do's and don'ts of data display sepsis/clabsi collaborative
TRANSCRIPT
Do’s and Don’ts of Data Display Sepsis/CLABSI Collaborative
April 15, 2013
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Jared Quinton Jim Stotts
Susan Garritson
Michael McElroy
Joe Clement
Kim Delahanty
Kathleen Quan
Debbie Thompson
Jennifer Yim
Data, Data, and More Data
Default NHSN Graph Output
NHSN Resource Guide: http://www.cdc.gov/nhsn/pdfs/training/Resource-book.pdf
Peer to Peer Data Tips
Kim Delahanty from UC San Diego
California Confidential Evidence Code
1157
• UC San Diego DSRIP House wide CLABSI Goals:
2012-2013
• Target: 1.52
• Threshold: 1.55
• Maximum: 1.51
Curos, CHG
bath, 2 x a day
environ clean
California Confidential Evidence Code
1157
Curos, CHG
bath, 2x a day
environ
cleaning
• UC San Diego DSRIP House wide CLABSI Goals:
2012-2013
• Target: 1.52
• Threshold: 1.55
• Maximum: 1.51
Telling a Story with Data
1. CL Insertion Kit proposed 6. Start CL PPE Insertion Kit
2. CL Dressing Kit start 7. Start Insertion Kit
3. CLBSI SICU Study start 8. Standardized Education and
4. HC ED Insertion Kit pilot Compete CL Insertion
5. CL PPE Insertion Kit piloted 9. CHG Bathing
• Data is not just the output of a mechanical process. There is a real human dimension in your work. The numbers represent individuals, so you should approach the data in that way.
• It’s also not just a graph, but a graphic.
• Labels and annotations provide context, while color direct your attention to what’s important.
• Chart and graph design isn’t just about statistical visualizations, but also explaining what the visualization shows.
Susan Garritson from UC San Francisco
* = change in denominator to include inpatient
and observation days per NHSN criteria
Hospital Onset- defined as specimen collected > 3
days after admission to the facility ( on or after day
4).
• C.dificile Toxin-positive C.difficile stool assay for
a patients in inpatient location in with no prior
toxin positive C.difficile stool assay reported
within 14 days for the same patient/location
• MRSA and VRE positive blood cultures for a
patient in a location with no prior MRSA positive
blood culture reported within 14 days interval
between specimens.
Jim Stotts from UC San Francisco
(Unit) Sepsis Dashboard July 2012 – January 2013
0%
20%
40%
60%
80%
100%
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Mar
-13
May
-13
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
Lactate Compliance
0%
20%
40%
60%
80%
100%
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Mar
-13
May
-13
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
BCx Compliance
0%
20%
40%
60%
80%
100%
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Mar
-13
May
-13
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
ABX Compliance
0%
20%
40%
60%
80%
100%
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Mar
-13
May
-13
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
Fluids Compliance
0%
20%
40%
60%
80%
100%
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Mar
-13
May
-13
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
Bundle Compliance (UCSF IAP Target 70%)
0
20
40
60
80
100
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Average
Days
Nights
Target
% C
om
plia
nce
(Unit) Sepsis Screening Compliance
Blood culture before ABX administration
ABX within 1 hour of TOP of severe sepsis
At least 1L NS or 20-30 cc/kg bolus NS for severe sepsis
Compliance with all 4 bundle elements.
Abbreviations: Abx = antibiotic; BCx = blood culture; TOP = time of presentation of severe sepsis; NS = Normal Saline
This decrease in lactate compliance is due
to 1 out of 4 patients in whom a lactate
wasn’t obtained within 6 hours from TOP.
Though this shows that BCxs were obtained
before antibiotics in 4 out of 4 cases, the
average time it took to get BCxs was 198 mins
in this cohort. Our goal is to obtained BCx
within 60 mins from order.
This drop in antibiotic compliance is due a
delay in initiating orders to treat severe
sepsis. The average time it took to administer
antibiotics once an order was written was 29
mins in this cohort. Call a code sepsis to
expedite antibiotic treatment.
This compliance is based on 14 L patients
only. The drop in compliance is due to the
drop in compliance with lactates and ABxs.
Bundle compliance for all patients on all
pilot units taken together is 81% for
January.
No patients required this fluids month for
hypotension or a lactate greater than 4.
Screening compliance is at 98% for this
month. Overall goals for this month are
to draw lactates for every positive screen
and call code sepsis for every patient that
meets code sepsis criteria.
