Sepsis and Venous Thromboembolism

Sepsis and Venous Thromboembolism

• Why we did it ?

• What we embarked to do?

• How we are doing presently?

The Sepsis / VTE Collaborative:Why we did it?

Why is it important?

Courtesy of Dr I Roberts

SEVERE SEPSIS AND HAI MORTALITY

• SEVERE SEPSIS

• 2004: 14000 DEATHS

• 300 per million of 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 of 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

Lung1 Colon2 Breast3 Sepsis4

cancers

Annual

UK mortality

(2003),

thousands

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

4 Intensive Care National Audit Research Centre (2006)

0

20

30

40

10

© Ron Daniels 2010

A U.K. Perspective

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

Variation In Sepsis Care

15,022 Patients

165 Hospitals

Median of 14 Months

Mortality Decreased from37 to 30.8 Percent

6.2% Absolute16% Relative

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??

Complacency, Education & Trying Harder isn’t enough

New ways of thinking

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

“He who must not be named”

Reliable Recognition, Assessment & Rescue

VTE – the facts

• Up to 25,000 deaths each year in England & Wales• No reason to believe that Scotland is any better• Numbers likely to increase in line with risk factors• Known and significant gap in delivery of evidence based

interventions• Process and outcome are disparate• Patient’s clinical condition change• Patient’s location changes

What are the consequences?

• Some VTE are silent• Some VTE kill• Often are associated with long term poor health

– Post thrombotic syndrome– Chronic thromboembolic pulmonary hypertension

Why should we care?

• VTE is underestimated – many are diagnosed after discharge from hospital (Sweetland S et al BMJ 2009,339:b4583)

• Around 25 to 50% of episodes relate to admission to hospital (Heit JA et al Arch Int Med 2002, 162:1245-8; Wiseman DN & Harrison J NZ Med J 2010, 123:37-90)

• Adherence to thromboprophylaxis recommendations is incomplete, especially in medical in-patients (Cohen A et al Lancet 2008, 371:387; Bergman JF et al Thrombos Haemostas 2010, 103:736 )

What should we be doing ?

0%

• Assessment of patient and admission related risk of VTE

• Assessment of contra-indications to anti-coagulant and mechanical Interventions

• Treat according to outcome of assessment and recommended action

• Plan for timely re-assessment

• Documented evidence that the risks and benefits of thromboprophylaxis have been discussed with the patient

The Sepsis / VTE Collaborative:What we embarked to do?

Will, Ideas and Execution

Complacency, Education & Trying Harder isn’t enough

17 years to apply 14% of research knowledge to patient care!

Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70

Team Scotland

How has the frontline done it?

• Get goals.• Get bold.• Get together.• Get a model (and stick with it)• Get patients and families

• Get the facts.• Get to the field.• Get a clock.• Get the numbers.• Get the stories.

The Collaborative Model

LSAlignment with national work

SupportsExpert clinical faculty

Listserv Site Visit

Phone conf Assessments

Monthly Reports via web

LS

A

P

D

S

A D

P

S

1.5 day Kickoff

D

S

P

A

LS

Key Changes

Improvement

Measures

OrganisationalSelf Assessment

Continued Supports

Driver Diagra

m

Change Packag

e

Measurement Plan

Learning Session

Action Period

Monthly Conference Calls & WebEx

Monthly Site Visits

Monitoring & Measurement

The Model for Improvement

‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’

Dr Donald M. BerwickFormer Administrator of the Centres for Medicare &

Medicaid Services Professor of Paediatrics and Health Care Policy at

the Harvard Medical School

Learn from Experience

• Segmentation

• Real Time Data Collection

• Early Feed Back of Metrics

• Early Case Review and Feedback

• Use Level 2 Reliability Tools

Having the best professionals in the world is no longer enough

Support

• Collaborative

• Leadership

• Political attention

• Prioritisation

• Measurement

Responsibility

• Leadership

• Participation

• Outcomes

Building Will

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

The Sepsis / VTE Collaborative:

• “The NHS is….. not good at capturing, using and sharing information. Lots of data, a lot less information and even less knowledge, and that's bad for patients and their families, it's bad for clinicians, bad for managers, bad for regulators and bad for policy-makers.”

Ann Abraham, Parliamentary and Health Service Ombudsman, reporting on Mid-Staffordshire Inquiry.

