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Surviving Sepsis: How Health IT Saves One Life Per Week

Session #272, February 14, 2019

Devin Horton, MD, Hospitalist and Assistant ProfessorMatt Sanford, MBA, Senior Value Engineer

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Devin Horton, MD

Matt Sanford, MBA

Have no real or apparent conflicts of interest to report.

Conflict of Interest

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• About University of Utah Health

• Understanding sepsis and why it’s a challenge for every

hospital

• Background on our approach using Lean Six Sigma

principles and process mapping

• How we measured before and after to determine effect

• The results, including how we reduced sepsis mortality rate

for patients with MEWS Scores 7-11 by 20%, costs by 10%

Agenda

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• Explain why sepsis poses a unique challenge to hospitals and the

imperative to improve the way it is recognized and treated

• Define the process and resources required to successfully

redefine sepsis recognition and treatment workflows hospital-wide

• Demonstrate how your EHR and communication technology can

leverage interoperability to deliver sepsis alerts to the right

caregivers

• Illustrate the real-world results University of Utah Health was able

to accomplish and apply them at your own organization

Learning Objectives

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About University of Utah Health

• Located in Salt Lake City

• 4 hospitals

• 10 community clinics

• 1,400 physicians

• 5,000 employees

• 200+ specialties

• Epic EHR

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Value Equation

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Value Stream: A Siloed Perspective

Wait

Wait

Wait

Pro

cess C

Pro

cess A

Pro

cess B

Pro

ce

ss F

Pro

cess E

Pro

cess H

Pro

cess G

Pro

cess D

Wait Wait

Wait Wait

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Patient’s Perspective Value Stream

Pro

cess A

Pro

cess B

Pro

ce

ss F

Pro

cess E

Pro

ce

ss H

Pro

cess G

Pro

cess C

Pro

ce

ss D

Patient’s Value Stream

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Value Stream Assignment

10TRUE NORTH = Perfection

Quality Improvement ApproachWhy PDSA (Plan, Do, Study, Act)

Learning from informed action

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Top patient safety issue for virtually every hospital

1 in 3patients who die

while hospitalized

have sepsis

>250,000patient deaths each year

$24 billionspent annually on treatment

50%mortality rate for

septic shock

Keehan SP, Cuckler GA, Sisko AM, et al.

2015;34(8):1407-1417.

Liu V, Lei X, Prescott HC, Kipnis P, Iwashyna TJ, Escobar

GJ. 2014;9(8):502-507.

Understanding Sepsis

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Plan• Motivation

• Define the problem

• Get baseline data

• Build a team

Do• Design the project

• Education

• Implement change

Study• What is the effect?

• Feedback

Act• Change process to

address problems

• Implement changes

• Redefine scope

Plan Study

ActDo

Quality Improvement Approach

http://www.deming.org

Plan Study

ActDo

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Seeing decompensation throughout the

hospital

Realizing residents and sometimes providers

couldn’t define what they were seeing

ACP 2014

No process in place (no “campaign”)

Anecdotally seeing delay

Motivation

Plan Study

ActDo

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What is happening at

the U?

How does sepsis affect our mortality?

What is the gold standard for treatment?

How good are we at treating

sepsis?

Can our nurses and residents

recognize a patient with

sepsis?

Plan: Define the Problem

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Severe Sepsis is #1Cause of Death

#1

University of Utah

MortalitySepsis upon

Admission

Sepsis mortality

TransferredAffects all our

Patients

Phil Dellinger, ACP Internal Medicine 2014

Plan Study

ActDo

26%42%

46%

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Crit Care Med 2013; 41:580-637.

Measure lactate level

Obtain blood cultures prior to administration of antibiotics

Administer broad spectrum antibiotics

Administer 30 ml/kg crystalloid for hypotension or lactate ≥4 mmol/L

The administration of

effective intravenous

antimicrobials within the first

hour of recognition of septic

shock (grade 1B) and

severe sepsis without septic

shock (grade 1C) should be

the goal of therapy.

