R ELIABLE A PPLICATION OF THE S EPSIS B UNDLE E LEMENTS North - - PowerPoint PPT Presentation

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R ELIABLE A PPLICATION OF THE S EPSIS B UNDLE E LEMENTS North - - PowerPoint PPT Presentation

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R ELIABLE A PPLICATION OF THE S EPSIS B UNDLE E LEMENTS North Shore-LIJ Health System Martin E. Doerfler, MD SVP, Clinical Strategy and Development Pr Pres esent entation ation Ou Outline ne The NSLIJ HS High Reliability in Health

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SLIDE 1

RELIABLE APPLICATION OF THE SEPSIS BUNDLE ELEMENTS

North Shore-LIJ Health System

Martin E. Doerfler, MD SVP, Clinical Strategy and Development

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SLIDE 2

Institute for Clinical Excellence & Quality

Pr Pres esent entation ation Ou Outline ne

  • The NSLIJ HS
  • High Reliability in Health Care
  • Process for Improvement

– Adjunct improvement techniques

  • Evolving focus
  • Next Steps

1

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SLIDE 3

Institute for Clinical Excellence & Quality

2

We We Are re Or Orga gani nized zed as as a Sy a Syst stem em

  • Common Mission, Vision and Values
  • Single Governance: All entities are under common control

with a unity of purpose

  • Single System-wide management
  • Clinical Leadership involved in all aspects of operations and

strategy - e.g. Chairs, Service Line leaders, etc.

  • Corporate Services infrastructure supports all System

activities

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SLIDE 4

Institute for Clinical Excellence & Quality

NORTH SHORE-LIJ HEALTH SYSTEM

North Shore – LIJ Health System

3

CONFIDENTIAL EDUCATION LAW 6527 - PUBLIC HEALTH LAW 2805, J., K., L., M.

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Institute for Clinical Excellence & Quality

A Cas ase e for

  • r Cha

hang nge

  • Michael Dowling (NSLIJ CEO) identifies sepsis as our key
  • pportunity for preventable mortality (2008)
  • Greatest single cause of in-hospital mortality in our health

system

  • Developed Evidence Based Sepsis Management Guidelines

(algorithm, screening tool, order sets and management bundles) (2009)

  • Developed database and data collection process
  • Partnered with IHI to initiate an improvement collaborative

(2011)

4

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Institute for Clinical Excellence & Quality

Th The e Se Seps psis s Con

  • ntinuum

nuum

  • A clinical response arising from

a nonspecific insult, with 2 of the following:

  • T >38oC or <36oC
  • HR >90 beats/min
  • RR >20/min
  • WBC >12,000/mm3 or

<4,000/mm3 or >10% bands

SIRS = systemic inflammatory response syndrome SIRS with a presumed

  • r confirmed

infectious process

Chest 1992;101:1644.

Sepsis SIRS Severe Sepsis Septic Shock

Sepsis with

  • rgan failure

Refractory hypotension

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EVER

ERY SIN INGL GLE ONE NE:

WHAT

HAT DOES ES HIGH REL ELIABI ABILI LITY TY

REA

EALLY LLY LOOK OOK LIKE

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Institute for Clinical Excellence & Quality

Li Livi ving ng in a 99 n a 99.9 .9% % Err rror

  • r Fr

Free ee Env nvironmen ronment

99.9 % Reliability =

  • 84 unsafe landings per day at O’Hare Airport
  • 1 major commercial plane crash every 3 days
  • 16,000 items lost in the mail per hour
  • 37,000 checks deposited to the wrong account per hour

(1 Error/1000 Attempts)