• 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 24-79%

0%

• Assessment of patient and admission related risk of VTE

• Assessment of contra-indications to anti-coagulant and mechanical Interventions

• Treat according to outcome of assessnt and recommended action

• Plan for timely re-assessment

• Documented evidence that the risks and benefits of thromboprophylaxis have been discussed with the patient

Bridging the Knowledge-Practice Gap

“Knowing is not enough; we must apply. Willing is not enough; we must do”

‘The transfer of knowledge is care’”

Transfer of Knowledge into Quality Healthcare Clinical Knowledge (Evidence

Based Practice):MEDLINE, Cochrane etc

Improvement Knowledge:System, context, process,

patient

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-basedmedicine and clinical quality improvement learn from each other? 2011. BMJ Qual Saf 20 (suppl 1): i13-i17

Example of Knowledge into Action support package: Sepsis and VTE Collaborative

Aim: Define and Implement a Change Package for Management of Sepsis and VTE

Knowledge Management Support

• Know-What, Know-How, Know-Who• Evidence for intervention and implementation• Community of practice support

Driver Diagrams, Change Packages & Measurement Plans

• Subject experts

• Improvement experts

• A facilitated afternoon session to agree content

The Result

The Sepsis / VTE Collaborative:How are we doing ?

Action Period 1

• Community of Practice

• Monthly Conference Calls and WebEx

• Site Visits

• Measurement

• Learning Session 2

A & A

Borde

rs

D & G Fife FV

GJNH

Gram

pian

GG&C

Highlan

d

Lana

rk

Loth

ian

Orkne

y

Shetla

nd

Taysid

e WI

0%10%20%30%40%50%60%70%80%90%

100%

% Board participation in Conference Calls/WebExSepsis Collaborative

% calls attended

Jan-12 Feb-12 Mar-12 Apr-12 May-120

5

10

15

20

25

9 8 79 10

12 1311

17

20

4 5 4

8 7

Participation on conference calls/WebExVTE Collaborative

BoardsParticipantsClinicians

No.

att

ende

d

email reminder1 week prior to call

The Sepsis / VTE Collaborative:Ayrshire & Arran - Sepsis

What we are trying to accomplish?

• All patients in an in the pilot area with a MEWS score of 4 or more will be assessed for SIRS within 30 minutes by July 2012

• 95% of patients identified as septic using the SIRS criteria will receive the sepsis six within one hour of confirmation, by July 2012

• Full hospital spread to be confirmed

Managing the septic patient

• Within the general ward areas an Advanced Nurse practitioner is on duty, with a roving mandate, 24 hrs a day 7 days per week, for the Emergency Response Team / H@N

• To meet the time sensitive need of the septic pt within these areas a dual response was planned

First series of small tests

Worksheet for Testing Change Aim: Every goal will require multiple smaller tests of change

Describe your first (or next) test of change: Person responsible

When to be done

Where to be done

H@N ANP (not in Sepsis group) to review next MEWS4 pts using sepsis documentation and implement Sepsis6 for one weekend

ED Now Pan hospital

Plan List the tasks needed to set up this test of change Person

responsible When to be done

Where to be done

Non sepsis group ANPs identified on shift, to test Sepsis group ANP to support

ED now Pan hospital

Predict what will happen when the test is carried out

Measures to determine if prediction succeeds

Pt assessed appropriately. If SIRS/Sepsis +ve implement sepsis 6. If SIRS +ve but NOT septic- no antibiotics etc

Case note review on pts Monday am Review of times required for implementation Staff comments on documentation

Do Describe what actually happened when you ran the test 4 Pts reviewed at MEWS 4. One pt not SIRS positive. Three SIRS +ve. One SIRS +ve but not septic (first night post op).

Study Describe the measured results and how they compared to the predictions System worked appropriately. Non septic pts did not receive sepsis 6. Documentation agreed as effective (finally)

Act Describe what modifications to the plan will be made for the next cycle from what you learned Re do test with new documentation. Also test for MEWS 4 pt who is SIRS +ve but NOT septic

Tested Documentation and

First Full Testing

• Base line audit of SIRS review and and Sepsis intervention commenced within area

Purpose As part of the work to improve Sepsis management we require to obtain base line data prior to implementation. Therefore we require:- Case note review of all respiratory patients within the confines of ward 3b who have scored MEWS 4 or above. The ERT ANP should liaise with nursing staff and medical staff(if available) to identify ANY respiratory patient who has triggered MEWS 4 and above. This should take place during first trawl if possible. Reviewing the case note entry for that clinical episode the following assessment should take place:- Date and time of MEWS trigger…………………………………… Date and time of clinician response………………………………… Y N Was there evidence that the patient was assessed using SIRS criteria? If NO, would patients have been SIRS positive at time of MEWS trigger? Was patients identified as having SEPSIS, with or without SIRS criteria review?

If no- was SEPSIS present?

If SEPSIS was present, were the following reviewed or implemented? :-

Documented as:- REVIEWED IMPLEMENTED

Comments……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….............................................................................................................................................................................................................................................................................................................................................................................................................................................

