Sepsis Webinar Series 2018 Presenter: Angela Craig, APN, MS, CCNS - - PDF document

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Sepsis Webinar Series 2018 Presenter: Angela Craig, APN, MS, CCNS - - PDF document

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1/26/2018 Sepsis Webinar Series 2018 Presenter: Angela Craig, APN, MS, CCNS Tennessee Center for Patient Safety: Sepsis Topic Lead Rhonda Dickman, MSN, RN, CPHQ Clinical Quality Improvement Specialist 615-401-7404 - office 706-570-5700 -

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1/26/2018 1

Sepsis Webinar Series 2018

Presenter: Angela Craig, APN, MS, CCNS Rhonda Dickman, MSN, RN, CPHQ

Clinical Quality Improvement Specialist 615-401-7404 - office 706-570-5700 - mobile rdickman@tha.com

Tennessee Center for Patient Safety: Sepsis Topic Lead

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1/26/2018 2

  • Sepsis professionals
  • Shared learning and networking
  • Collaborative efforts to reduce sepsis

mortality in Tennessee

  • Quarterly face-to-face meetings at THA

– THA HIIN hospitals can receive travel support

  • Monthly conference calls

Next meeting: Friday, February 2nd at THA

Sepsis Collaborative

  • Consultant Angela Craig, APN, MS, CCNS
  • For THA HIIN hospitals
  • Conducted on site at your hospital
  • Tailored to meet your unique interests and

needs

Sepsis Consultation Services

“It helped to have someone from "the outside," to go over what we had accomplished so far & identify our needs, our strengths and where we needed to improve to meet our goals.”

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  • Save the Date - May 9, 2018
  • In partnership with Qsource

– Will include nursing homes, home health agencies, and other post-acute providers

Sepsis Readmissions Workshop

  • Four-month project
  • 8 webinars (recorded)

– 4 instructional – 4 sharing/coaching

  • One-hour individual coaching call with

Angela for interested THA HIIN hospitals

  • Post-project evaluation

Sepsis Webinar Series

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1/26/2018 4

TIER 1: Organizational Consensus that Sepsis be Managed Early and Aggressively

  • January 26, 2018 – Introduction to topic
  • February 9, 2018 – Sharing / Touch Base

Sepsis Webinar Series

TIER 2: Early Screening with Tools and Triggers

  • February 23, 2018 – Introduction to topic
  • March 9, 2018 – Sharing / Touch Base

Sepsis Webinar Series

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TIER 3: Implementation of the Sepsis Bundles

  • March 23, 2018 – Introduction to topic
  • April 13, 2018 – Sharing / Touch Base

Sepsis Webinar Series

TIER 4: Measuring Success

  • April 27, 2018 – Introduction to topic
  • May 11, 2018 – Sharing / Touch Base

Sepsis Webinar Series

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Pre-Assessment: Tell us about your sepsis program

AN G E L A C R AI G AP N , M S , C C N S I C U C C N S & S E P S I S F AC I L I T AT O R AT C R M C

SEPSIS PROGRAM DEVELOPMENT TIER I

Angela’s Contact Information: acraig@crmchealth.org 931-239-4904 (cell)

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GOALS FOR TIER 1

  • Is your executive leadership on board?
  • Do you have a sepsis coordinator or someone who is filling that

need?

  • Do you have champions for this project – they need to be

positive and respected individuals from the ED, ICU and Infection Prevention

  • Have you developed an interdisciplinary team?
  • What bedside nurses are on the team?
  • Do you have meeting scheduled for this very important group?
  • Do you feel the culture of safety is a priority?
  • Has a team charter been developed with mission vision and

team goals?

