a clinician-led quality initiative: enhancing inpatient sepsis care
TRANSCRIPT
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Inpatient Sepsis Provincial Toolkit and Strategy
February 25th, 2015
BC Patient Safety and Quality Council
Dr. David Sweet MD FRCP(C) Critical Care and Emergency Medicine Sepsis Clinical Lead
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WHY?
• Severe sepsis and septic shock in adults have a mortality rate of 25 percent. Many of these deaths are preventable.
• More patients die from sepsis than prostate cancer, breast cancer and HIV/AIDS combined.
Finfer S, Bellomo R, Lipman J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Medicine 2004; 30:589–596.
Czura CJ Merinoff Symposium 2010: sepsis – speaking with one voice. Molecular Medicine; 2011; 17:1-2, 2-3.
World Sepsis Day Organisation [internet] 2014. [cited 2014,March 31] Available from: http://www.world-sepsis- day.org/
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DATA COLLECTION
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Results: Collaborative-Wide
UCL
123.2 CL
74.5
LCL
62.4
72.4
82.4
92.4
102.4
112.4
122.4
132.4
142.4
152.4
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Min
ute
s t
o G
oal
Patients in order of arrival to ED in 2010 (each point is median taken from 50 patients, chart n=1,300)
Goal 1: < 90 Minutes to Fluid Bolus
UCL
121.5 CL
90.8
60.1
35.9
55.9
75.9
95.9
115.9
135.9
155.9
175.9
195.9
215.9
235.9
A C E G I K M O Q S U W Y AA AC AE
Min
ute
s t
o G
oal
Patients in order of arrival to ED in 2010 (each point is median taken from 50 patients, chart n= 1,550)
Goal 2: < 60 Minutes to ABx
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BC Sepsis Network
The BC Sepsis Network was established in June 2011
The network has 257 members.
1) share resources
2) improve consistency of care
3) spread innovation and improvement ideas
4) and collaborate on change.
VISION
Stop unnecessary sepsis deaths. ‘Best Care, No Matter Where’
GOAL
We will reduce sepsis mortality rates throughout BC by identifying sepsis patients early, using best clinical practices, and achieving seamless transitions of care.
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UCL
LCL 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
12
/13
P1
P2
P3
P4
P5
P6
P7
P8
P9
P1
0
P1
1
P1
2
P1
3
13
/14
P1
P2
P3
P4
P5
P6
P7
P8
P9
P1
0
P1
1
P1
2
P1
3
14
/15
P1
P2
P3
P4
P5
P6
P7
P8
P9
P1
0
P1
1
P1
2
P1
3
Fraser Health 150 Lives Campaign: (Oct–Mar)
Sepsis Mortality – severe sepsis
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Why In-Patient Sepsis?
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WHY?
• Appropriate recognition and timely management of patients with severe infection and sepsis is a significant problem in health care facilities. Delayed treatment is associated with high mortality rates, significant morbidity and high costs to the health care system.
NSW Sepsis Kills In-Patient Program Implementation Guide 2014
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WHY?
• In the complex hospital ward environment there are frequently long delays between medical review and antibiotic prescription particularly when decision making is by junior medical staff.
Australasian Resuscitation in Sepsis Evaluation (ARISE) Investigators and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) Management Committee. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Critical Care and Resuscitation 2007; 9:8-18.
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May lead to at least 1 life being saved for every 7 patients treated for severe sepsis and septic shock.
