sni sepsis & clabsi collaborative webinar sepsis & clabsi collaborative webinar september...

SNI Sepsis & CLABSI Collaborative Webinar

September 17, 2012

Welcome to Today’s Webinar

Code Sepsis

Video

Christmas Tree

RRT screening for sepsis

Designate a Sepsis month

Make Data Visible

Overhead Sepsis

Real-time Feedback

Brainstorming

More Time to Network

Call for Volunteers

Phone Interviews

• UC Davis Medical Center

• San Francisco General Hospital

• UC San Francisco Medical Center

SNI Sepsis Collaborative September 17, 2012

An update from the

Sepsis Improvement Collaborative (SIC)

at UC Davis Medical Center

Serving 6 million residents in 33 counties

encompassing 65,000 square miles

Major educational, research and patient-care facilities

spread across more than 140 acres

Only Level 1 trauma center for both adult and pediatric

emergencies in inland Northern California

Licensed beds 619

Admissions 31,025

ED Visits 58,023

Clinic Visits 893,788

Severe Sepsis Detection & Management QI

• Fully leverage the EHR

• Utilize

• Partner with

– Gordon and Betty Moore Foundation

– California Health Care Safety Net Institute

– University HealthSystem Consortium

• Comply with the UCDMC DSRIP Proposal

Improvement of severe sepsis detection and

management to reduce unnecessary death and harm

attributable to sepsis

SIC Structure

UCDMC Quality Initiative

Ex

tern

al

Re

po

rtin

g

SIC Steering Committee[Meets Weekly]

SIC Task Force[ad hoc]

Chief Executive Officer(Rice)

Chief Medical Officer(Siefkin)

Chief PCS Officer(Robinson)

Sepsis Improvement Collaborative[Meets Monthly]

Ove

rsig

ht

Re

po

rtin

g

Vision & Commitment

Strategic Direction & Resource Commitment

Govern QI

Guide QI

Solve Problems & Implement Solutions

Health System Committees:Quality & Safety Operations Committee

PCS Quality & Safety Council

SIC Process Map

PROBLEM STATEMENT: Severe Sepsis and Septic Shock mortality.

METRICS: Sepsis related mortality data (clinical & coding sources) SIC bundle compliance data (clinical data from electronic screening tool) Financial data (UCDMC data of sepsis related patients) Ad hoc quality improvement data External reporting requirements

i. DSRIP – Category IV Project ii. Gordon and Betty Irene Moore Foundation Grant

GOALS / OBJECTIVES: Fully implement evidence-based practices for the early identification and treatment of Severe Sepsis and Septic Shock with the goal of significantly reducing Severe Sepsis and Septic Shock mortality (individually, in rate and absolute number) at UCDMC using advanced EPIC EHR tools.

SCOPE: All patients admitted to UCDMC: focusing on pathways in the emergency

department (ED), acute care units (ACUs) and intensive care units (ICUs)

Member Lic. / Cert. Role

Albertson, Timothy MD Sepsis Expert

Berger, Tony MD ED Physician Representative

Black, Hugh MD ICU Physician Representative

Chenoweth, James MD ED Resident Representative

Cocanour, Christine MD Surgery Physician Representative

DiPierro, Christine RN Acute Care Nursing Representative

Dunbar, Karrin RN Nursing Education Representative

Henk, Bobbi RN CQI Representative

Hill, Michelle MD Internal Medicine Resident Representative

Hunkins-Flores, Marcie RN ED Nursing Representative

Johl, Hershan MD Acute Care Physician Representative

Koopman, Marsha RN Infection Prevention Representative

Lonigan, Joleen RN Rapid Response Team Representative

Meyers, Jaime RN PCS Quality & Safety Champion Representative

Mondino, Karen RN ICU Nursing Representative

Natale, Joanne MD Pediatric Physician Representative

Parker, Tricia PharmD Pharmacy Representative

Polage, Christopher MD Laboratory Representative

Stocking, Jacqueline RN PCS Quality & Safety Representative

Teach, Lori EHR / IT Representative

Warren, Scott PMP Lean Six Sigma Green Belt

QI Leadership:

