ihi expedition treating maternal sepsis session 1.pptx ......3/20/2013 1 ihi expedition treating...

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IHI ExpeditionTreating Maternal Sepsis

Thursday, March 21

These presenters have nothing to disclose

Pete Cherouny, MD

Kevin Rooney, MBChB, FRCA

Sue Leavitt Gullo, RN, BSN, MS

Today’s Host2

Jesse McCall, Project Manager, Institute for Healthcare Improvement (IHI), currently manages Expeditions (2 – 4 month web-based educational programs) and various other projects including Passport, The $10 Million Saved Seminar, and the Co-Operative Education Program in partnership with Northeastern University. He began his career at IHI as the Project Coordinator for the 5 Million Lives Campaign. Mr. McCall is a graduate of Northeastern University in Boston, MA with a specialization in marketing. He enjoys music, trivia, the beach, and cooking.

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Chat Time!

What is your goal for participating in this Expedition?

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Join Passport to:

• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-

line teams make rapid improvements.

• Train your middle managers to effectively lead quality improvement initiatives.

. . . and much, much more for $5,000 per year!

Visit www.IHI.org/passport for details.

To enroll, call 617-301-4800 or email [email protected].

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What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some specific purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

Expedition Support

All sessions are recorded

Materials are sent one day in advance

Listserv address for session communications: [email protected]

– To add colleagues, email us at [email protected]

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Where are you joining from?

Expedition Director10

Sue Leavitt Gullo, RN, BSN, MS, Managing Director, Institute for Healthcare Improvement (IHI), brings 30 years of health care experience to her current roles, which include work in IHI's national and international patient safety work, and IHI's faculty for leadership and patient safety. She is the Director of the Perinatal Improvement Community and The Safer Patient Project in Denmark. Prior to joining IHI, Ms. Gullo was the Director of Women's Services at Elliot Hospital in New Hampshire. Her prior nursing roles included experience in the frontline clinical areas of maternal-child health, oncology, and medical-surgical nursing. Ms. Gullo has also been active as national faculty in obstetrical care for the last 15 years. Her involvement with IHI dates back to 1995 as a participant in the IHI Breakthrough Series on Improving Maternal and Neonatal Outcomes and continued as IHI faculty until she joined the IHI staff in 2005.

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Today’s Agenda11

Ground Rules & Introductions

What is Sepsis?

The Golden Hour – Sepsis Doesn’t Wait

Review Maternal Sepsis at Your Organization

Case Study of Maternal Sepsis

Developing a Measurement System

Next Steps

Ground Rules12

We learn from one another – “All teach, all learn”

Why reinvent the wheel? - Steal shamelessly

This is a transparent learning environment

All ideas/feedback are welcome and encouraged!

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Overall Program Aim

The program aims to help participants learn how to identify and treat maternal sepsis by sharing

screening techniques and treatment protocols geared toward maternal populations.

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Expedition Objectives

At the end of the Expedition, participants will be able to:Identify maternal and perinatal morbidities and mortalities associated with infectionExplain the known strategies to prevent infection in the maternal patient during and following pregnancyDescribe the process of recognizing and managing of infection in order to minimize morbidity and mortalityDefine the critical points in mitigating the advancement of shock and septic shock, with a focus on the Golden HourDesign a reliable early response system to decrease morbidity, mortality and cost

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Schedule of Calls

Session 1 – Prevention, Identification, and Mitigation of Maternal

Sepsis

Date: Thursday, March 21 1:00 PM – 4:00 PM ET

Session 2 – Designing a Reliable Process to Identify and Treat

Maternal Sepsis

Date: Friday, April 26, 1:00 – 2:30 PM ET

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Faculty16

Peter H. Cherouny, MD, Professor of Obstetrics and Gynecology, University of Vermont College of Medicine, has strong clinical interests in obstetric health care quality improvement and is currently serving as Chair of the Institute for Healthcare Improvement's Perinatal Improvement Community. He was also the lead author of the IHI white paper, "Idealized Design of Perinatal Care." He has been Chair of Quality Assurance and Improvement and Credentialing for the Women's Health Care Service of Fletcher Allen Heathcare for the last 15 years. His recent research and work in obstetric quality improvement is as Chair of the March of Dimes collaborative, "Improving Prenatal Care in Vermont," and as co-investigator of the MedTeams project.

