Confidential – Internal Use Only

Sepsis Team Meeting

February 6th 2014

Confidential - Internal Use Only 2

Path forward to Spring 2014 DC Conf

October 2013 Baseline Data

Analysis

October 2013-March 2014 Year 2 Site

Implementation

February 3rd 2014

Sepsis Data Submission

April 2014 Spring

Conference

Agenda

• Updates – Conference – CMMI quarterly reporting – Data

• Shared Learnings Presentation- Beth Israel Deaconess Medical Center

3

Confidential – Internal Use Only

CMMI Sepsis Bundle Counts

4

Ct Site Oct Nov DecQuarter

TotalTotal To

Date

1 Baylor University Medical Center (BUMC) 34 28 44 106 2902 Beaumont Health System - Troy 12 15 28 55 1753 Beth Israel Deaconess Medical Center (BIDMC) 25 20 35 80 2264 Denver Health Medical Center 17 9 16 42 1675 Intermountain Healthcare - Dixie Regional Medical Ctr 14 25 24 63 1466 Intermountain Healthcare - LDS Hospital 19 7 13 39 1167 Intermountain Healthcare - McKay-Dee Hospital Center 42 44 53 139 3148 Intermountain Healthcare - Utah Valley Regional Med Ctr 11 23 24 58 1689 Intermountain Healthcare - Intermountain Medical Ctr 60 57 58 175 42610 NSLIJ - Lenox Hill* 90 20 5 115 29711 NSLIJ - Manhasset* 168 117 119 404 116512 Sutter Health - Central Pacific Medical Center 0 0 0 0 10413 University of Iowa Health Care 0 0 0 0 3915 MaineHealth 0 4 4 8 814 Dartmouth-Hitchcock - - - - -16 Providence Health & Services - - - - -17 Scott & White Healthcare - - - - -18 Virginia Mason Medical Center - - - - -19 EMHS - - - - -

TOTAL 492 369 423 1284 3641

6QR

Confidential – Internal Use Only

CMMI Launch Dates

5

Confidential – Internal Use Only

CMMI Quarterly Reporting

Feb 10: PMO will send you: 1. STAT SPEC (data submission requirement for members not using STAT) 2. Progress Report Follow up request to include:

a. All Members: additional clarifying questions on or plans for: process measures; tracking and monitoring methods for progress and bundle compliance; final call for STAT; course corrections made, etc. b. Members with a launch date prior to December 31, 2013: Submission of current process measures tracking reports (aggregate data indicating count of patients who received the intervention from the start date through December 31, 2013 *** NOT Patient level data (reach out to PMO with questions) ,

3. STAT Site Set up form – for members who are considering using STAT Due by 2/24

Feb 24: • Submit Progress report follow up requirements (# 2a above) • Submit current process measure tracking reports through Dec 31, 2013 (#2b above) • For members using STAT: data entry into STAT to be complete through Dec 31st. All

subsequent entry by the 15th of the following month (e.g. December data in STAT by Jan 15th)

March 12: STAT go-live dates will be assigned by HVHC PMO as applicable

6

Confidential – Internal Use Only

Agenda

• Updates – Conference – CMMI quarterly reporting – Data

• Shared Learnings Presentation- Beth Israel Deaconess Medical Center

7

Confidential – Internal Use Only

Beth Israel Deaconess Medical Center Boston, Massachusetts

Presented by: Kristin O’Reilly MPH

Parth Patel Michael Cocchi MD

8

Confidential – Internal Use Only

• Outline • Background: Sepsis at BIDMC • Baseline compliance data collection • Rapid improvement event – March 2013 • Tools • Ongoing improvements • Data collection tool: RedCap

9

BIDMC

Confidential – Internal Use Only

• Historical perspective • MUST protocol 2006 • MUST 2.0 protocol 2011

10

BIDMC

Confidential – Internal Use Only

Confidential – Internal Use Only

• Baseline compliance data collection

• Performance on the bundle measures • Generally good on the 3 hour measures, less so on 6 hour

measures » ScVO2 » CVP

12

BIDMC

Confidential – Internal Use Only

• Rapid improvement event

13

BIDMC

Confidential – Internal Use Only

Initial State

14

Initial State ED ICU VA steps: 30% NVA steps: 70% Floor ICU VA steps: 26% NVA steps: 74%

Confidential – Internal Use Only

Target State

• 100% compliance with both the 3 and 6 hour bundles • Musts:

– Standardized assessment & treatment – Intuitive process – Proper identification – Allows for thoughtful/ appropriate exclusion – Mistake proof – System supports best practice – Clear visual communication to all caregivers of where pt was at in bundle – Buy-in and education of all staff (true understanding of bundle)

• Wants: – Access to access (to get peripherals &CLs) – Decision support in electronic systems – Clear understanding of how we are doing in real time – Decision support that helps display compliance

Confidential – Internal Use Only

Target State (continued)

