OHA STATEWIDE SEPSIS INITIATIVE

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1 OHA STATEWIDE SEPSIS INITIATIVE Ohio Organization of Nurse Executives Annual Fall Conference James V. Guliano, MSN, RN-BC, FACHE Vice President, Quality Programs November 10, 2016

2 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

3 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

4 WHAT IS SEPSIS? Sepsis is a life-threatening condition that arises when the body s response to infection injures its own tissues and organs. November 10,

5 SEPSIS Confirmed or suspected infection in the presence of 2 or more SIRS criteria UTI, flu, pneumonia, abscesses, gastroenteritis Affects millions of people every year Infection S E P S I S 2 or more SIRS November 10,

6 SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) The body s reaction to infection, inflammation or injury Temperature less than 96.8 F Temperature greater than F Heart rate greater than 90 beats per minute Respiratory rate greater than 20 breaths per minute WBC count less than 4,000/mL WBC count greater than 12,000/mL WBC greater than 10% bands

7 SEPSIS CONTINUUM (PRE-3 RD CONSENSUS DEFINITIONS) Infection Systemic Inflammatory Response Syndrome Sepsis Severe Sepsis Septic Shock November 10,

8 SEVERE SEPSIS Sepsis + Organ Failure Respiratory Increased O2 requirements SaO2 < 90% Metabolic Blood glucose level greater than 180 mg/µl Lactate > 2 mmol/l Neurological * Altered level of consciousness Cardiovascular SBP<90 mmhg Renal * Urine output <0.5 ml/kg/hr November 10,

9 SEPTIC SHOCK Sepsis + Persistent Hypotension Sepsis with persistent hypotension (SBP less than 90 mmhg) that does not resolve despite fluid resuscitation More than a 40 point decrease in systolic blood pressure from baseline Vasopressor dependency to maintain SBP greater than 90 mmhg Also includes lactate level greater than 4 mmol/l (with or without hypotension) November 10,

10 3 RD INTERNATIONAL CONSENSUS DEFINITIONS Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection Septic shock: a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality Source: Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8): doi: /jama

11 3 RD INTERNATIONAL CONSENSUS DEFINITIONS: CLINICAL CRITERIA Sepsis: Suspected or documented infection; AND Acute increase of 2 Sequential Organ Failure Assessment (SOFA) points (a proxy for organ dysfunction) Septic Shock: Sepsis; AND Vasopressor therapy needed to elevate MAP 65 mmhg; AND Lactate >2 mmol/l (18 mg/dl) despite adequate fluid resuscitation Source: Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8): doi: /jama November 10,

12 3 RD INTERNATIONAL CONSENSUS DEFINITIONS Quick Sequential Organ Failure Assessment (qsofa) Adults with suspected infection meeting at least 2 of the following criteria are at significantly higher risk of a prolonged ICU stay ( 3 days) or death in the hospital: Alteration in mental status Systolic blood pressure 100 mmhg Respiratory rate 22/min Patients meeting at least 2 of these criteria should prompt: Further investigation for organ dysfunction Initiation or escalation of therapy if appropriate Consideration of referral to critical care Consideration of more frequent monitoring Consideration of possible infection, if not previously recognized Source: Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8): doi: /jama

13 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

14 WHY SEPSIS? November 10,

15 RESEARCH DOLLAR ALLOCATION NIH Research $ per death Sepsis $190 November 10,

16 MEDIA ATTENTION Sepsis 7,478 November 10,

17 WHY SEPSIS? November 10,

18 WHY SEPSIS? November 10,

19 WHY SEPSIS? November 10,

20 Deaths OVER 4,000 LIVES EACH YEAR Mortality 2,500 Without Palliative Care With Palliative Care 2,000 1,500 1, Over 4,000 people die from Sepsis who are not in palliative care November 10,

