improving sepsis risk adjusted mortality · •lack of consistent use of sepsis workup and...

Improving Sepsis Risk Adjusted Mortality

Sandra A. Kemmerly, MD, MACP, FIDSA

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2October 24, 2019

Disclosures: None

Acknowledgements: Ashton Sloan, PA-C

System Sepsis Core Team, OHS

• Where we started

• What we tried, and why it did not work

• Lean approach to ED sepsis care

• Spread & Scale

• Starting a sepsis program

• Nosocomial Sepsis Pilot

3October 24, 2019

Agenda

• Sepsis is the leading cause of death in U.S. hospitals

• Mortality rates for severe sepsis and septic shock range ~20-50%

• As many as 92% of sepsis cases originate in the community

• Mortality from sepsis increases 8% for every hour that treatment is delayed

• As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatment

4October 24, 2019

Why Is Sepsis Important?

5October 24, 2019

Key Sepsis Performance Indicators: ED Order Set Use Tied to Goal Achievement

6October 24, 2019

Sepsis Actual vs Predicted Mortality Trend – All Payer

SEPSIS-3

• Expert sepsis task force convened by the SCCM and ESICM

• Concerns of previous definitions • Misleading continuum of sepsis to shock

• Inadequacy of SIRS criteria

• New definitions and clinical criteria generated

JAMA 2016;315(8):801-10

8October 24, 2019

OHS Definition

• Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection• Organ dysfunction is defined as an increase of 2 points or more in the Sequential Organ Failure

Assessment (SOFA) score

• Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.

• Clinical criteria: Sepsis and (despite adequate volume resuscitation) both of:• Persistent hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg, and

• Lactate greater than or equal to 2 mmol/L

• In December of 2017, Ochsner Health System adopted the Sepsis-3 definition.

• A unified definition is needed to establish protocols, standardize Epic builds, and train our workforce.

• Beginning January 2019, two of our commercial payors will only recognize the Sepsis-3 definition.

• We anticipate our other commercial payors will follow suite, making proper diagnosis and documentation even more important.

9October 24, 2019

Why did the Definition of Sepsis Change?

10October 24, 2019

SOFA Score

11October 24, 2019

SOFA Score: Trending and Criteria

• Several well designed studies published after initial success questioning role of EGDT, intense monitoring and other strategies led to variations by physicians based on personal bias

• “Official” physician champions roles were eliminated

• Migration to EMR, negating usefulness of printed standardized order sets

• PI efforts were redeployed

• Resources, focus, measurements were reduced for “sepsis”

• Impending CMS core measure reporting slated for Oct 2017 necessitated a new burning platform• First strategy: redoing electronic orders for EPIC• Spread throughout system• Poor adoption• Recognition of needing a new approach

12October 24, 2019

Lessons Learned

13October 24, 2019

14October 24, 2019

CMS Sepsis Bundle

15October 24, 2019

Perfect Care: Where Did We Start?

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17October 24, 2019

• Sepsis patients are not treated with the same urgency as code STEMI or stroke code. Lack of overhead page for the sickest patients (situational awareness and resource surge)

• Creation of Code Sepsis

• Change ESI triage assignments for sepsis patients in the ED

• Antibiotics: Mismatch between ED sepsis treatment panel and Pyxis inventory. Incorrect/delayed orders. Delay verifying/compounding abx in central pharmacy

• Optimize treatment panel and place most common antibiotics in ED Pyxis

• Build on stat order process developed

• Create mechanism for pharmacist assistance ordering abx for code sepsis

18October 24, 2019

Key Root Causes

• No QI process in place• Creation of QI process

• Making it more complicated than it needs to be• Elimination of weight based antibiotics

• Decision support to ED providers using treatment panel

• Difficulty in defining sepsis• System-wide adoption of Sepsis-3 definition

• Lack of consistent use of sepsis workup and treatment panels. Variety of providers rotating through OMCNO ED

• Standardize onboarding for new providers. Optimize workup & treatment panels

19October 24, 2019

Key Root Causes

Project Results

Median time to antibiotic administration improved from

1h53 min to 45 minutes

• Code Sepsis is NOT for all sepsis patients

• Code Sepsis targets the subset of sepsis patients in the ED that disproportionately drive inpatient mortality and complications (RAMI & ECRI)

• Code Sepsis Triggers:

Sepsis PLUS: SBP<90 or lactate ≥ 4

21October 24, 2019

Why Code Sepsis?