Target State ED ICU VA steps: 53% (from 30%) NVA steps: 47% Floor ICU VA steps: 75% (from 26%) NVA steps: 25%

Confidential – Internal Use Only

Gap Analysis

• Many wastes observed in the process

• Identified top 10 barriers to perfect bundle care

• Prioritized based on impact to goals & ability to tackle in one week

Confidential – Internal Use Only

Rapid Experiments

• Validated screening tool with front line staff in the ED & in the ICUs

• Secret shopper in the ED • Report template for floor to ICU reviewed with ICU RNs

screening process for all ICU admissions (opt-out only) with visual ‘bundle bugs’

• Revised sepsis bundle order set in POE test, (went live during RIE)

Confidential – Internal Use Only 19

Confidential – Internal Use Only 20

Confidential – Internal Use Only

• Ongoing process improvements

• Email to MD + RN staff about performance on measures for specific cases

21

BIDMC

Confidential – Internal Use Only

Hi everyone - As you know, we recently introduced a Sepsis Pathway on the Dashboard and a bedside tool sheet to aid with resuscitation of patients with severe sepsis/septic shock, to reflect the revised Surviving Sepsis Campaign and the National Quality Forum's Sepsis Bundle. We are collecting data for all of these patients, and we wanted to provide some feedback on a patient that you cared for (XX on xx/xx/xx) who presented with septic shock secondary to cholangitis. This patient who met eligibility for the 3 hour and 6 hour Bundles: 3 hour (Basic Sepsis Care Bundle) components: 100% 1) Check lactate: YES 2) 30cc/kg minimum IV fluid: YES 3) Broad spectrum antibiotics: YES 4) Blood cultures before antibiotics: YES 6 Hour (Advanced Sepsis Care Bundle) components: 75% 1) Check CVP: YES 2) Check SCVO2: NO 3) Pressors for ongoing hypotension: YES 4) Recheck lactate if initially elevated: YES This patient received all of the required elements of the 3 hour sepsis bundle, but missed the ScVO2 check for the 6 hour bundle - any thoughts on how this could have been avoided? Were there any barriers to completing this aspect of the bundle? Just a reminder that a Sepsis POE order set is now live on the Dashboard as well to aid in your care of these patients.

• Thanks,

22

BIDMC

Confidential – Internal Use Only

• Ongoing process improvements

• Email to MD + RN staff about performance on measures for specific cases

• Graphs with current and past performance displayed in ED and ICU every month

23

BIDMC

Confidential – Internal Use Only

• Ongoing process improvements • Email to MD + RN staff about

performance on measures for specific cases

• Graphs with current and past performance displayed in ED and ICU every month

• Text page alert to senior EM resident for every lactate >4

• ED Dashboard alert: the Sepsis Pathway

24

BIDMC

Confidential – Internal Use Only 25

BIDMC

Confidential – Internal Use Only 26

Confidential – Internal Use Only 27

Confidential – Internal Use Only

• Email to MD + RN staff about performance on measures for specific cases

• Graphs with current and past performance displayed in ED and ICU every month

• Text page alert to senior EM resident for every lactate >4

• ED Dashboard alert: the Sepsis Pathway • ‘Sepsis station’ added to annual nurse

competency training 28

BIDMC

Confidential – Internal Use Only

• Email to MD + RN staff about performance on measures for specific cases

• Graphs with current and past performance displayed in ED and ICU every month

• Text page alert to senior EM resident for every lactate >4

• ED Dashboard alert: the Sepsis Pathway • ‘Sepsis station’ added to annual nurse

competency training • Working to obtain technology to measure CVP

via PICC line

29

BIDMC

Confidential – Internal Use Only

• Data collection tool: RedCap • RedCap is a free, secure, web-based

application designed to support data capture for research studies.

• RedCap is built around HIPAA guidelines and working towards 21 CFR Part 11 compliance

• RedCap allows for customization for any study or clinical trial

30

BIDMC

Confidential – Internal Use Only 31

RedCap Report Form Snapshot

Confidential – Internal Use Only 32

RedCap Easy data export to various software

Confidential – Internal Use Only

BIDMC

Year 1 Accomplishments: Learnings/Insights:

• Created electronic alerts-based screening procedures for eligible patients

• Designed an electronic pathway for the ED Dashboard to include bedside tool sheet and order set to help drive practice

• Provide clinician feedback on performance via targeted emails and monthly data reports

• CVP/Scv02 remains a challenge • Communication between ED + ICU staff

essential for completion of bundle measures after admission

• Clinicians choosing other measures of hemodynamic monitoring – we are collecting data on these variables as well

Barriers: Next Steps:

• Resistance to use of central lines for subset of population with cleared lactate and normotension

• Patients with PICC lines/indwelling ports and no additional CVL placement limits ability to measure CVP

• Provide ongoing feedback to frontline staff about performance

• Special focus of efforts on areas in need of most improvement: ScVO2, CVP, adequate IVF