  • What is your baseline data? (can use CMS data)
  • Have you educated your team to understand the latest

guidelines and pathophysiology

KEEP GAP ANALYSIS FORM CLOSE

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1/26/2018 8 Infection Prevention

VAE (VAP) Bundle BSI

Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively Early Screening with Tools and Triggers Implementation of the Sepsis Bundles Measuring Success CQI1

SEPSIS PRACTICE COLLABORATIVE MODEL 4 TIER PROCESS FOR PROGRAM IMPLEMENTATION

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CAUTI

Hand Washing

Documentation Improvement ~ Accurate Coding

1Continuous Quality Improvement

Adapted from: Sepsis Solutions International

Infection Prevention

VAE (VAP) Bundle BSI

Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Early Screening with Tools and Triggers Implementation of the Sepsis Bundles Measuring Success CQI1

SEPSIS PRACTICE COLLABORATIVE MODEL 4 TIER PROCESS FOR PROGRAM IMPLEMENTATION

16

CAUTI

Hand Washing

Documentation Improvement ~ Accurate Coding

1Continuous Quality Improvement

Adapted from: Sepsis Solutions International

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1/26/2018 9

TIER I: ORGANIZATIONAL CONSENSUS AND SUPPORT MILESTONES AND CHECKLIST

1. Define Sepsis Program Goal and aligned with

  • rganizational goals

2. Identify Executive sponsor 3. Collect Baseline Data—essential step

4. Develop sepsis team(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting 6. Begin to define action plan and timeline for program development and implementation

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  • 1. DEFINE SEPSIS GOAL:

DEVELOP PROJECT TEAM CHARTER

2014 CHE Trinity Health, Livonia, MI

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Severe Sepsis is Common and Deadly

Problem Statement: Team Members

ED, ICU, Patient Care Unit Representatives, Administration, Medical Staff, Nursing, Pharmacy, Performance Improvement, Case Management, Laboratory

Business Case

In comparison to other ICU patients, severe sepsis patients have a higher mortality rate, increased LOS, and an increased need for a ventilator

Benefits

Potential to improve outcomes

Goals

Reduce severe sepsis mortality (make the goal specific and measurable)

Scope

Severe sepsis patients in the ED, ICU, and patient care units

Milestones

Implementation of Tiers 1, 2, 3, and 4

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1/26/2018 10 ECONOMIC IMPLICATIONS OF AN EVIDENCE-BASED SEPSIS PROTOCOL: CAN WE IMPROVE OUTCOMES AND LOWER COSTS? Objective

  • To determine financial impact of a sepsis protocol

designed for use in the ED in a Academic, tertiary care

hospital in US

Design

  • Analysis of results from recent prospective study

comparing outcomes in patients with septic shock before and after initiation of sepsis protocol

  • Adults (n=120) who sequentially presented to ED with septic

shock, specifically

  • At least two systemic inflammatory response syndrome (SIRS) criteria
  • Known or suspected infection (based on radiologic imaging and

clinical suspicion)

  • Shock requiring both fluid resuscitation and vasopressor

administration

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  • ED = Emergency Department

Shorr AF et al. Crit Care Med. 2007;35:1257–1262.

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SUMMARY OF RESULTS

  • Post-protocol, savings of ~$6,000/patient
  • bserved
  • Translated into total cost difference of $573,000

between the two groups

  • Post-protocol, ICU costs reduced by ~35%

(p=0.026) and ward costs fell by 30% (p=0.033)

  • Protocol resulted in a reduction in overall hospital

LOS of 5 days (p=0.023)

  • Pre-protocol, 28-day mortality rate was 48.3% vs.

30.0% following protocol initiation (p=0.040)

Shorr AF et al. Crit Care Med. 2007;35:1257–1262.

  • ICU, intensive care unit; LOS, length of stay

TIER I: ORGANIZATIONAL CONSENSUS AND SUPPORT MILESTONES AND CHECKLIST

1. Define Sepsis Program Goal and aligned with

  • rganizational goals

2. Identify Executive sponsor 3. Collect Baseline Data—essential step

4. Develop sepsis team(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting 6. Begin to define action plan and timeline for program development and implementation

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THE ROLE OF EXECUTIVE SPONSORSHIP

1. Sponsors are executive leaders explicitly tied to a process being improved. 2.

  • Sr. executives round regularly (q

week, q 2 weeks) on process aims, goals, targets, outcomes with the frontline team.