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217 patients
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BC Provincial In-Hospital Sepsis Project
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Step One
In- Hospital Sepsis Interest Group 5 Health Authorities
Nurses, Administrators Doctors ER/ICU/IM/ID/Microbio/Peds/GPs
Over 50 members
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Trial Documents
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BC Sepsis Inpatient Pilot Project
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In- Hospital Sepsis Pilot Teams
Kelowna General Hospital
Lions Gate Hospital
West Coast General
Vancouver General Hospital
BC Children’s Hospital
Surrey Memorial Hospital
St. Paul’s Hospital
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Identifying and Responding to Sepsis
Presentation Based on the work done by: Dr. David Sweet and colleagues from: BC Patient Safety & Quality Council and VGH Sepsis Working Team: Dr. Sweet, Doris Bohl, Leighanne MacKenzie, Dr. Mackenzie-Feder, Jenifer Tabamo, Alison Beaty, Suzanne Miller, Dr. Yousefi
Inpatient Learning Module
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Audit Forms
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Number of Sepsis Cases n=24 Figure 1
• Identified Cases: n=15
• No PPO: n=4
• Missed Cases: n=5
20
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21
Values based on
documentation of initial
SIRS symptoms
Identified with PPO
Used
N=15
Identified and no PPO
N=4 Missed Cases
N=5
% Lactate Ordered
100 50 20
% Blood cultures
ordered
73 25 20
% IV Fluids ordered
73 100 40
% Antibiotics ordered
93 75 100
% BC done before
antibiotics
100 25 20
Average time to call
doctor
17 min Unknown 11.5 hours
Average time for
doctor to return call
15 min Unknown4 15 min
Time to obtain lactate
specimen
49 min (average)
Range: 20-150 min
20 min (average)
Range: 1-40 min n=2
8 hours
Range: 8 hours
Time to obtain blood
cultures
40 min (average)
Range: 20-90 min
2.5 hours
Range 1-4 hours
12 hours
Range: 9-15 hours
Time to initiate fluids 23 min (average)
Range: 1-80 min
105 min
Range: 30-180 min
9 hours
Range 8-10 hours
Time to administer
first dose antibiotics
55 min (average)
Range: 10-150 min
Unknown4 12.3 hours
Range 9-18 hours
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Sepsis Pilot Data KGH LGH SMH SPH VGH
Timeframe of pilot (weeks) 8 36 7 24 40
# of cases reviewed 16 20 1 20 24
# of SIRS cases identified with algorithm 15 11 1 NA2 19
# of cases with PPO used 4 4 0 3 15
# of cases with PPO missed NA1 16 1 17 5
1No data available.
2 SPH MEWS tool when used and completed is 100% effective in identifying SIRS. 3 VGH median time of 0:49. 4 SPH does not report on 30min time goal for lactate but use 3 hour time goal instead. 5 SMH physician response reported as immediate. 6 SPH physician response time not obtainable (no way to measure).
Mean time to lactate from SIRS ID 1:30 1:15 0:18 14:12 0:403
% of cases met 30min time goal for lactate 17% 55% 100% 10%4 25%
Mean time to IV antibiotics 2:30 2:05 0:30 16:12 0:55
Mean physician response time from SIRS ID 0:14 0:40 NA5 NA6 0:15
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Pilot Sepsis Missed Cases
Most common reason(s) for missed case(s): • LGH: Not recognized. • SMH: Physician did not want to use PPO • VGH: Nurse did not recognize early warning signs. Nurse
usually gave Tylenol when patient had an elevated temp. and other signs, and masked the sepsis.
Outcome for patient(s) with missed case(s): • LGH: 8 to ICU, 1 to OR, 1 stayed on unit, 1 death. • SPH: Discharged home. • VGH: 1 patient transferred to ICU, survived, and went
home. Other 4 patients were treated on the unit, survived, and either went home or discharged to lower level of care.
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Survey Results
Algorithm / Screening Tool Strongly Agree
Agree
Easy to understand 3 3
Helps clinicians identify sepsis 4 2
Feedback from clinicians has been positive 2 4
Early Sepsis Investigation & Treatment PPO Strongly Agree
Agree
Easy to understand 3 3
Helps clinicians treat and manage 4 2
Feedback from clinicians has been positive 2 4
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Inpatient Sepsis Provincial Toolkit and Strategy
Working Day
November 25th, 2015
BC Patient Safety and Quality Council
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VGH
• January 2016: Implementation to rest of
Medicine Units: T10CH, T11AD and T14G
(CTU wards), and trial to 2 Surgical Units:
T8AB and T9AB
• January-February 2016: Sepsis Education
CTU wards
• February 22, 2016: Go-live Date CTU wards
27
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Future
• Completion of “In-Patient Sepsis Tool/PPO Implementation Guide/Package”
• Completion of online e-learning module for in-patient sepsis to assist in implementation/education
• Approach and support hospitals around the province in implementation
• Design provincial QA/QI metrics to assist in further improvement
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Thank You
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WHY?
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WHY?