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Faculty17

Kevin Rooney, MBChB, FRCA, Professor of Care Improvement, University of the West of Scotland was appointed as a consultant in Intensive Care and Anaesthesia at the Royal Alexandra Hospital in Paisley in July 2003. From February 2009 to January 2011, he was the Lead Clinician in Critical Care for Greater Glasgow & Clyde Health Board, the largest strategic health authority in Scotland serving a population of 1.2 million people and providing tertiary referral services to over 50% of Scotland’s 5.2 million population. In January 2011, Kevin was made a Professor of Care Improvement at the University of the West of Scotland, where he leads the Institute for Care and Practice Improvement. He continues to practice in Intensive Care & Anaesthesia at the Royal Alexandra Hospital where he can pursue his interests of patient safety and healthcare quality improvement. Professor Rooney is the National Clinical Adviser on Sepsis to Healthcare Improvement Scotland and is leading their breakthrough series collaborative on Sepsis. He is also the National Clinical Lead for Knowledge into Action for NHS Education for Scotland, where he helps to align the use of knowledge in NHS Scotland with care that is safe, effective and person-centred.

What is Sepsis?IHI Expedition: Treating Maternal Sepsis

March 21, 2013



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Background

ICU ConsultantRoyal Alexandra Hospital, PaisleyProfessor of Care ImprovementNational Clinical Lead for SepsisHealthcare Improvement Scotland

Conflicts of Interest

In the last 5 years I have acted as consultant, or received honoraria / research grants from:

Abbott, Baxter, Eli Lilly

What is Sepsis?

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Diagnostic Criteria for Sepsis:

Crit Care Med 2013; 41:580-647

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Severe Sepsis

Crit Care Med 2013; 41:580-637

Severe Sepsis And HAI Mortality

SEVERE SEPSIS

2004: 14000 DEATHS

300 per million dying of severe sepsis in any one year

ODDS: 1 in 3333

SEPSIS in UK: 37000 DEATHS

ODDS 1 in 125

MRSA & CDI

2006: 8132 DEATHS

91 per million dying of MRSA or CDI in any one year.

ODDS: 1 in 11,000.– For those aged under 45

years : 1 in 250,000.

– For those aged 85 years or older, 1 in 300.

www.statistics.gov.uk

UK Sepsis Group, Harrison D et al Critical Care 2006; 10:R42

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Acute MI & Trauma

5% Mortality 3% Mortality

“Similar to polytrauma, acute myocardial infarction, or

stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome.”

“Most of these recommendations are appropriate for the severe sepsis patient in the ICU and non-ICU settings.”

Crit Care Med 2013; 41:580-637

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Lung1 Colon2 Breast3 Sepsis4

cancers

Annual

UK mortality

(2003),

thousands

0

20

30

40

10

© Ron Daniels 2010

A U.K. Perspective

1,2,3 www.statistics.gov.uk

4 Intensive Care National Audit Research Centre (2006)

Courtesy of Dr I Roberts

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Courtesy of Dr I Roberts

Why is it important?

Incidence of sepsis is increasing (330% in 20 years)

Leading cause of death in non-cardiac ITUs (40% of deaths)

Septic shock has 50-60% mortality

Major cause maternal morbidity (75,000 p.a.worldwide)

Centre for Maternal & Child Enquiries (CMACE): Saving Mothers LIves

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Copyright 2010 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions

Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. Published by

American Medical Association.

2

Sepsis in General Surgery: The 2005-2007 National

Surgical Quality Improvement Program Perspective.

Moore, Laura; Moore, Frederick; Todd, S; Jones, Stephen;

Turner, Krista; Bass, Barbara

Archives of Surgery. 145(7):695-700, July 2010.

