improving sepsis risk adjusted mortality · •sepsis is the leading cause of death in u.s....

Improving Sepsis Risk Adjusted Mortality

Sandra Kemmerly, MD, MACP, FIDSA

Ashton Sloan, PA-C

1

• Where we started

• What we tried, and why it did not work

• Lean approach to ED sepsis care

• Spread & Scale

• Starting a sepsis program

• Lessons learned

2March 19, 2019

Agenda

• Sepsis is the leading cause of death in U.S. hospitals

• Mortality rates for severe sepsis and septic shock range ~20-50%

• As many as 92% of sepsis cases originate in the community

• Mortality from sepsis increases 8% for every hour that treatment is delayed

• As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatment

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Why Is Sepsis Important?

4March 19, 2019

Sepsis Actual vs Predicted Mortality Trend – All Payer

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Sepsis Actual vs Predicted Mortality Trend – All Payer

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Key Sepsis Performance Indicators: ED Order Set Use Tied to Goal Achievement

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% Mortality of Sepsis as PDx by Facility

• Several well designed studies published after initial success questioning role of EGDT, intense monitoring and other strategies led to variations by physicians based on personal bias

• “Official” physician champions roles were eliminated

• Migration to EMR, negating usefulness of printed standardized order sets

• PI efforts were redeployed

• Resources, focus, measurements were reduced for “sepsis”

• Impending CMS core measure reporting slated for Oct 2017 necessitated a new burning platform• First strategy: redoing electronic orders for EPIC• Spread throughout system• Poor adoption• Recognition of needing a new approach

8March 19, 2019

Lessons Learned

9March 19, 2019

CMS Sepsis Bundle

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11March 19, 2019

Perfect Care: Where Did We Start?

Severe Sepsis and Septic Shock Project Charter Summary

Project: Sepsis and Septic Shock Core Measures

In Scope: Adult patients presenting to the ED at OMC-Jefferson Highway with the diagnosis of sepsis and septic shock.

Out of Scope: Patients younger than 18 years of age; Patients developing sepsis during their inpatient stay; Epic Secure Chat, other

hospitals, provider escalation/hierarchy protocol, Regional Referral Center, sepsis pathway.

: Outpatients, code blue, Epic Secure Chat, HCAHPS, other healthcare facilities.

Green Belt(s): Ashton Sloan Coach: Xavier Viteri

Problem Statement: Only 20% of sepsis patients at OMC-Jefferson Highway receive “Perfect Care”. Order sets and/or panels that

contain sepsis measures of “perfect care” are significantly underutilized.

Goal: Increase the instances of achieving perfect care for sepsis patients arriving to OMC-Jefferson Highway via the ED to 85%;

improved data capture

Expected Benefits: Increased and earlier capture of patients with sepsis and septic shock; increased contribution to margin from

CMS Value Based Purchasing program; decreased patient mortality from sepsis.

Targeted Start Date: Mid-August

Anticipated End Date: March (For ED patients)

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HOW DID WE GET

HERE?

• Sepsis patients are not treated with the same urgency as code STEMI or stroke code. Lack of overhead page for the sickest patients (situational awareness and resource surge)

• Creation of Code Sepsis

• Change ESI triage assignments for sepsis patients in the ED

• Antibiotics: Mismatch between ED sepsis treatment panel and Pyxis inventory. Incorrect/delayed orders. Delay verifying/compounding abx in central pharmacy

• Optimize treatment panel and place most common antibiotics in ED Pyxis

• Build on stat order process developed

• Create mechanism for pharmacist assistance ordering abx for code sepsis

16March 19, 2019

Key Root Causes

• No QI process in place• Creation of QI process

• Making it more complicated than it needs to be• Elimination of weight based antibiotics

• Decision support to ED providers using treatment panel

• Difficulty in defining sepsis• System-wide adoption of Sepsis-3 definition

• Lack of consistent use of sepsis workup and treatment panels. Variety of providers rotating through OMCNO ED

• Standardize onboarding for new providers. Optimize workup & treatment panels

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Key Root Causes

• Code Sepsis is NOT for all sepsis patients

• Code Sepsis targets the subset of sepsis patients in the ED that disproportionately drive inpatient mortality and complications (RAMI & ECRI)

• Code Sepsis Triggers:

Sepsis PLUS: SBP<90 or lactate ≥ 4

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Why Code Sepsis?

