UCLA HEALTH High Reliability Organization & Sepsis Program

UCLA Health Key FindingsOf all patient deaths at UCLA, Septic patients account for 25.34%, and Septic Shock pa-tients have an average mortality rate of 40%

Septic patients have >300% of dying com-pared to other patients

Septic patients generate >1000 excess bed days per year

On average 20% of septic patients readmit Septic patients stay 20% longer than other patients

Bundle Compliance (CMS SEP-1)RRMC 25% SMMC 48%

27% of clinical surveillance encounters are related to Sepsis and 30% of inital deteriora-tion

Greater than 75% of Sepsis patients present in the Emergency Department at SM and 64% at RR

2/5 patients who are diagnosed with severe sepsis or septic shock will die before leaving the hospital

A comprehensive sepsis infastructure

Santa Monica ED Bundle Compliance im-proved ~25% from 2015-2017

Repeat Lactate compliance increased from 71% at SM and 87% at RR in Jan ‘17 to 100% in March ’17

90% of nurses screen their patients upon admission to the unit

UCLA Health Best Practices

UCLA’s Sepsis Program comprises a comprehensive infrastructure aligned with “High Reliability” organizational principles. The program uses an interdisciplinary approach to improve overall patient outcomes through sustainable actions. The program uses current education and outreach, care connect improvements, clinical champions, and data analysis to improve overall care of the septic shock patient.

The goal of the program is to recognize and treat Severe Sepsis and Septic Shock early and thereby decrease Sepsis related mortality rates and improve patient outcomes across the UCLA Health System.

Research Program Integration

Joint Commission Sepsis Certi�ed Center

Integration of Clincial Documentation Teams into Sepsis Improvement

Complete infusion of sepsis language in clinical practice

BarriersAlignment with Care Connect/ISS

Dedicated resources for data analytics

Systematic organizational support

Consensus about treatment of septic shock/-severe sepsis treatment among Physician groups

Process & Protocols

Data

Culture

Accountability

No Sepsis Guidelines

Sepsis Screen-ings and Bun-dles

Integrated Order Sets and Protocols

Backup & Redu-dant Systems

No way to measure errors

Event Reports & Sepsis Dash-boards

Sepsis process and outcome benchmarking

Continous Re-al-Time Sepsis Sur-veillance

Trial and Error De�ning Roles in Sepsis

Collective Drive Sepsis Day

Preoccupation with Sepsis Failure

Individual Au-tonomy

Sepsis Safety & Quality Teams

Centralized Sepsis Control

Organizational Awareness

2018 GOALS 1. Standardize UCLA de�nition for Sepsis that integrates de�nitions for Sepsis 2.0, 3.0 and includes SOFA and qSOFA using ICD-10. 2. Develop unit based and service line speci�c dashboards (Include Time of Presentation). 3. Implement evidence based and highly reliable innovations in Care Connect to support clinical de-cision making.

4. Ensure appropriate resources to support the sepsis program, i.e. Full time sepsis coordinator

5. Improve compliance with CMS (SEP-1) core measure. Track & develop learning system from fallouts

6. Re�ne emergency response for sepsis, and integrate the surveillance team initatives ie. code sepsis

7. Research and complete a gap analysis on the Joint Commission certi�ed sepsis center accreditation.

Areas of Innovations and Future Opportunities: Sepsis Continuum of Care

Implemented

In Progress

Future Opportunities

EMS & Community Floor

Sepsis RN (SM) & STAR (RR)

Nurse Driven Protocol Nurse Driven Protocol

Emergency Department

SM RN BPA RRT

RN Screening Tool

Sepsis Audit Graph RN Screening ToolDynamic RN tool

Code Sepsis

RN Screening Tool Dynamic RN toolMD BPA

MD BPA

ED to IP SBAR

MD Orderset & Panels MD Orderset & Panels

ED to IP SBAR

ICU

MD Ordersets

Repeat Lactate

MD BPAAlerts for Palliative Care

RN BPA

EMS Screening

EMS to ED Standard

2012

Simulation Center Collaboration (MDs/RNs)

Care Connect go-live

Adult MD order set LIVE in Care Connect

Nursing Protocol developed

System level nursing champions

MD order sets developed

Sepsis Website Launched

Adult sepsis screening tool launched

Second Annual Sepsis Day

QMS Manager hired for sepsis

Sepsis Project Manager hired

SRRMC Sepsis Coordinator hired

RN mandatory education ( yearly)

ED sepsis screening tool launched (CView)