Surgical Sepsis

Direct Causes of Maternal Deaths

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CMACE

During the 2006 – 2008 triennium, sepsis was the leading cause of direct maternal deaths, accounting for 26 direct deaths and a further 3 deaths classified as ‘Late Direct’Whilst maternal mortality is declining overall, maternal deaths due to sepsis have risen in recent triennia, particularly those associated with Group A streptococcal infection (GAS)

2000-2002 2003-2005 2006-2008

Rate per 100000 maternities

0.65 0.85 1.13

Numbers (all organisms)

13 21 29

Numbers (GAS) 3 8 13

Sepsis Deaths and Fetal Outcomes

29 Deaths altogether

Before 24 weeks, (n=8 ) women died of sepsis

– 100% fetal loss

After 24 weeks (n=21)

12 women had vaginal delivery

9 women had caesarean section

Antenatal Sepsis

9 women developed sepsis antenatally @ >24wks

– 4 c-section/ 5 vaginal deliveries

Fetal outcome : 16 survived5 stillbirths

5 in-utero deaths

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Why do Obstetric Patients Die?

Immunosuppressed

Uncommon

Bad signs very late

Low index of suspicion

Factors affecting Mortality

Subtle signs and symptoms

Lack of recognition of disease severity

Delay in diagnosis

Delay in treatment

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Q&A - Challenges in managing septic patients (tick all that apply/clinical unit level responses)

38%

33%

30%

26%

18%

18%

17%

13%

8%

0% 10% 20% 30% 40% 50%

Deficits in skill and knowledge e.g. lack offamiliarity with assessment / screening tools

Time / workload constraints

Issues relating to referrals / consultation

Multiple physicians admit to the unit, such thatcare processes and teams are fragmented

Absent or unclear procedures / protocols

Lack of supervision of junior clinicians(details)

None

Other (provide details)

Access to relevant information, assistance orother resources (provide details)

The 3 delays model38

DEMAND:

Delays in

deciding to

seek care

SUPPLY:

Delays in

receiving

routine and

emergency

high quality

care

LINKAGE:

Delays in

identifying and

reaching

appropriate

care setting

Delay 1 Delay 2 Delay 3

Designing an integrated care system that accounts for the patient journey

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Why all septic patients?

Sepsis Disease Continuum:

15% → 30% → 50%

Sepsis Deterioration

SIRS

Sepsis

Severe Sepsis

Septic Shock

Action

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Risk Factors for Maternal / Genital Sepsis

ObesityImpaired glucose tolerance / diabetesImmunosuppressionAnaemiaVaginal DischargeHistory of pelvic infectionHistory of Group B Streptococcal InfectionGroup A Strep in close contacts

Invasive intrauterine proceduresProlonged Spontaneous Rupture of MembranesPyrexia in LabourRetained products of conceptionC-Section/MidcavityforcepsPoverty & Minority ethnic groups

Variation In Sepsis Care

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15,022 Patients

165 Hospitals

Median of 14

Months

Mortality Decreased from

37 to 30.8 Percent

6.2% Absolute

16% Relative

Stages of Facing Reality

“The data are wrong”

“The data are right, but it’s not a problem”

“The data are right; it is a problem; but it is not my problem.”

“I accept the burden of improvement”

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STAG Sepsis Management in Scotland

Signs of sepsis < 2 days

2% of emergency admissions (~5000)

71% had a EWS

34% had severe sepsis

21% blood cultures

32% IV Antibiotics

70% IV fluids

Scottish

Defect Rate

was 18-74%

Why is implementation so difficult?

Too many elements in the bundle

Some are controversial

Time Sensitive Process

Difficult To Diagnosis Sepsis Early

Human Factors Get In The Way

Invasive procedures needed

ICU stuff??

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Complacency, Education & Trying Harder isn’t enough

US Prevention and Prevalence

IHI Expedition: Treating Maternal Sepsis

March 21, 2013


Pete Cherouny, MD

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Patient Story

Maternal Sepsis Case Example

Sepsis and Pregnancy

Dr. Cherouny has no conflicts of interest requiring declaration

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Why is this important?