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WHY?
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WHY?
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WHY?
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WHY?
• Severe sepsis and septic shock in adults have a mortality rate of 25 percent. In pediatric patients, sepsis is the leading causes of death with mortality rates as high as 10 percent. Many of these deaths are preventable.
• More patients die from sepsis than prostate cancer, breast cancer and HIV/AIDS combined.
Finfer S, Bellomo R, Lipman J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Medicine 2004; 30:589–596. Czura CJ Merinoff Symposium 2010: sepsis – speaking with one voice. Molecular Medicine; 2011; 17:1-2, 2-3. World Sepsis Day Organisation [internet] 2014. [cited 2014,March 31] Available from: http://www.world-sepsis- day.org/
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WHY?
• Appropriate recognition and timely management of patients with severe infection and sepsis is a significant problem in health care facilities. Delayed treatment is associated with high mortality rates, significant morbidity and high costs to the health care system.
NSW Sepsis Kills In-Patient Program Implementation Guide 2014
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WHY?
• In the complex hospital ward environment there are frequently long delays between medical review and antibiotic prescription particularly when decision making is by junior medical staff.
Australasian Resuscitation in Sepsis Evaluation (ARISE) Investigators and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) Management Committee. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Critical Care and Resuscitation 2007; 9:8-18.
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May lead to at least 1 life being saved for every 7 patients treated for severe sepsis and septic shock.
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217 patients
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WHY?
• In single site study in Hustville Alabama the implementation of an alerting and change management system were associated with a 53% drop in sepsis mortality.
• In relative terms, the mortality rate fell from 9% to 4.2% (P value = .03; 95% confidence interval, 1.06 - 5.25).
Healthcare Information and Management Systems Society (HIMSS) Annual Conference and Exhibition: Presentation 109. Presented April 14, 2015.
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WHY?
• Reduced overall sepsis mortality by 44 percent during the study period. One year poststudy, mortality rates declined even further by 54.5 percent. The initiative also generated a positive ROI.
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UCL
LCL 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
12
/13
P1
P2
P3
P4
P5
P6
P7
P8
P9
P1
0
P1
1
P1
2
P1
3
13
/14
P1
P2
P3
P4
P5
P6
P7
P8
P9
P1
0
P1
1
P1
2
P1
3
14
/15
P1
P2
P3
P4
P5
P6
P7
P8
P9
P1
0
P1
1
P1
2
P1
3
Fraser Health 150 Lives Campaign: (Oct–Mar)
Sepsis Mortality – severe sepsis
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Why?
The Sepsis Kills toolkit provides significant benefits at both the clinical and system levels, including: • Enhanced clinician skills in sepsis recognition and management • More timely, standardized and effective detection and management
of sepsis • Reduced mortality, morbidity and bed-stays from sepsis-related
conditions • Improved quality and safety of care and a better and safer patient
experience NSW Sepsis Kills In-Patient Program Implementation Guide 2014
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Adult Screening tool Draft
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Adult CTU screening tool draft
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BCCH Pediatrics screening tool on Child Health BC website
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Sepsis Kills (Australia) Adult Inpatient Pathways / Screening Tool
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Sepsis Kills (Australia) Pediatric Inpatient Pathways / Screening Tool
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Sepsis Kills - Tag Cards
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Note for Screening Tools
• Adult Screening
• Pediatric Screening
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Note for Screening Tools
• CTU
• Rural?
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ISBAR Tool
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Sepsis Specific SBAR (Providence)
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Notes for SBAR Tool
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Coffee and Networking
1045 to 1100
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PPO Review
1100 to 1215
• Adult and Neonatal / Pediatrics
• Rural, CTU, Urban ?
• Diagnostics
• Nursing orders for monitoring
• Antibiotic orders?
• Plan for 48-72 hours (look at Sepsis Kills example)
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Pediatrics – inpatient sepsis orders
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Pediatrics – ICU PPO
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Antibiotic Guidelines
• Alignment with best practices for antibiotic ordering for initial sepsis treatment and ongoing after cultures received
• What kind of guidance do we want to include in the toolkit?
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Adult antibiotic guidelines – Providence
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Pediatrics – antibiotic guidelines
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Sepsis Kills - 48 hour management plan