1. Sepsis Dissemination & Implementation
January 13, 2016

2. CONFIDENTIAL - Internal Use Only
Agenda
Introduction
Lucy Savitz, PhD, MBA
Judy Tatman, MSHA, BSN, RN
Resources & Website Overview
Andreas Taenzer, MD, MS
Physician SME for Sepsis Safety Team
Lessons Learned From Sepsis Bundle Implementation
Terry P. Clemmer, MD
Intermountain Healthcare
Becoming Reliable: Tips for Achieving Sepsis Bundle Adherence
Shelley Schoepflin Sanders, MD, MTS, FACP
Providence St. Vincent Medical Center
CONFIDENTIAL - Internal Use Only

3. CONFIDENTIAL - Internal Use Only
Welcome
This webinar is being recorded and will be available at
and on the HVHC Dissemination Project workspace site: and
If you have any success stories regarding sepsis safety, please send them to
CONFIDENTIAL - Internal Use Only

4. CONFIDENTIAL - Internal Use Only
Poll
Please complete the poll that is on the right side of the screen.
Be sure to click the “submit” button when finished.
CONFIDENTIAL - Internal Use Only

5. CONFIDENTIAL - Internal Use Only
Website Information
CONFIDENTIAL - Internal Use Only

6. Development of Web-Based Tools
Members will have the ability to:
Download useful templates and tools
Connect with HVHC members who have discovered a successful approach and learn what hasn’t worked in the past
View resources that have provided value to other HVHC members
Use a search tool to find specific content
CONFIDENTIAL - Internal Use Only

7. Dissemination and Implementation Web Site
General Dissemination and Implementation Tab
The general tab is still under construction and will contain more information in the upcoming weeks
CONFIDENTIAL - Internal Use Only

8. Sepsis Dissemination and Implementation
To access the Sepsis Dissemination workspace
1) In the navigation drop down – click on Patient Safety
2) Click on Sepsis
Click in the middle to access the Implementation Playbook
CONFIDENTIAL - Internal Use Only

9. Submitting New Content
We want to hear from you!
Clicking on the Submit new content link from any of the home pages – will bring up an to the PMO office.
In the body of the please include:
Name of the Tool or Resource
Brief Description
Intended Audience
Where in the framework you would like the content to appear
CONFIDENTIAL - Internal Use Only

10. Terry P. Clemmer, MD Intermountain Healthcare
Implementation of New Care Process Models Lessons Learned From Sepsis Bundle Implementation
Terry P. Clemmer, MD
Intermountain Healthcare

11. QUALITY ASSURANCE QUALITY IMPROVEMENT
THEORY of QI
QUALITY ASSURANCE QUALITY IMPROVEMENT QA QI
BEST
BAD
BEST
BAD
Measure of Outcomes
Measure of Outcomes

12. Theory Creation is Easy Implementation is Hard

13. Key Lessons Leadership Is All About Relationships
Establishing True Trust and Respect
Creating ‘Shared’ Mission, Vision and Values
Engaging & Involving Front Line
Set GOALS & MEASURES Then “LET GO”
Understand The Current Process First
Standardizing Processes Forces Learning
Computerization elevates explicitness
Metrics are Essential
The Power Of Small Tests Of Change
Spread Is Dependent On Organizational Structure and Vertical Alignment

14. Intermountain Healthcare Clinical Programs
BOARD
Management Team
Senior VP Clinical Services
Clinical Programs
Cardiovascular CP
Women & New Born
Oncology CP
Intensive Medicine
Behavioral Health
Primary Care
Surgery CP
Pediatrics CP
Neuroscience CP
Musculoskeletal CP
Critical Care
Development Team
14 ICUs
Intermountain Healthcare Clinical Programs
2015
Emergency Services
Development Team
Front Line
Trauma Services
Development Team
Hospitalists
Development Team
Tele-CCM Services
Development Team
Transport Services
Development Team

15. Intermountain Board Alignment Coordination With Other DT/CP
Resources (Manager, Database, Analyst)
Joint Education
Approve Joint Goals
Set Develop Team Goals
Establish Measures
Educate
Provide Tools
Script the Process
Small Rapid Cycle Trials
Learning (finding problems)
Iterative Cycles of Improvement
Implementation
Part of Natural Work Flow

