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Taking Better Care of Sepsis Patients
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Diana Tarone, MSN, MBA, RNJennifer Axelband, DO
St. Luke’s University Health Network
Sepsis by the Numbers
• More than 1.7 Million people get sepsis each year in the US
• About 84,000 admissions in PA annually1.7 Million• At least 270,000 Americans die from sepsis each year (that’s
one every two minutes!)
• About 7,000 deaths in PA annually270,000
• About 1 in 3 patients who die in the hospital have sepsis1 in 3 Patients• 1 in 15 severe sepsis discharges will be readmitted within 7
days
• 1 in 5 are readmitted within 30 days1 in 15
• Just over half of all Americans know the signs and what sepsis is55%
• Only about one third of sepsis patients nationwide receive the best care
• Late and missed diagnoses are common1/3rd
• Total annual US hospital costs for treating sepsis$24 Billionwww.cdc.gov
www.sepsis.org
HAP Raising the Bar for Sepsis Care in Pennsylvania, September 6, 2017, Harrisburg, PA
St. Luke’s University Health Network
Our Sepsis Story
Our sepsis journey began in 2012 – PI project with a private payer
Higher volume diagnosis
Higher associated cost
Higher associated mortality rate
CMS publically reported measure – CMS mandated reporting beginning with Oct 2015
discharges
– First posted on Hospital Compare July 2018
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St. Luke’s University Health Network
Quality/PI Structure
Network Sepsis PI Team
– Report out to Network PI Council
– Executive sponsor
– Various disciplines represented
– Representation from every campus
Monthly meetings
Data reviewed and discussed
– Premier
– CMS Sep-1 Core Measure compliance
Trends and opportunities are identified
Seek feedback and recommendations
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St. Luke’s University Health Network
Opportunities For Improvement
Feedback on measure failure is provided
Each measure failure is reviewed for opportunities and feedback is solicited
Measure failures are viewed as learning opportunities
Opportunity letters
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St. Luke’s University Health Network
Baseline Network Sepsis Compliance
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0
10
20
30
40
50
60
70
80
90
100
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16
Baseline Sep-1 Compliance Oct 2015-September 2016
Rate CMS state compliance median CMS national compliance median CMS top decile
EPIC go-live
St. Luke’s University Health Network
CMS Sepsis-1 Core Measure
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Follows CMS SEP-1 Measure 1.7.2019
Organ Dysfunction: SBP < 90 or MAP < 65 or↓SBP by >40 points (related to
infection) Acute respiratory fa ilure (new need for invasive or noninvasive
mechanical ventilation) Creatinine > 2.0 or > 0.5 increase from baseline with CKD urine output < 0.5ml/kg/hr for 2 hours
Bi l irubin > 2mg/dL (34.2 mmol/L) Platelet count < 100,000 INR> 1.5 or aPTT > 60 seconds
(SBP
Monitor vi tals igns
Measure Lactate Blood Cultures x2
Antibiotics
Diagnosis: Severe Sepsis
Repeat lactate in 2 hours
Diagnosis: septic shock
Givevasopressors
Repeat Lactate
in 2 hours
Infection? (suspected or
documented)
≥ 2 SIRS?
Lactate ≥ 4 ?
Lactate > 2 ?(but < 4)
SBP < 90 ?
Give 30ml/kg
crysta l loid IVF bolus (use actual
body weight)
SBP remains
< 90?
Perform Focused Reassessment in
one hour after bolus initiated
other end organ
dysfunction?
Sepsis/Severe Sepsis/Septic Shock AlgorithmNo
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Lactate >2 ?
(but < 4)
Yes
Not Severe Sepsis
Not Sepsis
Focused reassessment: Provider completion and documentation of the following by provider (all):L
Vital Signs Cardiopulmonary Exam Capillary Refill evaluation Peripheral Pulse Evaluation Skin Examination Arterial oxygenation saturation
or pulse oximetry Urine output Shock Index
SIRS Criteria: Temp > 38.3C (100.9F)
or < 36C (96.8F) HR > 90
RR > 20 WBC >12,000 or
< 4,000 or >10% bands
Repeat lacate in 2 hours
Give 30ml/kg crystalloid IVF bolus (use actual
body weight)
Note time of presentation!(Infection plus
SIRS plus organ
dysfunction)
SBP < 90?
Give
vasopressors
Monitor vi tals igns
No
Yes
[end]
[end]
Repeat Lactate
in 2 hours
Lactate > 2 ?
