Sepsis:Overcoming Common Barriers

Dr. Jim Frazier, MD, System VP of Medical Affairs

&

Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC

Clinical Nurse Specialist

Norton HealthcareLouisville, Kentucky

• 5 Acute Care Hospitals

– 1,837 licensed beds

• 7 Outpatient Centers

• 13 Norton Immediate Care Centers

• Nearly 14,000 employees

• Approximately 1,000 Employed Medical Providers

Objectives

Recognize the intricacy of the SEP-1 Core Measure

Compare state of the environment pre- and post-interventions implementation

Describe strategies to influence project management and system change for common barriers

SEP-1 Core Measure

• National standards of care and treatment processes for common conditions

– Proven to reduce complications and lead to better patient outcomes

– SEP-1 introduced October 2015

• All measures must be met to be compliant

SEP-1 Core Measure, continued

• Two main definitions of interest:

– Severe Sepsis

– Septic Shock

• Multiple criteria must align to “start the clock” for presentation time

• Provider documentation of severe sepsis or septic shock overrides criteria in most cases

Interventions

Processes

Code Sepsis

ED ID Project

Tools

Predictive Analytics

(EPIC tool)

Sepsis Screening Tool

Accountability

Facility sepsis meetings

Notification to RNs and

Providers

Failure Analysis Tool Development

Standardized tool to categorize misses and develop interventions

Operational definitions of categories defined

System and site lead both categorize misses and compare results

Interventions reviewed monthly

MonthPatient

ID Who What Why When Where How [to fix] Additional Comment

December APRN Late IVF A ED/ICU

STAR technique. Additionally

removing 250ml bolus from

standing orders will decrease the need to

recalculate the total fluid amount

ED NP saw a "bolus" was ordered and then ordered additional amount to meet total 30mL/kg bolus requirement. First bolus however was only 250mL, not 1L.

December MDwrong abx A ED Order sets

MD dx sepsis. Ordered abx to cover intra-abdominal infx however these abx don't meet SEP-1 guidelines

December MDinitial lactate UA ED

heightened awareness of

infection criteria

Criteria met: HR, RR, Cr, perf bowel. Additional note, IP ordered lactate however it was ordered as routine 0400

0

20

40

60

80

100

120

DI LOHT A UA O DI LOHT A UA O DI LOHT A UA O DI LOHT A UA O DI LOHT A UA O

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NAH NBH NH NWCH SYSTEM

NHC System Sepsis Timeline

Noted Improvements

Jan17-Dec17*Norton System

Common Barriers: Bolus

Educate!

• Bolus only has to be initiated within 3 hours

• Lactate >=4 or 2 low BPs in 6 hour timeframe before or after time zero

Ideal Body Weight

Patient/decision maker can always refuse after appropriate provider

conversation

Focused exam can be completed after

initiation of bolus up to six hours after

presentation time

30mL/Kg IVF Bolus

Common Barriers: Repeat Lactate

Order sets – 2 lactates, second within 4 hours of

first

Exploring a reflex order if initial is

>2.0

Common Barriers: Documenting “Sepsis”

Show the dataGive the why

• Fixed payment based on DRGs

• Longer GMLOS for sepsis (compared to UTI, etc)

• Better representation of truly septic patients when officially coded and discharged

Common Barriers: Finding Your Champions

Ask for volunteers

Invest your time

Focus on high population areas

first

• ED, ICU, then IP and specialty services

• Don’t turn away any engagement!

Future Implications

Mentoring Leaders

Celebrating successes

Recognizing unique contributions

Improve accountability

References

• CMS Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-18 through 06-30-18, manual version 5.3

• Santistevan, Jamie (2016). Sepsis CMS Core Measure (SEP-1) Highlights. American College of Emergency Physicians. www.acep.org