21 WHY SEPSIS? November 10,

22 IS SEPSIS HOSPITAL ACQUIRED? About 80% of sepsis patients arrive at the ED with the condition November 10,

23 INPATIENT MORTALITY AND SEPSIS Mortality for patients hospitalized for septicemia or sepsis is more than 8 times higher than overall inpatient mortality Sepsis contributes to 1 in every 2 to 3 deaths in hospitals Most had sepsis on presentation to the hospital Sources: Elixhauser, A., Friedman, B., & Stranges, E. (2011). Septicemia in U.S. Hospitals, 2009 (Statistical Brief No. 122). Rockville: Agency for Health Care Research and Quality. Retrieved from Liu V, Escobar GJ, Greene JD, & et al. (2014). Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA, 312(1),

24 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

25 THE SURVIVING SEPSIS CAMPAIGN 3-HOUR BUNDLE TO BE COMPLETED WITHIN 3 HOURS: 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 4 mmol/l Time of presentation is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review Revised April 2015 November 10,

26 1. MEASURE LACTATE LEVEL Hyperlactatemia typically present in severe sepsis/septic shock May be secondary to anaerobic metabolism (result of hypo-perfusion or other factors) Prognostic value established and greater than that of oxygen-related variables Especially important to identify hypo-perfusion in patients at risk of septic shock but not yet hypotensive Source: Surviving Sepsis Campaign. (April 2015.) Updated Bundles in Response to New Evidence.

27 2. OBTAIN BLOOD CULTURES 30-50% of patients presenting with severe sepsis/septic shock have positive blood cultures Blood cultures prior to antibiotic administration allows maximum likelihood of identifying infectious organism Source: Surviving Sepsis Campaign. (April 2015.) Updated Bundles in Response to New Evidence.

28 3. ADMINISTER BROAD SPECTRUM ANTIBIOTICS Mortality reduced when appropriate antimicrobials administered to patients with severe Gram-negative and Gram-positive bacterial infections Pneumonia s prevalence in severe sepsis and septic shock supports antibiotic administration Severe sepsis and septic shock mortality increases every hour that antibiotic administration is delayed Source: Surviving Sepsis Campaign. (April 2015.) Updated Bundles in Response to New Evidence.

29 4. ADMINISTER CRYSTALLOID (30 ML/KG) For Hypotension or Lactate > 4 mmol/l Vasodilation due to infection or impaired cardiac output may result in poor arterial circulation Hypo-perfusion may lead to global tissue hypoxia and increased serum lactate Intravenous fluids may increase circulating volume and perfusion pressure Source: Surviving Sepsis Campaign. (April 2015.) Updated Bundles in Response to New Evidence.

30 THE SURVIVING SEPSIS CAMPAIGN 6-HOUR BUNDLE TO BE COMPLETED WITHIN 6 HOURS: 1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP 65 mmhg 2. 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, by 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: o o o o Measure CVP Measure ScvO2 Bedside cardiovascular ultrasound Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge 3. Re-measure lactate if initial lactate elevated. Revised April 2015 November 10,

31 CMS CORE MEASURE Required of hospitals beginning in October 2015 Assesses compliance with the 3-hour and 6-hour bundles

32 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

33 STRATEGIC PLAN GOAL AND OBJECTIVE Goal: Lead the nation in quality improvement on key issues as identified by OHA members Objective: Reduce severe sepsis and septic shock incidence and mortality by 30 percent by Q4 2018

34 STRATEGIC PLAN: KEY TACTICS Tactic 1: Lead a statewide sepsis reduction hospital collaboration to improve implementation of best practices, specifically early identification and treatment

35 OVERVIEW OF INITIATIVE 92 participating member hospitals Monthly data submission on process metric compliance Quarterly reporting on sepsis incidence, mortality, length of stay, readmissions Monthly education and coaching calls Regional strategies implemented via quality collaboratives

36 GAP ANALYSIS, JULY 2015 Gaps in Sepsis Initiative Hospital Capabilities Sepsis screening in medical/surgical units and ICUs Regular inpatient screening Alert mechanisms in place 3-hour bundle: fluid administration 6-hour bundle: reassessment of volume and perfusion; re-measurement of lactate Time zero method with visual cues Tracking of clinician adherence to 3-hour bundle Meetings to discuss sepsis

