Improving Sepsis Management: A Plan to Reduce Time...
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UCL 0 50 100 150 200 250 300 350 10/2… 11/2… 12/3… 1/20/17 1/30/17 3/3/17 3/12/17 4/15/17 4/26/17 5/27/17 5/30/17 Minutes Date of sepsis event Min between ordering vanc and adm to pt in sepsis (non-POA) UCL 0 50 100 150 200 250 300 350 10/27/16 11/26/16 12/30/16 1/20/17 1/30/17 3/3/17 3/12/17 4/15/17 4/26/17 5/27/17 5/30/17 Minutes Date of sepsis event Min between ordering cefepime and adm to pt in sepsis (non-POA) Improving Sepsis Management: A Plan to Reduce Time to First Antibiotic Dose Amir Meiri, MD; Deb Whalen, MSN, MBA, APRN; Lisa Caruso, MD, MPH AIM • The goal of this hospital-wide initiative was to identify workflow issues to improve the timely recognition of sepsis on the medical floors (vs the ED), and improve system protocols to appropriately manage these patients since the literature demonstrates mortality benefits in timeliness of antibiotic administration • Since evidence shows a reduction in mortality with timely antibiotic administration, we set a goal to decrease average time to first antibiotics by 50% (from 2 to 1 hr) in patients on the medical services diagnosed with sepsis. METHODS: WORKFLOW ASSESSMENT • Real-time chart review of all cases identified as sepsis based on ICD coding occurring on inpatient medical teams (general medicine, hospitalist, family medicine) • Identify workflow for key stakeholders: primarily pharmacists and residents; and assess for target areas of improvement • Outcome measure: Time to first antibiotic dose • T0 = first documentation of fever > 100.4 deg F (38.0 deg C) and >2: HR>100, RR>20, SBP<90 • Process measures: • Time between initial documentation of vital sign changes and time when first abx order written • Time when Early Warning System Score (EWS) > 5 is identified • Time between abx order written and MAR documentation time of administration of first abx dose (surrogate for when abx given) • Balance measure: Inappropriate abx use – measure any change in adverse drug events related to antibiotic use through data extraction and chart review RESULTS THUS FAR • Time to abx administration varied between vancomycin and cefepime • Mean time to abx for cefepime: 72 min; vs vancomycin: 102 min • Stable use of sepsis order panel since go-live date 5/24/2017 • Potential association b/w ↓ in abx time after go-live of Sepsis Order Panel CONCLUSION & NEXT STEPS • There are many initiatives being implemented to improve sepsis mortality through reducing abx administration time to within 60 min of T0 • The Sepsis Order Panel is resident-driven, as medical providers must order the correct lab tests and antibiotics for patients • We will continue to improve utilization of the Sepsis Order Panel through an advertisement campaign using detailed flyers and educational conferences for sepsis (such as patient safety incident cases) • Measure utilization of the Order Panel and promote utilization by resource nurses • Targeted engagement with pharmacy and nursing to further reduce time between ordering antibiotics and their administration • Consider implementing a ”Code Sepsis” team to help further streamline workflow processes, include more interdisciplinary sepsis education among house staff, students, and nursing, and promoting utilization by resource nurses • Early Warning System (EWS) score pilot initiated 9/25/17 to target “at-risk” patients for developing sepsis, using real-time chart review by nursing to signal evaluation for infection by resource nurses and care team. BACKGROUND • Sepsis is a significant public health concern, accounting for more than $20 billion (5.2%) of total US hospitals costs in 2011. • In 2015, CMS added the SEP-1 Sepsis Core Measure and began penalization in October 2016, with the overall goal of decreasing mortality due to sepsis. • Evidence shows a mortality benefit in patients identified with sepsis who receive appropriate broad spectrum antibiotics within one hour of suspected new sepsis • At BMC, the mortality of patients who developed sepsis as inpatients varied greatly each month but was higher than the expected amount calculated, and as compared to all patients with sepsis (i.e. including those arriving in the ED with sepsis and those who developed sepsis in the hospital) • On the inpatient medical wards at BMC, a chart review and data analysis demonstrated that the time to first antibiotic administration was averaged at 2 hours using a time 0 of documentation of first vital sign change, which is 100% higher than what is recommended per recent guidelines. INTERVENTIONS • There were many workflow processes to target to help improve antibiotic administration time in patients suspected of developing sepsis on the wards • Multiple interventions were targeted, including: • New education modules for nursing regarding identification and documentation change in mental status (i.e. delirium) • New Sepsis Order Panel in Epic EHR • Campaign to advertise new Epic Order Panel – morning report sessions, flyers posted in all team rooms to educate residents, include in orientation materials, partner with resource nurses • PDSA to focus on utilization of new Order Panel • Order Panel included Sepsis identification education (SIRS, QSOFA), easy ordering of elements of the SEP-1 3-h bundle, including lactate, blood cultures, broad spectrum abx, and IVF all STAT POA = Present on arrival Medical Assistant -Obtains Vital Signs -EWS updated in Epic Floor Nurse -Note VS change -Assess mental status Intern -Assess patient -Order antibiotics -Order cultures Floor Nurse -Alert intern of VS change Pharmacy - Receive antibiotic order – “STAT” or “routine” Pharmacy - Approve abx and tube to patient floor Lab -Receive STAT blood cultures order - Draw labs Floor Nurse -Start antibiotics (after labs drawn) Resource nurse: -Notes changes in EWS - Works with floor nurse and intern to triage patient Top of Rx List Approved Pyxis Epic Order Bottom of Rx List STAT Routine Verified ID approval Tech preps Rx Delivered Pharmacist Workflow Sepsis Flyer Resident Workflow I chart: Mean 102.9 min with goal of ABX in under 60 min with 13/34 (38%) under 60 min. Order panel go live I chart: Mean time is 71.7 min with target under 60 min with 17/35 (49%) under 60 min. There are 3 special cause variation with one point outside UCL. Order panel go live 0 5 10 15 June July Aug Sept Utilization of Sepsis Order Panel
Transcript of Improving Sepsis Management: A Plan to Reduce Time...