US prevalence of Obstetric Sepsis

Preventing Infection and Sepsis


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Maternal mortality in the US has been increasing at 2% per year for the last 20 years

Top four causes of maternal death includes infectious causes

Septic maternal deaths are most common cause of direct maternal mortality in UK

Approximately 50 severe morbidities for each maternal death

The Joint Commission. Preventing Maternal Death. Sentinel Event Alert Issue 44. January 26, 2010


Maternal mortality in the US has been increasing at 2% per year for the last 20 years

Top four causes of maternal death includes infectious causes

Septic maternal deaths are most common cause of direct maternal mortality in UK

Approximately 50 severe morbidities for each maternal death

The Joint Commission. Preventing Maternal Death. Sentinel Event Alert Issue 44. January 26, 2010

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Infectious deaths can be delayed and underreported (as a maternal death)

Patient with delayed morbidities, like infection, often present to non-obstetric personnel

Substandard care is noted in up to 70% of septic related maternal deaths

Increasing cesarean section rate


Infectious deaths can be delayed and underreported (as a maternal death)

Patient with delayed morbidities, like infection, often present to non-obstetric personnel

Substandard care is noted in up to 70% of septic related maternal deaths

Increasing cesarean section rate

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Physiologic change in pregnancy can alter the presentation and response to infection

“Rose-colored glasses” effect – pregnant patients tend to be young and healthy

System based issues in patient care

Change in the spectrum of infectious disease in the obstetric population


Continuum of Infectious Disease Process

InfectionTraumaBurn

SIRS

SepsisSevere Sepsis

Septic Shock

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Spectrum of Infectious Disease

Definitions

Sepsis

– SIRS plus infection

Severe Sepsis

– Sepsis plus organ failure

Septic Shock

– Sepsis plus arterial hypotension


Continued reports of developing bacterial resistance to current antibiotics

Obesity continues to increase

Unclear guidelines for prevention

This is a war against antibiotics, not bacteria

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Obstetric sepsis related morbidity and mortality are increasing

Changing population and changing criteria of diagnosis and management

Good tools available for prevention and management


Process changes have shown significant improvement in mortality and outcome

Inadequate therapy in maternal obstetric deaths attributable to failures in prevention, recognition, and prompt management

Ferrer R et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008:299;2294.

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Prevention of Obstetric Sepsis

Known prophylaxis strategies

Process improvement strategies for culture performance and followup

Immunization status


Prophylaxis strategies

– Patient based

– Provider based

– Procedure based

– System based

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Prophylaxis strategies– Patient based

– Patient Colonization/InfectionMRSA (screening not recommended)Chlorhexidine cleaning prior to elective procedureGroup A Strep knowledge

– BMI issuesCounsel on weight loss prepregnancy or appropriate weight gain

antepartum

– ImmunizationsInfluenzaPneumococcus


Prophylaxis strategies– Provider based

– Hand washing

– AsepsisChanging gloves intraoperatively or during vaginal/perineal repair

Allow spontaneous placental delivery at cesarean section

– Respect isolation

– Provider Immunizations

– Staying home when sick

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– Procedure based

– Surgical prophylaxis

– Group B Streptococcus prophylaxis

– Pyelonephritis prophylaxis

– Endocarditis prophylaxis



– Surgical prophylaxis

– Single dose therapy in most settings

*Including unlabored cesarean section patients

– 1st generation cephalosporin (2 gm for obese patients)

– Preincision rather than after cord clamping

– Clindamycin monotherapy is not considered adequate prophylaxis (+ aminoglycoside)

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– Group B Strep prophylaxis

– Penicillin is drug of choice

– Cephalosporin for PCN allergic patients without IgE-mediated allergic reaction

– Sensitivities to clindamycin and erythromycin (D-test) in patients with severe allergic reaction to PCN

– Erythromycin is no longer used due to resistance

– Patients with unknown culture at term should be treated by indication



– Pyelonephritis prophylaxis

– Early pregnancy urine culture

– Treatment if UTI (>105 CFU/ml)

– Up to half will develop pyelonephritis if untreated

– Follow up for cultures and treatment necessary

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– Endocarditis prophylaxis

– Neither vaginal delivery nor cesarean section are considered high risk procedures requiring prophylaxis

