Upload
others
View
23
Download
0
Embed Size (px)
Citation preview
© 2015 Lehigh Valley Health Network
LVHN Sepsis Quality Improvement Project
Matthew McCambridge, MD, MS
Chief Quality Officer
Don Levick, MD, MBA
Chief Medical Information Officer
2
LVHN Sepsis Quality Improvement
93 Providers30 Nurses12 Tech Partners 20 RRT 17 Physicians 14 Therapists (PT, OT, Speech)
119 Blood Products48 PRBCs 6 FFP 29 Platelets36 Cryoprecipitate
3
Reduce Sepsis MortalityThe Local Problem
4
Sepsis Quality Improvement
5
Sepsis Quality Improvement
238278 292
256 260
317 315
259
152
0.850.95 0.99
0.931.01
1.151.07
0.90 0.91
0
50
100
150
200
250
300
350
400
450
500
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
Q3 2013 (n=13,882)
Q4 2013 (n=13,833)
Q1 2014 (n=13,986)
Q2 2014 (n=13,817)
Q3 2014 (n=13,996)
Q4 2014 (n=14,032)
Q1 2015 (n=13,470)
Q2 2015 (n=13,578)
Jul/Aug 2015(n= 8,903)
# o
f P
atie
nts
Wh
o D
ied
Mo
rtal
ity
Ind
ex
LVHN*Mortality Index According to Calendar Year Quarter
Deaths Mortality Index LVHN Benchmark Linear (Mortality Index)
Numerator: Number of deaths observedDemoninator: Number of deaths expected according to UHC 2014 AMC Risk Adjustment Model *LVH-H data in not included
6
Sepsis Quality Improvement
7
Reduce Sepsis MortalityDesign and Implementation
8
Sepsis Quality Improvement Task Forces
PharmacyED Physicians & Residents
HospitalistsEnterprise Analytics
Pathology –Blood Bank
Internal Medicine
ED Nurse EMSLean & Quality
Education
PharmacyED Physicians & Residents
HospitalistsEnterprise Analytics
Clinical Quality
Infection Control
NursingSurgeons -
GeneralSPPI Pulmonary
Internal Medicine
Clinical Informatics
Non-Present on Admission Med/Surg/ICU▪ Rescuing▪ Resuscitation▪ Patients who develop sepsis in-house
Present on Admission ED ▪ Protocols▪ Order Sets ▪ Early Resuscitations
9
Sepsis Quality ImprovementPOA Sepsis Subcommittees
Pharmacy Physicians NursingEnterprise Analytics
Quality
Group 1 A▪ Physical & Operational Changes in the ED ▪ Flow Diagram, Sepsis Order Set▪ Lab/Pharmacy, Sepsis Response Team
Physicians Education Quality PCS
Group 1 B▪ Sepsis Education ▪ Transition of Care, Residents
Group 1 C▪ Reporting / Feedback
Physicians EMS Quality
Group 1 D▪ Education for EMS Staff for Pre-Hospital
Arrival
Nursing
Nursing
Physicians Quality PCS / PCM Quality
10
Sepsis Mortality Improvement Task ForceTimeline January 2016 through April 2016
1st Sepsis Task Force
Meeting
DEC 23
JAN 27
MAR 02
FEB 10
FEB 17
FEB 25
FEB 26
MAR 03
MAR 14
MAR 16
MAR 17
MAR 18
MAR 22
FEB 24
JAN 07
Begin Monthly Sepsis
Mortality Review
High Sepsis Mortality
Recognized
Design Sepsis Info
Graphic
BPA Planning Meeting
APR 06
APR 07
1st Non-POA Sepsis Sub-Committee
Meeting
1st POA Sepsis Sub-Committee
Meeting
Begin Weekly Sepsis
Rounding Education
2nd Non-POA Sepsis Sub-Committee
Meeting
Sepsis Order Set Planning
Meeting
Lab / Pharmacy Planning Meeting
Update Antibiotic List with
Pharmacy
2nd POA Sepsis Sub-Committee
Meeting
POA Reporting Feedback
Sub-Committee
Meeting
POA Operational Changes in ED, Order Set, Flow
Diagram, Labs, Task Force Sub-Committee
Meeting
POA Education
for EMS Staff for Pre-Hospital
Arrival Sub-Committee
Meeting
POA Sepsis Education,
TOC, Residents
Sub-Committee
Meeting
Sepsis Care Coordination Between ED / Inpatient
Units
Quarterly Sepsis Task
Force Meeting
11
Reduce Sepsis MortalityHow Healthcare Information Technology was Utilized
12
The Sepsis Pathway
Severe Sepsis Non-Invasive Protocol
SIRS + confirmed infection + one organ system dysfunction
2 LB IV30 cc/kg NSS over 1 – 3 hours
Blood CultureAntibiotics
Admit to ICUSepsis transition SmartText
13
Epic Sepsis Initiation Order Set
14
Epic Sepsis Initiation Order Set
15
Epic Sepsis Initiation Order Set
16
Epic Sepsis Initiation Order Set
17
Epic Sepsis Initiation Order Set
18
Reduce Sepsis MortalityLVHN Tableau Sepsis Reporting
LVHN Sepsis Clinical Analytics Model
▪ Use to monitor LVHN’s performance in managing patients with Sepsis
▪ Developed over 4 months
▪ Built in Tableau and fed by data from Epic EHR
▪ 79 different clinical metrics
▪ Model has over 5 million rows of data
▪ Design based on Best Evidence, reporting requirements, and ability to review data from many perspectives
▪ Can drill from Tableau down into actual Patient record in Epic EHR as relevant
