efforts and establish shared expectations
for a system approach.
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Tackling Sepsis
“Tackling the overall sepsis clinical
performance improvement initiative described
in this newsletter is in my opinion, one of the
most important tasks that falls under the
umbrella of clinical transformation for the
University of Maryland Medical System.”
UMMS hospitals treat about 10,000 patients each year with a
primary or secondary diagnosis of sepsis.
Our overall sepsis mortality rate is 10.2%, and
20.2% for severe sepsis and septic shock patients.
All of this tells us that we have real opportunity to limit the variability in the way that we
approach the care of patients with sepsis across the System, to ensure that we are
tracking our performance consistently and that overall, we are delivering the best possible
care to the patients who put their trust in us every day.
This effort focuses on diagnosing patients sooner, treating them more quickly and
responding to them faster when they develop evidence of decompensation in the
hospital. Those are three important cornerstones to UMMS’ effort to combat sepsis. If we
do those things effectively, we will be more successful and our patients will benefit.
As we progress further in this effort, we will memorialize our performance improvement
targets and incorporate them into the overall structure through which we evaluate the
performance of our senior executives and in fact our entire organization. This effort is
intended to literally put everyone's skin in the game of improving the quality of care our
patients receive.
These efforts are hopefully only the beginning of our trek toward improved care for sepsis
patients. We need to work more closely with our primary care, case management and
social work colleagues to ensure that the care our patients receive after their discharge
from our hospitals and prior to ever being admitted to one of our hospitals is focused on
limiting the impact of sepsis. All of this is part of our statewide effort to improve the health
of Maryland and in doing so, to limit the total cost of healthcare for all of our citizens.
It is a true privilege to work with the group of individuals engaged in this particular project
under the leadership of Dr. Scalea. I sincerely look forward to the improvement in quality
and patient safety that will result from these efforts.
Andrew N. Pollak, M.D.
Senior Vice President for
Clinical Transformation
& Chief of Orthopedics
The O:E mortality varies from 0.48 to 1.30 for hospitals within our system.
Our O:E for readmissions of patients whose initial discharge diagnosis
includes sepsis is 0.74 overall and varies from 0.48 to 0.96.
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Sepsis Program Development
Sepsis is a public health threat that
requires both population- and
system-based solutions
Sepsis represents a significant global risk to public health.
While the worldwide burden is difficult to ascertain, there are
over 48 million cases and 11 million sepsis-related deaths
each year, accounting for almost 20% of global deaths (1-3).
This life-threatening complication of infection remains the
leading cause of non-coronary deaths in ICUs and has an
overall case fatality rate that ranges from 10 to 50% depending
on patient factors and severity (2-3).
Approximately one half of all cases occur outside the ICU and
one quarter of patients die from sepsis at some point during
hospitalization (1-2). Hence, sepsis cannot be solely
conceptualized a s problem of individual patients in our
emergency departments and intensive care units.
Sam Galvagno, DO, PhD,
Physician Sponsor
We have made many strides towards reducing sepsis-related mortality in our healthcare
system. For known cases of sepsis, system-wide mortality has fallen from 14.3% to 10.2%
from 2016 to 2020. We have made significant progress regarding data analytics, early
antibiotic administration, early recognition, and definitive diagnosis. We still have more work
to do, especially given the unavoidable interruptions caused by the unprecedented COVID-19
pandemic. Moreover, as we have discovered with our work, the complexities of sepsis
preclude any one-size fits all policy.
In the past, I presented the sepsis work done at Intermountain Healthcare—an internationally
recognized organization that embarked upon a similar journey in 2005. Since that time,
Intermountain has made record strides in decreasing sepsis-related mortality across their
healthcare system. We believe we are well positioned to do the same! Our organized
approach is largely modeled after the Intermountain experience, and we believe that with
early identification, standardized evaluation, and rapid, consistent interventions, we too can
continue to decrease sepsis-related morbidity and mortality throughout our healthcare system.
We thank you for joining us on this important journey!
References:
(1) Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and
national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet
(London, England). 2020;395(10219):200-11.
(2) World Health Organization. WHO Report on the burden of endemic health care-associated infection
worldwide. 2017-11-21 15:11:22 2011.