37 OPERATIONAL OBSTACLES CITED BY HOSPITALS Nursing assessments and vital signs too infrequent Challenges with EMR sepsis alerts and functionality Alarm fatigue Need for education resources for clinicians Sepsis ruled in rather than ruled out Frontline staff discomfort with escalating cases Promptness of lab result reporting Timeliness of treatment establishing sepsis as an emergency Lack of familiarity with sepsis on the floor vs. in the ED

38 CHALLENGES Incidence target CMS SEP-1 bundle (October 2015) ICD-10 implementation (October 2015) 3 rd International Consensus Definitions publication (February 2016) Ongoing EMR challenges Continuum of care focus

39 OHA STATEWIDE SEPSIS INITIATIVE SEVERE SEPSIS AND SEPTIC SHOCK INCIDENCE AND MORTALITY 2012 Q Q4 NOTE: - Data are not risk-adjusted. - Severe sepsis and septic shock case selection is based on ICD-9-CM diagnosis codes and and ICD-10-CM diagnosis codes R65.20 and R65.21, respectively. This data contains protected peer review information of hospitals and health systems that participate in the quality review activities of the Collaborative. Disclosure of protected peer review information may undermine the Collaborative s integrity, processes, and continued viability. The confidentiality of all peer review information that is made available as a result of participation in the Collaborative must be maintained. Such information may not be provided or otherwise shared with any individual or entity other than the Collaborative and then only in a committee meeting setting or as otherwise authorized and/or required by applicable state or federal law. If a hospital is unsure as to whether certain information may or should be disclosed, it will contact the Collaborative s chair, or the chair s designee, prior to making any disclosure. November 10,

40 KEYS TO SUCCESS Executive sponsorship Sustainability planning Multi-level strategies and support: Statewide Regional Hospital-specific

41 WHAT IS OHA DOING ABOUT SEPSIS? OHA Board of Trustees 2015: Adopted the Clinical Advisory Committee s recommendation to place a statewide focus on Sepsis 2016: Adopted the Clinical Advisory Committee s recommendation to promote hospital executive sponsorship to prioritize sepsis and commit to implementing at least one leadership and operational standard November 10,

42 PRIORITIZING SEPSIS To adopt a statewide standard of executive leadership commitment to addressing early recognition of and early appropriate treatment of sepsis, through implementation of at least one of each of the following leadership strategies: LEADERSHIP Resource allocation at the hospital level (e.g., sepsis coordinator position) Organizational certification (e.g., Joint Commission Disease-Specific Care certification) Fostering a culture of learning, accountability, and sustainability (e.g., onboarding process) Visible and vocal leadership endorsement (e.g., leadership/purposeful rounding) Identification of hospital metric related to mortality reduction (e.g., scorecard, dashboard) Join OHA Statewide Sepsis Initiative (e.g., educational calls, coaching calls, data)

43 PRIORITIZING SEPSIS To adopt a statewide standard of executive leadership commitment to addressing early recognition of and early appropriate treatment of sepsis, through implementation of at least one of each of the following operational strategies: ORGANIZATIONAL Incorporation of early recognition and intervention into staff performance evaluation and competency (e.g., annual) Action plan development for sepsis reduction (e.g., driver diagram methodology) Focus on opportunities for operational improvement (e.g., turnaround times for lactate levels, order to antibiotic administration time) Actively participate in Statewide Sepsis Initiative (e.g., presentations, share best practices) Collaboration across the provider continuum (e.g., via outreach, case review, incorporation into contract language): o Emergency department o o o o Hospitalists Patient and Family Advisory Council (PFAC) Post-acute care EMS

44 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

45 STRATEGIC PLAN: KEY TACTICS Tactic 2: Develop educational materials geared toward caregivers and generate public awareness on sepsis and the potential warning signs

