Mount Vernon Hospital High Reliability Organization (HRO) Brown Bag - - PowerPoint PPT Presentation

SOS! Spotlight on Sepsis at Inova Mount Vernon Hospital

High Reliability Organization (HRO) Brown Bag Presented by Inova Mount Vernon Hosted by Virginia Hospital & Healthcare Association September 23, 2019

SOS! Spotlight on Sepsis at Inova Mount Vernon Hospital

John Lawrence, RN, BSN, SCRN RN Sepsis Coordinator Inova Mount Vernon Hospital Alexandria, VA

SOS! Spotlight on Sepsis

SOS! Spotlight on Sepsis

Founded in 1976, Inova Mount Vernon Hospital is a 237-bed community hospital offering patients convenience and state-of-the-art care in a unique healing environment.

• Our Opportunity
• Process Improvement & Interventions
• Our Results
• Next Steps

SOS! Spotlight on Sepsis

• Our Opportunity
• Process Improvement & Interventions
• Our Results
• Next Steps

SOS! Spotlight on Sepsis

0.85 0.80 0.80 0.68 0.99 0.81

0.00 0.50 1.00 1.50 2.00 IAH IFOH IFMC ILH IMVH Inova

O/E Ratio

2016 Q4 Inova Sepsis Mortality Performance (Acute Inpatient Only)

Q4 2016

Premier Top Quartile .68

Our Opportunity

PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17

200 400 600 800 1,000 1,200 IFH IAH ILH IFOH IMVH

1/1/16 - 8/20/16 Sepsis Cases

Cases Deaths Hospital Beds

Our Opportunity

Our Opportunity

• In 2016, our SEP-1 compliance was 49%, which was the lowest in our health

system.

• Our Opportunity
• Process Improvement & Interventions
• Our Results
• Next Steps

SOS! Spotlight on Sepsis

Process Improvement & Interventions

Critical Success Factors

• Executive Sponsorship: CEO, CMO, CNO
• A Coordinated System-wide, Multi-disciplinary Approach

– 90-day clinical effectiveness sprint at end of 2016

• Dedicated Sepsis Coordinator (0.5 FTE)
• Real-time Focused Feedback & Education
• Following the Principles of HRO

Process Improvement & Interventions

Staff Education Is Key

• Education rollout beginning of 2017

across the entire health system – for both RNs and clinical technicians

• Annual nursing and clin tech skills fair
• 30 minutes at new employee orientation
• Ongoing coaching of front-line staff
• All new providers receive sepsis
• rientation

Top: Sepsis simulation during annual nursing skills fair Bottom: Staff and students heard from a sepsis survivor at our 2018 Sepsis Lunch & Learn

Process Improvement & Interventions

Standardized Tools

• Our nurses and

providers use a “Code Sepsis” checklist whenever they suspect sepsis.

• This ensures

patients receive a standardized “bundle” of care.

• Each nurse also

has a sepsis “badge buddy.”

Process Improvement & Interventions

Sepsis Order Sets for Providers

Process Improvement & Interventions

Centralized 24/7 eICU Support

Process Improvement & Interventions

Modified Early Warning Score

• The MEWS tool is built into Epic, our EMR.

– Helps nurses monitor their patients and more quickly recognize a patient experiencing a sudden decline.

3 2 1 1 2 3 Respiratory Rate Less than 9 9-14 15-20 21-29 30 or more Heart Rate Less than 40 40-50 51-100 101-110 111-129 130 or more Systolic Blood Pressure 70 or less 71-80 81-100 101-199 200 or more Level of Consciousness Unrespon- sive Responds to Pain Responds to Voice Alert New agitation, confusion Temperature (F) 95 or less 95.1-96.8 96.9-100.4 100.5-101.3 101.4 or more

Process Improvement & Interventions

MEWS Color MEWS Score Action Green 0-2 Continue to monitor Yellow 3 Re-assess patient and VS Orange 4 Notify RRT RN

• r call RRT

Red 5+

Process Improvement & Interventions

Process Improvement & Interventions

Focused Feedback & Recognition

PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17

Process Improvement & Interventions

Focused Feedback & Recognition

Process Improvement & Interventions

Focused Feedback & Recognition

Celebrating Our Sepsis Stars!

• Nurse A. screened patient positive for sepsis.
• “Pt positive sepsis screen, low bp. hr increased low grade fever, o2 91 on

RA pt only complained of decreased sensation to the right side. MD notified awaiting for new orders.”

• Escalated to provider who ordered lactic, cultures and increased fluids.

Lactic was in fact elevated at 2.7.

• Infectious disease and medical service

were consulted and antibiotics ordered for prostatitis and possible other potential infection.

• Patient transferred to medical unit for

closer observation and further management as he is unable to participate in therapies.

