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

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 Care  Process for Improvement – Adjunct improvement techniques  Evolving focus  Next Steps Institute for Clinical Excellence & Quality 1

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 Institute for Clinical Excellence & Quality 2

North Shore – LIJ Health System Institute for Clinical Excellence & Quality CONFIDENTIAL EDUCATION LAW 6527 - PUBLIC HEALTH LAW 2805, J., K., L., M. N ORTH S HORE -LIJ H EALTH S YSTEM 3

A Cas ase e for or Cha hang nge  Michael Dowling (NSLIJ CEO) identifies sepsis as our key opportunity 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) Institute for Clinical Excellence & Quality 4

Th The e Se Seps psis s Con ontinuum nuum Severe Septic SIRS Sepsis Sepsis Shock  A clinical response arising from a nonspecific insult, with  2 of Refractory SIRS with a the following: Sepsis with hypotension  T >38 o C or <36 o C presumed organ failure  HR >90 beats/min or confirmed  RR >20/min infectious  WBC >12,000/mm 3 or process <4,000/mm 3 or >10% bands SIRS = systemic inflammatory response syndrome Chest 1992;101:1644. Institute for Clinical Excellence & Quality

E VER ERY S IN GLE O NE NE : INGL W HAT HAT D OES ES H IGH R EL TY ELIABI ABILI LITY R EA LLY L OOK OOK L IKE EALLY

Li Livi ving ng in a 99 n a 99.9 .9% % Err rror or Fr Free ee Env nvironmen ronment (1 Error/1000 Attempts) 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 Institute for Clinical Excellence & Quality

RELIABILITY OF EACH STEP No. of STEPS 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 (ScvO 2 ) 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 Institute for Clinical Excellence & Quality 8

Design for Reliability LEVEL 1: Good Intent, Vigilance and Hard Work  Guidelines / Recommendations  Education and Training  Personal Commitments and Checklists  Feedback None Of The Above Are Very Effective At Preventing Human Factor Errors Institute for Clinical Excellence & Quality 9

Design for Reliability LEVEL 2: Human Error Prevention – Decision Aids • 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 Institute for Clinical Excellence & Quality 10

Design for Reliability LEVEL 2: Human Error Prevention – Decision Aids • Scheduling Activities – • Med. Schedule • Explicit Protocols & Standardize Processes • Sepsis “Bundle”, • Local Explicit “Protocols” for Sepsis • Forced Functions By Design – • O 2 and Air Outlets, Institute for Clinical Excellence & Quality 11

Design for “High” Reliability Level 3: Requires a culture change including a sophisticated design of human interactions and working relationships. (Weick) 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 Institute for Clinical Excellence & Quality 12

Chara racteri cteristi tics cs of of 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 Institute for Clinical Excellence & Quality

S URVIVIN RVIVING S EPS IS C AMP IGN PSIS MPAIG (SSC) SSC) S EPS IS B UND NDLES 2012 2012 PSIS

NQF QF BUNDLE: LE: Se Seps psis s 0500 TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION : Measure lactate level 1. Obtain blood cultures prior to administration of 2. antibiotics Administer broad spectrum antibiotics 3. Administer 30ml/kg crystalloid for hypotension or 4. lactate ≥4mmol/L 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 . Institute for Clinical Excellence & Quality

Pe Perf rformance ormance 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 Institute for Clinical Excellence & Quality 17

IHI Mod Model el for or 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? Rapid Cycle • TEST: Testing Act Plan Study Do Langley, Nolan, Nolan, Norman & Provost ‘ The Improvement Guide ’ Institute for Clinical Excellence & Quality 18

U SING M UL LE R EPEAT C YCLES ULTI TIPLE TO TO C REATE R AMPS Standardize CAP Protocol In This Unit Test Revised CAP Protocol Until successful on5 Patients Act Plan Study Do Test Revised CAP Do Protocol on Another Pt. Plan Study Test the Local Act Study Act Protocol On a Patient Do Obtain a Local Consensus Plan Act of a CAP Abx Protocol Plan Study Do Act Plan Study Do Langley, Nolan, Nolan, Norman & Provost The Improvement Guide 19

NSL SLIJ/IHI IHI Coll llab abora orativ tive e Tim imeli line ne – focus s on ea n early ly ident id ntification ification & tr treat atme ment nt in in th the ED Learning Action Learning Action Learning Getting Action Session 1 Period Session 3 Period Session 2 Started: Period February includes includes July includes includes January monthly monthly calls & 2012 monthly 2012 2013 calls & team calls & team activities calls & team reports reports reports 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 Institute for Clinical Excellence & Quality

Le Lear arning ning Se Sess ssion on 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 Institute for Clinical Excellence & Quality 21

Le Lear arning ning Se Sess ssion on 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 Institute for Clinical Excellence & Quality 22