16. Key Lessons Leadership Is All About Relationships
Establishing True Trust and Respect
Creating ‘Shared’ Mission, Vision and Values
Engaging & Involving Front Line
Set GOALS & MEASURES Then “LET GO”
Understand The Current Process First
Standardizing Processes Forces Learning
Computerization elevates explicitness
Metrics are Essential
The Power Of Small Tests Of Change
Spread Is Dependent On Organizational Structure and Vertical Alignment

19. Sedation and Mobility Opportunity
Documentation of variability through better audits
Improved sedation and mobility documentation and problem identification
Through standardized documentation ability to have standardized data available for reports and improvement
Through audits the ability to capture improved data regarding practice style
Ability to find out what works best for patient outcomes

20. Key Lessons Leadership Is All About Relationships
Establishing True Trust and Respect
Creating ‘Shared’ Mission, Vision and Values
Engaging & Involving Front Line
Set GOALS & MEASURES Then “LET GO”
Understand The Current Process First
Standardizing Processes Forces Learning
Computerization elevates explicitness and compliance
Metrics are Essential
The Power Of Small Tests Of Change
Spread Is Dependent On Organizational Structure and Vertical Alignment

21. IHI - Model for Improvement Use “Small” Rapid Cycle Testing
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
Use “Small” Rapid Cycle Testing
Langley, Nolan, Nolan, Norman & Provost
‘ The Improvement Guide’
2121

22. Small Rapid Cycle Trials
It Make Development of Protocols Safe
It Results in Effective Change
It Demonstrates the Change is Doable in the current environment
It Drives Agreement and Acceptance Among Provider
It Stimulates Change in the Local Culture

23. Key Lessons Leadership Is All About Relationships
Establishing True Trust and Respect
Creating ‘Shared’ Mission, Vision and Values
Engaging & Involving Front Line
Set GOALS & MEASURES Then “LET GO”
Understand The Current Process First
Standardizing Processes Forces Learning
Computerization elevates explicitness
Metrics are Essential
The Power Of Small Tests Of Change
Spread Is Dependent On Organizational Structure and Vertical Alignment

24. Intermountain Healthcare Clinical Programs
BOARD
Management Team
Senior VP Clinical Services
Clinical Programs
Cardiovascular CP
Women & New Born
Oncology CP
Intensive Medicine
Behavioral Health
Primary Care
Surgery CP
Pediatrics CP
Neuroscience CP
Musculoskeletal CP
Critical Care
Development Team
14 ICUs
Intermountain Healthcare Clinical Programs
2015
Emergency Services
Development Team
Front Line
Trauma Services
Development Team
Hospitalists
Development Team
Tele-CCM Services
Development Team
Transport Services
Development Team

25. QUESTIONS

26. Standardizing Care with EMR
Ventilator management and weaning
Glucose control
Electrolyte management
Pneumonia decision support for Triage and Management
Pulm. Emboli Dx and Management
Sepsis Bundle
Alerts
Check lists
Order sets
Computerized Decision support algorithms
Information gathering and feedback
Organizing work flow “Tracking Board”
Communication of progress

27. Key Lessons Leadership Is All About Relationships
Establishing True Trust and Respect
Creating ‘Shared’ Mission, Vision and Values’
Engaging & Involving Front Line
Set GOALS & MEASURES Then “LET GO”
Understand The Current Process First
Standardizing Processes Forces Learning
Computerization elevates explicitness
Metrics are Essential
The Power Of Small Tests Of Change
Spread Is Dependent On Organizational Structure and Vertical Alignment

28. Becoming Reliable: Tips for Achieving Sepsis Bundle Adherence
January 13, 2016
Shelley Schoepflin Sanders, MD, MTS, FACP
Providence St. Vincent Medical Center

29. Outline Common barriers to bundle adherence Tips for engaging heartsED
Wards
Tips for engaging hearts
Data as a tool for change
Real world results
Know how to take care of a septic patient
See how the system can help us

30. ED Workflows

31. What’s Possible: Intermountain Health
3 hour bundle adherence
Sepsis mortality

32. Can we get Grandma home from the hospital?

33. 1) Administrative Support
ED physician financial incentive for bundle adherence
Dot did not move for 2 years
Lesson:
Administrative support necessary but not sufficient
Dave Underriner, Providence Oregon Region CEO