Gold Standard

Plan Study

ActDo

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0

5

10

15

20

25

30

AIM HCH HCICU MICU OTSS SICU SSTUABX

Ryan Bender, Josh Marr, Nathan Cook

University of Utah Health Average

9 Hours

LactateHours

AntibioticHours

IVF Bolus7.5 9.5

Plan Study

ActDo

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3.6

11.7

NURSES RESIDENTS

21 QUESTIONS | AVERAGE SCORE

Administered by Chief Medical Residents 2014-2015

Clinician Sepsis Knowledge

17%

56%

Plan Study

ActDo

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Physicians

Nursing

Education

Pharmacy

Information

Technology

Rapid Response

Team

Value Engineers

ARUP

Pulmonary Lab

Quality

Build a Team

Plan Study

ActDo

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Gemba = Japanese translated to “the real place”

Translated to English = Where the work happens

Going to the Gemba

Purpose

• Gain understanding of what actually happens

• Engage those doing the work

• Humble Inquiry = respect people

-Fujio Cho

Leaders must spend time on the

plant floor (not just walk through

or take a tour).

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Japanese for “actual place”

http://www.lean.org

HCA takes vital signs

Writes them down, sees next patient

Enters information into

Epic

Nurse sees abnormalities

Pages providerNurse waits for

responseProvider calls

backRN / MD

discussion

Orders lactate, fluids,

antibiotics

Pharmacy approval

Antibiotics sent Nurse

administration

GEMBAPlan Study

ActDo

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Difficult for hospital staff to identify early stages of sepsis

Step-intensive process with multiple opportunities for

human error

No forced function – no universally accepted threshold

ChallengesPlan Study

ActDo

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Plan• Motivation

• Define the problem

• Get baseline data

• Build a team

Do• Design the project

• Education

• Implement change

Study• What is the effect?

• Feedback

Act• Change process to

address problems

• Implement changes

• Redefine scope

Plan Study

ActDo

Quality Improvement Approach

http://www.deming.org

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Why Process Mapping

Steps in the processOwner

• Bring clarity to the entire value stream

• Define gap between current and future state

• Pinpoint origins of defects

Change in Ownership

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Early Stages

Plan Study

ActDo

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Final Process MapPlan Study

ActDo

9 different owners must

work in harmony for

recommended care

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Strong

Weak

Forced functions and constraints

Automation and computerization

“nudge to do the right thing”

Standardization and protocols

Checklists

Rules and policies

Education and information

“Be more careful”

https://www.ismp.org/newsletters/ambulatory/archives/200602_4.asp

Designing a System

Plan Study

ActDo

28Journal of Hospital Medicine pages S5-S10, 2 NOV 2016 DOI: 10.1002/jhm.2653

http://onlinelibrary.wiley.com/doi/10.1002/jhm.2653/full#jhm2653-fig-0001

Likelihood of death

or major post-

discharge morbidity

Capability for self-

care and likelihood

of preventing

deterioration using

limited therapies

Early Detection, Prevention, and Mitigation of Critical Illness Outside Intensive Care Settings

Plan Study

ActDo

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SIRS vs. mEWS

Developed using vital signs from nearly 35,000 patients

Evaluated test performance for mortality

Resuscitation 2010; 81(8): 932-937

Early Warning ScorePlan Study

ActDo

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Building the Intervention

PLA

N

STUD

Y

ACTDO

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0 1 2 3 4 5 6 7 8 9 10 11

mEWS Score

Distinct patients

450

400

350

300

250

200

150

100

50

0

Data analysis by Dan Findley, M.B.A.

Sept. 2015 to

Sept. 2016

In-hospital mortality

for patients at max

mEWS score

All patients had an

ICD-9/10 code for

sepsis

Developing Measurement Tools

Plan Study

ActDo

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Information

technology /

forced function

Reliable

communications

Education

Multi-faceted Approach

Plan Study

ActDo

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34

0

5

10

15

20

Nurses ResidentsPRE POST

60%56%

39%

CMRs 2015-2016

17%

Survey: Sepsis KnowledgePlan Study

ActDo

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Patient vitals entered in Epic

are outside normal range

Alert triggered, sent to the

primary team / rapid response

team’s device

Primary/Rapid response team

begins intervention right away

Nurse validates vitals and

elevated mEWS score

ABX

MEWS WorkflowPlan Study

ActDo

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Clinical Decision Support Advisory – Smith, Jane

You have entered vital signs that are concerning for the safety of

your patient; mEWS 5-7* Click ACCEPT if the vital signs you entered are correct. This will trigger an automatic page to

the Charge RN

* Click CANCEL to re-enter vital signs.