Senior Leadership: Allan Siefkin, MD & Carol Robinson, RN

QI Champions: Hien Nguyen, MD & Marci Hoze, RN

QI Black Belt: Jared Quinton, CSSBB

Start Date:

01/01/2012

End Date:

12/31/2012

BENEFITS: Improve detection & management of severe sepsis and septic shock Reduce Severe Sepsis and Septic Shock mortality Reduce ALOS for sepsis population in UCDMC Build quality improvement partnerships across UCDMC

Project Charter

SIC Quality Initiative Directory QI

Priority D M A I C Category QI Name QI Objective QI Lead(s) Start End Comments

2 - High Mortality SIC Mortality

Reduce SIC mortality by at

least 15% from the 2009

baseline of 36%

Hien Nguyen, MD

Marci Hoze, RN01/01/12 12/31/12 Data source department = HIM

2 - High Process SIC Bundle Compliance

Improve SIC bundle

compliance (85% individual

and 65% total)

Hien Nguyen, MD

Marci Hoze, RN01/01/12 12/31/12 Data source department = IT

2 - High Cost Reduce ICU ALOS Reduce SIC related ICU ALOS Jared Quinton 07/13/11 12/31/12 Data source department = FINANCE

2 - High Process SIRS BPAImprove use of SIRS BPA by

front-line RNsJamie Meyers, RN 07/13/11 12/31/12 Data source department = PCS Q&S

5 - Complete Process SIC QI Website

Build and maintain SIC QI

website to provide

communication and

infrastructure

Jared Quinton 07/13/11 12/31/12 Update/refresh planned for 4/11/2012

5 - Complete ProcessModification of SIRS BPA

Acknowledgement Options

Physician and nursing input

dictated a change to be made

for clarity of BPA options

Marci Hoze, RN 03/26/12 04/03/12Update on SIC website and posted to First

Tuesday

6 - Proposed EHRValidate clinical data vs.

coding data

Analyze data accuracy &

propose process

improvements

Hershan Johl, MD

STATUS

DEFINE:

SIRS BPA Jamie L. Meyers, RN, MSN, Brittney Caldera RN, BSN, Christopher McKinney, RN, BSN

PROBLEM STATEMENT: Knowledge deficits with use of SIRS BPA

MEASURE: Through report audits monitor SIRS BPA response for missed opportunities of screening patient and incorrect use of BPA.

CONTROL PLAN: Monitor for changes in education topics and adjust education appropriately.

IMPROVE:

ANALYZE: Nurses response of BPA

SCOPE: The units in the hospital affected by the SIRS BPA

QI

GOAL: Establish an automated identification system to guide clinician review of cases and reduce the number of missed screening opportunities and incorrect use of SIRS BPA buttons.

Perform one-on-one RN

education related to response or

misuse of BPA.

Inform and work with unit

leadership of completed

education.

DEFINE:

SIC Mortality Rate

PROBLEM STATEMENT: Sepsis related mortality at UCDMC

MEASURE:

CONTROL PLAN: Develop a control plan to monitor the process in order to sustain improvement.

IMPROVE: Generate, prioritize and implement solution(s) to the stated problem. State result(s) of implemented improvement(s).

ANALYZE:

GOAL: By December 2012: Reduce combined severe sepsis and septic shock mortality by ≥15% Reduce severe sepsis mortality by ≥15% Reduce septic shock mortality by ≥15%

in percentage rate and absolute numbers from 2009 baseline data

SCOPE: All UCDMC patients (ED, ACU and ICU) with severe sepsis and/or septic shock

QI

4137332925211713951

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Observation (month)

Mo

rtal

ity

Rat

e

_X=26.0%

UCL=34.0%

LCL=18.1%

2009 2010 2011 2012

SIC Mortality Rate by Calendar Year

YearPatient

PopulationNumerator Denominator

UCDMC SIC

Mortality Rate

Septic Shock 112 257 43.6%

Severe Sepsis 67 235 28.5%

SIC Population 179 492 36.4%










2011

2009

2010

2012

SIC Intranet Site

SIC dashboard

SIC meeting materials

Resources

Education

Contact Information

Contact Information Hien Nguyen, MD, MAS Associate Clinical Professor of Medicine, Division of Infectious Diseases Medical Director, Electronic Health Records Co-lead, Sepsis Improvement Collaborative [email protected] Marci Hoze, RN, BSN, MPA Manager, Apheresis/PICC Department, Pulmonary Lab Services, AIM Service Co-lead, Sepsis Improvement Collaborative [email protected] Jared Quinton, MHSM, CSSBB Director, Lean Six Sigma Administrative & Billing Officer, Patient Care Services [email protected] UC Davis Medical Center 2315 Stockton Boulevard Sacramento, CA 95817