46 EDUCATIONAL STRATEGIES Monthly calls Educational focus (evidence-based) Coaching focus (operational issues) Spotlight presentations featuring effective practices/rapid cycle improvements

47 EDUCATIONAL RESOURCES Visit our Sepsis Website Education page at: Quality/Institute/sepsis/Education.aspx

48 FROM LEADERSHIP TO IMPROVED MORTALITY The Kirkpatrick Model of Training Evaluation Level Description Summary Level 1: Reaction Level 2: Learning Level 3: Behavior Level 4: Results The degree to which participants find the training favorable, engaging and relevant to their jobs The degree to which participants acquire the intended knowledge, skills, attitude, confidence and commitment based on their participation in the training The degree to which participants apply what they learned during training when they are back on the job The degree to which targeted outcomes occur as a result of the training and the support and accountability package Like it Know it Do it So what? Source: Kirkpatrick Partners.

49 FROM LEADERSHIP TO IMPROVED MORTALITY Measuring the Impact of an Education Program Level of Strategy/Evaluation Leadership commitment to early recognition and treatment of sepsis Metric Participation in Statewide Initiative, inclusion of sepsis on scorecard, etc. Implementation of education/training program for staff: Level 1: Like it Level 2: Know it Level 3: Do it Level 4: So what? % of eligible providers completing education/training Post-training evaluation or competency test Compliance with the elements of the sepsis bundles Severe sepsis and septic shock incidence, progression, and mortality

50 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

51 STRATEGIC PLAN: KEY TACTICS Tactic 3: Work with other provider groups (EMTs, physicians, long-term care facilities, and others) to improve early identification and treatment through the continuum of health care

52 COLLABORATIVE STRATEGIES NE EMS Outreach Education Packet NW Template for Sepsis Case Reviews Central - Early Recognition among the Non-Present on Admission Medical- Surgical Patient Population OHA HIIN Integration with Statewide Initiative Coordination with QIO

53 COLLABORATIVE STRATEGIES OONE Board Representation Columbus Division of Fire/EMS Sepsis Alliance Partnership

54 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

55 SEVERE SEPSIS AND SEPTIC SHOCK MORTALITY BY MONTH Ohio Hospitals, % 20.0% CY 2014 Baseline: 21.3% 9% Reduction 15.0% 30% Reduction Target (2018): 14.9% 10.0% 5.0% 0.0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2015

56 AGENDA I. Sepsis Pathophysiology II. III. The Impact of Sepsis Treating Sepsis IV. OHA Strategic Plan and Statewide Sepsis Initiative Overview V. Educational Strategies VI. Collaborative Strategies VII. Progress to Date VIII. Getting Involved November 10,

57 OPPORTUNITIES FOR PARTNERSHIP WITH OHA Join the Statewide Sepsis Initiative More information available at Join OHA s Hospital Improvement Innovation Network (HIIN) 2.0 More information available at Quality/Institute/Hospital-Engagement- Network.aspx

58 WHAT IS OHA DOING ABOUT SEPSIS? OHA Community Campaign Nursing Homes Home Health Family Caregivers EMTs Parents Community at Large November 10,

59 WHAT IS OHA DOING ABOUT SEPSIS? OHA Signs of Sepsis Campaign November 10,

60 ACKNOWLEDGMENTS Rhonda Gluckner, BSN, RN Sepsis Coordinator, Mercy Health-Youngstown Co-Chair, Mercy Health Sepsis Management Advisory Team James M. O Brien, MD, MS System Vice President, Quality and Patient Safety OhioHealth November 10,

61 QUESTIONS?

62 OHA collaborates with member hospitals and health systems to ensure a healthy Ohio James V. Guliano, MSN, RN-BC, FACHE Vice President, Quality Programs James.Guliano@ohiohospitals.org Ohio Hospital Association 155 E. Broad St., Suite 301 Columbus, OH T ohiohospitals.org

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