Presentation on theme: "Integrated Care In Action Sepsis Bundle"— Presentation transcript:
1Integrated Care In Action Sepsis Bundle Todd L. Allen MDBoard and Executive Learning SeriesVancouver, BCJune 2, 2012
2Disclosures Former site Co-PI, the ProCESS Trial www.processtrial.net Registered atNCTActively recruitingSponsored by NIGMSNo trade names will be used in this presentation
3Development and Deployment of the Intermountain Sepsis Bundle Title: Development, deployment and integration of a sepsis bundle for the Intensive Medicine Clinical Program of Intermountain HealthcareProject leaders: Terry C. Clemmer MD, Nancy Nelson RN, and Todd L. Allen MDStart date: July 2004 to present
4International Background Of the 750,000 Americans that severe sepsis and septic shock strike every year, about 215,000 die. Cost estimates reach almost $17 billion. In spite of aggressive research and technology development, mortality in septic shock decreased only slightly between 1970 and the late 1990s. It remains the most frequent cause of death in the non-cardiac intensive care unit — and the 11th leading cause of death overall.Describe How was this project chosen
5Mortality in Severe Sepsis Is this slide valuable?
6Surviving SepsisIn the past 10 years, several specific strategies for managing sepsis and its sequellae have proven their ability to decrease the risk of death. These therapies include early goal-directed therapy, low-dose steroid replacement, intensive insulin therapy, and protective ventilation, among others. These therapies appear to yield greater benefits than even thrombolysis in acute myocardial infarction.Recombinant APC NNH 70 with no benefit by Cochrane review: Cochrane Database Syst Rev Apr 13;(4):CDHuman recombinant activated protein C for severe sepsis. Martí-Carvajal AJ, Solà I, Lathyris D, Cardona AF.Lung protective strategy NNT = 10
7Early Goal Directed Therapy Landmark study in 2001Protocol carried out over 6 hoursSpecific screening protocolMaximize CVPMaximize MAPMaximize O2 deliveryRivers E. NEJM 2001; 345:
8Sepsis in the ER 114 million adult ED visits per year 571,000 for suspected severe sepsis20.6% of these to a low volume ED53.5% of these to hospitals without medical school affiliationsPatient spent about 5 hours in the EDWang HE et al. Crit Care Med 2007 June 19; epub
9Intermountain Background Key process analysisNumber of patients affectedThe health risk to patients (intensity of care)Internal variability (Cv of intensity of care)Founding of Intensive Medicine Clinical ProgramCritical care development teamEmergency medicine development teamCv = SD/MeanIMCP: associated clinical support services plus adminstration
10Screening for Sepsis in the ER Suspected infectionTwo of four SIRS criteriaTemp > 38oC or < 35.5oCRR > 20 or PaCO2 < 32HR > 90WBC > 12 or < 4 or > 10% band formsSepsis = infection + SIRS criteriaSevere sepsis = sepsis + organ dysfunctionSeptic shock = sepsis + hypotension after fluids
11The Intermountain Bundle Resuscitation BundleSerum lactateBlood culturesBroad-spectrum antibioticsFluid resuscitationVasopressorsCVP and CvO2 measurementInotropes and/or PRBCsMaintenance BundleSteroidsGlucose controlrAPC use in eligible patientsLung protective ventilator strategy
13Sepsis Screening P-Chart Statistical process control chartManny Rivers gave a lecture in September 2006From Shewhart and DemingTo understand common causes of variation versus special causes of variationIn SPC: understand the process, understand the variation, eliminate the causes of variation
14Team Structure Team leader: Todd L. Allen MD Facilitator: Nancy Nelson RNSponsor: Intensive Medicine Clinical Program, Brent Wallace MD, Nancy Nowak NR (CMO and CNO)Team members: Anne Marie Bickmore RN, Alan H. Morris MD, Peter Haug MD, Jeffrey Ferraro, Terry Clemmer MD, Ryan Black, Ben Briggs, Lisa Bagley RNTodd L. Allen MDAnne Marie Bickmore RNAlan H. Morris MDPeter Haug MDJeffrey FerraroTerry Clemmer MDRyan Black ED phlebotomistBen Briggs research assistant
15Aim StatementAim statement: To lower the mortality rate of ED patients who present with severe sepsis and septic shock who require admission to the ICU of any Intermountain hospital by improving compliance with the 11-point “sepsis bundle” to > 80% during 2008 and 2009.
