Improving Pediatric Sepsis Outcomes (IPSO)

A Multicenter Quality Improvement Collaborative Hosted by The Children’s Hospital Association

1

Pacific Northwest Sepsis Conference – 6/16/2020Dr. Matthew Niedner, MD

2(CHA has >220 Children’s Hospitals)

IPSO Co-Chairs

3

Rich Brilli, MDNationwide Children’s

HospitalIPSO Co-Chair

Emeritus

Charles Macias, MDUH Rainbow Babies &

Children’s Hospital

Raina Paul, MDAdvocate Children’s

Hospital

Matthew Niedner, MDPediatric Intensivist

CHA IPSO Team

Ruth RiggsData Analyst

Jayne StuartDirector, QI

Mary HeadleyProgram Manager

Troy RichardsonManager, Biostatistician

Lowrie WardQI Consultant

(QIC)

Heidi Gruhler

Statistics

Patty KohnRecruitment

Carol RosenbergClinical QI Consultant

(QIC)

Jennifer ColdrenQI Consultant (QIC)

+ Over 50 National Experts in IPSO Leadership &

Advisory Roles

IPSO High-level Overview

4

Form teams

Partnerships

Resources

Train staff

Data sources

Validate

Submit data

Reports

IPSO bundles

5 key processes

Rapid cycle improvement

Peer-to-peer sharing

Web-based libraryDirect

coaching

March 2020 – Inclusion in Aggregate Status

5

50 Sites Actively Submitting Data

47 Sites Included in Aggregate

3 Sites Excluded from Aggregate

April 2018 Reports# of Data Quality Issues

0 1 2 317 4 2 2

16 3 3

1 3

March 2020 Reports# of Data Quality Issues

0 1 2 3Minimum Data Submission Met 47

Minimum Baseline Submission Not Met

Minimum Prospective Submission Not Met 2Neither Baseline nor Prospective Minimum Met 1

TerminologyBlood culture & antibiotic within 24 hours

and inpatients or intent to admit (ED)IPSO Suspected

Infection (ISI)8 ways to meet inclusion from treatments to ICD

(sensitivity>specificity)

IPSO Sepsis

Subset with Treatment Criteria AND 3rd Bolus OR Pressor

IPSO Critical Sepsis (ICS)

Subset not meeting IPSO Critical criteria

IPSO Non-Critical Sepsis (INS)

6

>200k

>15k

>30kn over3 yrs

Highly correlated to Goldstein Criteria for

Severe Sepsis / Shock

IPSO Key Driver Diagram (sans 2o drivers)

7

Reduce Sepsis-Attributable

“IPSO Critical Sepsis”

Mortality by 25%

II Recognition: Sensitive, specific, efficient, and timely recognition of IPSO Sepsis III Diagnostic Evaluation: Appropriate and timely diagnostic evaluation of IPSO SepsisIV Resuscitation / Stabilization: Appropriate, timely, and effective treatment of IPSO SepsisV De-escalation: Appropriate and timely de-escalation of careVI Patient and Family Engagement

I Prevention: Appropriate & timely treatment of IPSO Suspected Infection that may progress to IPSO Sepsis

VII Optimize Performance

Reduce Hospital-Onset“IPSO Critical

Sepsis” by 25%

0

50,000

100,000

150,000

200,000

250,000

300,000

2017

-06

2017

-07

2017

-08

2017

-09

2017

-10

2017

-11

2017

-12

2018

-01

2018

-02

2018

-03

2018

-04

2018

-05

2018

-06

2018

-07

2018

-08

2018

-09

2018

-10

2018

-11

2018

-12

2019

-01

2019

-02

2019

-03

2019

-04

2019

-05

2019

-06

2019

-07

2019

-08

2019

-09

2019

-10

2019

-11

2019

-12

2020

-01

2020

-02

2020

-03

2020

-04

Epis

odes

Submission Month

by Episode Type

Baseline IPSO Sepsis IPSO Sepsis (not critical) IPSO Critical Sepsis IPSO Suspected Infection