34. 2) ED Sepsis Champions
Required: Significant leadership and external organization
Nurses and doctors meet q 2 months.
Ditched order set and electronic sepsis alert.
Built sepsis kit similar to stroke and MI kits.
Educated stakeholders
Providence Stroke Team served as a model for sepsis workgroup

35. 3) Data Feedback Trustworthy Timely
Changed definition of Time 0 to CLINICAL Time 0
Feedback to reviewers until cases all “real”
Timely
Cases identified based on discharge diagnosis are >45 days from their ED visit
Electronic Sepsis Alert based on hypotension or high lactate used to identify cases prospectively
Feedback s every 2 weeks to nurses and doctors

36. 3 Hour ED Bundle Adherence

37. 3 Hour ED Bundle Adherence
Achievable benchmark?
Can we declare victory and go home?

38. 3 Hour ED Bundle Adherence
Lesson: Frequent feedback required

40. PSVMC 3 Hour ED Bundle Adherence
Systems Based Practice
Assess achievable benchmark
Provide real time feedback
Persistence pays off
Begin q 2 week
feedback

41. 4) Found the recipe: Now Spread

42. Practice-based Learning and Improvement across the Health System
Workflow from PSVMC generalized to all 8 Providence Oregon ED’s
May 2015 ED 3 hour bundle adherence across Oregon = 49% of cases
December hour bundle adherence across Oregon = 47/59 = 79.7%

43. Begin q 2 week
feedback*
Feedback s q 2 weeks improved all-Oregon adherence from 49% to 79.7% over 6 months
*PSV began June 2015, all others July 2015

44. PSVMC Mortality for ED Patients

45. Summary: Steps to ED Bundle Adherence
Secure administrative support and a leader
Identify nurse and physician champions
Perform root cause analysis
Educate others
Take a stand
Provide meaningful data
Real time
Real names (doc, nurse, patient)
Red ink, simple notes
Lather, rinse, repeat (i.e., spread)

46. Inpatient Sepsis

47. On the Inpatient side . . .

48. Mortality for Severe Sepsis and Septic Shock*
Current performance: 2 in 5 die
*Not present on admission

49. Mortality for Severe Sepsis and Septic Shock*
Expected performance: 1 in 5 die
*Not present on admission

50. 1) Education: Severe Sepsis is a “Body” Attack
Heart Attack
Door to Balloon Time

51. 1) Education: Severe Sepsis is a “Body” Attack
Heart Attack
Severe Sepsis
Door to Balloon Time
Door to Bundle Time

52. Body Failure from Infection

53. 2) Inpatient Order Set Frequent vitals with call parameters x 24 hrs
MEWS-like workflow with sign on patient’s door for “sepsis vitals”
Lactate, cultures, other labs
Antibiotic decision support
IVF bolus

54. The computer knows who’s hypotensive
3 month monitoring all non-ICU patients with sepsis rule, RRT activation, MD bedside evaluation within 30 min
For composite of death, ICU t-fer, RRT, sepsis at DC:
PPV 26%
NPV 94%
+LR 5.3
-LR 0.9
Before: 15% bolus >500 ml
After: 26% bolus >500 ml
Trend toward lower mortality disappeared after adjusting for severity of illness
Preimple June to Sept 2012 “silent”
Postimplementaiton June to Sept 2013
Dr. Umscheid and colleagues at University of Pennsylvania
Journal of Hospital Medicine 2015;10:26-31.

55. 3) Providence Sepsis Rule Clinical Criteria
Two or more of the following:
Respiratory rate >20 breaths per minute
Heart rate >90 beats per minute
Temperature >38.3O C or <36.0O C
WBC >12,000 mL-1 or <4,000 mL-1 or Bands >10%
And one or more of the following:
Systolic Blood Pressure < 90 mmHg
Drop of 40 points in SBP
Lactate >2.0 mmol/L
The clinical criteria use the most recent vital signs taken and entered in the past two hours, and the most recent lab values entered in the past 24 hours.
In response to the alert, the physician determines the presence of “known or suspected infection”, the other required clinical criterion for severe sepsis. 