  • Informative, not punitive.
  • Accountable, not “in

trouble”

3. Sponsors remove barriers to progress.

ROLE OF EXECUTIVE SPONSOR

  • Review project plans
  • Review results from first team

meeting

  • Identify anticipated barriers

that senior leader can help address

  • Enlist support and help AND

ASK for a sponsor to be assigned to the project

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ANY CHALLENGES/BARRIERS/QUESTIONS RELATED TO:

  • Setting up your team (getting champions)
  • Creating your team charter
  • Getting an executive sponsor

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TIER I: ORGANIZATIONAL CONSENSUS AND SUPPORT MILESTONES AND CHECKLIST

1. Define Sepsis Program Goal and aligned with

  • rganizational goals

2. Identify Executive sponsor 3. Collect Baseline Data---essential step 4. Develop sepsis team(do we have all the right people here?) and schedule monthly(minimum) meeting for at least 6 months 5. Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting 6. Begin to define action plan and timeline for program development and implementation

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BASELINE DATA COLLECTION PROCESS: DEFINING CURRENT STATE

  • Pick time period for medical record query
  • Sample size: minimum of 20 pts per ICU
  • Query strategies:
  • ICD 9 codes: 785.52 and 995.92
  • Patients in ICU on 1-2 antibiotics, vasopressor (review charts

to see if meet criteria for severe sepsis with lactate > 4 or septic shock before including in outcome data or process data

  • Select Data Collection Elements
  • Outcome: mortality, cost per case, LOS
  • Process

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SEP-1

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 † “time of presentation” is defined as the time of earliest chart annotation consistent with all elements severe sepsis or septic shock ascertained through chart review.

SEP-1

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SEP-1

TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:

5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to table 1. 7. Re-measure lactate if initial lactate elevated.

SEP-1 SEP-1

TABLE 1

DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH:

Either

  • Repeat focused exam(after initial fluid resuscitation)

by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse and skin findings. Or two of the following:

  • Measure CVP
  • Measure ScvO2
  • Bedside cardiovascular ultrasound
  • Dynamic assessment of fluid responsiveness with

passive leg raise or fluid challenge

SEP-1

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ANY CHALLENGES/BARRIERS/QUESTIONS RELATED TO:

  • Baseline data collection

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TIER I: ORGANIZATIONAL CONSENSUS AND SUPPORT MILESTONES AND CHECKLIST

  • 1. Define Sepsis Program Goal and aligned with
  • rganizational goals

2. Collect Baseline Data—essential step

  • 3. Develop sepsis team(do we have all the right

people here?) and schedule monthly(minimum) meeting for at least 6 months

  • 4. Identify nursing and physician champions in ED

and ICU and ensure champions attend team meeting

  • 5. Begin to define action plan and timeline for

program development and implementation

32

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THE TEAM IS KEY! CAN BE MAJOR BARRIER IF NOT FUNCTIONING WELL

  • Must have nurse and physician champions from ED

and ICU (need at least one physician at all meetings)

  • Must be linked in the organization’s quality or
  • perational structure— Are you linked?
  • Must meet at least 1-2 times per month
  • Team members must be well educated on the evidence

and armed with tools and knowledge to change behavior at the bedside— Does the team need more education?

  • MUST have bedside nurses on team—provide reality

check and best knowledge of barriers— Do you?

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TIER I: ORGANIZATIONAL CONSENSUS AND SUPPORT MILESTONES AND CHECKLIST

  • Complete Team Charter
  • Sepsis Goals aligned with organizational goals
  • Identify sepsis coordinator/resource(s) for program
  • Develop sepsis team(do we have all the right

people here?) and schedule monthly(minimum) meeting for at least 6 months

  • Identify nursing and physician champions in ED and

ICU and ensure champions attend team meeting

  • Collect Baseline Data—essential step
  • Begin to define action plan and timeline for

program development and implementation

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TIER 1: CHALLENGES AND BARRIERS

  • Scheduling meetings and consistent attendance
  • Time
  • Skipping key steps---charter, communication plan,

align team/program within organization

  • Baseline data

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SEPSIS PROGRAM ACTION PLAN

Item Responsibility Due Date Status

  • 1. Assemble team
  • 2. Identify

executive sponsor

  • 3. Educate team
  • n evidence
  • 4. Project

Charter

  • 5. Baseline data

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Questions:

Rhonda Dickman, MSN, RN, CPHQ

Clinical Quality Improvement Specialist 615-401-7404 - office 706-570-5700 - mobile rdickman@tha.com

Angela Craig, APN, MS, CCNS ICU CCNS & Sepsis

Facilitator at CRMC 931-239-4904 - mobile acraig@crmchealth.org