Define

Measure

Analyze

Improve

Control

DMAIC methodology

y = f(x) data collection

data analysis

controlled interventions

sustainability

Charter

Observe

Process Map

Plan

Collect

Validate

Correlation

Hypothesis Testing

RCA

Generate

Prioritize

Pilot

Monitor

Act

Determine Current State Obtain Future State

DEFINE:

QUALITY INITIATIVE FORM (A3)

PROBLEM STATEMENT: A brief description of the problem at hand and why it is a priority.

PROCESS MAP / VALUE STREAM MAP (VSM):

MEASURE: Identify, collect and validate specific measurements that describe the process and reveal whether the goals have been achieved. SIPOC diagram Spaghetti diagram

CONTROL PLAN: Develop a control plan to monitor the process in order to sustain improvement. Control chart 5S Poka-yoke (mistake-proofing)

IMPROVE: Generate, prioritize and implement solution(s) to the stated problem. State result(s) of implemented improvement(s). Pilot Kaizen Standard work processes

ANALYZE: Identify the root cause(s) of stated problem. Ishikawa/Fishbone diagram Correlation testing Hypothesis testing FMEA

GOAL:

Expected outcome of Quality Improvement process.

SCOPE: Identify operational or organizational boundaries.

A B C

QI

San Francisco General Hospital

Joe Clement, RN, MS, CCNS

Interview

Use of Stories

Making Data Visible

Exposing the Laundry

Focused on the Obvious

Most Recent Small Tests of Change

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

“What will happen if we try something different?”

“Let’s try it!” “Did it work?”

“What’s next? ”

Letters from Sepsis Task Force

Jim Stotts, RN, MS, CNS

Retreat Agenda

• Opening Remarks • Where Are We and Where Are We Going • Data Reliability and Case Reviews for Opportunities for Improvement • Update on Surviving Sepsis Guidelines • Update on Subgroup Work

– Feedback letters to providers – Sepsis View in Apex – Communication Boards – Sepsis Simulation Bus – Intranet Evidence Repository – Sepsis Pocket Card – Lactate Procedure – Code Sepsis – Time of Presentation

Patient Screens Positive on sepsis

screening tool

Acute Care/Transitional Care

ICU

Call RRT and Primary

Team

Positive screen

with organ dysfunction*

Positive screen with SIRS

criteria only

Order venous lactate, draw

using blood gas syringe, send to blood gas

lab.Call Primary or Designated

Team and activate Code Sepsis Team. Assist with sepsis resuscitation as

needed.

Positive screen with SIRS

criteria only

Lactate ≥ 2

Call Primary Team and Code Sepsis Team and report

lactate result w/in 30 min. Assist

with sepsis resuscitation if

initiated

Lactate < 2

Call Primary Team and report

lactate result w/in 30 mins. Inquire about further action.

* Criteria for organ dysfunction includes: worsening mental status, SpO2 > 90% on RA or if the patient requires more O2 to maintian SpO2> 90%, decrease in u/o, SBP < 90 mm Hg, ≥ 40 mm Hg below baseline or MAP ≤ 65, increase in vasopressor dose to maintain BP (ICU only), mottled skin or capillary refill ? 3 secs (ICU only)

Order venous or arterial lactate using blood gas

syringe, and send to blood gas lab.

Lactate ≥ 2

Call Primary or Designated Team and Code Sepsis Team and report

lactate result w/in 30 mins. Assist with sepsis resuscitation

if initiated

Lactate < 2

Call Primary or Designated

Team and report lactate result w/

in 30 mins. Inquire about further action.

Call Primary or Designed

Team

Conclusion: Next Steps

sni sepsis & clabsi collaborative webinar sepsis & clabsi collaborative webinar september...

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