Transcript Adult Core Implementation Meeting

UNC Hospitals Sepsis Mortality
Reduction Initiative
Code Sepsis
Core Adult Patient Sepsis Training Slides
UNC’s Mortality Index is ranked 65th out of 73 Academic
Hospitals with 500 or more beds in 2014.
Comparison Hospital Sepsis Mortality Index
2013 and 2014 Risk Adjusted Model
UNC to UHC Top 10
2.50
2.00
Sepsis Mortality Index
Top Ten UHC
Utah
Emory
Beaumont
Ohio State
NYU
Indiana
Vermont
Iowa
Wake Forest
Kansas
1.50
1.00
0.50
If UNC's performance was consistent with the UHC
Top Ten, there would have been 218 fewer inpatient
deaths in the last two years.
0.00
UNC Sepsis Mortality Index
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec13 13 13 13 13 13 13 13 13 13 13 13 14 14 14 14 14 14 14 14 14 14 14 14
1.77 1.21 1.63 1.46 1.21 1.69 1.16 1.43 1.91 1.21 1.38 1.51 1.28 1.36 1.49 1.89 1.54 1.31 1.59 1.82 1.54 1.58 1.76 1.63
Top 10 Sepsis Mortality Index 0.85 0.92 0.89 0.76 0.84 0.81 0.79 0.73 0.78 0.70 0.81 0.85 0.99 0.90 0.81 0.92 0.82 0.84 0.89 0.97 0.88 0.83 0.92 0.79
50.00
UNC's mortality rate in severe sepsis cases is above the median for
comparable organizations.
45.00
Mortality Rate-Sever Sepsis (ICD-9=99592)
40.00
DUKE 33.4
35.00
UNC 31.4
30.00
25.00
Median 29.6
WFBH 21.3
20.00
15.00
10.00
5.00
0.00
Top Ranked hospitals have a
sepsis reduction initiative
Hospitals with 500 Beds or More
Deaths at UNC with a Diagnosis
Code of Sepsis July-September 2014
Unit
Deaths
MICU
44
SICU
8
CICU
6
NCCC
5
NSIU
5
PICU
5
BMTU
4
MPCU
2
8 BT
2
6 BT
2
TICU
2
ISCU
2
6 EST
1
3 WST
1
5 BT
1
4 ONC
1
Grand Total
91
67% of deaths in
the MICU involved
Sepsis
Sepsis is a
VERY common cause of inpatient deaths
National Sample % Deaths
UNC % Deaths
Other
55%
All
Sepsis
45%
Sepsis POA
Documented
Sepsis
Documented
Other
Sepsis Documented
Other
48%
All
Sepsis
52%
Sepsis by
Review
Other
Source: UHC Data, 2013, excl NNB, Psych, Rehab
National Sample data shows that coding doesn’t catch all sepsis cases, UNC rates are
likely higher than reported.
Hospital Deaths in Patients with Sepsis from Two Independent Cohorts Liu et al JAMA May 18, 2014
Other Organizations with successful
sepsis reduction programs
•
•
•
•
•
Wake Forest Baptist
Nation of Scotland
Penn State
Long Island Jewish Health System
Many more
Wake Forest reduced their time to first antibiotic significantly.
Time to Antibiotic Administration Is the Most Important
Predictor of Survival in Septic Shock*
0.9WFBMC Code Sepsis average time is 53 minutes
0.8
Survival Fraction
0.7
6 hours considered “Early” Sepsis management
0.6
0.5
0.4
0.3
0.2
0.1
0
0.5
1
2
3
4
5
6
7 to 9 10 to 12 13 to 24 25 to 35
>36
Hours
*Kumar A et al : Duration of hypotension before initiation of effective antimicrobial therapy is the
critical determinant of survival in human septic shock. Critical Care Medicine 2006; 34(6): 1589-1596.
Scotland is using an Early Warning Score, an advanced sepsis screen, and a one hour bundle.
The entire country of Scotland uses an early warning score and sepsis management protocol to
reduce their mortality ratio by almost 16%
North Shore University Hospital in Long Island Jewish system reduced ALOS and Mortality.
MORTALITY REDUCTION STRATEGY
Healthcare
Acquired
Conditions
Failure to Rescue
Appropriate
Palliative Care
SEPSIS
Improve Early Warning Systems and Response Systems
Implement Early Suspicion and Accurate Recognition Sepsis
Implement Prompt and Accurate Sepsis First Hour Treatment
Implement Antibiotic Stewardship in Sepsis Program
* Kumar A et al : Duration of hypotension before initiation of effective
antimicrobial therapy is the critical determinant of survival in human
septic shock. Critical Care Medicine 2006; 34(6): 1589-1596.
