SEPSIS - AN INSTITUTIONAL PRIORITY

PEGGY CUSACK, RN, BSNDIRECTOR OF NURSING, CRITICAL CARE

NORA CATIPON, RN, MSN, GNP-BC, CRITICAL CARE

POMONA VALLEY HOSPITAL MEDICAL CENTER

CRITICAL CARE VOLUMECRITICAL CARE VOLUME

1,660 1,750 1,809 1,902

2,333

805

2,228

2,483

29.0%

16%

19%21%

16%19%

14% 15%

-

500

1,000

1,500

2,000

2,500

3,000

2003 2004 2005 2006 2007 2008 2009 2010

Disc

harg

es

0%

5%

10%

15%

20%

25%

30%

35%

% o

f Tot

al

CRIT CARE DSCH % OF TOTAL ADULT ACUTE DSCH (excl Deliveries)

LOOK AT THE POPULATION YOU SERVE

• Checked out the top five admission diagnosis for Critical Care– Respiratory Failure– Sepsis– Pneumonia

CURRENT STATEPayor Mix

DISTRIBUTION OF SERVICE BY TYPE OF INSURANCE

18%MEDICARE

36%MEDICAL

29%CONTRACT

17%OTHER

● Hospital cost for patients with severe sepsis are 162% higher than any other diagnosis

● The challenges of flow of patients and bed availability ~ ICU beds costly

MANAGEMENT OF SEPSIS……WHY IS IT SO IMPORTANT ?

• Severe sepsis ~ leading cause of death / non-coronary ICU

• Effects 10% of all ICU patients

• Substantial burden on hospital resources and represents a significant portion of our increased mortality, high ventilator usage, and long LOS

MANAGEMENT OF SEPSISWHY IS IT SO IMPORTANT ?

● Limited Resources■ Where could we reap the most benefit from a

EVIDENCE BASE PRACTICE / BEST PRACTICE initiative

■ What is reported to the public ~ insurance companies ?

♦ Hospital and ICU Mortality Rates ● 2007 ~ 25% = Diagnosis of Severe Sepsis

■ Case Mix Index 4.6 ■ Ave ICU LOS 9.86■ Total Hospital Ave. LOS 20.0

CalHospitalCompare.org

BRAINSTORMING

BUILDING A BUSINESS PLAN• VISION

– Provide cost effective, quality care

– Recognized as “Center for Excellence”

• CURRENT STATE – Critical Care ~ 20%

increase in vol. – ALOS in I.C.U. 4.6 days – ICU patients frequently

held in E.D.

• CHALLENGES – Address bed

availability– Reduce ALOS – Improve ability to meet

increased census demands

– Recruitment and retention of BEST nurses and physicians

BUSINESS STRATEGIES• INITATIVE

– Sepsis program• OPPORTUNITY

– Strengthen ED & ICU bond/teamwork

– Build a stronger relationship among our physicians

• RISK– Loss of support by

the team members • SUMMARY

– Improve patient care / outcomes

– Maintain profit margin

– Manage overcapacity issues

– Standardize care for severe sepsis patients

POTENTIAL SAVINGS

DECREASE ICU ALOS300 patients

Days saved

Cost savings

.25 DAYS 75 $42,000

.50 DAYS 150 $84,000

DECREASE HOSP ALOS

1.00 DAYS 300 $600,000

YEAR PTS CMI HOSPALOS DAYS

ACTUAL MORTALITY RATE

PRED. MORTALITY RATE

2007 567 4.6 20.0 32.6% 31.5%

2008 608 4.3 14.91 28.1% 31.2%

2009 735 4.0 12.76 19% 30.8%2010 316 4.1 14.47 20% 27.6%

MORTALITY RATES HOSPITAL LENGTH OF STAY 38.6%

REDUCTION

28% REDUCATION IN HOSP. ALOS

DEVELOPMENT• Heightened focus in 2007 at POMONA VALLEY

HOSPITAL MEDICAL CENTER to reduce mortality rate of 32.6% and ICU length of stay of 9.86 days

• ICU Physician champion and ICU nurse practitioner appointed to spearhead the project

• Formed a project leadership team – ED and ICU staff nurses, physician champion, ICU NP and ED CNS, added an ED physician champion

IMPLEMENTATION

• Standardized treatment of sepsis based on evidence-based guidelines: a) to include 6 – hour resuscitation bundle and 24 - hour management bundle, b) bed side tools: sepsis screening tools, checklists, pocket guides, remindersc) new central line cart placed in ED

SEPSISBUNDLE CHECK-LIST

Sepsis Order Set6- Hour Bundle

Page 1 of 3Page 2 of 3

Sepsis Order Set

6- 24 Hour Bundle

Page 3 of 3

Sepsis Screening tools

IMPLEMENTATION …• “GOLD ALERT”- initiated in the ED - July 2009 ♦ Focus - foster early treatment and teamwork across departments, with the single goal of improved care for the most vulnerable patients♦ A timeline algorithm that incorporates the components of the EGDT –key focus is timed sensitive interventions♦ EGDT will improve outcomes by saving lives, reduce length of stay, complication rates, and overall improve patients outcome♦ Goal is to transfer patient to the ICU in less than 5 hours

GOLD ALERT ALGORITHM

IMPLEMENTATION …….