Adult Sepsis MD order set developed

Sepsis champions model de�ned

QMP database for sepsis cases

Sepsis Lab panel created

First Annual Sepsis Day

Dr. Dan Uslan – named MD Champion

2013

2014

2015

2016

2017

New De�nitions: Sepsis 3.0/SOFA

ProCESS, ARISE, ProMISe Studies

2001

2003

2008

Early-Goal Directed Therapy

Surviving Sepsis Campaign

National Quality Forum

A�ordable Care Act

Innovation: BPA pilot launched and ended

Innovation: ED code sepsis page launched

Innovation:MEWS - RRMC pilot

3rd Annual Sepsis Day

ProCESS, ARISE, ProMISe Studies

SEP-1 (CMS)

Follow-up/MD fallout letter process update

Clinical Triggers pilot SMH

Dr. Steven Chang – interim Sepsis MD

Dr. Tischa Wong – Sepsis Physician champion

Sepsis module for all 1st year residents

4th Annual Sepsis Day

Innovation: Parahealth Pilot

RRMC Clinical Surveillance Team – pilot

Dr. Russ Kerbel – Sepsis Physician Champion

RRMC Clinical Surveillance Team –LIVE 24/7

RRMC Revised RRT team – LIVE 3/2017

SMH Sepsis RN hired

New Website launched

Innovation: Repeat lactate available

Innovation: Sepsis IV �uid bolus order

Innovation: Code Sepsis Inpatient (System)

Value-Based Purchasing ?

Hospital Compare

2018

NationalUCLA

Long Term Goals

UCLA Health Sepsis Program

Project Coordinator

Summer Maxwell

ValU Support

Sabrina Adelaine

Business Owner

Kim Ternavan

Physician Champion

Russ Kerbel

Executive Committee

Data Development

Meng Wei

Education & Outreach

Lee Galuska

Information Technology

Carson Del Greco/Lisa Harrison

Process Improvement

Sabrina Adelaine

Physician Champions

Russ Kerbel

Nursing Champions

Yuhan Kao /Mary Lawanson-

Nichols

Abstractor Specialists

Trudy Rhodes

Pediatrics

Lynne McCullough/

Kerry Gold

Mortality Sepsis

MOVERS

Pt meets criteria for Severe Sepsis & /or Septic Shock (Time of Presentation or TOP)

Document POSITIVE severe sepsis &/or

septic shock screen in CareConnect

Initiate Severe Sepsis & /or

Septic Shock Bundle (per adult sepsis Nursing protocol & core measure requirements)

NURSES

Initial Lactate Level (per nursing protocol, no co-sign required)

Blood Cultures X 2 sets

(per nursing protocol, no co-sign required)

*NOTE: 4 bottles total; minimum of 8-10mL

per bottle

Administer IV broad spectrum antibiotic or other approved

combination of antibiotics

(RN to contact MD/NP/PA to request orders for Abx)

COMPLETE WITHIN 1 HOUR (max) Following initial time of presentation (TOP)

If hypotension persists within 1hour of

completing 30mL/kg �uid bolus, continue

interventions. If pt. no longer hypotensive

after 30ml/kg, STOP!

If initial lactate > 18mg/dl

redraw within 3 hours after

initial lactate

SEVERE SEPSIS & SEPTIC SHOCK: EARLY MANAGEMENT BUNDLE

Changes & Updates highlighted in REDREV 11/24/2015

RN RN &/or MD/NP/PA

NURSES

NURSES

MD/NP/PA

REPEAT serum Lactate level per nursing

protocol if most recent lactate level

>18mg/dL

Initiate VASOPRESSORS (contact MD/NP/PA for orders )

Vasopressors to be initiated for hypotension unresponsive to fluid

bolus of 30mL/kg

COMPLETE WITHIN 6 HOURS (max)Following initial time of presentation (TOP)

Repeat volume & tissue perfusion assessment including (ALL must be documented by MD/NP/PA): � Complete Vital Signs, AND� Cardiopulmonary exam, AND� Capillary refill evaluation, AND� Peripheral pulse evaluation, AND � Skin exam - OR -Any two of the following:� Central venous pressure (CVP) measurement � Central venous oxygen (sCVO2) measurement � Bedside cardiovascular ultrasound� Passive leg raise or fluid challenge 500mL NS/LR (min.)

ANDNURSES &/or

If INITIAL Lactate is ≥36mg/dL, MUST

perform repeat volume & tissue

perfusion assessment (regardless of repeatLactate level results )

*RN to contact MD/NP/PA to request orders for IV Abx & �uid bolus*

IF SBP <90 or >40 below baseline or MAP <65

-OR- Initial Lactate level

≥36mg/dL------------------

Total bolus minimum of 30mL/kg must complete

in < 3hrs from TOP;Administer only

0.9% NS or LR �uids

1 HOUR

Sepsis Program Infastructure

Sepsis Bundle Timeline

Current Data for Sepsissource: Vizient & Tableau