How To Review A Sepsis Case In Qmp Quality Management Portal

Transcription

1 Quality Management Portal (QMP) & Sepsis Data Analysis Lessons Learned & Progress To Date Nicole Falgout, RN Sepsis Coordinator Rei Cates Sr. Software Engineer UCLA Quality Management Services 1

2 Quality Management Portal (QMP) Quality Management Portal (QMP) Online based application tool and database designed for staff in Quality Management Services (QMS) Department to complete clinical case reviews for compliance metrics related to: - Sepsis - Core Measures (i.e. AMI, heart failure, etc.) - Mortality & Readmissions - Peer Review - HAC/PSI - Surgical Site Infections, - Infection Prevention Metrics and - Other hospital acquired conditions complications 2

3 Sepsis Case Review Process in QMP Quality Management Portal = QMP (eff. 12/2012) Patients coded with ICD9 codes for Sepsis (995.91), Severe Sepsis (995.92) &/or Septic Shock (785.52) at time of discharge are filtered into QMP from EPSI (billing database) & randomized for review Average ~ coded cases/month (Both RR & SM) RN review for DSRIP measure requirements - 50 cases/month RRMC & 30 cases/month SM **NOTE: SEPSIS CASES ARE NOT 100% REVIEWED** Goal to ID and Tx Severe Sepsis & Septic Shock in real-time using sepsis bundle to meet DSRIP compliance goals; real-time concurrent data collection and rounds process 3

4 Sepsis Case Review Process - QMP Quality Management Portal (QMP) 4

5 Sepsis Case Review Process 1. Determining Time of Presentation (TOP) 2. Pt. must meet criteria for Severe Sepsis &/or Septic Shock to require Sepsis Bundle compliance 5

6 Sepsis Case Review & QMP Data Entry 6

7 Sepsis Case Review & QMP Data Entry 7

8 Sepsis Case Review & QMP Data Entry Bundle NOT Met vs. Bundle Met 8

9 Sepsis Case Review & QMP Data Entry 9

10 Example of Data Analysis Mortality associated with Antibiotic timing *UCLA s avg. time from TOP to time of Abx: 8/2013 = 5hrs 28 minutes 3/2013 = 10hrs 20 minutes GOAL <1hr 8/2013 = 5hr. 28min. 3/2013 = 10hr 20min. AntibioticsDuration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in humanseptic shock.kumar A; Roberts D; Wood KE; Light B; Parrillo JE; Sharma S; Suppes R; Feinstein D; Zanotti S; Taiberg L; Gurka D; Kumar A; Cheang MCritical Care Medicine. 34(6): , 2006 Jun. 10

11 Sepsis Case Review & QMP Data Entry Attribution of Services & Unit at TOP Fallouts & Discrepancies 11

12 Data Definitions Indicator ED- Screening Tool ICU-Screening Tool M/S Screening Tool Lactate Blood Cultures X 2 Antibiotic Fluid Resuscitation All Bundle Components REVISED DATA DEFINITIONS (eff. 3/2013) Data Definition Numerator=Number of ED patients >18 screened for sepsis Denominator- TOTAL Number of ED patients in overall monthly coded sepsis population Numerator=Number of ICU patients >18 screened for sepsis Denominator-TOTAL Number of ICU patients in overall monthly population Numerator=Number of M/S patients >18 screened for sepsis Denominator-TOTAL Number of M/S patients in overall monthly population Numerator=Number of patients who had lactate results within (4) hours before TOP & up to (6) hours after TOP Denominator=Number of patients who met the overall population criteria ("included") Numerator=Number of patients who had BC drawn within 6 hours prior to TOP or up to (1) hour after TOP and before antibiotics Denominator=Number of patients who met the overall population ("Included") Numerator=Number of patients who received antibiotic(s) prior to TOP or 1 hour after TOP (on floor/unit) OR 3 hours after TOP in ED ONLY (ED TOP = time of triage) Denominator=Number of patients who met the overall population ("Included") Numerator=Number of patients who received 20ml/kg of fluid within 6 hours before or after TOP - unless fluids of 20mL/kg contraindicated Denominator=Number of patients who met the overall population criteria Numerator=Number of patients who received ALL four (4) components of the sepsis bundle within the allotted 1hour and 6 hour timeframes allowed following Time of Presentation (TOP) Denominator=Number of patients who met the population criteria 12

13 Excluded Data EXCLUDED Cases Pts who do not meet defined criteria for severe sepsis &/or septic shock (i.e. Sepsis only and SIRS only cases are EXCLUDED) 18 years of age OB pts. or OB/GYN pts. <48hr PostPartum DNR/DNI or Palliative Care on admission or patients with an order for DNR/DNI or Palliative Care within 24hrs prior to or after TOP Severe Sepsis or Septic Shock Outside hospital ICU to UCLA ICU transfers AMA No SIRS, No Infection or No Organ dysfunction/failure 13

14 Data Analysis & Compliance DSRIP Data 2Q2013 (04/01/2013 to 6/30/2013) Overall Sepsis Bundle Compliance 1. RRMC 2. SMMC 3. Both Hospitals (avg. per quarter) Each Facility Reports Individual Bundle Element Compliance but overall just total bundle compliance *All data sampled using DSRIP approved sampling methodology for a minimum of 30% of total number of cases/mo. * BOTH (AVG) 14

15 Sepsis Dashboard prior to QMP reports 2013

16 Sepsis Dashboard prior to QMP reports March 2013

17 2013 Sepsis Bundle Compliance RR UCLA Hospital (01/01/2013 to 9/11/2013) New report format when generating reports in QMP 17

18 Data Reports Metric definition Action plan! Unit Champion If a month is missing, there were no cases reviewed by the RN which were INCLUDED for DSRIP reporting **NOTE: Each month, 50 charts are reviewed for RRMC & 30 for SMMC. This is sampling based on DSRIP approved methodology. The data recorded for each unit is based on cases reviewed by an RN. The total # of cases per service or unit may be significantly higher than what is reflected in report due to sampling methods and qualification as Included vs. Excluded based on DSRIP reporting ** 18

19 Data Reports BUNDLE MET = ALL four (4) sepsis bundle elements are completed, completed accurately, and within the appropriate timeframes allotted BUNDLE NOT MET = Any one or more element which is not completed, not completed accurately or not within the appropriate timeframe allotted (aka: noncompliant ) These are referred to as fallouts *NOTE: You can have Bundle MET & still have fallouts (ex: fluid bolus 20mL/kg contraindicated) 19

20 Fallouts or Noncompliance Fallouts listed on report are from the most recent month of data only This sample report is for May 2013 so the fallouts listed in this report are for May 2013 ONLY. Fallouts listed by hospital, the Unit or Service chosen at the time report is generated, and lists fallouts individually by category & MRN# *NOTE: this is sampled case review data only and not 100% of sepsis cases* 20

21 Interactive QMP LogIn for QMP Interactive Demonstration Quality Mgmt. Services Department staff view READ Only/Report View (for Sepsis Champions, UD s, CNS s, etc.) Report generation by Service, Unit, Hospital, etc. Access QMP using AD\ user ID & Password Request access to QMP through sepsis website 21

22 QUESTIONS?