UMMS Sepsis Program

June 2021 | Edition 1

NEWSLETTER

Dr. Tom Scalea

Physician in Chief

Shock Trauma

Sepsis Program

Executive Sponsor

For more information contact:

Dorsey Dowling, Program Facilitator | Dorsey.dowling@umm.edu

“We want to reiterate the magnitude of the problem. These

statistics represent individual patients that die.

We want to highlight the power of harnessing all of the

expertise available locally to hone down on this particular

disease.

We want to thank all the individuals at the UMMS

institutions for their past and future cooperation.

We want to highlight the need to use accurate data of the

highest quality and accuracy.

Buckle your seatbelts, here we go!!!”

Sepsis at UMMS hospitals remains a significant cause of mortality. In our first program

newsletter, we are highlighting our most recent efforts to identify barriers, compare practice and

improve processes. We believe we can make great strides by focusing on a consistent methods

for decreasing morbidity and mortality secondary to sepsis.

Three system subgroups have been formed to explore barriers and opportunities by:

establishing a better understanding of when and how clinician’s diagnose sepsis; a Tableau

Dashboard to aid interrogation of data for promoting timely antibiotic administration; and related

diagnostic processes aimed to reduce the time from blood culture order to bacterial identification

and antimicrobial susceptibility results. We will continue to grow our program and expand our

interventions as we continue to learn lessons from our efforts and establish shared expectations

for a system approach.

2

Tackling Sepsis

“Tackling the overall sepsis clinical

performance improvement initiative described

in this newsletter is in my opinion, one of the

most important tasks that falls under the

umbrella of clinical transformation for the

University of Maryland Medical System.”

UMMS hospitals treat about 10,000 patients each year with a

primary or secondary diagnosis of sepsis.

Our overall sepsis mortality rate is 10.2%, and

20.2% for severe sepsis and septic shock patients.

All of this tells us that we have real opportunity to limit the variability in the way that we

approach the care of patients with sepsis across the System, to ensure that we are

tracking our performance consistently and that overall, we are delivering the best possible

care to the patients who put their trust in us every day.

This effort focuses on diagnosing patients sooner, treating them more quickly and

responding to them faster when they develop evidence of decompensation in the

hospital. Those are three important cornerstones to UMMS’ effort to combat sepsis. If we

do those things effectively, we will be more successful and our patients will benefit.

As we progress further in this effort, we will memorialize our performance improvement

targets and incorporate them into the overall structure through which we evaluate the

performance of our senior executives and in fact our entire organization. This effort is

intended to literally put everyone's skin in the game of improving the quality of care our

patients receive.

These efforts are hopefully only the beginning of our trek toward improved care for sepsis

patients. We need to work more closely with our primary care, case management and

social work colleagues to ensure that the care our patients receive after their discharge

from our hospitals and prior to ever being admitted to one of our hospitals is focused on

limiting the impact of sepsis. All of this is part of our statewide effort to improve the health

of Maryland and in doing so, to limit the total cost of healthcare for all of our citizens.

It is a true privilege to work with the group of individuals engaged in this particular project

under the leadership of Dr. Scalea. I sincerely look forward to the improvement in quality

and patient safety that will result from these efforts.

Andrew N. Pollak, M.D.

Senior Vice President for

Clinical Transformation

& Chief of Orthopedics

The O:E mortality varies from 0.48 to 1.30 for hospitals within our system.

Our O:E for readmissions of patients whose initial discharge diagnosis

includes sepsis is 0.74 overall and varies from 0.48 to 0.96.

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Sepsis Program Development

Sepsis is a public health threat that

requires both population- and

system-based solutions

Sepsis represents a significant global risk to public health.

While the worldwide burden is difficult to ascertain, there are

over 48 million cases and 11 million sepsis-related deaths

each year, accounting for almost 20% of global deaths (1-3).

This life-threatening complication of infection remains the

leading cause of non-coronary deaths in ICUs and has an

overall case fatality rate that ranges from 10 to 50% depending

on patient factors and severity (2-3).

Approximately one half of all cases occur outside the ICU and

one quarter of patients die from sepsis at some point during

hospitalization (1-2). Hence, sepsis cannot be solely

conceptualized a s problem of individual patients in our

emergency departments and intensive care units.

Sam Galvagno, DO, PhD,

Physician Sponsor

We have made many strides towards reducing sepsis-related mortality in our healthcare

system. For known cases of sepsis, system-wide mortality has fallen from 14.3% to 10.2%

from 2016 to 2020. We have made significant progress regarding data analytics, early

antibiotic administration, early recognition, and definitive diagnosis. We still have more work

to do, especially given the unavoidable interruptions caused by the unprecedented COVID-19

pandemic. Moreover, as we have discovered with our work, the complexities of sepsis

preclude any one-size fits all policy.