Process Improvement & Interventions

Multi-disciplinary Approach: Clinical Documentation Improvement

0.99 0.85 0.80 0.80 0.68 0.81

IMVH IAH IFOH IFMC ILH Inova O/E Ratio

2016 Q4 Inova Sepsis Mortality Performance

Premier Top Quartile .68

Process Improvement & Interventions

• Data show that sepsis, especially “early” sepsis and severe sepsis, is under-documented

at IMVH

• This skews our mortality numbers and does not reflect the care that you provide
• IMVH currently has highest sepsis mortality in system!

IMVH Sepsis Diagnosed Compared to National Trends (2014-2016)

Red = 80th %tile Green 20th %tile Blue = IMVH Sepsis Diagnoses

Example of Sepsis Education for Providers

Process Improvement & Interventions

Multi-disciplinary Approach: Palliative Care

• We have a growing and responsive palliative care team to serve patients with

serious illness and comorbidities

• Clarifying goals of care early on helps everyone involved

Process Improvement & Interventions

HRO Principles IMVH Sepsis Process Preoccupation with Failure

• Every potential core measure fallout is examined, even if it is not sampled
• Even mistakes that did not lead to harm are examined
• Staff utilize the “Safety Always” reporting system

Sensitivity to Operations

• Sepsis coordinator and nursing supervisors monitor several times each day

– and at all hours – for potential sepsis patients

• Sepsis coordinator has easy access both to front-line staff and those higher

up in the chain of command Reluctance to Simplify

• Our interdisciplinary sepsis committee always asks how we can take things

to the next level

• We are never satisfied with our progress or let down our guard
• We dig deep to find root causes of failures
• We attempt to look at data in new ways or from different angles

Commitment to Resilience

• We view mistakes as opportunities
• Each nurse and provider is made directly aware of potential fallouts as soon

as they are identified

• We trust and respect each other and strive for a blame-free culture

Deference to Expertise

• Front-line staff are used to develop new processes and protocols
• Sepsis coordinator provides real-time coaching to nurses and providers

Following the Principles of High Reliability

Process Improvement & Interventions

• “The line of communication between the hospital and the nursing home is

critical in reducing admissions and mortality from sepsis” (HQI)

• Each month we host a well-attended Continuum of Care Collaboration with
• ur local SNFs, ALFs, home health and more
• We conduct Apparent Cause Analyses for readmissions with facilities

Working with Our Community Partners to Reduce Readmissions

• Our Opportunity
• Process Improvement & Interventions
• Our Results
• Next Steps

SOS! Spotlight on Sepsis

Our Results

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

Target Area Percent

Septicemia

Hospital Natl: 80th %ile Juris: 80th %ile State: 80th %ile Natl: 20th %ile Juris: 20th %ile State: 20th %ile

Our Results

Focused Population: Severe Sepsis/Septic Shock - Core Measure Mortality results reflect admitted patients (excluding psych, rehab, hospice) and exclude acute transfers in or transfers out PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17

Source: Medicare.gov Hospital Compare data for Q4 ’17 to Q3 ’18

Our Results

Our Results

44 71 56 52 25 100 200 300 400 500 600 700 2015 2016 2017 2018 2019 (Jan-Jul)

IMVH Sepsis Cases

Outcome Cases Deaths

Focused Population: Severe Sepsis/Septic Shock - Core Measure PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17

Our Results

All-Cause Hospital-Wide 30-Day Readmission Methodology with Planned Readmission Algorithm v4.0 Focused Population: Severe Sepsis/Septic Shock - Core Measure PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2016 2017 2018 2019 O/E

Sepsis Risk-adjusted 30-day Readmissions - CareScience

• Our Opportunity
• Process Improvement & Interventions
• Our Results
• Next Steps

SOS! Spotlight on Sepsis

• Maintain SEP-1 core measure and mortality rates
• Continue relationship with skilled nursing facilities to reduce readmissions
• Focus on reducing complications
• Continue patient and family education

Next Steps

Next Steps

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2

Sepsis: Risk-Adjusted Complication Comparison

IMVH O/E Peer O/E

Focused Population: Severe Sepsis/Septic Shock Peer: {Council of Teaching Hospitals}:Non-COTH and {Bed-Size}: Hospitals w/ 201 to 300 Beds) PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17

• Maintain SEP-1 core measure and mortality rates
• Continue relationship with skilled nursing facilities to reduce readmissions
• Focus on reducing complications
• Continue patient and family education

Next Steps

Sepsis Education Pilot

What? We are piloting new sepsis education cards on IMCU. Who? We will start with patients who have been diagnosed with sepsis. The charge nurse or sepsis coordinator will inform if you have a sepsis patient that needs education. How? Use the card to teach what is sepsis and what to watch for. Chart this education in Epic, including “Handout” and “Teachback”. Where? Cards are located next to the heart failure folders on ICMU.

WHAT IS SEPSIS? WHAT TO WATCH FOR: T-I-M-E

Thank you!

SOS! Spotlight on Sepsis