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
LVHN Sepsis Clinical Analytics Model
28
Reduce Sepsis MortalityValue Derived
29
LVH Mortality Index
30
LVH Muhlenberg Mortality Index
31
LVH Sepsis Mortality
32
LVHN Muhlenberg Sepsis Mortality Index
33
LVHN Vizient Current Rankings – 2017 Q1
▪ Total inpatient 12th / 140 ▪ Post-surgical 11th / 140 ▪ Urology tied 1st / 135 ▪ OB tied 1st / 124▪ Gynecology tied 1st / 133▪ Gyn Onc tied 1st / 116▪ HIV tied 1st / 110 ▪ Burn 5th / 57 ▪ Cardiac Surgery 7th / 118 ▪ Medical Oncology 8th / 134
34
Reduce Sepsis MortalityWork in progress to make further improvements
35
Next Clinical Phase - Sepsis BPA for Hospital Acquired Sepsis
Next Phase for LVHN Sepsis care management
▪ Real-time Sepsis reporting
▪ EHR alert terminology update
36
Sepsis Best Practice AdvisoryInpatient Nurse BPA
Inpatient nurse BPA
▪ Alerts based on LVHN-developed, modified SIRS criteria
▪ Alerts at “File” of vital signs, or chart opening
▪ Algorithm hyperlink included
▪ Acknowledge Reasons assist in tracking compliance
37
Sepsis Best Practice AdvisoryInpatient Provider BPA
Inpatient provider BPA
▪ Alerts based on LVHN-developed, modified SIRS criteria
▪ Alerts at chart opening
▪ Algorithm hyperlink included
▪ Sepsis initiation order set automated to open
▪ Acknowledge reasons assist in tracking compliance
▪ Lock-out period to avoid over-alerting
38
Next Economic Phase - Linking Clinical with Claims Data
Sepsis Cohort Profile
▪ For the 253 patient/members who had a sepsis diagnosis in December 2016, 87 of them were in one of LVHN’s accountable care (at risk) contracts
▪ Some non-surprising highlights▪ 84 of these patient/members are classified as very high risk
▪ The PMPM for these members of $7,427 is extremely high
▪ This cohort had 343 ER visits
▪ There were 343 readmissions, with a 53% readmission rate per 1,000 members -extremely high
▪ 66 of these members are age 65+
▪ Summary on next slide - example patient cohort summary▪ Created with Epic EHR data loaded to Optum One where claims data was
integrated
▪ Detailed clinical and economic data about this patient/member cohort
▪ This type of analytics is critical to understand the underlying economics of providing care, especially in a world of value based purchasing where providers absorb risk
39
Initial Findings: Sepsis Clinical and Claims Summary
▪ Sepsis patients are clinically complex patients with multiple conditions:
▪ Very high risk stratification
▪ 95% of patients have chronic conditions, most prevalent chronic conditions include
– Diabetes, Ischemic Heart Disease, COPD, CHF and Hypertension
▪ 18% of members have no PCP continuity (No PCP visits in the past year)
▪ These complex patients can benefit from better care coordination with PCP involvement
▪ Largest cost drivers throughout the care continuum after the index admission are readmissions and skilled nursing care
▪ 32% of episodes result in readmission and 30% include Skilled Nursing Facility care
▪ Readmissions result from various clinical conditions with the largest contributors being cardiac, respiratory and gastrointestinal related conditions
▪ Most skilled nursing care is provided outside of LVHN so there is a need for better care coordination with these non-LVHN SNF’s
▪ There are Outmigration opportunities (care rendered outside of LVHN) for Sepsis patients after the index admission
▪ More care rendered inside LVHN would enable better care coordination between providers
▪ More effective care coordination should result in lower cost and improved clinical outcomes
40
Clinical and Claims Profile from Epic EHR and Optum
41
Pathway Overview Dashboard
▪ Reflects both reimbursement and associated cost pathways extended to Sepsis episode patients
Deeper insight into Sepsis care delivery throughout the continuum of care
42
Readmission Analysis Understanding Sepsis Readmissions
43
Triple Aim Drives LVHN Strategy and Goals
Berwick, D., Nolan, T., Whittington, J. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs 27:3.
LVHN Mission: We heal, comfort and care for the people of our community by providing advanced and compassionate health care of superior quality and value supported by education and clinical research.
Better Health, Better Care, Better Cost…