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SLIDE 9

Institute for Clinical Excellence & Quality

8

  • No. of

STEPS RELIABILITY OF EACH STEP

99% 98% 95% 90% 80% 1 (Lactate) 99.0 98.0 95.0 90.0 80.0 2 (Cultures) 98.0 94 90.3 81.0 64.0 3 (Antibiotics 97.0 92 85.7 72.9 51.2 4 (Fluid Bolus) 96.1 90 81.5 65.6 41.0 5 (Vasopressors) 95.1 88.6 77.4 59.0 32.8 6 (CVP) 94.1 86.9 73.5 53.1 26.2 7 (ScvO2) 93.2 85 69.8 47.8 21.0 8 (Glucose) 92.3 83.4 66.3 43.0 16.8 9 (Low Vt) 91.4 81.7 63.0 38.7 13.4 10 (Steroids) 90.4 80 59.9 34.9 10.7

8

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Institute for Clinical Excellence & Quality

LEVEL 1: Good Intent, Vigilance and Hard Work

  • Guidelines / Recommendations
  • Education and Training
  • Personal Commitments and Checklists
  • Feedback

Design for Reliability

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None Of The Above Are Very Effective At Preventing Human Factor Errors

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Institute for Clinical Excellence & Quality

Design for Reliability

  • Reminders Built Into The System –
  • Defaulted Order Sets,
  • Real Time Data Collection & Feedback
  • Defaults – Evidence Base
  • Predetermined Antibiotic Selection,
  • Specified Fluid Bolus
  • Redundancy –
  • Medication Double Checks

LEVEL 2: Human Error Prevention – Decision Aids

10

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Institute for Clinical Excellence & Quality

Design for Reliability

  • Scheduling Activities –
  • Med. Schedule
  • Explicit Protocols & Standardize Processes
  • Sepsis “Bundle”,
  • Local Explicit “Protocols” for Sepsis
  • Forced Functions By Design –
  • O2 and Air Outlets,

11

LEVEL 2: Human Error Prevention – Decision Aids

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Institute for Clinical Excellence & Quality

Level 3:

Requires a culture change including a sophisticated design of human interactions and working relationships.

(Weick)

Design for “High” Reliability

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Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services by The Lewin Group, Falls Church, VA

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Institute for Clinical Excellence & Quality

Chara racteri cteristi tics cs of

  • f a

High gh Rel eliabil bility ity Env nvironment ronment

  • A shared vision the future environment
  • A Leadership committed to high reliability
  • Frontline by-in and active engagement
  • Established human error prevention practices
  • An environment of continuous process improvement

– goal setting, measuring, testing and spread

  • A culture of team work, awareness, an obsession for

best care

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SURVIVIN

RVIVING SEPS PSIS IS CAMP MPAIG IGN

(SSC) SSC) SEPS

PSIS IS BUND NDLES 2012

2012

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Institute for Clinical Excellence & Quality

NQF QF BUNDLE: LE: Se Seps psis s 0500

TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION :

1.

Measure lactate level

2.

Obtain blood cultures prior to administration of antibiotics

3.

Administer broad spectrum antibiotics

4.

Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

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Institute for Clinical Excellence & Quality

Ant ntibiotics biotics – Mi Minu nutes es Ma Matter er

Adapted from Kumar et al. Crit Care Med 2006; 34: 1589-96.

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Institute for Clinical Excellence & Quality

Pe Perf rformance

  • rmance Go

Goal als s Cha hallenges enges

  • Not feasible to apply similar metrics, expectations and goals

for the entire Spectrum

–

  • Example Goal: Lactate draw within 30 minutes of arrival to

emergency department

– If patient presents in shock then T – 0 of triage time is

reasonable

– If stable patient presents with common complaint (ex. Cough,

Temp 101 and pulse of 92) then in busy ED may not see MD for 30 minutes

17

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Institute for Clinical Excellence & Quality

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IHI Mod Model el for

  • r Imp

mprovement rovement

  • AIM: What are we trying to accomplish.
  • MEASURE: How will we know the change is an

improvement?

  • CHANGE CONCEPT: What change can we

make that will result in an improvement?