Triage:

• SBP<90 plus positive sepsis screen in triage

• Triggers ESI 1 and activates code sepsis process

22October 24, 2019

Code Sepsis Triggers

Provider:

• SBP<90 or lactate ≥4 plus known or suspected infection

• Activates code sepsis process

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Code Sepsis Process

24October 24, 2019

Code Sepsis Results

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Sepsis Accelerator

System ED Sepsis Spread and Scale

• New to Ochsner Health System…but not new to the tech industry

• Accelerators provide limited, intensive coaching and support to entrepreneurs seeking to take their companies and ideas to the next level

• Variability in needs is understood, but certain key milestones for startups are universal

26October 24, 2019

Accelerator Model

• Teams should be multi-disciplinary and include nursing, physicians, pharmacy, informatics, quality, and other key stakeholders

• Leverage an executive sponsor to remove any barriers

• Don’t bite off more than you can chew: the emergency department is a defined cohort that captures ~90% of sepsis cases

• Use informatics to automate data collection

27October 24, 2019

Starting a Sepsis Program

• Jeff Hwy root causes are likely different from each campus’ root causes

• Local solutions should match local root causes

• Root causes that do match Jeff Hwy can borrow from Jeff Hwy solutions

• 90%(+) of ED operations are the same/very similar across campuses

• Jeff Hwy templates already developed (SIPOCs, process maps, etc) can be shared to significantly reduce the time needed to complete the exercises organically

• ED Sepsis Performance Report created by the Jeff Hwy Sepsis team provides robust, campus-specific data eliminating the need to develop a data collection plan and obtaining measurements

28October 24, 2019

Assumptions

1. Ochsner Baptist

2. Ochsner Baton Rouge

3. Ochsner Kenner

4. Ochsner St. Charles

5. Ochsner West Bank

6. Ochsner St. Anne

7. Ochsner North Shore

8. Chabert Medical Center

9. St. Bernard Parish Hospital

10. St. Tammany Parish Hospital

11. Terrebonne General

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System Accelerator Event

**Cumulative Impact: 22(+) months saved**

Advantages:• Decentralized spread & scale uses local resources to identify and

tackle local root causes

• Allows for the formation of teams that may not have already existed

• Provides framework to create and share internal knowledge

• Does not rely on System OHS Quality Team to do all of the work

Trade Offs: • Less control over completion timelines, deliverables, etc

• Variability between campuses

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Accelerator Strategy

OHS Sepsis Perfect Care

31October 24, 2019

• Any project that affects nursing care needs to involve nursing leadership up front

• Do not underestimate the help informatics can lend

• Best practice tools (ED panels, order set, etc) need to be optimized to make it easier for clinicians to care of patients

• For projects involving mostly clinical staff, build redundancy into your team

32October 24, 2019

Lessons Learned

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Code Sepsis Inpatient Project

Data Review – What Did We Learn?

35October 24, 2019

Length of Stay

• Mean: 27.44 days

• Median: 20.12 days

• Minimum: 1.07 days

• Maximum: 269.6 days0%

5%

10%

15%

20%

25%

30%

0-5 DAYS 5-10 DAYS 10-15 DAYS 15-20 DAYS 20-25 DAYS 25-50 DAYS 50+ DAYS

5% 5%

18%

12%10%

28%

12%

Nosocomial Sepsis Length of Stay

36October 24, 2019

Antibiotic Start to Patient Death

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

0-1 DAYS 1-2 DAYS 2-3 DAYS 3-4 DAYS 4-5 DAYS 5-6 DAYS 6-7 DAYS 7-8 DAYS 8-9 DAYS 9-10 DAYS 10-20 DAYS 20+ DAYS

5%2%

4% 3% 4% 5% 4% 5%3% 4%

20%

41%

Antibiotic Start to Death

• Patients would be identified through traditional rapid response process or by a primary team MD/APP

• If the Rapid Response Team suspects the decompensation is due to sepsis, the Rapid Response Team will call the Critical Care Medicine fellow and collect a POCT capillary blood gas, lactate, and blood glucose

• Joint discussion/decision between the primary team and the Critical Care Fellow or designee regarding activating the code sepsis process

• Code sepsis would be activated by calling x4444 with the patient’s location, name, and MRN

• Lab would come to the bedside to collect blood cultures and labs

• Pharmacy would assist in the rapid verification, compounding, and delivery of broad spectrum antibiotics• Goal: Provider orders antibiotics within 15 minutes of code sepsis

• Goal: Antibiotics are infusing within 1 hour of code sepsis

37October 24, 2019

Inpatient Code Sepsis Overview: Go Live June 6th

• Project team was challenged by the heterogeneity of the data—no smoking gun

• However, some themes eventually emerged:• Long lengths of stay

• Delays in receiving antibiotics

• Sepsis treatment generally started long before death

• Palliative Medicine overlap

38October 24, 2019

Are You Confused Yet?