Send message: Send this advisory via in Basket

AcceptAccept CancelCancel

Clinical Decision Support

Plan Study

ActDo

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Plan• Motivation

• Define the problem

• Get baseline data

• Build a team

Do• Design the project

• Education

• Implement change

Study• What is the effect?

• Feedback

Act• Change process to

address problems

• Implement changes

• Redefine scope

Plan Study

ActDo

Quality Improvement Approach

http://www.deming.org

Plan Study

ActDo

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Data

SourcesData

Warehouse

Metadata

Data Marts

ETL

Epic

ADT

Lab

X-ray

Billing

Reporting & Analytics

Web Applications

Registries

CMS

Predictive Models

Data

Consumption

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RESULTS

OCT 2016 – SEPT

2017

Plan Study

ActDo

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Blood cultures, lactate → antibiotics within 3 hours

30 ml/kg IVF if hypotension/shock

Pressors if hypotensive after fluid

CMS measure for severe sepsis and septic shock:

Sepsis Early Management Bundle

Plan Study

ActDo

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Data analysis by Polina V. Kukhareva M.S., M.P.H.

Odds of septic patients receiving ABX in

the first 24 hours after SIRS increased

31 % (95% CI, 1% to 70%; p=0.041)

Length of stay decreased by

10%(95% CI, -14% to -5%; p<.001)

Total direct cost decreased by

10%(95% CI, -15% to -5%; p<.001)

After Adjusting for Covariates

Plan Study

ActDo

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Data analysis by Matt Sanford, M.B.A.

Ma

y

June

July

Augu

st

Septe

mb

er

Octo

be

r

No

ve

mbe

r

De

ce

mbe

r

Janu

ary

Feb

ruary

Ma

rch

April

Ma

y

June

July

Augu

st

Septe

mb

er

Octo

be

r

No

ve

mbe

r

De

ce

mbe

r

Janu

ary

Feb

ruary

Ma

rch

April

Ma

y

June

July

Augu

st

Septe

mb

er

Octo

be

r

No

ve

mbe

r

De

ce

mbe

r

Janu

ary

Feb

ruary

Ma

rch

April

Ma

y

June

July

Augu

st

2014 2015 2016 2017

Total Direct Cost of Sepsis MS-DRG Cases

Baseline Mean

Post Implementation Mean

= 10% decrease in cost

(does not include capacity)

Baseline = May 2014 to Sept 2015

Post-Implementation = May 2016 to July 2017

Baseline and Implementation Parameters

Plan Study

ActDo

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Plan• Motivation

• Define the problem

• Get baseline data

• Build a team

Do• Design the project

• Education

• Implement change

Study• What is the effect?

• Feedback

Act• Change process to

address problems

• Implement changes

• Redefine scope

Plan Study

ActDo

Quality Improvement Approach

http://www.deming.org

Plan Study

ActDo

Plan Study

ActDo

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PDSA Cycles: mEWS of 7+ Mortality

ResultsPlan Study

ActDo

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Decrease in length of stay

Decrease in direct costs

Decrease in mortality rate for elevated MEWS scores

Results

10%

10%

20%

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Continued PDSA Cycles

ED version

2.0

Modify trigger

thresholds

Modify vital sign

thresholds

Blood cultures

helpful or not? Surgical

services

Modify RRT team and

cancer center

Modify snoozing capability

Plan Study

ActDo

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EHR + Clinical Communication

Plan Study

ActDo

Communication

Platform

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Educate your clinical organization on how to tap the potential

of your communication platform

Use your clinical platform to make your EHR better

Hardwire communication to automate notification and

speed response

Use multi-disciplinary teams to solve complex problems

Measure impact, adjust, and expand success throughout

the hospital

Communication and Improving Clinical Outcomes

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• Thanks for listening!

• Devin Horton, MD

• devin.horton@hsc.utah.edu• https://www.linkedin.com/in/devin-horton-2b219811b

• Matt Sanford, MBA

• matt.sanford@hsc.utah.edu• https://www.linkedin.com/in/matthewnsanford

• Please remember to complete online session evaluation.

Questions