Baseline IPSO Sepsis Episodes - 12,426Prospective IPSO Sepsis Episodes - 45,038

IPSO Critical Sepsis Episodes - 15,290

Total Episodes - 259,324IPSO Suspected Infection Episodes - 201,860

IPSO Sepsis (not critical) Episodes - 29,748

Cumulative Sepsis Episodes Submitted

8

2017 2018 2019 2020

91.1%

92.5%

81.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2017

-06

2017

-07

2017

-08

2017

-09

2017

-10

2017

-11

2017

-12

2018

-01

2018

-02

2018

-03

2018

-04

2018

-05

2018

-06

2018

-07

2018

-08

2018

-09

2018

-10

2018

-11

2018

-12

2019

-01

2019

-02

2019

-03

2019

-04

2019

-05

2019

-06

2019

-07

2019

-08

2019

-09

2019

-10

2019

-11

2019

-12

2020

-01

2020

-02

2020

-03

2020

-04

% o

f Mon

ths

Subm

itted

Submission Month

Target Baseline IPSO Sepsis Prospective IPSO Sepsis IPSO Suspected Infection

% Overall Submission Progress 4.25.20

9

> 90% of total IPSO Sepsis months possible have been submitted

2017 2018 2019 2020

IPSO’s 5 Key Processes

10

62% 65% 63% 58% 50%94%

0%

20%

40%

60%

80%

100%

ScreenImproving

HuddleImproving

Order SetImproving

BolusImproving

ABXImproving

Improvingin at leastone keyprocess

Perc

ent o

f Hos

pita

ls

% of Hospitals Showing Improvement*

*Last 12 data points improved over first 12 data points

11

49 43 33 19 1005

101520253035404550

improved inat least 1

improved inat least 2

improved inat least 3

improved inat least 4

improved inall 5

Num

ber o

f Hos

pita

ls

Number of Hospitals Showing Improvement*

IPSO’s 5 Key Processes

*Last 12 data points improved over first 12 data points

12

2017 2018 2019

13

2017 2018 2019 2020

14

2017 2018 2019 2020

15

2017 2018 2019 2020

16

2017 2018 2019 2020

17

2017 2018 2019 20202016

18

2017 2018 2019 20202016

19

2017 2018 2019 20202016

Treatment

Within 6 Hours

Antibiotic

2 Boluses OR

1 Bolus + Pressor

Third Bolus OR Pressor

IPSO Critical Sepsis

What do we mean by “IPSO Critical Sepsis”?

20

[Third Bolus or Pressor] Plus Treatment

Note: “IPSO Critical Sepsis” cannot be identified from IPSO baseline data set; baseline for IPSO Critical Sepsis is defined as the first 12 months of IPSO prospective data set (2017 for Wave 1).

Incidence Comparison (per 1000 admissions)

21

0

5

10

15

20

25Ja

n 20

17Fe

b 20

17M

ar 2

017

Apr 2

017

May

201

7Ju

n 20

17Ju

l 201

7Au

g 20

17Se

p 20

17O

ct 2

017

Nov

201

7D

ec 2

017

Jan

2018

Feb

2018

Mar

201

8Ap

r 201

8M

ay 2

018

Jun

2018

Jul 2

018

Aug

2018

Sep

2018

Oct

201

8N

ov 2

018

Dec

201

8Ja

n 20

19Fe

b 20

19M

ar 2

019

Apr 2

019

May

201

9Ju

n 20

19

18.320.3

14.1

0

5

10

15

20

25

Jan

2017

Feb

2017

Mar

201

7Ap

r 201

7M

ay 2

017

Jun

2017

Jul 2

017

Aug

2017

Sep

2017

Oct

201

7N

ov 2

017

Dec

201

7Ja

n 20

18Fe

b 20

18M

ar 2

018

Apr 2

018

May

201

8Ju

n 20

18Ju

l 201

8Au

g 20

18Se

p 20

18O

ct 2

018

Nov

201

8D

ec 2

018

Jan

2019

Feb

2019

Mar

201

9Ap

r 201

9M

ay 2

019

Jun

2019

8.8 9.6

IPSO Critical Sepsis (ICS)IPSO Non-Critical Sepsis (INS)