• We’ve learned a lot without a clear direction on changes to make clinically

• Significant opportunity in palliative medicine/end of life care at Jeff Hwy

• The “sick but salvageable” patients could likely be helped by streamlining care, but it is unlikely to improve hospital acquired sepsis related RAMI

• Pursue more limited opportunity on streamlining care for decompensating patients

39October 24, 2019

Gut Check

• Measuring the CMS sepsis bundle is built on “time zero”

• 80% of patients have LOS > 10 days

• Which event do you pick to mark time zero?• Leukocytosis• Hypotension• Fever• Tachycardia• Lactate• AKI• LFTs• Etc.

40October 24, 2019

CMS Core Measure – Unclear Baseline Data

• Jefferson Hwy’s patient population is different than the community setting• What are your local drivers?

• Will this process help improve RAMI at your facility?

• Consistent screening for sepsis (using more than current SIRS, MEWS, SOFA) is still needed

• Is targeting hospital acquired sepsis RAMI a meta-strategy?

• Applicability of the CMS bundle to hospital acquired sepsis?

Let’s Discuss!

• RAMI as a “systems” marker

• Continuous improvement is needed

• Staying in the “arena”

• Needs continuous attention, can easily revert back to “status quo” once the novelty wears off (despite seemingly hardwired)

42October 24, 2019

Lessons Learned

Questions

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Appendix

October 24, 2019

Severe Sepsis and Septic Shock Project Charter Summary

Project: Sepsis and Septic Shock Core Measures

In Scope: Adult patients presenting to the ED at OMC-Jefferson Highway with the diagnosis of sepsis and septic shock.

Out of Scope: Patients younger than 18 years of age; Patients developing sepsis during their inpatient stay; Epic Secure Chat, other

hospitals, provider escalation/hierarchy protocol, Regional Referral Center, sepsis pathway.

: Outpatients, code blue, Epic Secure Chat, HCAHPS, other healthcare facilities.

Green Belt(s): Ashton Sloan Coach: Xavier Viteri

Problem Statement: Only 20% of sepsis patients at OMC-Jefferson Highway receive “Perfect Care”. Order sets and/or panels that

contain sepsis measures of “perfect care” are significantly underutilized.

Goal: Increase the instances of achieving perfect care for sepsis patients arriving to OMC-Jefferson Highway via the ED to 85%;

improved data capture

Expected Benefits: Increased and earlier capture of patients with sepsis and septic shock; increased contribution to margin from

CMS Value Based Purchasing program; decreased patient mortality from sepsis.

Targeted Start Date: Mid-August

Anticipated End Date: March (For ED patients)

46October 24, 2019

Sepsis Actual vs Predicted Mortality Trend – All Payer

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% Mortality of Sepsis as PDx by Facility

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Of 851 sepsis cases in the cohort from October 2015 to September 2017:• 281 (33%) passed SEP-1 and 570 (67%) failed. • SEP-1 failures had higher rates of septic shock (20% vs 9%; p < 0.001)• Hospital-onset sepsis (11% vs 4%; p = 0.001)• Vague presenting symptoms(46% vs 30%; p < 0.001)

• Delays of > 3 hours until antibiotics were significantly associated with death (p = 0.038)

• Failing SEP-1 for any other reason was not associated with increased mortality (p = 0.674)

• Failing SEP-1 was not associated with increased in-hospital mortality when adjusted for severity of illness

OMCNO Nosocomial Sepsis RAMI Charter

Project Leader: Suma Jain, MDProject Manager: Ashton Sloan

Executive Sponsors: Sandy Kemmerly, MD Yvette Bertaut, VP

Business Case: Patients are our first priority at Ochsner. Despite significant effort, too many of our patients develop infections and sepsis while they are admitted for other conditions. Hospital acquired infections represent a significant, often avoidable cost to Ochsner Health System, and hospital acquired sepsis is a known yet unquantified driver of costs, length of stay, and avoidable mortality. Administrative data sets do not allow for a clear understanding of the scope or root causes of hospital acquired sepsis mortality, and OHS currently lacks useful infrastructure to identify and treat sepsis early in its onset. Average OMCNO RAMI for nosocomial sepsis is currently 2.22.