Lactate within 6 hrs from time of presentation of severe sepsis
UCSF Physician letter UCSF Letter to Clinical Staff – ED
Sent via Secure Email
From: ED Attending
Sent: Date/Time
To: MD (names), RN (names), Pharmacists (names)
Cc: Sepsis Champions, ED Quality Physician Chair
Subject: ePHI: ED severe sepsis/septic shock QI case review
Names et al: As part of the UCSF Medical Center's initiative to improve the care of patients with severe sepsis/septic shock, we are reviewing each case seen in the ED that has failed to meet compliance with the following bundle of interventions (which are tracked closely by the Med Center and used in QI reporting). There are 2
sets of criteria to which we are being held (DSRIP and SNI). Please see below for details. The following patient was seen by you and did not meet the full bundle criteria as noted below: Patient name: Last name, first MR #: XXXXXXXXX Date of visit: Date/time Initial lactate: 9.2 Organ dysfunction: elevated lactate (<2)
Timeline for Sepsis Bundle Elements (time is the x-axis, bars represent time intervals, numbers on either end of bars represent time event occurred):
*Time of presentation (TOP) = time that patient meets the following 3 criteria (all 3 must be present, TOP = time of the last criteria to be met):
1. 2 or more SIRS criteria 2. Clinical suspicion for infection 3. Evidence of organ dysfunction
Bundle Element Compliance (green = compliant, red = not in compliance) Sepsis Bundle Component DSRIP criteria (lenient) SNI criteria (stringent) Lactate Within 6hrs of TOP 4hrs before-6hrs after TOP Blood Culture Before antibiotics Before antibiotics Broad Spectrum Antibiotics Within 3hrs (for ED) of TOP Within 1hr of TOP Fluid Bolus 20ml/kg or 1000ml crystalloid or 300-
500ml colloid if SBP<90 or MAP<66 or lactate >4, within 6hrs of TOP
20ml/kg or 1000ml crystalloid or 300-500ml colloid within 1hr of TOP, regardless of BP or lactate
Vasopressor Pressors started within 6h of TOP if SBP failed to respond to initial fluid resuscitation
N/A
Full Bundle Compliance All of the above All of the above *As an aside, we understand the controversy around fluid bolus administration in the SNI criteria. Notes: This was a patient with (disease) who had a (significant event) at home. The patient had received ACLS in the field by EMS prior to arrival in the ED and was intubated, tachycardic, hypoxic, and hypothermic on ED arrival. The patient was admitted to ICU (service) with (service) involved for therapeutic hypothermia. After transfer to the ICU, it appears that the admission team ordered antibiotics which triggered this case for our review (I.e. Possible sepsis case). There is no mention in the ED note of a concern for infection as the underlying etiology and it's not clear to me that her underlying etiology was infectious. However, to be complete, I am forwarding this on to you all (including the admission team). Any thoughts on the delayed antibiotics (163 mins after TOP) and absence of a fluid bolus (presumably due to this patient being (disease))? Please let us know if there were systems issues or other impediments that played a role in meeting these bundle elements. Physician Sepsis Champions
Michael McElroy from SFGH
Joe Clement from SFGH
Kathleen Quan, Debbie Thompson, Jennifer Yim UC Irvine
SIR
Nurse-Sensitive Quality Indicators
Unit: SICU
Unit Specific Dashboard
Understanding SIR
Jared Quinton from UC Davis
The Usual Suspects…
baseline DY-8
actual DY-8 goal
DY-9 goal
DY-10 goal
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Bu
nd
le C
om
plia
nce
(%
)
Boxplots Dashboard
s
0.70.60.50.40.30.2
Median
Mean
0.700.650.600.550.500.45
1st Q uartile 0.45163
Median 0.55769
3rd Q uartile 0.67803
Maximum 0.73314
0.46833 0.63203
0.45469 0.67691
0.11857 0.24229
A -Squared 0.51
P-V alue 0.171
Mean 0.55018
StDev 0.15920
V ariance 0.02534
Skewness -0.984283
Kurtosis 0.819763
N 17
Minimum 0.15152
A nderson-Darling Normality Test
95% C onfidence Interv al for Mean
95% C onfidence Interv al for Median
95% C onfidence Interv al for StDev95% Confidence Intervals
Descriptive Statistics Process Maps Planning Grant Process Map Sepsis Improvement CollaborativeAs of 07/11/2011
Phase 1
[Completed 11/03/2010]
Phase 2[Completed 12/01/2010]
Phase 3
[Completed 01/05/2011]
Phase 4
[Completed 02/16/2011]
ED / ACU ICU
Primary Screen
Secondary Screen
Early Recognition
Alert Screen
Sepsis Screening Order Set**
Notification ofPotential EGDT
Activation
SepsisTreatmentProtocol
Treatment
Sepsis Treatment Order Set**
EMR
Met Criteria?