16Project StructureInclusion criteria: Patients > 18 with a final diagnosis of severe sepsis or septic shock who presented to the ER and were admitted to the ICUExclusion criteria: Transferred patients, patients admitted to the floorOutcome measures: Cost, Quality, Service
17Sepsis Key Process Analysis and Data How did we go about using data to identify key processes?How was the data selected?Align with workflowAlign with key medical interventionsHow was the data used?Q1: Clinical programsQ3: Describe meetings
19Data Analysis 2006 dataset from LDS Hospital 34,962 patients and 100 had severe sepsis or septic shockBest AUC wasSIRS > 2 gave a SN of and SP of 0.714So for every 100 patients with severe sepsis or septic shock, you would miss 10 using SIRS alone, and overcall on 29.
20Evidence Based CPM Development How was the first draft of the CPM developed?How was it maintained and modified?How is its success (or failure) measured/monitored?Dashboard development
22Tests of ChangeMoved to automated alerting functionality
23Outcomes Quality improvement is the science of process management Process improvement results in parallel outcomesClinical outcomes (physical outcomes)Cost outcomesService outcomesIf you can’t describe what you are doing as a process, you do not know what you are doing. W. Edwards Deming
28Challenges and Opportunities To succeed with complex care processes you must start and end with the front line clinicianReal time data, delivered in real time to the clinician is also keyScreening is hard, we were fortunate to have the resources to develop tools to assist with screeningConstant nagging reminders are importantWhy are here talking about this and why is this important? Most hospitals have attempted some variant of the sepsis bundle time and resource intensive bundles, higher level of care and skill required for full protocol, labor intensive QA process, need continuous education of support staff and new employees.
29Central Leadership (Not Management) Administration (Board Goal)Intensive Medicine Clinical ProgramRegions with leadership and unique approachesClinical collaboration: nurses, doctors, phlebotomists, laboratory, ICU, ER etc.Re-iteration (PDSA) at the front line
304 Step Plan for Sepsis at Intermountain Step 1: Identify Severe Sepsis as an Institutional PriorityStep 2: Implement Early Detection Screening ProceduresStep 3: Implement Aggressive Treatment Policies/StandardsStep 4: Track, Evaluate, and Report Outcomes
31Next Steps PLAN ACT DO STUDY What are we trying to accomplish? Identify outcomes and set acceptable ranges of significancePLANDevelop action steps to optimize careACTDODevelop criteriaEducateImplementAssess consistency of implementationWhat changes can we make to improve?STUDYProcess & Outcome Measures
32The 5 Axioms of Intermountain Healthcare Most treatments for a specific condition have similar characteristicsThere is still massive variation in clinician’s practicesAll have something to learn and something to teachClinicians will lead most changes themselvesClinical integration is our strategic planAxiom: Self evidently true
33The Principles Of Shared Baselines Select a high priority care processGenerate an evidence-based best practice guidelineBlend the guideline into the flow of clinical workUse the guideline as a shared baseline with clinicians free to vary based on individual patient needsMeasure, learn from and (over time)Eliminate variation arising from the professionalRetain variation arising from patientsMeasure = data systems
34The IOM on the Quality Chasm “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.”1“Health care does not yet reliably transfer best-known science into practice, and processes frequently fail, despite the best intentions of a dedicated and highly skilled workforce.”2According to the IOM, there exists a “chasm” between scientific practice and implementing evidence-based medicine at the bedside.
35And So We Begin Again"I am sorry for you, young men (and women) of this generation. You will do great things. You will have great victories, and standing on our shoulders, you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is not given to every generation."Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press, 1931 (p. 241).