Sepsis Program Overview
• Triage and Screening System for rapid
recognition
• Rapid treatment with antibiotics and fluid
resuscitation, lactate, CBC, and blood cultures
• Each area will have representation on
implementation teams
• Adaptation of best practices from centers of
excellence
Complacency, Education & Trying Harder isn’t enough
3 Recent Large Randomized Control Trials:
Although advanced severe sepsis therapies (such as central line
placement, SVO2 goals, etc) did not show improved outcomes, all
were randomized after early recognition and standard therapies
including antibiotics and fluid resuscitation which are the goals of
UNC Code Sepsis
Surviving Sepsis Campaign: Association Between
Performance Metrics and Outcomes in a 7.5-Year
Study – published on line Critical Care Medicine December 2014
• Increased compliance with sepsis performance bundles was
associated with a 25% relative risk reduction in mortality rate
• Every 10% increase in compliance and additional quarter of
participation in the SSC initiative was associated with a
significant decrease in the odds ratio for hospital mortality
• total hospital LOS 4.8 days shorter compared to preimplementation group (p = 0.043)
• ICU LOS decreased 2.6 days shorter (p = 0.004)
Reliable Sepsis Recognition and
Assessment
• Primary Drivers
• Reliable Recognition and
Assessment
• Reliable Care Delivery
• Education and Awareness
• Culture of Safety and Quality
Improvement
• Patient and Family Centered
Care
• Secondary Drivers
• Reliable Sepsis Screening
• Early Warning System + SIRS
• Ensure reliable communication
SBAR
• Ensure timely rescue of
deteriorating patient by
competent team
• Involve patient and family
advisors in design
UNC Sepsis Implementation
• Goal: to reduce the raw mortality rate by 10%
at UNC Hospitals by June 2016 when
compared to 2013 baseline
– Scope: Children’s Hospital, ED, ICU’s and all areas
of ARRT activation
– Phase I: Children’s Hospital implementation
complete by June 30, 2015
– Phases II-IV: ED, Critical Care Units, Inpatient Units
Project Updates
UNC Children’s Hospital Working Timeline
Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Peds ED implementation
Peds Acute Care
Screening Implementaion
Peds Clinics Screening
Implementation
NCCC standardized
protocol
NBN Screening
Implementation
Measurement
Administration
Educational Spread Plan
Go Live
PRRT Training and
Response
Soft Start
Expert Panel
Recommendations
Expert Panel
Recommendations
ARRT Training and
Response
Adult ED pilots and
testing
Adult ICU pilots and
testing
Acute Care Screening
Implementaion
Measurement
Administration
Educational Spread
Plan
Children’s Hospital
Go-Live
Stretch
Goal
Implementation
Goal
Jun-16
May-16
Apr-16
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
Jul-15
Jun-15
May-15
Apr-15
Mar-15
Feb-15
Jan-15
Dec-14
UNC Hospitals Implementation Timeline
Early Warning Score Development
• Modified Pediatric Early Warning Score
– Children’s Hospital IP units – currently being modified
• Modified Early Warning Score
– Currently being tested on adult acute care units
– EPIC 2014 tools
• MEWS-ED
– Currently being tested in general ED
UNC Adult Implementation Team
Training Timeline
Phase III: November 2015
UNCMC Staff
•
Awareness of Sepsis Alert
Screening Areas
Phase II: August 2015
• ED Care Team
• Inpatient Care Areas
• ED Paper Go-Live June 2015
MEWS Scoring and clinical
Response
Sepsis
Experts
Advanced Sepsis
screening and
treatment
All Medical Center staff
Phase I: March/April 2015
•
•
•
•
Air care
ED advanced care team
ARRT –primary and secondary
Hem/Onc Responders
Working Adult
Patient Bundle
UNC Adult Early Sepsis Screen
Does patient have > 2 of the following:
Core Temp < 36 or > 38
(home temp also valid)
Respiratory Rate >20
ADULT Sepsis Response Team
Assess to confirm sepsis
COMPLETE BUNDLE IN < 60 MINUTES
& notify primary team:
Heart Rate >90
Alert Pharmacy of sepsis for faster antibiotic
delivery - use closed loop communication
WBC count <4 or >12
Measure Lactate Level
Altered Mental State
High Risk* (see next page)
Obtain Blood Culture
(attempt 2 sets prior to antibiotic)
Initial dose of antibiotic
(even if no blood culture is available)
see adult sepsis antibiotic algorithm
+
Suspected Infection
Fluid Resuscitation
30 ml/kg or 2L in the first hour
Then Trigger Sepsis Response - in design
Consider transfer to higher level care if
inadequate response to fluid
resuscitation or based on clinical status
ADULT Sepsis HIGH RISK* Patients
Immunocompromised
Burn Patients
Transplant (BMT or Solid Organ)
Diabetes
Cancer
Geriatric
Indwelling medical device
Recent surgery/invasive procedure
Congestive Heart Failure
When in doubt…
• Think to yourself first, “This is sepsis!”
• Then ask, “Why isn’t this sepsis?”
• When no other reason found, then conclude,
“Oh wait, it is sepsis.”