  • TEST:

Plan Act Study Do

Langley, Nolan, Nolan, Norman & Provost ‘ The Improvement Guide’

Rapid Cycle Testing

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SLIDE 20

USING MUL

ULTI TIPLE LE REPEAT CYCLES

TO

TO CREATE RAMPS

Plan Do Study Act Plan Do Study Act Plan Do Study Act Plan Do Study Act Plan Do Study Act Langley, Nolan, Nolan, Norman & Provost The Improvement Guide

Test the Local Protocol On a Patient Test Revised CAP Protocol on Another Pt. Obtain a Local Consensus

  • f a CAP Abx Protocol

Test Revised CAP Protocol Until successful on5 Patients Standardize CAP Protocol In This Unit

19

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Institute for Clinical Excellence & Quality

Action Period

includes monthly calls & team reports

Getting Started:

includes calls & activities

Action Period

includes monthly calls & team reports

Learning Session 2 July 2012 Learning Session 3 January 2013 Action Period

includes monthly calls & team reports

Learning Session 1 February 2012

NSL SLIJ/IHI IHI Coll llab abora

  • rativ

tive e Tim imeli line ne – focus s on ea n early ly id ident ntification ification & tr treat atme ment nt in in th the ED

Learning Sessions:

  • Clinical Content – IHI/NSLIJ faculty
  • Improvement Science – What changes can we make that will result in

improvement?

  • Increasing emphasis on participating hospitals sharing their learnings

and experience

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n St

Stru ructure ture

  • Focused Plenary Sessions

– PDSA methodology – Antibiotic Timing – Antibiotic Stewardship (in conflict with Antibiotic timing?)

  • Detailed breakout sessions

– Lactate assessment: importance and Kinetics – Fluid administration – Data analysis – The role of the Executive Sponsor

  • Team work reports

– Each hospital team presents an update of their focus / progress

21

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 1 Fo

Focus s & To Topi pics

  • Making the case for improvement in the ED
  • The Problem and the Vision
  • A “face to the case” A patient story of sepsis
  • Creating a Culture for Change
  • Understanding the “current state”
  • Process Maps and Walkthroughs
  • What Changes Can We Make?
  • Tools to support improvement
  • How Can We Improve?
  • Part I: Model for Improvement
  • Part II: Measures, Changes, and Reliable Design
  • Exercise: Setting Your Project Aim & 90 day plan

22

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 2 Fo

Focus s &To Topi pics cs

  • Increasing Reliability with the sepsis bundle:
  • The Early Recognition of Sepsis
  • Antibiotic Timing, Selection and Stewardship
  • Responding to Elevated Lactates
  • Fluid Resuscitation
  • What are we learning?
  • Individual team Progress reports from all sites
  • What is the data telling us?
  • Focus on: Real Time Data Collection
  • Data collection, preparing charts and graphs

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 3 Fo

Focus s &To Topi pics cs

  • Enhancing Reliable care:
  • From the Patient Perspective – Ensuring Reliable Care
  • Focus on: Real Time Patient-level Data
  • Fluid Resuscitation: Taking it to the Next Level
  • Engaging the Front Line Team
  • Handoffs and Transitions: Transfer of Care Related Issues
  • Focus on: Situational Awareness
  • What are we learning?
  • Individual team Progress reports from all sites
  • Tools to support improvement:
  • More About PDSA: Getting Results From Small-scale Testing
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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 4 Fo

Focus s &To Topi pics cs

  • Expanding the Focus: ED and Inpatient floor
  • Early detection & triggering on the inpatient floor: guidelines &

treatment challenges

  • Focus on Fluids
  • Transitions between levels of care
  • Increasing Reliability with the sepsis “bundle”
  • What are we Learning?
  • Collaborative Rounds: challenges and issues:
  • Tools to support improvement:
  • Improvement Tools Bazar
  • Value Stream Mapping: defining the process on the inpatient floor
  • Data collection on the inpatient floor