Triage:

• SBP<90 plus positive sepsis screen in triage

• Triggers ESI 1 and activates code sepsis process

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Code Sepsis Triggers

Provider:

• SBP<90 or lactate ≥4 plus known or suspected infection

• Activates code sepsis process

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Code Sepsis Process

Project Results

Median time to antibiotic administration improved from

1h53 min to 45 minutes

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Code Sepsis Results

23March 19, 2019

Of 851 sepsis cases in the cohort from October 2015 to September 2017:• 281 (33%) passed SEP-1 and 570 (67%) failed. • SEP-1 failures had higher rates of septic shock (20% vs 9%; p < 0.001)• Hospital-onset sepsis (11% vs 4%; p = 0.001)• Vague presenting symptoms(46% vs 30%; p < 0.001)

• Delays of > 3 hours until antibiotics were significantly associated with death (p = 0.038)

• Failing SEP-1 for any other reason was not associated with increased mortality (p = 0.674)

• Failing SEP-1 was not associated with increased in-hospital mortality when adjusted for severity of illness

ED System Spread & Scale

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Sepsis Accelerator

System ED Sepsis Spread and Scale

• New to Ochsner Health System…but not new to the tech industry

• Accelerators provide limited, intensive coaching and support to entrepreneurs seeking to take their companies and ideas to the next level

• Variability in needs is understood, but certain key milestones for startups are universal

26March 19, 2019

Accelerator Model

• Jeff Hwy root causes are likely different from each campus’ root causes

• Local solutions should match local root causes

• Root causes that do match Jeff Hwy can borrow from Jeff Hwy solutions

• 90%(+) of ED operations are the same/very similar across campuses

• Jeff Hwy templates already developed (SIPOCs, process maps, etc) can be shared to significantly reduce the time needed to complete the exercises organically

• ED Sepsis Performance Report created by the Jeff Hwy Sepsis team provides robust, campus-specific data eliminating the need to develop a data collection plan and obtaining measurements

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Assumptions

1. Ochsner Baptist

2. Ochsner Baton Rouge

3. Ochsner Kenner

4. Ochsner St. Charles

5. Ochsner West Bank

6. Ochsner St. Anne

7. Ochsner North Shore

8. Chabert Medical Center

9. St. Bernard Parish Hospital

10. St. Tammany Parish Hospital

11. Terrebonne General

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System Accelerator Event

**Cumulative Impact: 22(+) months saved**

Advantages:• Decentralized spread & scale uses local resources to identify and

tackle local root causes

• Allows for the formation of teams that may not have already existed

• Provides framework to create and share internal knowledge

• Does not rely on System OHS Quality Team to do all of the work

Trade Offs: • Less control over completion timelines, deliverables, etc

• Variability between campuses

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Accelerator Strategy

OHS Sepsis Perfect Care

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• Teams should be multi-disciplinary and include nursing, physicians, pharmacy, informatics, quality, and other key stakeholders

• Leverage an executive sponsor to remove any barriers

• Don’t bite off more than you can chew: the emergency department is a defined cohort that captures ~90% of sepsis cases

• Use informatics to automate data collection

31March 19, 2019

Starting a Sepsis Program

• Any project that affects nursing care needs to involve nursing leadership up front

• Do not underestimate the help informatics can lend

• Best practice tools (ED panels, order set, etc) need to be optimized to make it easier for clinicians to care of patients

• For projects involving mostly clinical staff, build redundancy into your team

32March 19, 2019

Lessons Learned

Questions