• ED RN to initiate the screening tool for sepsis • Identification of severe sepsis in the ED, begin

the implementation of the 6-hour bundle, ED physician to insert the central line and initiate the first set of severe sepsis orders

• ED checklist consists of the 6 hour bundle components to be initiated by ED RN

RN to complete checklist Clerical associate to complete checklist

IMPLEMENTATION…..

• Rapid response team members FCCS certified, trained on sepsis screening; a daily print out of all lactic acid results on adult in-house patients, collected and reviewed; lactic acid algorithm created to aid in screening for bedside nurses

• Lactic acid algorithm

“GOLD ALERT”…ED BARRIERS

■ LACK OF NURSING STAFFProbability of an immediately available team to assume the care of the patient requiring Early Goal Directed Therapy (EGDT)

▪ Time & resource intensive protocol▪ Effect on ED throughput, which was

already overwhelmed▪ Development of the “Gold Alert”

“GOLD ALERT”…ED BARRIERS

EQUIPMENT ▪ Limited number of monitors with CVP

capability in the ED

▪ Use of the Central Line Cart in the ED,

▪ Need for monitoring CVP in the ED

“GOLD ALERT”…ED BARRIERS

■ Awareness that the Sepsis Order Set existed and how its use could help impact care of septic patients

■ Timely Edwards Catheter (PreSep) insertion

OTHER BARRIERS

• ED and ICU combined committee was a challenge

• No extra resources for sepsis , like for MI • Sepsis is not seen as an emergency like MI• ED does not see the mortality of sepsis• Physicians take ownership of patients

in the ED for short term

“GOLD ALERT”…STRATEGIES

• SECOND WAVE of EDUCATION- 2 hours didactic

class- Hand-on training on

CVP measurement- Shift to shift

huddles

• GOLD ALERT” ICU clinical support and coaching of bedside ED RN – assist CVP set up and monitoring; available resource 24/7

GOLD ALERT CALLS

22

17

13

1110

19

17

15

13

11

9

18

5

2

0 01 1

0

5

10

15

20

25

July August September October November December

YEAR 2009

NO

. OF

PATI

ENTS

Gold Alerts AnnouncedActual Gold AlertsGold Alert Fall-Outs

1214

9

13

17

24

0

5

10

15

20

25

30

Janu

aryFeb

ruary

March

April

May

June

YEAR 2010

NUM

BER

OF

PATI

ENTS

Gold Alerts Called *Gold Alert Fall-Outs

RESUSCITATION BUNDLE ON ALL GOLD ALERT PATIENTS

90 93

75

8593 96

7568 67

63

79 78

48

35

09

20

35

0

10

20

30

40

50

60

70

80

90

100

Jan-10 Feb-10 Mar-10MONTHS

PER

CEN

TAG

E

Serum lactate within 6 Hrs

Blood Culture beforeAntibiotics

Antibiotic Compliance

Fluids and Vasopressors forhypotension or elevatedlactateCVP>=8mm Hg within 6 Hrsfor shock or elevated lactate

ScvO2>=70% or SvO2>=65%within 6 Hrs for shock orelevated lactate

OVERALL COMPLIANCE AND MORTALITY OF ALL GOLD ALERT

PATIENTS

10

25

50 0

3526

815

01020304050

60708090

100

Jan-10 Feb-10 Mar-10MONTHS

PER

CEN

TAG

E

Resuscitation Bundle Management Bundle Mortality

MEDIAN TIME TO QUALITY INDICATORS

1.2 0.75 1.21.6 2 2

4.7 4.7 4.45

11.7

6.8 6.77.1

11

8.8

0123456789

10111213

Jan-10 Feb-10 Mar-10

MONTHS

HO

UR

S

Serum lactate measured

Antibiotics administered

CVP>=8mm Hg achieved

ScvO2>=70% or SvO2>=65%achieved

Low Dose SteroidsAdministered

Mortality Rates32.6%

28.1%

Sepsis Volume - ICU

KEYS TO SUCCESS

● Leadership, team collaboration, innovative thinking, and systems management are needed

● Clinical resources available everyday on all shifts 24/7 in the management sepsis

– ED nurses and physician – ICU nurses and Intensivists– RRT

BENEFITS

• 173 LIVES SAVED• HOSPITAL ALOS DOWN BY 7.24• ICU ALOS DOWN by 3.25 DAYS• DECREASE WAIT TIMES IN ED• SEPSIS MORTALITY RATES DOWN BY

39%• ICU MORTALITY RATES DOWN BY 18% • TOTAL COST SAVING OF 7.5 MILLION

TEAM COLLABORATIONTEAM COLLABORATION

NEW IDEAS ~ CONTINUE TO REFINE PROCESS & DEVELOP STAFF

NEW IDEAS ~ CONTINUE TO REFINE PROCESS & DEVELOP STAFF