Suspected Infection?
Yes (BPA Fires)
Yes
BPA lock outACU = 12-hoursICU = 12-hours
ED = 2-hours
BPA lock out24-hours
Met Activation Criteria?
No** See related P&Ps:
· Severe Sepsis Early Recognition and Management Policy
No
Sepsis Reassessment Order Set**
RN RN
RRT
Primary Team
Attending Physician / Primary Team
5 minute response to evaluation
UCDMC Patient Population
Met Activation Criteria?
BPA lock out24-hours
No
5 minute response to EGDT activation after evaluation
Follow-up q2 labs
No
Start
Yes
“Yes (suspected infection)” with Low BP in ACUSepsis Reassessment:
-BP-HR-RR-GCS-Urine Output-CVP (if available)-Lactate-O2 Sat.-ABG / VBG-Documented RN/MD communication
Blood Cultures
ABX
Lactate q4 x2
ScvO2
ABG / VBG
Fluids
Catheter Eval.
Vasopressors
Steroids
Activated Protein C
Glucose Control
Fluids / Blood
Products
Yes
Lactic Acid ABG / VBG
INRCBC
LFTs
Type & Screen
CXR
UA
Sputum Culture
Blood Culture (x2)
BPA lock out7-days
Mini-BAL
Stim. Test
O2
AcuityScoring
30-60 min.
PCR Evaluation
PCT
· Related Standardized Procedure
EMR
Critical Care
Consult
Future element pending laboratory validation
256 patients
H 17 hospitals
Sepsis Collaborative DY-8 Bundle Compliance
Patients by Hospital
DPH w/o Level 1 Trauma Center
DPH w/Level 1 Trauma Center
baseline DY-8
actual DY-8 goal
DY-9 goal
DY-10 goal 0.00
0.20
0.40
0.60
0.80
Bu
nd
le C
om
plia
nce
(%
)
SNI Sepsis Bundle
Compliance
DPH Sepsis Bundle Compliance
This snapshot represents the semi-annual
DY-8 performance of the SNI Sepsis Collaborative
Baseline DY8 DY9 DY10
Three Tips from Your Peers
One size does not fit all
Know Your Audience
Check for Accuracy
Data Tips
• 3D charts
• Pie charts
– Difficult to compare groups; bar charts almost always better
• Deceptive Y-axis scaling
– Are the max and min levels appropriate? How many gridlines are truly necessary?
• Using coded variables
– What does ‘inDateYM’ mean to someone not familiar with NHSN?
• Unnecessary information
– Going out several decimal places
• Lack of benchmarks, comparison groups, goals
More Tips
• No labels
– What units (per 1,000 line-days? Patient days?) are you measuring in? When was the data abstracted? Who collected the data? What’s the data source?
• Too many colors/categories in one chart
– Be careful with color; Red can be a good for a main point if used sparingly
– Small multiples (smaller, side-by-size charts) can get the point across better for multiple categories
• Using serif fonts, especially for small sizes
– San serif fonts like Arial are easier to read
Active Duty Personnel, 1998
Army
35%
Navy
27%
Airforce
26%
Marines
12%
Active Duty Personnel, 1998
Army
35%
Navy
27%
Airforce
26%
Marines
12%
Beware of 3-D
Pie Charts
Resources
• Books – The works of Edward Tufte
• Visual Display of Quantitative Information
• Envisioning Information
• Visual Explanations: Images and Quantities, Evidence and Narrative
• Beautiful Evidence
– Visualize This by Nathan Yau
– Presentation Zen by Garr Reynolds
• Web – New York Times graphics department
• Examples: http://www.nytimes.com/interactive/2012/12/30/multimedia/2012-the-year-in-graphics.html
– www.flowingdata.com
– www.junkcharts.typepad.com
• Scholarly Journals – JAMA, Nature, BMJ, Health Affairs
• Video – The Value of Visualization - http://vimeo.com/29684853
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