– Most causes of endocarditis not attributable to procedure

– Risk of antibiotic associated adverse event higher than potential benefit

– Mitral valve prolapse never needs prophylaxis

– Multiple dose protocols are no longer recommended



– Preterm PROM

– Latency antibiotics

– Preterm Labor

– Group B Strep only

– 3rd and 4th degree lacerations

– Consensus is data is inadequate

– Manual removal of the placenta after vaginal delivery

– Inadequate data for recommendation

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– System based

– Reliable system for followup and reporting of positive cultures

– Availability of antibiotics

– Reliable system for appropriate prophylaxis

Timing, Antibiotic choice, Duration



– Immunizations

– Influenza

– Pnuemococcal vaccine

– Varicella

– Childhood immunizations

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Summary

– Remain current on prophylactic antibiotic therapies

– Collect and know your data

– Reliable design strategies for improvement in compliance

– Provider reminders regarding immunizations

– Don’t forget to care for yourself

Questions?82

Raise your hand

Use the Chat

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The Golden Hour: Sepsis Doesn’t Wait


March 21, 2013


Pete Cherouny, MD


New ways of thinking84

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New ways of thinking

Front line engagement

Segmentation

Real Time Data Collection

Early Feed Back of Metrics

Early Case Review and Feedback

Use Level 2 Reliability Tools

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10

Basic Bundle Compliance Mortality Rate

Basic 4 Bundle Compliance vs. Mortality

30%

21%

Center Line = 70%

Center Line = 24%

IHI – Reducing Sepsis Mortality Collaborative86

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Center Line = 65.4%

87

8.9%

20.2%

Center Line = 14%

110 Lives Saved Per Year

88

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Knowledge into Action for Change Package

Clinical Knowledge (Evidence Based Practice):

MEDLINE, Cochrane etc

Improvement Knowledge:

SPSP experience, etc

Know-What

Know-How

Quality

Patient Care

Doing the

right thing

Doing it right

Clinical

Decisions

Process/System

Changes

Adapted from: Glasziou, P et al. Can evidence-based

medicine and clinical quality improvement learn from

each other? 2011. BMJ QualSaf 20 (suppl 1): i13-i17

89

Evidence for the Change Package90

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91

“He who must not be named”92

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Socio-economic Factors93

Type of physiological abnormality at time of ED patient inclusion in audit (first signs of sepsis) n=626 – median age 73 years

Gray et al Emerg Med J (2012) doi:10.1136/emermed-2012-201361

94

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Reliable Recognition, Assessment & Rescue95

What can we do?

Early recognition

Early resuscitation

Early antibiotics

Review

Appropriate help

96

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Screening for Sepsis and Performance Improvement

We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy (grade 1C).

Performance improvement efforts in severe sepsis should be used to improve patient outcomes (UG).

Crit Care Med 2013; 41:580-637

97

Sepsis Screening

MEWS: >95% reliable in pilot wards

Systemic Inflammatory Response Syndrome (SIRS) criteria

98

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MEOWS99

MEOWS100

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SIRS Criteria102

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Suspicion of Infection103

The Sepsis Six

1. Deliver O2 (>94% SpO2 or >88% in COPD)

2. Take blood cultures and consider source control

3. Give IV antibiotics according to local protocol

4. Start IV fluid resuscitation (min 500ml) and reassess

5. Check serum lactate & FBC

6. Commence accurate urine output measurement and consider urinary catheterisation

All within one hour

104

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History

Diarrhoea +/- vomiting

Severe lower abdominal pain/ severe “after pains”requiring frequent analgesia

Sore throat

Myalgia

Fever

Productive cough, shortness of breath

Urinary symptoms

Vaginal discharge/ wound pain and redness

105

History

“diarrhoea is an important sign of pelvic sepsis, the combination of abdominal pain and fetal loss should alert the clinician to the possibility of sepsis as well as consideration

of abruption””””

106

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Clinical Features Suggestive of Sepsis

Fever or rigors

Diarrhoea or Vomiting

Rash

Abdominal / Pelvic pain & tenderness

Offensive vaginal discharge

Productive cough

Urinary symptoms

Breast Engorgement

Wound infection

Heavy Lochia

Delay in Uterine involution

Non-specific

– Lethargy

– Reduced appetite

Investigations

FBC, U&Es, LFTs, glucose

Coagulation

Blood Cultures

ABGs

Blood lactate

CRP

HVS, MSSU, throat swab, wound swab

108

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Investigations-Severe Sepsis