In Scope: Inpatients >18 years old at Jeff Hwy who develop sepsis > 48 hours after admission; rapid response team; artificial intelligence; Epic; code sepsis for inpatients; pharmacy; nursing; provider documentation

Out of Scope: Post-operative sepsis; infection prevention bundles; outpatients; ED; patients <18 years old; sepsis present on admission

Expected Benefits: Success looks like improving overall sepsis mortality and decreasing RAMI to <1.0 for patients with sepsis not present on admission, decreased length of stay, improved measurement systems for nosocomial sepsis, tools to assist in early identification of sepsis, and improved responsiveness to patients once nosocomial sepsis is identified.

Metrics: Mortality rate and RAMI for sepsis not POA; inpatient length of stay; time to antibiotics after nosocomial sepsis diagnosis

Targeted Start Date: October 25th, 2018Anticipated End Date: March 21st, 2019

Resources Needed: Informatics/Epics

Project Team Members: Suma Jain, MD; Emily Ramee, MD; Heather Kahn, MD; Travis King, PharmD; Kat Jennings, PharmD; Marlene Alonzo; Heather Webre; Kristen Linde; Stratton Reichen, MD; Behr Khan, MD; Mike Truxillo, MD; Teresa Arrington; Douglass Koysdar

• Patients on the dashboard are patients with a sepsis diagnosis after they are admitted

• Death can come from any cause

• Inclusion into the dashboard does notnecessarily mean:

• The patient died from sepsis

• Sepsis was an active problem at death

50October 24, 2019

Hospital Onset Sepsis RAMI Inclusion/Exclusion Criteria

• Nosocomial Sepsis RAMI = early recognition + timely evaluation/recognition + time to appropriate antibiotics + time to resuscitation (if needed) + timely care team communication (patient changes) + documentation + time to labs + IV access + IV access + patient population + palliative medicine + unit characteristics (nursing ratios, etc)

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Nosocomial Sepsis y=(fx)

52October 24, 2019

Nosocomial Sepsis Admission Sources

20%

45%

31%

2% 1% 0.3%

Physician or Clinic Referral Outside Hospital Self Referral Outside Health Care Facility Skilled Nursing Facility Transfer From One Distinct Unit of aHospital to Another Distinct Unit

• Percentage of nosocomial sepsis patient deaths: 46% (n=175)

• Length of Stay (Admission Until Death)• Mean: 38.8 days

• Median: 19.1 days

• Minimum: 1.06 days

• Maximum: 326 days

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Nosocomial Sepsis Hospital Deaths

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0-5 DAYS 5-10 DAYS 10-15 DAYS 15-20 DAYS 20-25 DAYS 25-50 DAYS 50+ DAYS

6%

19%

15%

12%

10%

20%

18%

Length of Stay for Nosocomial Sepsis Associated Deaths

Percentage of deaths that occur with LOS > 30 days: 31%

• Percentage of patients with sepsis on problem list: 54%

• Time to sepsis on problem list from admission:• Mean: 12.06 days

• Median: 8.6 days

• Percentage of patients with sepsis on problem list marked as resolved: 37%

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Sepsis On Problem List

55October 24, 2019

Blood Cultures to Patient Death

0%

5%

10%

15%

20%

25%

30%

35%

40%

0-1 DAYS 1-2 DAYS 2-3 DAYS 3-4 DAYS 4-5 DAYS 5-6 DAYS 6-7 DAYS 7-8 DAYS 8-9 DAYS 9-10 DAYS 10-20 DAYS 20+ DAYS

2%

6%5%

1%

5%2%

4% 5%4% 4%

25%

38%

Blood Cultures to Death Date

56October 24, 2019

Antibiotics

Provider Order to Pharmacist Verification

ORDER TO PHARMACIST VERIFICATION

Mean 9.5

Standard Error 1.4

Median 4.0

Mode 1.0

Standard Deviation 26.5

Sample Variance 701.3

Kurtosis 148.7

Skewness 11.3

Range 394.0

Minimum 0.0

Maximum 394.0

Sum 3471.0

Count 364.0

Antibiotics Order to Taken (min)