SEPSIS 6 Y N Y N Oxygen Fluid challenge Antibiotic Blood culture Lactate & Full Blood Count Urine output review

Situation- Audit of SIRS/Sepsis assessment and implementation of the Sepsis 6 bundle on pts with MEWS score of 4 and above

Initial data

• First live testing within Respiratory ward.• Baseline data for 4 weeks commenced 9.1.12• Patients with MEWS 4 and above n=18• New septic episodes n=9

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23:45

00:00

00:14

00:28

00:43

00:57

01:12

01:26

01:40

01:55

02:09

Time to first antibiotic Respiratory

Consecutive Patients

Dual response commenced

• Pre intervention median time 1hr 25 min• Post intervention median time 37 minutes• Area chosen due to high probable compliance.• ANP presence• Consultant SPSP fellow

Balancing measures

• Antibiotic usage- area now compliant with empirical antibiotic use.

• Blood culture contamination- non significant levels noted

• ERT ANP workload – ongoing review

Currently

• Cardiology• Surgical • Orthopaedics (all three wards)

Baseline data for Cardiology,Orthopaedic Department (ward x3) and

one general surgical ward

• Baseline data being collected over 4 week period (3 weeks presented) Commenced 23rd April

• Number of patients with MEWS of 4 or above n=21

• SIRS assessed n=0• Septic patients n=10• Median time to first antibiotic= 2hrs 30mins

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 Patient 1200:00

01:12

02:24

03:36

04:48

06:00

07:12

08:24

09:36

10:48

Time to first antiobiotic- cardiology, orthopaedics and general surgery

Consecutive Patients

dual response commenced

pt not handed over

Challenges

• Acute baseline assessment and implementation.• Dual site response – Ayr Hospital baseline data

collection commencing. ERT on both sites.

The Sepsis / VTE Collaborative:Grampian – VTE

Plan Do Study Act (PDSA)In Practice

Testing the validity of the VTE screening tool

VTE Screening Relia

bility

Change Two: Consultants found the flowchart a bit confusing as still referred to surgical patients and included mechanical prophylaxis, which is not advocated in SIGN for medical patients. Having just the medical patient considerations on the back was seen to be easier to complete with more space for writing in follow-up. Agreed to involve others in testing.

Change Three: Feedback was that the flowchart was perhaps too complicated. Agreed to test the elements of the flowchart in a table format where staff to “tick all that applied” with a guide then to give or not give prophylaxis based on these results. Feedback was that page 2 of the form was easy to complete.

Change Four: Feedback was that the form was much easier to follow and they liked the tick boxes in terms of risk and bleeding risk factors and found it easy to complete. All forms were completed correctly. Agreed screening and treatment options could be incorporated into one page leaving space for guidance on the back.

Change Five: Layout of the form worked with all staff saying it was clear, easy to follow and to complete. A patient had come in to the Unit on the ACS protocol and currently this was not identified on the form as a risk factor. In addition it was felt that there needed to be the word MEDICAL on the form to avoid confusion.

Change One: Flowchart was easy to follow and that the form contained all relevant information. The issue was that the form was too busy as it included consideration of medical, surgical and orthopaedic admissions. This was seen to be confusing, take extra time to complete and may lead to no-compliance.

Change Six: Form amended and retested by all staff week beginning 16th April 2012. Minor amendment required to the mobility section of the form.

Change Seven: Data being collected on random sample of all patients being admitted. Form gone to reprographics for initial print run and moving to implementation.

VTE DATA

Patient Information Leaflet

“Quite impressive. Very good and very interesting. Never knew about dehydration and that can cause a blood clot.”

“It was very clear and concise, all the abbreviations were explained.”

Patients in Aberdeen Royal Infirmary

1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728290

20

40

60

80

100VTEP5 Patient Information

Median

5 patient case notes reviewed each day

%

Co

mp

lian

ce

Goal 95%

Next Steps Taken

• Orthopaedics now on test 2 of form with compliance data being collected.

• General Surgical on test 5 of form with compliance data being collected.

• Now focusing on 48hr re-assessment in the step-down medical wards.

• Maternity Hospital form being developed in same format for consistency.

• Patient information leaflet now as stock order item.

• Risk assessment tool tested in ED for patients with long leg plasters.

Success…..

The Sepsis / VTE Collaborative:Conclusion

“ The key is collective impact !”

“ working together means that you should never worry alone.”

“Each of you ... All of us”

http://www.cec.health.nsw.gov.au/programs/sepsis

http://www.thrombosis-charity.org.uk/cms/index.php?option=com_content&task=view&id=65&Itemid=13

Our journey has begun?

• 10% reduction in mortality from sepsis by 2014

• Reliable risk assessment and appropriate thromboprophylaxis administration

95% of all adult hospital admissions by December 2014

Thank You