In the past, I presented the sepsis work done at Intermountain Healthcare—an internationally

recognized organization that embarked upon a similar journey in 2005. Since that time,

Intermountain has made record strides in decreasing sepsis-related mortality across their

healthcare system. We believe we are well positioned to do the same! Our organized

approach is largely modeled after the Intermountain experience, and we believe that with

early identification, standardized evaluation, and rapid, consistent interventions, we too can

continue to decrease sepsis-related morbidity and mortality throughout our healthcare system.

We thank you for joining us on this important journey!

References:

(1) Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and

national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet

(London, England). 2020;395(10219):200-11.

(2) World Health Organization. WHO Report on the burden of endemic health care-associated infection

worldwide. 2017-11-21 15:11:22 2011.

(3) Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for

Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315(8): 801-10.

The primary objective

of our UMMS sepsis

program is to reduce

mortality by

consistently applying

evidence-based

interventions. Early

identification and

prompt treatment

remain cornerstones

for achieving our

desired clinical

outcomes.

4

Timely Antibiotic Administration

PAF Columns (added to Patient List):

Sepsis outcomes have improved over the years, however,

mortality still remains between 10-50%. Much of the work from

the Surviving Sepsis Campaign1 has focused on rapidity of

treatment once the diagnosis of sepsis has been made. One

element of the SSC guidance has been early antibiotic

administration. This is mainly due to a retrospective analysis by

Kumar, et al. that showed an average 7.6% decrease in mortality

for every hour there was a delay in receiving antibiotics after

onset of septic shock2.

Other studies have also shown benefit of timely antibiotic

administration3,4. It is important to note that many of the available

studies are retrospective and difficult to delineate confounding

factors such as patient complexity, time to identification, etc.

Overall, it is recognized and agreed that timely antibiotic

administration from the time the order is placed is beneficial

References:

1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for

management of sepsis and septic shock. Crit Care Med. 2017;45(3):486-552.

2. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial

therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596.

3. Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis

and septic shock from the first hour: results from a guideline-based performance improvement

program. Crit Care Med. 2014;42(8):1749-1755.

4. Gaieski, DF, Mikkelsen, ME, Band, RA, et al. Impact of time to antibiotics on survival in patients with

severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency

department. Crit Care Med. 2010;38(4):1045-1053.

Given the above, the Timely Antibiotic Workgroup has released a Tableau Dashboard as a

tool to stimulate discussion and help our site hospitals be able to accurately measure time

from antibiotic order to time of administration.

ACTION PLANNING

From June, local sepsis committees will use it to help investigate why there may be delays in

administration in <60 min. from the time of order. They will be asked to draft action plans for

submission at the end of August. At that point we will collect baseline data for internal,

quarterly comparison. From September, we hope these plan will help to drive improvements

that will meaningfully impact patient care as we begin to set nursing and provider performance

measures for 2022.

We thank all the members of the Data Analytics and Quality Business Intelligence Teams that

developed the dashboard through validation and production.

Antibiotics are an important part of sepsis management. Overall, this is one portion in the

much larger work that the Sepsis Program is focusing on to provide meaningful positive

impacts on the care of our patients.

Mary Ghaffari, PharmD.

Sub-Group Lead

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Timely Abx Administration Dashboard

On 13 May 2021, the Timely

Antibiotic Dashboard that

was launched as an

investigative tool to inform

process improvements that

will remove barriers to

antibiotic administration.

The following is a brief illustration of the four main tabs within the dashboard. Users can

filter tabs by facility, department, transfer status and arriving by ED, if the diagnosis included

“severe/shock”, and whether the medication was available in the automated dispensing

cabinet or was delivered by pharmacy, etc.

Please contact Samantha Wilkes: Samantha.wilkes@umm.edu if you would like to request

access to the dashboard. We encourage users to be contributors to their local sepsis

committees and contribute to the investigations and action planning for improvements.

Samantha Wilkes

Quality Sr BI Analyst

Mike Sokolow

Sr Dir BI & Quality Mangt

Time Trend Tab 1: Allows you to see the percentage of medications

that were given within each time bucket from time of order placed by facility.

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Timely Abx Administration Dashboard Cont.

Compliance Tab:

Allows you to see the

breakdown of total numbers

and percent within targeted

time frame verses not meeting

target.

Case Details Tab:Allows you to see the

breakdown of Medication by

Time Bucket and ability to

drill down to the see

encounter details.

Indication tab: Allows you to see which

antibiotics are being

administered and the

indication chosen. This will

help in determining

appropriateness of the

antibiotic choice, if particular

antibiotics are more commonly

seen in not meeting target, etc.