Mean 311.45

Standard Error 65.7648293

Median 90

Mode 62

Standard Deviation 1247.7999

Sample Variance 1557004.6

Kurtosis 53.2487331

Skewness 7.30296613

Range 10906

Minimum 4

Maximum 10910

Sum 112122

Count 360

Provider Order to Antibiotic Administration

Abx Pulled from Pyxis

Antibiotics Order to Taken (min)

Mean 488.9473684

Standard Error 136.2644819

Median 91

Mode 113

Standard Deviation 1781.889319

Sample Variance 3175129.544

Kurtosis 23.94379462

Skewness 5.020983078

Range 10906

Minimum 4

Maximum 10910

Sum 83610

Count 171

Abx NOT Pulled from Pyxis

Antibiotics From Pyxis

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Percentage of Abx Pulled from Pyxis: 47%

Antibiotics Order to Taken (min)

Mean 150.8571429

Standard Error 15.8539585

Median 90

Mode 62

Standard Deviation 217.9558947

Sample Variance 47504.77204

Kurtosis 28.15194222

Skewness 4.819154176

Range 1751

Minimum 9

Maximum 1760

Sum 28512

Count 189

• OMCNO and OHS RAMI workgroups have achieved significant RAMI improvements through:• Proactive nursing rounds

• Data driven patient screening (MEWS, AI, etc)

• Streamlined nursing interventions

• New Tools Needed: Sepsis Predictive Model• Rolled out in the ED at Jeff Hwy

• Not ready for the inpatient setting

• How can we utilize existing systems and structures?• Rapid Response Team

• Code Sepsis

58October 24, 2019

Where Did We Go?

Screen

Recognize

Respond

• Do patients with a code sepsis activation require transfer to the ICU?• No. The decision to activate a code sepsis does not require transfer to the ICU

• How often are code sepsis activations likely to happen?• We estimate two code sepsis activations per week

• Will I need ID clearance for restricted antimicrobials?• Antimicrobials ordered using the Code Sepsis Order Set do not require approval for the first dose

• Does the Critical Care Fellow have to respond in person?• The Critical Care Fellow may send a designee

• Can a primary team activate a code sepsis outside of the rapid response team?• Yes, but the rapid response team will respond when code sepsis is activated

59October 24, 2019

Code Sepsis FAQs

Gram Positive-active Antimicrobials(S. aureus, Enterococcus spp., etc.)

VancomycinAND

Vancomycin Random

2000 mg, IV, for 60 minutes, for 1 dose

Now + 12 hours

Gram Negative-active Antimicrobials (E. coli, Pseudomonas spp., Klebsiella spp.)

Piperacillin-tazobactam

Meropenem (if history of MDR GNR)

Tobramycin AND

Tobramycin Random

*** IF PCN ANAPHYLAXIS*** Aztreonam

AND Metronidazole

4.5 g, IV, for 30 minutes for one dose

2g, IV, for 60 minutes, for 1 dose

7 mg/kg, intravenous, for 60 minutes, once

Now + 12 hours

2000 mg, IV, for 60 minutes, for 1 dose

500 mg, IV, for 60 minutes, for 1 dose

Antifungal Agents (Candida spp.)

Fluconazole

Micafungin

800 mg IV, for 60 minutes one dose

100 mg, IV, for 60 minutes, for 1 dose

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Code Sepsis Order Set

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Inpatient Code Sepsis Results

77%

100%

86%

0%

42%

75%

0%1ST LACTATE BLOOD CULTURES ANTIBIOTICS FLUID BOLUS 2ND LACTATE VASOPRESSORS PERFUSION ASSESSMENT

Inpatient Code Sepsis Results

n=22

Median time to antibiotics delivery: 53 minutes

• Sepsis or Septic Shock should be added to the inpatient problem list or the ED Clinical Impression depending on the setting (inpatient vs ED)

• Any organ failure resulting from sepsis should be indicated• “AKI secondary to ischemic ATN resulting from septic shock”

• “Metabolic encephalopathy resulting from sepsis”

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How Should Sepsis Be Documented?

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EPIC Sofa Score

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EPIC Additional Reports: SOFA

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1892