BP <90mmHg or MAP<65mmHg or systolic 40 mmHg below normal

Urine output <30 mls/hr for 2 hours

New altered mental state

New oxygen requirement

Serum creatinine >120mmol/l

Lactate >4 mmol/l

Unexplained coagulopathy

109

Common organisms causing Puerperal Sepsis

GAS, also known as Streptococcus pyogenes

Escherichia coli

Staphylococcus aureus

Streptococcus pneumoniae

meticillin-resistant S. aureus (MRSA), Clostridium septicum and Morganella morganii.

110

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© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott

Williams & Wilkins, Inc.

Duration of hypotension before initiation of effective

antimicrobial therapy is the critical determinant of

survival in human septic shock *.

Kumar, Anand; Roberts, Daniel; Wood, Kenneth; Light,

Bruce; Parrillo, Joseph; Sharma, Satendra; Suppes,

Robert; Feinstein, Daniel; Zanotti, Sergio; Taiberg, Leo;

Gurka, David; Kumar, Aseem; Cheang, Mary

Critical Care Medicine. 34(6):1589-1596, June 2006.

DOI: 10.1097/01.CCM.0000217961.75225.E9

Figure 1. Cumulative effective antimicrobial initiation

following onset of septic shock-associated hypotension

and associated survival. The x-axis represents time (hrs)

following first documentation of septic shock-associated

hypotension. Black bars represent the fraction of

patients surviving to hospital discharge for effective

therapy initiated within the given time interval. The gray

bars represent the cumulative fraction of patients having

received effective antimicrobials at any given time point.

Why within an hour?111

The Sepsis Six

1. Deliver O2 (>94% SpO2 or >88% in COPD)

2. Take blood cultures and consider source control

3. Give IV antibiotics according to local protocol

4. Start IV fluid resuscitation (min 500ml) and reassess

5. Check serum lactate & FBC

6. Commence accurate urine output measurement and consider urinary catheterisation

All within one hour

112

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Surviving Sepsis 2012

We recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (> 45 minutes) in the start of antimicrobial(s) administration(grade1C).

The administration of effective IV antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) should be the goal of therapy.

The antimicrobial regimen should be reassessed daily for potential de-escalation to prevent the development of resistance, to reduce toxicity, and to reduce costs (grade 1B).

Crit Care Med 2013; 41:580-637

113

Antimicrobial Choices

Co-amoxiclav

– Lack of cover of MRSA, pseudomonus (NEC!)

Metronidazole

– Only covers anaerobes

Clindamycin

– Covers Strep, Staph & most MRSA

Piperacillin & Tazobactam

Gentamicin

– Caution in AKI, monitor serum levels

114

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Indications for transfer to Critical Care

Cardiovascular

– �BP & Cryptic Shock

Respiratory

– Pulmonary oedema, Respiratory Failure, Airway Protection

Renal

– Acute Kidney Injury

Neurological

– Altered conscious level

Miscellaneous

– MOF, Acidosis, Hypothermia

115

When to Escalate Care?116

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Fetal Monitoring & Delivery

Patient & Multidisciplinary decision re. timing & mode of delivery

If premature, cautious consideration of corticosteroids

Continuous electronic fetal monitoring / CTG

Regional anaesthesia for Delivery is relatively contra-indicated

117

Modification of the Bundles

Crit Care Med 2013; 41:580-637

118

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Initial Resuscitation

We recommend the protocolised, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion

During the first 6 hrs of resuscitation, the goals should include all of the following as a part of a treatment protocol (grade 1C):

a) CVP 8–12 mmHg (12-15 if vent)

b) MAP ≥ 65 mmHgc) Urine output ≥ 0.5 mL/kg/hrd) ScvO2 or SvO2 70% or 65%, respectively

Suggest targeting resuscitation to normalize lactate in patients with elevated lactate (grade 2C).