(but < 4)
No
Yes
OR... Any 1 of the following
CVP measurement ScVO2 measurement
Bedside Cardiovascular US Passive Leg Raise or Fluid Challenge
Perform Focused
Reassessment in one hour after bolus intiated
St. Luke’s University Health Network
Basic Workflow
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Automated IT functions
Actions built into IT system
Human action/decision
Legend
St. Luke’s University Health Network
The “Purple Sepsis Checklist”
Process prior to EPIC
Limitations of legacy product
Numerous paper processes
“The purple sepsis checklist”
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St. Luke’s University Health Network
The “Purple Sepsis Checklist”
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Built the sepsis checklist into EPIC
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Inpatient and ED RN Screening Process
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SIRS Criteria Options
Organ Dysfunction Options© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
ED First Nurse Sepsis Protocol
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© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Provider Initial Sepsis Assessment
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qSOFA
Infection
SIRS
Organ dysfunction
Shock
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Patient Banner
Providers can add weights to the banner
Impacts functionality of order sets
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© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Order Sets/Panels
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General Orders
Labs
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Order Sets/Panels - Fluids
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Micro & Imaging
Fluids
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Order Sets/Panels - Antibiotics
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Monotherapy
Combo Therapy
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Order Sets/Panels
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Vasopressors
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Provider Sepsis Reassessment
19© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network 20
Provider Sepsis Reassessment
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Notes
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© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Navigator
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Emergency Department
Inpatient
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Report/Summary – EPIC SideBar
Link from Sepsis Navigator
Includes:– RN Sepsis Screening
– qSOFA
– Initial Sepsis Screen (provider)
– Sepsis Checklist
– Lactic Acid
– Other Labs
– Microbiology results
– Vital Signs and shock index
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© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Best Practice Alert for RN
Indicates SIRS criteria is met and sepsis should be considered
Screen patient
Notify provider as appropriate
Lactate has not been completed
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SIRS
Direction
Action
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Best Practice Alert for Provider
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Indicates SIRS criteria is met and sepsis should be considered
Lactate has not been completed
SIRS
Action
Direction
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Sepsis Predictive Model
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© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network 27
7% and 9% Best Practice Alerts
Acknowledge
Screen
Acknowledge
Direction
Screen
Direction
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
ED Sepsis Patient List
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© 2019 Epic Systems Corporation. Used with permission.
© 2019 Epic Systems Corporation. Used with permission.
St. Luke’s University Health Network
Failure Types
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0
20
40
60
80
100
120
140
160
2015Q4
2016Q1
2016Q2
2016Q3
2016Q4
2017Q1
2017Q2
2017Q3
2017Q4
2018Q1
2018Q2
2018Q3
2018Q4
2019Q1
2019Q2
2019Q3
Network Quarterly Count of Failures by Type
reassessment
vasopressors
fluids
repeat lactate
blood cultures
antibiotic selection
antibiotic time
initial lactate
St. Luke’s University Health Network
87.1
0
10
20
30
40
50
60
70
80
90
100
Rat
e
Network CMS Sep-1 Bundle Compliance
Rate CMS top decile CMS state compliance median CMS national compliance median
Performance Data
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EPIC
go-live
Sepsis
Navigator
Simplified
Abx List
Grand
Rounds
SLMC
Opened
Lactate >2
= critical
lab value
Optimize
Weight
Based
Orders
Predictive
Analytics
7% and
9% BPAs
Mandatory
Education9% Page
Functionality
Suspected
Sepsis
Report
Provider
Reassessment
BPA –
background
page to RRT
SLBM
joined
SLSH
joined
EMR Functions
Sepsis
Alert
St. Luke’s University Health Network
St. Luke’s Hospital Compare Performance
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78%
55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
SLA SLB SLA/SLB SLRA SLM SLQ SLW SLMC SLSH SLGH Network
CMS Hospital Compare Q4 2017 - Q3 2018Sep-1 Measure Compliance July 2019 Update
Q1 2017 - Q3 2017 Q1 2017 – Q4 2017 Q2 2017 - Q1 2018
Q3 2017 - Q2 2018 Q4 2017 - Q3 2018 CMS top decile 78%
CMS National Median 55%
St. Luke’s University Health Network
Hospital Compare – Regional
Hospital Jul18 Oct18 Feb19 Jul19
SL Allentown/ Bethlehem
77% 77% 78% 81%
SL Anderson 72% 78% 80% 86%
SL Miner’s 55% 57% 61% 80%
SL Quakertown 63% 68% 67% 82%
SL Warren 67% 68% 74% 76%
SL Monroe 69% 74% 71% 70%
SL Sacred Heart 27% 30% 34% 55%
SL Blue Mt. (SLGH)
63% 64% 63% 65%
Geisinger Danville 30% 31% 32% 41%
Grandview 44% 44% 47% 49%
Thomas Jefferson Univ.