IPSO Suspected Infection (ISI) = 120/1000 admissions

Better and/or earlier recognition of sepsis syndrome earlier in continuum

Relatively stable baseline

30-Day Sepsis-Attributable Mortality Comparison

22

0%

1%

2%

3%

4%

5%

6%

7%

8%Ja

n 20

17Fe

b 20

17M

ar 2

017

Apr 2

017

May

201

7Ju

n 20

17Ju

l 201

7Au

g 20

17Se

p 20

17O

ct 2

017

Nov

201

7D

ec 2

017

Jan

2018

Feb

2018

Mar

201

8Ap

r 201

8M

ay 2

018

Jun

2018

Jul 2

018

Aug

2018

Sep

2018

Oct

201

8N

ov 2

018

Dec

201

8Ja

n 20

19Fe

b 20

19M

ar 2

019

Apr 2

019

May

201

9Ju

n 20

19

1.8%

0%

1%

2%

3%

4%

5%

6%

7%

8%

Jan

2017

Feb

2017

Mar

201

7Ap

r 201

7M

ay 2

017

Jun

2017

Jul 2

017

Aug

2017

Sep

2017

Oct

201

7N

ov 2

017

Dec

201

7Ja

n 20

18Fe

b 20

18M

ar 2

018

Apr 2

018

May

201

8Ju

n 20

18Ju

l 201

8Au

g 20

18Se

p 20

18O

ct 2

018

Nov

201

8D

ec 2

018

Jan

2019

Feb

2019

Mar

201

9Ap

r 201

9M

ay 2

019

Jun

2019

3.6%

IPSO Critical Sepsis (ICS)IPSO Non-Critical Sepsis (INS)

All-Cause Mortality ~Double

Sepsis-Attributable Mortality (30-Day)By Care Setting Onset/Recognition (1/2017 – 6/2019)

23

IPSO Critical Sepsis

0%1%2%3%4%5%6%7%

Jan

2017

Feb

2017

Mar

201

7Ap

r 201

7M

ay 2

017

Jun

2017

Jul 2

017

Aug

2017

Sep

2017

Oct

201

7N

ov 2

017

Dec

201

7Ja

n 20

18Fe

b 20

18M

ar 2

018

Apr 2

018

May

201

8Ju

n 20

18Ju

l 201

8Au

g 20

18Se

p 20

18O

ct 2

018

Nov

201

8D

ec 2

018

Jan

2019

Feb

2019

Mar

201

9Ap

r 201

9M

ay 2

019

Jun

2019

ED

2.5%

0%

5%

10%

15%

20%

25%

Jan

2017

Feb

2017

Mar

201

7Ap

r 201

7M

ay 2

017

Jun

2017

Jul 2

017

Aug

2017

Sep

2017

Oct

201

7N

ov 2

017

Dec

201

7Ja

n 20

18Fe

b 20

18M

ar 2

018

Apr 2

018

May

201

8Ju

n 20

18Ju

l 201

8Au

g 20

18Se

p 20

18O

ct 2

018

Nov

201

8D

ec 2

018

Jan

2019

Feb

2019

Mar

201

9Ap

r 201

9M

ay 2

019

Jun

2019

ICU

8.5%

0%

10%

20%

30%

40%

Jan

2017

Feb

2017

Mar

201

7Ap

r 201

7M

ay 2

017

Jun

2017

Jul 2

017

Aug

2017

Sep

2017

Oct

201

7N

ov 2

017

Dec

201

7Ja

n 20

18Fe

b 20

18M

ar 2

018

Apr 2

018

May

201

8Ju

n 20

18Ju

l 201

8Au

g 20

18Se

p 20

18O

ct 2

018

Nov

201

8D

ec 2

018

Jan

2019

Feb

2019

Mar

201

9Ap

r 201

9M

ay 2

019

Jun

2019

Gen

Flo

or

5.3%

0%

20%

40%

60%

80%

Jan

2017

Feb

2017

Mar

201

7Ap

r 201

7M

ay 2

017

Jun

2017

Jul 2

017

Aug

2017

Sep

2017

Oct

201

7N

ov 2

017

Dec

201

7Ja

n 20

18Fe

b 20

18M

ar 2

018

Apr 2

018

May

201

8Ju

n 20

18Ju

l 201

8Au

g 20

18Se

p 20

18O

ct 2

018

Nov

201

8D

ec 2

018

Jan

2019

Feb

2019

Mar

201

9Ap

r 201

9M

ay 2

019

Jun

2019

Hem

Onc

10.5%

Hmmmm…

24

So we have evidence-based practices (such as it is)…

And we are improving recognition, process compliance, and timeliness…

But we aren’t seeing the mortality needle move as we had hoped…

So time to revisit if we’re doing the right things and looking at it the right way.