(3) Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for
Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315(8): 801-10.
The primary objective
of our UMMS sepsis
program is to reduce
mortality by
consistently applying
evidence-based
interventions. Early
identification and
prompt treatment
remain cornerstones
for achieving our
desired clinical
outcomes.
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Timely Antibiotic Administration
PAF Columns (added to Patient List):
Sepsis outcomes have improved over the years, however,
mortality still remains between 10-50%. Much of the work from
the Surviving Sepsis Campaign1 has focused on rapidity of
treatment once the diagnosis of sepsis has been made. One
element of the SSC guidance has been early antibiotic
administration. This is mainly due to a retrospective analysis by
Kumar, et al. that showed an average 7.6% decrease in mortality
for every hour there was a delay in receiving antibiotics after
onset of septic shock2.
Other studies have also shown benefit of timely antibiotic
administration3,4. It is important to note that many of the available
studies are retrospective and difficult to delineate confounding
factors such as patient complexity, time to identification, etc.
Overall, it is recognized and agreed that timely antibiotic
administration from the time the order is placed is beneficial
References:
1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for
management of sepsis and septic shock. Crit Care Med. 2017;45(3):486-552.
2. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial
therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596.
3. Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis
and septic shock from the first hour: results from a guideline-based performance improvement
program. Crit Care Med. 2014;42(8):1749-1755.
4. Gaieski, DF, Mikkelsen, ME, Band, RA, et al. Impact of time to antibiotics on survival in patients with
severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency
department. Crit Care Med. 2010;38(4):1045-1053.
Given the above, the Timely Antibiotic Workgroup has released a Tableau Dashboard as a
tool to stimulate discussion and help our site hospitals be able to accurately measure time
from antibiotic order to time of administration.
ACTION PLANNING
From June, local sepsis committees will use it to help investigate why there may be delays in
administration in <60 min. from the time of order. They will be asked to draft action plans for
submission at the end of August. At that point we will collect baseline data for internal,
quarterly comparison. From September, we hope these plan will help to drive improvements
that will meaningfully impact patient care as we begin to set nursing and provider performance
measures for 2022.
We thank all the members of the Data Analytics and Quality Business Intelligence Teams that
developed the dashboard through validation and production.
Antibiotics are an important part of sepsis management. Overall, this is one portion in the
much larger work that the Sepsis Program is focusing on to provide meaningful positive
impacts on the care of our patients.
Mary Ghaffari, PharmD.
Sub-Group Lead
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Timely Abx Administration Dashboard
On 13 May 2021, the Timely
Antibiotic Dashboard that
was launched as an
investigative tool to inform
process improvements that
will remove barriers to
antibiotic administration.
The following is a brief illustration of the four main tabs within the dashboard. Users can
filter tabs by facility, department, transfer status and arriving by ED, if the diagnosis included
“severe/shock”, and whether the medication was available in the automated dispensing
cabinet or was delivered by pharmacy, etc.
Please contact Samantha Wilkes: [email protected] if you would like to request
access to the dashboard. We encourage users to be contributors to their local sepsis
committees and contribute to the investigations and action planning for improvements.
Samantha Wilkes
Quality Sr BI Analyst
Mike Sokolow
Sr Dir BI & Quality Mangt
Time Trend Tab 1: Allows you to see the percentage of medications
that were given within each time bucket from time of order placed by facility.
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Timely Abx Administration Dashboard Cont.
Compliance Tab:
Allows you to see the
breakdown of total numbers
and percent within targeted
time frame verses not meeting
target.
Case Details Tab:Allows you to see the
breakdown of Medication by
Time Bucket and ability to
drill down to the see
encounter details.
Indication tab: Allows you to see which
antibiotics are being
administered and the
indication chosen. This will
help in determining
appropriateness of the
antibiotic choice, if particular
antibiotics are more commonly
seen in not meeting target, etc.
Sepsis Dashboard Wiki page
http://mrxlate.umm.edu/w/index.php5/Sepsis_Timely
_Antibiotics_Dashboard
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Infection Management
As we move forward with standardization of timely care delivery for sepsis, we
are prioritizing the development and implementation of a unified definition of
sepsis across our medical system in all domains.