Placeholder Adult Patient Sepsis
Antibiotic Guidelines
Sepsis Case Reviews
Inpatient Sepsis Case
•
•
Pt. admitted for a major surgical procedure
Procedure goes well and pt. is able to transfer out of ICU to floor on POD#2
•
On POD#8 at 0900, nursing begins charting that pt. is
confused/somnolent/hallucinating after having been alert and oriented for the six
days prior.
– VS at 0900 – HR 106, RR 18, SBP 107, Temp 36.9
* Pt would have had a MEWS score of 2 which may have prompted a physician
notification of change and a rapid response consult
•
POD#8 at 1500, pt. continues to be confused/somnolent
– VS at 1500 - HR 113, RR 18, SBP 89, Temp 35.3
– MEWS score of 5 based on vitals and provider concern
* Pt would have had a MEWS score of 5 based on vitals and provider concern
* With the new screening tool, this may have triggered a rapid response, potential
sepsis screening and Q 1 hr monitoring
•
No rapid response called and pt. remains on the floor
Inpatient Sepsis Case
•
20 hrs later, at 1100 on POD#9, nurse charts that pt. was extremely confused and
hallucinating
– VS at 1100 – HR 120, RR 18, SBP 81, Temp 35.6
– No urine output since POD#8 at 2200
•
POD#9 MD note states that sepsis suspected
– Blood culture ordered at 1210
– 2250ml of Albumin 5% given between 1225 and 1809
•
Pt. weighed 81.6 kg
– Zosyn ordered and first dose given at 1326
– Vanc ordered and first dose given at 1830
•
•
•
First lactate not drawn until POD#10 at 1530
Pt. transferred to SICU at 1458 on POD#9
Pt. eventually passed away 1 month post procedure
ED Sepsis Case
• 57 year old patient with ESLD presented to the ED complaining of syncope
• Underwent paracentesis one month prior and was scheduled to have
another paracentesis the day of the syncopal episode
• 0709 – ED triage
• 0718 – Pt. A&O x 4, HR 79, RR 18, BP 93/45, Temp 36.5, Sats 100%
• 0730 – 20 G PIV in left AC placed
• 0731 – Venous lactate drawn (3.9)
• 0810 – 500 ml given over 91 min. (stopped at 0941)
• 0819 – Resident note states low suspicion of infection due to “lack of fever
and nontoxic appearance”
• 0920 – Blood culture drawn
• 1243 – HR 76, RR 21, Temp 36.9, Sats 100%
ED Sepsis Case
•
•
•
•
•
•
•
•
•
•
•
•
•
•
1536 – Paracentesis done in ED
1542 – Pt. remained A&O x 4, HR 80, RR 20, BP 72/41
1548 – 500 ml NS bolus given
1557 – Paracentesis results showed spontaneous bacterial peritonitis
1559 – BP 76/42 (MD note states that pt. reported her baseline SBP’s at 90-100’s)
1626 – Cefotaxime ordered
1643 – 75 g 25% albumin started (stopped at 1855)
1645 – NS infusion started at 100 ml/hr
1646 – BP 77/40 according to nursing note
1749 – Cefotaxime started (stopped 1855)
1950 – HR 86, RR 17, BP 71/45, Sats 95%
2031 – 500 ml NS bolus given over 1 hr. 100 ml/hr NS infusion stopped.
2052 – HR 80, RR 15, BP 72/46, Sats 98%
2055 – Pt. transferred to MPCU
ED Sepsis Case
• 2057 – RN paged MD that SBP’s remaining in the 70’s.
• 2135 – 1000 ml NS bolus given over 35 min. (stopped at 2210)
• 2223 – RN paged MD that BP 74/49 after fluid bolus
• 2259 – 1000 ml NS bolus given over 56 min. (stopped at 2355)
• 2310 – RN paged MD that BP 69/33 with 2nd 1000 ml fluid bolus running
• 2341 – Med I at bedside to eval for admission to MICU
-------------• 0026 – Transferred to MICU
• 0103 – Norepi and vasopressin started
• 0106 – 1000 ml NS bolus started
• 0107 – 1000 ml NS bolus started
• 0253 – Arterial lactate drawn (2.2)
• Total of 3900 ml NS given in ED and MPCU prior to MICU transfer. Cefotaxime
continued. Vanc ordered but then discontinued and never given.
• Pt. transferred back to MPCU after several ICU days and then discharged the
following week
Placeholder Area Screening and
Treatment Plan
Take Home Points
• This new system is still in design and will be different in the
coming months when we “go live”
• Septic Shock may be more subtle than you think
• Call sepsis team (RRT for inpatient units – triggered ED response in ED) for
rapid IV access, fluid administration, antibiotic arrival, and lab studies – all
bundle elements
• Patients can worsen rapidly
• If you want to help us in the development or have feedback please contact
the Sepsis Program Team: [email protected]
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