Crit Care Med 2013; 41:580-637

119

Multidisciplinary Help

Senior Labour Ward Staff

Microbiology

ICU

120

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Top Tips fromWebEx

Brightly coloured paper for screening tool draws attention

Simplify the screening tool

Screening tool in blood culture bags to connect essential elements of the process

Case note review builds knowledge of system successes and failures

Target doctors through induction

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Lessons from

Beware

– Prescribing / Charting e.g. ward chart not ED stat dose

– Communication – doctor/nurse – no urgency

– Investigation & specimen collection – waiting for results before Abs!!

– “Don’t give Abs until I see him”

– Avoid infusions, go for IV bolus

Twitter124

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More Top Tips

Align data collection with junior doctors projects

Monthly snapshot audit of triggering patients – ‘who did we miss?’

Open door policy for staff to give real time feedback –what can we do better next time?

Named doctor as ‘rapid responder’

‘Sepsis order set’ for bloods

Sepsis pathways on front of EWS chart

Use patient stories – good and bad – to drive awareness

125

“the committee believes that the greatest outcome improvement can be made through education and

process change for those caring for severe sepsis

patients in the non- ICU setting and across the

spectrum of acute care.”

“these recommendations are intended to be best practice (the committee considers this a goal for clinical

practice) and not created to represent standard of care.”

126

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A Scottish Summary

Sepsis is a Medical Emergency

Awareness, Screening, Recognition and Prompt Treatment is the Key to Reliable Rescue

127

Community of Practicehttp://www.knowledge.scot.nhs.uk/sepsisvte.aspx

128

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Thank you and Good Luck

“I hated every minute of training, but I said, don’t quit, suffer now and live the rest of your life as a champion.”

Muhammed Ali

[email protected]

Activity – Review Maternal Sepsis at Your Organization


March 21, 2013


Sue Leavitt Gullo,

RN, BSN, MS

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Case Example of Maternal SepsisIHI Expedition: Treating Maternal Sepsis

March 21, 2013


Cheri Johnson, RN

Questions?132

Raise your hand

Use the Chat

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Designing a Measurement Strategy IHI Expedition: Treating Maternal Sepsis

March 21, 2013


Sue Leavitt Gullo,

RN, BSN, MS

What are we trying toAccomplish?

How will we know that a

change is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study Do

Source:

Langley, et al. The Improvement Guide, 1996.

Aim

The three

questions

provide

the

strategy

The PDSA cycle

provides the

tactical approach

to work

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Always ask…

What is the real problem we are trying to solve?

135

136

Aim Statement Worksheet

Team name:

How good?

By when?

Aim statement (What’s the problem? Why is it important? What are we going to do about it?)

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137

Check Points in Developing an Aim Statement

AIM Content

• Explicit over arching description

• Specific actions or focus

• Goals

AIM Characteristics

• Measurable (How good?)

• Time specific (By when?)

• Define participants and customers






Act Plan

Study Do

Source:


Measure

The three

questions

provide

the

strategy

The PDSA cycle

provides the

tactical approach

to work

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Question #2: How Do We Know that a Change is an Improvement?

“When you can measure what you are speaking about

and express it in numbers, you know something about it;

but when you cannot measure it, when you cannot

express it in numbers, your knowledge is of a meager

and unsatisfactory kind.”

Lord Kelvin, May 3, 1883

“In God we trust.

All others bring data.”

W. E. Deming

The purpose of measurement in QI work is for learning not judgment!

All measures have limitations, but the limitations do not negate their value for learning.

You need a balanced set of measures reported daily, weekly or monthly to determine if the process has improved, stayed the same or become worse.

These measures should be linked to the team’s Aim.

Measures should be used to guide improvement and test changes.

Measures should be integrated into the team’s daily routine.

Data should be plotted over time on annotate graphs.

Focus on the Vital Few!

Measurement is Central to the Team’s Ability to Improve

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Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result?

Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?

Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)?

Three Types of Measures

� Outcome Measures:Percent of patients alive at 30 days or discharged alive < 30 days, sampled patients

� Process Measures:

- Percent of patient with elevated EWS score who had documented SIRS score

- Median Time to First Antibiotic Dose

- Percent of patients with blood culture performed within 1 hour of time zero

- Percent of patients with Sepsis Six performed within 1 hour of time zero (Bundle)

Three Types of Measures

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143How do we analyze variation for quality improvement?