We have brought together a team of hospitalists, intensivists, and emergency
medicine physicians to draft a proposed sepsis definition after a thorough analysis of
the available supporting evidence. We are leveraging the expertise of our quality,
clinical documentation, coding, and finance teams to understand downstream
implications.
Concurrently, we will be partnering with a clinical research team at UMMC to survey
our medical staff to gain insights into the practice variation in the clinical definitions
of sepsis that are being utilized at the individual physician-level.
A shared definition of sepsis will enable us to obtain a deep
understanding of the impact of our current sepsis processes and
programs throughout UMMS. This understanding will inform the next
steps in getting the most effective sepsis care to each of our patients at
the most appropriate time.
Jason Heavner, MD
Subgroup Lead
Early diagnosis and intervention is paramount to achieving
successful sepsis outcomes. Despite the significant
contribution that sepsis has on morbidity, mortality, and critical
care resource utilization, there is notable variation in the
diagnosis of sepsis across UMMS—a 2-fold difference in
diagnosis rate ranging across our hospitals. This rate of sepsis
diagnosis varies provider-to-provider, department-to-
department, and hospital-to-hospital. Standardization of
diagnostic criteria is further complicated by the varying criteria
used for core measures, the MHAC program, and other quality
metrics and reporting requirements around sepsis.
A Shared Definition of Sepsis
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Sepsis Survey Overview
Prompt and appropriate diagnosis of sepsis can be challenging as multiple definitions have
been used over the years and patients’ presentations vary. Timely recognition and initial
interventions are critical for good outcomes as well as meeting quality metrics. To move
forward with an initiative to improve consistency of sepsis diagnosis and management, an
understanding of current approaches across different specialties (emergency physicians,
intensivists, hospitalists, advanced practice providers), locations (Emergency Department,
Intensive Care Units, Medical floors), and hospitals would help.
Consequently, we have designed a survey to evaluate provider understanding of sepsis
definitions and current practices regarding the initial diagnosis and interventions for patients
with sepsis.
The project will involve 2 separate surveys.
1.
2.
Sam Tisherman, MD
We will conduct interviews using a qualitative questionnaire with experienced
emergency physicians, intensivists, hospitalists, and advanced practice providers
to understand their definition(s) of sepsis, describe the findings (symptoms, signs,
laboratory values) that key them into the diagnosis of sepsis, and describe the
interventions they initiate once sepsis has been identified. Participants from all
UMMS hospitals will be recruited.
The themes in behaviors and practices identified in this qualitative survey will be
utilized for a subsequent web-based survey in which participants will be asked
for their responses to a variety of clinical situations. The participants will include
physicians, fellows, residents, and advanced practice providers from Emergency
Departments, ICUs, and medical floor services across all UMMS hospitals.
The information gained from these surveys will
serve as a baseline for current understanding and
practice that would aid in implementing strategies
for improving the initial recognition and management
of sepsis.
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Sepsis Diagnostics
Despite decades of research and advancements in
sepsis pathophysiology, there has been little progress
in developing diagnostic tests which differentiate sepsis
from non-sepsis syndromes.
The Sepsis Diagnostics Sub Group aims to define the
standard for sepsis diagnostics at UMMS. Our initial
focus is on rapid diagnostics for blood cultures
(bacterial identification and antimicrobial susceptibility).
We are currently in a Discovery stage on potential
Cerner reporting options for capturing lab turnaround
times from ordering to result.
We have also been collaborating with Antimicrobial
Stewardship Teams to standardize an algorithm for
treatment and related processing, recording, and
reporting test results.
From those recommendations,
we are outlining education
requirements for local
physicians on the optimal
utilization of results with this
new algorithm for treatment.
Wisna Jean, MD
Kristie Johnson, PhD
Co-Leads Our goals are to decrease time to organism/
resistance identification leading to a decrease
in unnecessary/ inappropriate use of broad-
spectrum antibiotics; foster a timelier
interpretation and action on rapid diagnostic
testing; and promote favorable patient
outcomes and quality metrics.
Reference for picture:
Messacar K, et al. J Clin Microbiol. 2017 Mar;55(3):715-723
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System Sepsis Program Structure
For more information contact:
Dorsey Dowling, Program Facilitator | [email protected]