51% 51% 50% 55%
HUP 75% 75% 74% 84%
Hospital Jul18 Oct18 Feb19 Jul19
LVH-CC 42% 42% 43% 45%
LVH-M 35% 39% 38% -
LVH-Pocono 40% 41% 43% 44%
LVH-Hazleton 62% 62% 63% 67%
Easton 45% 48% 59% 63%
Reading 45% 46% 53% 58%
Hershey 40% 44% 50% 51%
Hunterdon 33% 36% 35% 46%
Hackettstown 42% 49% 56% 58%
Cooper 67% 66% 68% 67%
Temple 58% 62% 61% 70%
Hahnemann 41% 38% 42% 47%
Benchmarks Jul18 Oct18 Feb19 Jul19
Top decile 76% 76% 76% 78%
PA Average 45% 46% 48% 53%
NJ Average 56% 57% 58% 61%
National Average
49% 50% 51% 55%
Data accessed: 8/2/2019
Timeframes:
Jul 2018: Jan- Sep 2017
Oct 2018: Jan-Dec 2017
Feb 2019: Apr 2017-Mar 2018
Jul 2019: Oct 2017-Sep 2018
Oct 2019: next update will drop
oldest quarter and add newest
quarter
Sep-1 Measure Compliance Comparison
St. Luke’s University Health Network
Fewer patients Progress to Septic Shock
33
0
10
20
30
40
50
60
70
80
90
100
Jan
-16
Feb
-16
Mar
-16
Ap
r-1
6M
ay-1
6Ju
n-1
6Ju
l-1
6A
ug-
16
Sep
-16
Oct
-16
No
v-1
6D
ec-1
6Ja
n-1
7Fe
b-1
7M
ar-1
7A
pr-
17
May
-17
Jun
-17
Jul-
17
Au
g-1
7Se
p-1
7O
ct-1
7N
ov-
17
Dec
-17
Jan
-18
Feb
-18
Mar
-18
Ap
r-1
8M
ay-1
8Ju
n-1
8Ju
l-1
8A
ug-
18
Sep
-18
Oct
-18
No
v-1
8D
ec-1
8Ja
n-1
9Fe
b-1
9M
ar-1
9A
pr-
19
May
-19
Jun
-19
Jul-
19
Percentage of Patients Coded with Severe Sepsis/Septic Shock
severe shock
St. Luke’s University Health Network
Network Sepsis Mortality Index APR DRG 720
34
.00
.10
.20
.30
.40
.50
.60
.70
FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Ind
ex
Network Mortality Index APR DRG 720 Septicemia & Disseminated Infections
Network Premier top decile top quartile
St. Luke’s University Health Network
Actual Mortality Rates
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0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Rat
e
Network Mortality APR DRG 720Septicemia & Disseminated Infections
Network Premier top decile Premier top quartile
St. Luke’s University Health Network
Return on Investment and Case Mix Index
Campus Year Cases Case Mix Index Average LOS Operating Margin Per Case
SLA 2018 573 1.71 6.59 $2,371
2017 410 1.57 6.65 $1,584
2016 336 1.67 6.41 $1,819
SLB 2018 764 1.97 7.59 $2,231
2017 1005 1.74 6.72 $1,286
2016 799 1.79 7.19 $917
SLRA 2018 803 1.65 5.35 $951
2017 683 1.62 5.76 $414
2016 542 1.65 5.96 $184
Combined 2018 2140 1.78 6.48 $1,788
2017 2098 1.67 6.39 $1,060
2016 1677 1.72 6.63 $861
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St. Luke’s University Health Network
Lessons Learned
Leadership support is vital
Physician buy-in and input
– We had physicians involved in process development and the EPIC builds prior to go-live
Empower your nursing staff
Set clear expectations up front
Feedback is essential
37
St. Luke’s University Health Network
Clinical Governance Technology
38
St. Luke’s University Health Network
Next Steps
Post Sepsis Syndrome
Readmissions
– Predictive model for readmissions
Length of Stay
Episode of care
Current Deterioration Index Pilot and Implementation
– Will augment our sepsis process
Exploring potential use of TigerConnect
Continued optimization of the EMR and our process
39
St. Luke’s University Health Network
Questions
40
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