Run and Control Charts are the best

tools to determine if our improvement

strategies have had the desired effect.

The Problem144

Aggregated data presented in tabular formats or with summary statistics, will not

help you measure the impact of process improvement/redesign efforts. Aggregated

data can only lead to judgment, not to improvement!

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Measure Over Time

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14

De

lay t

ime

(h

ou

rs)

Weeks






Act Plan

Study Do

Source:


Changes

The three

questions

provide

the

strategy

The PDSA cycle

provides the

tactical approach

to work

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Changes

Design reliable processes

Reduce variation

Limit waste

Discover through applied learning

147

Guidance for Testing a Change Concept

Test over a wide range of conditions in the sequence of tests, for example test at different times of day, different days, different patients

Celebrate your failures and learn from them.─ Do not try to design the perfect test─ Some theories are wrong

Don’t confuse a task with a test!

A test means that you are changing something: thus a test of change

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149

A test of change should answer a specific question!

A test of change requires a theory and a prediction!

Test on a small scale and collect data over time.

Build knowledge sequentially with multiple PDSA

cycles for each change idea.

Include a wide range of conditions in the sequence of tests.


Guidance for Testing a Change Concept

Why Rapid Cycle Testing

• Minimal investment to learn what works

• Engages individuals

• Being able to test leads to willingness to adopt

• “Just do it” does not work for large changes

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Testing

Test on a small scale and collect data over time.

Test with one nurse, one doctor, one patient 1----3----5----ALL

Build knowledge sequentially with multiple PDSA cycles for each change idea.

Test multiple times, with different changes

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They are closely related.

In order to run a PDSA test, you need to perform a number of tasks or activities

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A PDSA and related Tasks

Examples of Tasks

� Scheduling a meeting

� Creating a form to collect data

� Printing a survey

� Developing an educational program

� Writing a policy or procedure

� Deciding which form to use

� Determining when the test will be done

� Identifying who will run the test, where it will be done and when

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Tests and related task

Test Tasks (activities) we need to do in order

to run this test

In this test we plan to: 1.

2.

3.

In this test we plan to : 1.

2.

3.

4.

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How quickly can you test?

─ Depends on design of the test

─ Availability of situation to test

─ Can test many times a day

─ Test at least once a day or every two days

─ Based on level of ambition

155

Source: The Improvement Guide, API

Model for Improvement

Now, let’s focus

on the PDSA

part of the MFI

and tests of

change

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The PDSA Cycle for Learning and Improvement

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?

Testing v. Implementation

Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system.

Implementation – Making this change a part of the day-to-day operation of the system

Would the change persist even if its champion were to leave the organization?

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Factors that Determine SuccessCurrent Situation Resistant Indifferent Ready

Low Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small

Scale Test

Very Small

Scale Test

Very Small

Scale Test

Cost of failure small

Very Small

Scale Test

Very Small

Scale Test

Small Scale

Test

High Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small

Scale Test Small Scale

Test

Large Scale

Test

Cost of failure small

Small Scale

Test

Large Scale

TestImplement

What are the next steps…

As a Team, what will be your plan?

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Proposed Measures

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Next StepsIHI Expedition: Treating Maternal Sepsis

March 21, 2013


Sue Leavitt Gullo,

RN, BSN, MS

Will, Ideas, Execution

Will

Ideas

Execution

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Execution- What Will You Do?

What are you trying to accomplish?

How will you know a change is an improvement?

What changes will you make that will result in improvement?

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Action Period Assignment

Answer the 3 questions and begin your PDSA’s

Share your plan over the Listserv - faculty and other participants will provide feedback.

Be prepared to answer the following questions on Session 2

1. What went well and why?

2. What did not go well and why?

3. What surprised you?

Expedition Communications

Listserv for session communications: [email protected]

To add colleagues, email us at [email protected]

Pose questions, share resources, discuss barriers or successes

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Next Session

Friday, April 26, 1:00 PM – 2:30 PM ET

Session 2 – Designing a Reliable Process to Identify and Treat Maternal Sepsis

169

ihi expedition treating maternal sepsis session 1.pptx ......3/20/2013 1 ihi expedition treating...

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