Sepsis Dashboard Wiki page

http://mrxlate.umm.edu/w/index.php5/Sepsis_Timely

_Antibiotics_Dashboard

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Infection Management

As we move forward with standardization of timely care delivery for sepsis, we

are prioritizing the development and implementation of a unified definition of

sepsis across our medical system in all domains.

We have brought together a team of hospitalists, intensivists, and emergency

medicine physicians to draft a proposed sepsis definition after a thorough analysis of

the available supporting evidence. We are leveraging the expertise of our quality,

clinical documentation, coding, and finance teams to understand downstream

implications.

Concurrently, we will be partnering with a clinical research team at UMMC to survey

our medical staff to gain insights into the practice variation in the clinical definitions

of sepsis that are being utilized at the individual physician-level.

A shared definition of sepsis will enable us to obtain a deep

understanding of the impact of our current sepsis processes and

programs throughout UMMS. This understanding will inform the next

steps in getting the most effective sepsis care to each of our patients at

the most appropriate time.

Jason Heavner, MD

Subgroup Lead

Early diagnosis and intervention is paramount to achieving

successful sepsis outcomes. Despite the significant

contribution that sepsis has on morbidity, mortality, and critical

care resource utilization, there is notable variation in the

diagnosis of sepsis across UMMS—a 2-fold difference in

diagnosis rate ranging across our hospitals. This rate of sepsis

diagnosis varies provider-to-provider, department-to-

department, and hospital-to-hospital. Standardization of

diagnostic criteria is further complicated by the varying criteria

used for core measures, the MHAC program, and other quality

metrics and reporting requirements around sepsis.

A Shared Definition of Sepsis

8

Sepsis Survey Overview

Prompt and appropriate diagnosis of sepsis can be challenging as multiple definitions have

been used over the years and patients’ presentations vary. Timely recognition and initial

interventions are critical for good outcomes as well as meeting quality metrics. To move

forward with an initiative to improve consistency of sepsis diagnosis and management, an

understanding of current approaches across different specialties (emergency physicians,

intensivists, hospitalists, advanced practice providers), locations (Emergency Department,

Intensive Care Units, Medical floors), and hospitals would help.

Consequently, we have designed a survey to evaluate provider understanding of sepsis

definitions and current practices regarding the initial diagnosis and interventions for patients

with sepsis.

The project will involve 2 separate surveys.

1.

2.

Sam Tisherman, MD

We will conduct interviews using a qualitative questionnaire with experienced

emergency physicians, intensivists, hospitalists, and advanced practice providers

to understand their definition(s) of sepsis, describe the findings (symptoms, signs,

laboratory values) that key them into the diagnosis of sepsis, and describe the

interventions they initiate once sepsis has been identified. Participants from all

UMMS hospitals will be recruited.

The themes in behaviors and practices identified in this qualitative survey will be

utilized for a subsequent web-based survey in which participants will be asked

for their responses to a variety of clinical situations. The participants will include

physicians, fellows, residents, and advanced practice providers from Emergency

Departments, ICUs, and medical floor services across all UMMS hospitals.

The information gained from these surveys will

serve as a baseline for current understanding and

practice that would aid in implementing strategies

for improving the initial recognition and management

of sepsis.

9

Sepsis Diagnostics

Despite decades of research and advancements in

sepsis pathophysiology, there has been little progress

in developing diagnostic tests which differentiate sepsis

from non-sepsis syndromes.

The Sepsis Diagnostics Sub Group aims to define the

standard for sepsis diagnostics at UMMS. Our initial

focus is on rapid diagnostics for blood cultures

(bacterial identification and antimicrobial susceptibility).

We are currently in a Discovery stage on potential

Cerner reporting options for capturing lab turnaround

times from ordering to result.

We have also been collaborating with Antimicrobial

Stewardship Teams to standardize an algorithm for

treatment and related processing, recording, and

reporting test results.

From those recommendations,

we are outlining education

requirements for local

physicians on the optimal

utilization of results with this

new algorithm for treatment.

Wisna Jean, MD

Kristie Johnson, PhD

Co-Leads Our goals are to decrease time to organism/

resistance identification leading to a decrease

in unnecessary/ inappropriate use of broad-

spectrum antibiotics; foster a timelier

interpretation and action on rapid diagnostic

testing; and promote favorable patient

outcomes and quality metrics.

Reference for picture:

Messacar K, et al. J Clin Microbiol. 2017 Mar;55(3):715-723

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System Sepsis Program Structure

For more information contact:

Dorsey Dowling, Program Facilitator | Dorsey.dowling@umm.edu