© 2015 Lehigh Valley Health Network

LVHN Sepsis Quality Improvement Project

Matthew McCambridge, MD, MS

Chief Quality Officer

Don Levick, MD, MBA

Chief Medical Information Officer

2

LVHN Sepsis Quality Improvement

93 Providers30 Nurses12 Tech Partners 20 RRT 17 Physicians 14 Therapists (PT, OT, Speech)

119 Blood Products48 PRBCs 6 FFP 29 Platelets36 Cryoprecipitate

3

Reduce Sepsis MortalityThe Local Problem

4

Sepsis Quality Improvement

5

Sepsis Quality Improvement

238278 292

256 260

317 315

259

152

0.850.95 0.99

0.931.01

1.151.07

0.90 0.91

0

50

100

150

200

250

300

350

400

450

500

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Q3 2013 (n=13,882)

Q4 2013 (n=13,833)

Q1 2014 (n=13,986)

Q2 2014 (n=13,817)

Q3 2014 (n=13,996)

Q4 2014 (n=14,032)

Q1 2015 (n=13,470)

Q2 2015 (n=13,578)

Jul/Aug 2015(n= 8,903)

# o

f P

atie

nts

Wh

o D

ied

Mo

rtal

ity

Ind

ex

LVHN*Mortality Index According to Calendar Year Quarter

Deaths Mortality Index LVHN Benchmark Linear (Mortality Index)

Numerator: Number of deaths observedDemoninator: Number of deaths expected according to UHC 2014 AMC Risk Adjustment Model *LVH-H data in not included

6

Sepsis Quality Improvement

7

Reduce Sepsis MortalityDesign and Implementation

8

Sepsis Quality Improvement Task Forces

PharmacyED Physicians & Residents

HospitalistsEnterprise Analytics

Pathology –Blood Bank

Internal Medicine

ED Nurse EMSLean & Quality

Education

PharmacyED Physicians & Residents

HospitalistsEnterprise Analytics

Clinical Quality

Infection Control

NursingSurgeons -

GeneralSPPI Pulmonary

Internal Medicine

Clinical Informatics

Non-Present on Admission Med/Surg/ICU▪ Rescuing▪ Resuscitation▪ Patients who develop sepsis in-house

Present on Admission ED ▪ Protocols▪ Order Sets ▪ Early Resuscitations

9

Sepsis Quality ImprovementPOA Sepsis Subcommittees

Pharmacy Physicians NursingEnterprise Analytics

Quality

Group 1 A▪ Physical & Operational Changes in the ED ▪ Flow Diagram, Sepsis Order Set▪ Lab/Pharmacy, Sepsis Response Team

Physicians Education Quality PCS

Group 1 B▪ Sepsis Education ▪ Transition of Care, Residents

Group 1 C▪ Reporting / Feedback

Physicians EMS Quality

Group 1 D▪ Education for EMS Staff for Pre-Hospital

Arrival

Nursing

Nursing

Physicians Quality PCS / PCM Quality

10

Sepsis Mortality Improvement Task ForceTimeline January 2016 through April 2016

1st Sepsis Task Force

Meeting

DEC 23

JAN 27

MAR 02

FEB 10

FEB 17

FEB 25

FEB 26

MAR 03

MAR 14

MAR 16

MAR 17

MAR 18

MAR 22

FEB 24

JAN 07

Begin Monthly Sepsis

Mortality Review

High Sepsis Mortality

Recognized

Design Sepsis Info

Graphic

BPA Planning Meeting

APR 06

APR 07

1st Non-POA Sepsis Sub-Committee

Meeting

1st POA Sepsis Sub-Committee

Meeting

Begin Weekly Sepsis

Rounding Education

2nd Non-POA Sepsis Sub-Committee

Meeting

Sepsis Order Set Planning

Meeting

Lab / Pharmacy Planning Meeting

Update Antibiotic List with

Pharmacy

2nd POA Sepsis Sub-Committee

Meeting

POA Reporting Feedback

Sub-Committee

Meeting

POA Operational Changes in ED, Order Set, Flow

Diagram, Labs, Task Force Sub-Committee

Meeting

POA Education

for EMS Staff for Pre-Hospital

Arrival Sub-Committee

Meeting

POA Sepsis Education,

TOC, Residents

Sub-Committee

Meeting

Sepsis Care Coordination Between ED / Inpatient

Units

Quarterly Sepsis Task

Force Meeting

11

Reduce Sepsis MortalityHow Healthcare Information Technology was Utilized

12

The Sepsis Pathway

Severe Sepsis Non-Invasive Protocol

SIRS + confirmed infection + one organ system dysfunction

2 LB IV30 cc/kg NSS over 1 – 3 hours

Blood CultureAntibiotics

Admit to ICUSepsis transition SmartText

13

Epic Sepsis Initiation Order Set

14

Epic Sepsis Initiation Order Set

15

Epic Sepsis Initiation Order Set

16

Epic Sepsis Initiation Order Set

17

Epic Sepsis Initiation Order Set

18

Reduce Sepsis MortalityLVHN Tableau Sepsis Reporting

LVHN Sepsis Clinical Analytics Model

▪ Use to monitor LVHN’s performance in managing patients with Sepsis

▪ Developed over 4 months

▪ Built in Tableau and fed by data from Epic EHR

▪ 79 different clinical metrics

▪ Model has over 5 million rows of data

▪ Design based on Best Evidence, reporting requirements, and ability to review data from many perspectives