Definition: All-or-None Compliance

Episodes are compliant when:There is a positive screen OR positive huddle OR order set is

used

Bolus was administered in specified timeframe

Antibiotic was administered in specified timeframe

Episodes are non-compliant when:There is no positive screen

AND no positive huddle AND no order set is used

Bolus was not administered in specified timeframe

Antibiotic was not administered in specified timeframe

25

AND

AND

OR

OR

Bundles Evaluated

Bolus 20 min / ABX 60 min / Recognition*

• Reflects Original IPSO-specific targets

Bolus 60 min / ABX 180 min / Recognition*

• Reflects Modified IPSO targets (tripled); also updated to more closely match current Surviving Sepsis Guidelines and Internal Data Analyses

26*Recognition = positive screen, positive huddle or order set use

2019 Compliance by Bundle—IPSO Sepsis

27

BundleN, IPSO Sepsis

Any Recognition

Bolus, < Target

Abx,< Target

Overall Compliance

Bolus 20 min –Antibiotic 60 min –Recognition

12,329 72% 53% 57% 22%

Bolus 60 min –Antibiotic 180 min –Recognition

12,329 72% 78% 83% 49%

2019 Compliance by Bundle—IPSO Critical Sepsis

28

Bundle

N, IPSO Critical Sepsis

Any Recognition

Bolus, < Target

Abx,< Target

Overall Compliance

Bolus 20 min –Antibiotic 60 min –Recognition

3,829 71% 64% 64% 30%

Bolus 60 min –Antibiotic 180 min –Recognition

3,829 71% 88% 88% 58%

Bundle Compliance OutcomesAll Bundles below include

PLUS recognitionIPSO Critical Sepsis

SA Mortality % Diff Hospital Days % Diff

Bol 20 min/ABX 60 min (comp) 3.1%-14%

10.0-11%

Bol 20 min/ABX 60 min (non-comp) 3.6% 11.2

Bol 60 min/ABX 180 min (comp) 2. 5%-49%*

9.5-25%*

Bol 60 min/ABX 180 min (non-comp) 4.8% 12.7

29

* Statistically Significant (p<0.05)

Recognition Compliance TimelinessIPSO Critical Sepsis

Mean Time to ABX % Diff

Mean Time to Bolus % Diff

Screen compliant 73-21%

32-21%

No Screen 93 40

Huddle compliant 73-13%

28-22%

No huddle 84 36

Order Set compliant 63-35%

28-32%

No order set 97 42

Any Recognition compliant 71-37%

30-56%

No recognition 113 68

30

Bundle Compliance

31

Bolus 60 – ABX 180 – Recognition

2017 2018 2019 2017 2018 2019

TakeawaysBundle Compliance Matters

• Mortality & hospital days are lower in more compliant episodes• Time to 1st bolus & IV antibiotic are lower when recognition tools are used• So we believe we’re doing the “right things”

Improvement Opportunities• In aggregate, we have only made modest improvements in key processes• Numerous individual hospitals have made very large improvements in some areas,

demonstrating feasibility and providing an example of how to improve• So there is much more opportunity to improve processes/compliance• We are better powered to detect aggregate improvements in common process measures

that in more rare outcomes (i.e., mortality)• So if we increase “the dose” of the “right things done better” we believe that in time we will

see the needle move on mortality.

32

33This Photo by Unknown Author is licensed under CC BY-NC-ND

Bundle Compliance OutcomesAll Bundles below include

PLUS recognition

IPSO Sepsis IPSO Critical SepsisSA

Mortality % DiffHospital

Days % DiffSA

Mortality % DiffHospital

Days % Diff

Bol 20 min/ABX 60 min (comp) 1.76%-19.5%*

8.5-11.8%

3.12%-13.7%

10.0-11.1%

Bol 20 min/ABX 60 min (non-comp) 2.19% 9.7 3.62% 11.2

Bol 60 min/ABX 180 min (comp) 1.24%-56.9%*

7.9-26.9%*

2.45%-48.9%*

9.5-25.4%*

Bol 60 min/ABX 180 min (non-comp) 2.87% 10.8 4.80% 12.7

35

* Statistically Significant (p<0.05)

Recognition Compliance TimelinessIPSO Sepsis IPSO Critical Sepsis

Mean Time to

ABX % Diff

Mean Time to Bolus %Diff

Mean Time to

ABX % Diff

Mean Time to Bolus % Diff

Screen compliant 92-12.7%

35-13.3%

73-20.8%

32-21.4%

No Screen 106 41 93 40

Huddle compliant 93-6.8%

30-23.6%

73-12.5%

28-21.6%

No huddle 100 40 84 36

Order Set compliant 72-40.4%

33-23.5%

63-35.3%

28-32.3%

No order set 121 43 97 42

Recognition compliant 86-36.6%

34-47.4%

71-37.2%

30-56.0%

No recognition 136 64 113 68

36