25

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 5 Fo

Focus s &To Topi pics cs

  • Expanding the Focus:
  • Enhancing the role/partnership with Pharmacy
  • Inpatient Team Breakout Sessions
  • Focus on Fluids
  • Transitions between levels of care
  • What are we learning?
  • Team highlights: successes, challenges, in progress
  • Tools to support improvement:
  • Improvement Tools Bazar
  • Value Stream Mapping:
  • process of transitions from ED to the inpatient floor
  • process of sepsis care on the inpatient floor

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 6

6 Fo Focus s &To Topi pics cs

  • Identifying patients on the floors with sepsis before they

have progressed to the severe stage

  • MEWS triggers for Sepsis Screens
  • Provider notification and response
  • Focus and transitions and handoffs between levels of

care

  • Inpatient Code Sepsis
  • ED Code Sepsis and Fluid Administration
  • Run Charts
  • Concurrent Data Review

27

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 7 Fo

Focus s &To Topi pics cs

  • Review of Basics
  • Antibiotic Timing
  • Lactate TAT
  • Noninvasive Fluid Status assessment
  • Transitions to Inpatient Care
  • Improvement Tools Bazaar

28

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 8

8 Fo Focus s &To Topi pics cs

  • Where are we and where do we want to go?
  • Review of current status of each program
  • Define Goals of each program
  • Steps necessary to reach goals
  • Improvement Tools Bazaar
  • How to run a PDSA

29

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 8

8 Fo Focus s &To Topi pics cs

  • Where are we and where do we want to go?
  • Review of current status of each program
  • Define Goals of each program
  • Steps necessary to reach goals
  • Improvement Tools Bazaar
  • How to run a PDSA

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Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion

  • n 9 & 10 Fo

Focus s &To Topi pics cs

  • High Reliability
  • Every Patient Every Time
  • Review of data
  • Review of Recent Trials Results
  • PRoCESS
  • ARISE
  • PROMISE
  • Focus on Fluid Administration
  • Improvement Tools Bazaar

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Institute for Clinical Excellence & Quality

PDSA Testing, Implementation, and Spread

How to Develop a PDSA and Run It!

Improvement Science Team March 17

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Institute for Clinical Excellence & Quality

PDSA Concept

Act

  • What changes

are to be made?

  • Next cycle?

Plan

  • Objective
  • Questions and

predictions (why)

  • Plan to carry out

the cycle (who, what, where, when)

Study

  • Complete the

analysis of the data

  • Compare data to

predictions

  • Summarize what

was learned

Do

  • Carry out the plan
  • Document problems

and unexpected

  • bservations
  • Begin analysis
  • f the data

Measures

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

Aim Ideas

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Institute for Clinical Excellence & Quality

PDSA Testing Conditions

Trying new ideas on small scale while the old system is still in place Testing Conditions: Time:

  • New idea for specific time of a day
  • Shift Change

Location:

  • New Idea in a specific circumstances/units
  • Learning what works in local systems

Resources:

  • Focused and specific groups of people/ machines
  • Pioneers who are willing to try

Samples: 1-5 trials to make sure that specific setting is working

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Institute for Clinical Excellence & Quality

Case Study – Continued

  • Map the Current State Process
  • Identify Issues in the Current State Process
  • Prioritize the Issues
  • Select/Design the First PDSA Ramp
Act Plan Do Study

In the Next Meeting They First Map the Current Process and Identified the Roles in a Swim lane

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SLIDE 37

After Modification

Pre Post Designing a PDSA: Ramp 1:Cycle 1

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PDSA Cycles & Sequencing

Repeated Use of the PDSA Cycle

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

Model for Improvement Multiple PDSA Cycles -- Sequential Building of Knowledge – include a wide range of conditions in the sequence of tests before implementing the change Hunches / Theories Ideas for Change A P S D

Small Scale Testing Follow-up Tests Test new conditions Implementation

  • f Change

A P S D

Begin New PDSA Ramp

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Current Metrics

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SLIDE 40
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Institute for Clinical Excellence & Quality

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Institute for Clinical Excellence & Quality

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Institute for Clinical Excellence & Quality

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Martin E. Doerfler, MD mdoerfler@nshs.edu