▪ Can drill from Tableau down into actual Patient record in Epic EHR as relevant

LVHN Sepsis Clinical Analytics Model

LVHN Sepsis Clinical Analytics Model

LVHN Sepsis Clinical Analytics Model

LVHN Sepsis Clinical Analytics Model

LVHN Sepsis Clinical Analytics Model

LVHN Sepsis Clinical Analytics Model

LVHN Sepsis Clinical Analytics Model

28

Reduce Sepsis MortalityValue Derived

29

LVH Mortality Index

30

LVH Muhlenberg Mortality Index

31

LVH Sepsis Mortality

32

LVHN Muhlenberg Sepsis Mortality Index

33

LVHN Vizient Current Rankings – 2017 Q1

▪ Total inpatient 12th / 140 ▪ Post-surgical 11th / 140 ▪ Urology tied 1st / 135 ▪ OB tied 1st / 124▪ Gynecology tied 1st / 133▪ Gyn Onc tied 1st / 116▪ HIV tied 1st / 110 ▪ Burn 5th / 57 ▪ Cardiac Surgery 7th / 118 ▪ Medical Oncology 8th / 134

34

Reduce Sepsis MortalityWork in progress to make further improvements

35

Next Clinical Phase - Sepsis BPA for Hospital Acquired Sepsis

Next Phase for LVHN Sepsis care management

▪ Real-time Sepsis reporting

▪ EHR alert terminology update

36

Sepsis Best Practice AdvisoryInpatient Nurse BPA

Inpatient nurse BPA

▪ Alerts based on LVHN-developed, modified SIRS criteria

▪ Alerts at “File” of vital signs, or chart opening

▪ Algorithm hyperlink included

▪ Acknowledge Reasons assist in tracking compliance

37

Sepsis Best Practice AdvisoryInpatient Provider BPA

Inpatient provider BPA

▪ Alerts based on LVHN-developed, modified SIRS criteria

▪ Alerts at chart opening

▪ Algorithm hyperlink included

▪ Sepsis initiation order set automated to open

▪ Acknowledge reasons assist in tracking compliance

▪ Lock-out period to avoid over-alerting

38

Next Economic Phase - Linking Clinical with Claims Data

Sepsis Cohort Profile

▪ For the 253 patient/members who had a sepsis diagnosis in December 2016, 87 of them were in one of LVHN’s accountable care (at risk) contracts

▪ Some non-surprising highlights▪ 84 of these patient/members are classified as very high risk

▪ The PMPM for these members of $7,427 is extremely high

▪ This cohort had 343 ER visits

▪ There were 343 readmissions, with a 53% readmission rate per 1,000 members -extremely high

▪ 66 of these members are age 65+

▪ Summary on next slide - example patient cohort summary▪ Created with Epic EHR data loaded to Optum One where claims data was

integrated

▪ Detailed clinical and economic data about this patient/member cohort

▪ This type of analytics is critical to understand the underlying economics of providing care, especially in a world of value based purchasing where providers absorb risk

39

Initial Findings: Sepsis Clinical and Claims Summary

▪ Sepsis patients are clinically complex patients with multiple conditions:

▪ Very high risk stratification

▪ 95% of patients have chronic conditions, most prevalent chronic conditions include

– Diabetes, Ischemic Heart Disease, COPD, CHF and Hypertension

▪ 18% of members have no PCP continuity (No PCP visits in the past year)

▪ These complex patients can benefit from better care coordination with PCP involvement

▪ Largest cost drivers throughout the care continuum after the index admission are readmissions and skilled nursing care

▪ 32% of episodes result in readmission and 30% include Skilled Nursing Facility care

▪ Readmissions result from various clinical conditions with the largest contributors being cardiac, respiratory and gastrointestinal related conditions

▪ Most skilled nursing care is provided outside of LVHN so there is a need for better care coordination with these non-LVHN SNF’s

▪ There are Outmigration opportunities (care rendered outside of LVHN) for Sepsis patients after the index admission

▪ More care rendered inside LVHN would enable better care coordination between providers

▪ More effective care coordination should result in lower cost and improved clinical outcomes

40

Clinical and Claims Profile from Epic EHR and Optum

41

Pathway Overview Dashboard

▪ Reflects both reimbursement and associated cost pathways extended to Sepsis episode patients

Deeper insight into Sepsis care delivery throughout the continuum of care

42

Readmission Analysis Understanding Sepsis Readmissions

43

Triple Aim Drives LVHN Strategy and Goals

Berwick, D., Nolan, T., Whittington, J. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs 27:3.

LVHN Mission: We heal, comfort and care for the people of our community by providing advanced and compassionate health care of superior quality and value supported by education and clinical research.

Better Health, Better Care, Better Cost…