56. Sepsis Rule Ministry Participants
As of Sept. 30, 2014
Alert Page to Nursing Med-Surg
Holy Cross Medical Center
Little Company of Mary Torrance
Little Company of Mary San Pedro
St. Joseph Medical Center
Tarzana Medical Center
St. Patrick Hospital
All Oregon ministries
Regional Medical Center Everett
St. Mary Medical Center
Provider BPA
Kodiak Island
Little Company of Mary Torrance
Little Company of Mary San Pedro
St. Joseph Medical Center
St. Patrick Hospital
All Oregon ministries (only medical-surgical)
Regional Medical Center Everett
Alert Icon on ED Track Boards
All ministries

57. Aim: Highly reliable response to sepsis alert
Rapid Response Team (RRT) to see every patient
After assessment, notify attending doctor
Provider notification was about 70%

58. Assess Sepsis Rule to reduce false alarm fatigue
9 of 14 (64%) of SBP drop 40 events were false positives.
Often clinically obvious, e.g., gave NTP for elevated BP, then sepsis rule occurs
If we removed SBP Drop 40, PPV of rule would improve from 54% to 62%
We would remove 9 false positives
We might miss 5 true positives, but in our review 4 of these were caught by MEWS
Done October 2015

59. All that work . . . Mortality still high

60. 4) Case Review and Root Cause Analysis
Education – good
Floor sepsis order set – good
Sepsis Alert in Epic – good
But still, delayed diagnosis and very slow delivery of the bundle
IV infusion pumps run at max 999 cc/hour
Nurses really wedded to pumps b/c they automatically track I/O’s
Need 2 large bore IVs to deliver 30 ml/kg using pumps
Antibiotics delayed
Not automatically “STAT” on order set
Not in Pixus
Nurses not clear on priority
“Vanco per pharmacy” = another source of delay
Lactate and repeat lactate slow
Result: Delayed transfer to ICU

61. Improve “Alert to Bundle Completion” (ABC) time
Code sepsis brings resources to the patient right away
RRT, House Supervisor, IV therapy, phlebotomy
Closed loop communication: 2 hour call to MD
Explain the recipe for saving lives is the bundle – but that on chart review before the sepsis pilot even when doctors ordered, it wasn’t completed within 3 hours

62. Code Sepsis Pilot Case #1
34 year old woman s/p appendectomy
Triggered sepsis alert noon POD#1 for hypotension
Somnolent (had had no pain meds), Total Bili 6
Called surgeons, got bolus, within 2 hours of alert, conversant, improved
BUT still hypotensive
Workflow requires call to doctor at Hour 2.
Called and got another bolus
Recovered. DC on POD 4.
Emphasize how we resolve this within 2 hrs instead of prolonged time course on floor
Give statistics from pilot
Introduce workflow and handout the 3 pager

63. 5) PSVMC Code Sepsis Pilot
Goal: RRT respond to 100% of sepsis alerts and notify physician
Call “Code Sepsis” if physician orders 3 hour bundle
Pilot from July 15 to August 15, 2015
8 Code Sepsis cases: bundle delivered to all
26 severe sepsis cases, 65% got bundle

64. PSVMC Pilot Data Sepsis Alerts Data 7/15 to 8/11/15, 28 days, n=48
(2 excluded which occurred on hemodialysis units)
Unique patients 48
8 pts triggered >1 sepsis alert during their stay; 1 pt readmitted is counted twice (once per admission)
True Positive: Reviewer felt pt had severe sepsis
26 (54%)
Out of all 48 cases
Out of 26 “true” sepsis
Patient already on abx at time of alert
36 (75%)
22 (85%)
Provider notified
34 (71%)
16 (62%)
RRT saw pt
29 (60%)
13 (50%)
New orders after alert
19 (40%)
14 (54%)
Transfers
2 to tele, 3 to ICU
3 to ICU
Disposition
3 (6.3%) deceased
3 (6.3%) readmitted
6 (12.5%) hospice
2 (7.7%) deceased
3 (12%) readmitted
3 (12%) hospice
For the 26 patients with severe sepsis
Abx within 3 hrs
25 (96%)
30 ml/kg within 3 hrs
17 (65%)
lactate
Blood cx
PSVMC Pilot Data

65. Inpatient Sepsis: Diagnose. Treat. Save a life.

66. Inpatient Sepsis Summary
Education
Order set
Alert with reliable response (PDSA)
Case review  Code sepsis
Winning the Game: Grandma makes it home.