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Improving Sepsis Management: A Plan to Reduce Time to First Antibiotic Dose
Amir Meiri, MD; Deb Whalen, MSN, MBA, APRN; Lisa Caruso, MD, MPH
AIM• The goal of this hospital-wide initiative was to identify workflow issues to improve the timely recognition of sepsis on the
medical floors (vs the ED), and improve system protocols to appropriately manage these patients since the literature demonstrates mortality benefits in timeliness of antibiotic administration
• Since evidence shows a reduction in mortality with timely antibiotic administration, we set a goal to decrease average time to first antibiotics by 50% (from 2 to 1 hr) in patients on the medical services diagnosed with sepsis.
METHODS: WORKFLOW ASSESSMENT• Real-time chart review of all cases identified as sepsis based on ICD coding
occurring on inpatient medical teams (general medicine, hospitalist, family medicine)
• Identify workflow for key stakeholders: primarily pharmacists and residents; and assess for target areas of improvement
• Outcome measure: Time to first antibiotic dose• T0 = first documentation of fever > 100.4 deg F (38.0 deg C) and >2:
HR>100, RR>20, SBP<90• Process measures:
• Time between initial documentation of vital sign changes and time when first abx order written
• Time when Early Warning System Score (EWS) > 5 is identified • Time between abx order written and MAR documentation time of
administration of first abx dose (surrogate for when abx given)• Balance measure: Inappropriate abx use – measure any change in adverse drug
events related to antibiotic use through data extraction and chart review
RESULTS THUS FAR• Time to abx administration varied between vancomycin and cefepime
• Mean time to abx for cefepime: 72 min; vs vancomycin: 102 min• Stable use of sepsis order panel since go-live date 5/24/2017• Potential association b/w ↓ in abx time after go-live of Sepsis Order Panel
CONCLUSION & NEXT STEPS• There are many initiatives being implemented to improve sepsis mortality through reducing abx administration time to within 60 min of T0• The Sepsis Order Panel is resident-driven, as medical providers must order the correct lab tests and antibiotics for patients
• We will continue to improve utilization of the Sepsis Order Panel through an advertisement campaign using detailed flyers and educational conferences for sepsis (such as patient safety incident cases)
• Measure utilization of the Order Panel and promote utilization by resource nurses• Targeted engagement with pharmacy and nursing to further reduce time between ordering antibiotics and their administration• Consider implementing a ”Code Sepsis” team to help further streamline workflow processes, include more interdisciplinary sepsis education among
house staff, students, and nursing, and promoting utilization by resource nurses• Early Warning System (EWS) score pilot initiated 9/25/17 to target “at-risk” patients for developing sepsis, using real-time chart review by nursing
to signal evaluation for infection by resource nurses and care team.
BACKGROUND • Sepsis is a significant public health concern, accounting for more than $20 billion (5.2%) of total
US hospitals costs in 2011. • In 2015, CMS added the SEP-1 Sepsis Core Measure and began penalization in October 2016, with
the overall goal of decreasing mortality due to sepsis. • Evidence shows a mortality benefit in patients identified with sepsis who receive appropriate broad
spectrum antibiotics within one hour of suspected new sepsis• At BMC, the mortality of patients who developed sepsis as inpatients varied greatly each month but
was higher than the expected amount calculated, and as compared to all patients with sepsis (i.e. including those arriving in the ED with sepsis and those who developed sepsis in the hospital)
• On the inpatient medical wards at BMC, a chart review and data analysis demonstrated that the time to first antibiotic administration was averaged at 2 hours using a time 0 of documentation of first vital sign change, which is 100% higher than what is recommended per recent guidelines.
INTERVENTIONS• There were many workflow processes to target to help improve antibiotic administration time in patients suspected of developing sepsis on the wards• Multiple interventions were targeted, including:
• New education modules for nursing regarding identification and documentation change in mental status (i.e. delirium)
• New Sepsis Order Panel in Epic EHR• Campaign to advertise new Epic Order Panel – morning report sessions, flyers posted in all team
rooms to educate residents, include in orientation materials, partner with resource nurses • PDSA to focus on utilization of new Order Panel
• Order Panel included Sepsis identification education (SIRS, QSOFA), easy ordering of elements of the SEP-1 3-h bundle, including lactate, blood cultures, broad spectrum abx, and IVF all STAT
POA = Present on arrival
Medical Assistant-Obtains Vital Signs-EWS updated in Epic
Floor Nurse-Note VS change-Assess mental status
Intern-Assess patient-Order antibiotics-Order cultures
Floor Nurse-Alert intern of VS change
Pharmacy - Receive antibiotic order – “STAT” or “routine”
Pharmacy- Approve abx and tube to patient floor
Lab-Receive STAT blood cultures order- Draw labs
Floor Nurse-Start antibiotics (after labs drawn) Resource nurse:
-Notes changes in EWS- Works with floor nurse and intern to triage patient
TopofRxList
Approved
Pyxis
Epic Order Bottom of
Rx List STATRoutine
VerifiedIDapproval
Tech preps RxDelivered
Pharmacist Workflow
Sepsis Flyer
Resident Workflow
I chart: Mean 102.9 min with goal of ABX in under 60 min with 13/34 (38%) under 60 min.
Order panel go live
I chart: Mean time is 71.7 min with target under 60 min with 17/35 (49%) under 60 min. There are 3 special cause variation with one point outside UCL.
Order panel go live
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UtilizationofSepsisOrderPanel
