Inpatient Sepsis Provincial Toolkit and Strategy

February 25th, 2015

BC Patient Safety and Quality Council

Dr. David Sweet MD FRCP(C) Critical Care and Emergency Medicine Sepsis Clinical Lead

WHY?

• Severe sepsis and septic shock in adults have a mortality rate of 25 percent. Many of these deaths are preventable.

• More patients die from sepsis than prostate cancer, breast cancer and HIV/AIDS combined.

Finfer S, Bellomo R, Lipman J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Medicine 2004; 30:589–596.

Czura CJ Merinoff Symposium 2010: sepsis – speaking with one voice. Molecular Medicine; 2011; 17:1-2, 2-3.

World Sepsis Day Organisation [internet] 2014. [cited 2014,March 31] Available from: http://www.world-sepsis- day.org/

DATA COLLECTION

Results: Collaborative-Wide

UCL

123.2 CL

74.5

LCL

62.4

72.4

82.4

92.4

102.4

112.4

122.4

132.4

142.4

152.4

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Min

ute

s t

o G

oal

Patients in order of arrival to ED in 2010 (each point is median taken from 50 patients, chart n=1,300)

Goal 1: < 90 Minutes to Fluid Bolus

UCL

121.5 CL

90.8

60.1

35.9

55.9

75.9

95.9

115.9

135.9

155.9

175.9

195.9

215.9

235.9

A C E G I K M O Q S U W Y AA AC AE

Min

ute

s t

o G

oal

Patients in order of arrival to ED in 2010 (each point is median taken from 50 patients, chart n= 1,550)

Goal 2: < 60 Minutes to ABx

BC Sepsis Network

The BC Sepsis Network was established in June 2011

The network has 257 members.

1) share resources

2) improve consistency of care

3) spread innovation and improvement ideas

4) and collaborate on change.

VISION

Stop unnecessary sepsis deaths. ‘Best Care, No Matter Where’

GOAL

We will reduce sepsis mortality rates throughout BC by identifying sepsis patients early, using best clinical practices, and achieving seamless transitions of care.

UCL

LCL 0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

12

/13

P1

P2

P3

P4

P5

P6

P7

P8

P9

P1

0

P1

1

P1

2

P1

3

13

/14

P1

P2

P3

P4

P5

P6

P7

P8

P9

P1

0

P1

1

P1

2

P1

3

14

/15

P1

P2

P3

P4

P5

P6

P7

P8

P9

P1

0

P1

1

P1

2

P1

3

Fraser Health 150 Lives Campaign: (Oct–Mar)

Sepsis Mortality – severe sepsis

Why In-Patient Sepsis?

WHY?

• Appropriate recognition and timely management of patients with severe infection and sepsis is a significant problem in health care facilities. Delayed treatment is associated with high mortality rates, significant morbidity and high costs to the health care system.

NSW Sepsis Kills In-Patient Program Implementation Guide 2014

WHY?

• In the complex hospital ward environment there are frequently long delays between medical review and antibiotic prescription particularly when decision making is by junior medical staff.

Australasian Resuscitation in Sepsis Evaluation (ARISE) Investigators and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) Management Committee. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Critical Care and Resuscitation 2007; 9:8-18.

May lead to at least 1 life being saved for every 7 patients treated for severe sepsis and septic shock.

217 patients

BC Provincial In-Hospital Sepsis Project

Step One

In- Hospital Sepsis Interest Group 5 Health Authorities

Nurses, Administrators Doctors ER/ICU/IM/ID/Microbio/Peds/GPs

Over 50 members

Trial Documents

BC Sepsis Inpatient Pilot Project

In- Hospital Sepsis Pilot Teams

Kelowna General Hospital

Lions Gate Hospital

West Coast General

Vancouver General Hospital

BC Children’s Hospital

Surrey Memorial Hospital

St. Paul’s Hospital

Identifying and Responding to Sepsis

Presentation Based on the work done by: Dr. David Sweet and colleagues from: BC Patient Safety & Quality Council and VGH Sepsis Working Team: Dr. Sweet, Doris Bohl, Leighanne MacKenzie, Dr. Mackenzie-Feder, Jenifer Tabamo, Alison Beaty, Suzanne Miller, Dr. Yousefi

Inpatient Learning Module

Audit Forms

Number of Sepsis Cases n=24 Figure 1

• Identified Cases: n=15

• No PPO: n=4

• Missed Cases: n=5

20

21

Values based on

documentation of initial

SIRS symptoms

Identified with PPO

Used

N=15

Identified and no PPO

N=4 Missed Cases

N=5

% Lactate Ordered

100 50 20

% Blood cultures

ordered

73 25 20

% IV Fluids ordered

73 100 40

% Antibiotics ordered

93 75 100

% BC done before

antibiotics

100 25 20

Average time to call

doctor

17 min Unknown 11.5 hours

Average time for

doctor to return call

15 min Unknown4 15 min

Time to obtain lactate

specimen

49 min (average)

Range: 20-150 min

20 min (average)

Range: 1-40 min n=2

8 hours

Range: 8 hours

Time to obtain blood

cultures

40 min (average)

Range: 20-90 min

2.5 hours

Range 1-4 hours

12 hours

Range: 9-15 hours

Time to initiate fluids 23 min (average)

Range: 1-80 min

105 min

Range: 30-180 min

9 hours

Range 8-10 hours

Time to administer

first dose antibiotics

55 min (average)

Range: 10-150 min

Unknown4 12.3 hours

Range 9-18 hours

Sepsis Pilot Data KGH LGH SMH SPH VGH

Timeframe of pilot (weeks) 8 36 7 24 40

# of cases reviewed 16 20 1 20 24

# of SIRS cases identified with algorithm 15 11 1 NA2 19

# of cases with PPO used 4 4 0 3 15

# of cases with PPO missed NA1 16 1 17 5

1No data available.

2 SPH MEWS tool when used and completed is 100% effective in identifying SIRS. 3 VGH median time of 0:49. 4 SPH does not report on 30min time goal for lactate but use 3 hour time goal instead. 5 SMH physician response reported as immediate. 6 SPH physician response time not obtainable (no way to measure).

Mean time to lactate from SIRS ID 1:30 1:15 0:18 14:12 0:403

% of cases met 30min time goal for lactate 17% 55% 100% 10%4 25%

Mean time to IV antibiotics 2:30 2:05 0:30 16:12 0:55

Mean physician response time from SIRS ID 0:14 0:40 NA5 NA6 0:15

Pilot Sepsis Missed Cases

Most common reason(s) for missed case(s): • LGH: Not recognized. • SMH: Physician did not want to use PPO • VGH: Nurse did not recognize early warning signs. Nurse

usually gave Tylenol when patient had an elevated temp. and other signs, and masked the sepsis.

Outcome for patient(s) with missed case(s): • LGH: 8 to ICU, 1 to OR, 1 stayed on unit, 1 death. • SPH: Discharged home. • VGH: 1 patient transferred to ICU, survived, and went

home. Other 4 patients were treated on the unit, survived, and either went home or discharged to lower level of care.

Survey Results

Algorithm / Screening Tool Strongly Agree

Agree

Easy to understand 3 3

Helps clinicians identify sepsis 4 2

Feedback from clinicians has been positive 2 4

Early Sepsis Investigation & Treatment PPO Strongly Agree

Agree

Easy to understand 3 3

Helps clinicians treat and manage 4 2

Feedback from clinicians has been positive 2 4

Inpatient Sepsis Provincial Toolkit and Strategy

Working Day

November 25th, 2015

BC Patient Safety and Quality Council

VGH

• January 2016: Implementation to rest of

Medicine Units: T10CH, T11AD and T14G

(CTU wards), and trial to 2 Surgical Units:

T8AB and T9AB

• January-February 2016: Sepsis Education

CTU wards

• February 22, 2016: Go-live Date CTU wards

27

Future

• Completion of “In-Patient Sepsis Tool/PPO Implementation Guide/Package”

• Completion of online e-learning module for in-patient sepsis to assist in implementation/education

• Approach and support hospitals around the province in implementation

• Design provincial QA/QI metrics to assist in further improvement

Thank You

WHY?

WHY?

WHY?

WHY?

WHY?

WHY?

• Severe sepsis and septic shock in adults have a mortality rate of 25 percent. In pediatric patients, sepsis is the leading causes of death with mortality rates as high as 10 percent. Many of these deaths are preventable.

• More patients die from sepsis than prostate cancer, breast cancer and HIV/AIDS combined.

Finfer S, Bellomo R, Lipman J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Medicine 2004; 30:589–596. Czura CJ Merinoff Symposium 2010: sepsis – speaking with one voice. Molecular Medicine; 2011; 17:1-2, 2-3. World Sepsis Day Organisation [internet] 2014. [cited 2014,March 31] Available from: http://www.world-sepsis- day.org/

WHY?

• Appropriate recognition and timely management of patients with severe infection and sepsis is a significant problem in health care facilities. Delayed treatment is associated with high mortality rates, significant morbidity and high costs to the health care system.

NSW Sepsis Kills In-Patient Program Implementation Guide 2014

WHY?

• In the complex hospital ward environment there are frequently long delays between medical review and antibiotic prescription particularly when decision making is by junior medical staff.

Australasian Resuscitation in Sepsis Evaluation (ARISE) Investigators and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) Management Committee. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Critical Care and Resuscitation 2007; 9:8-18.

May lead to at least 1 life being saved for every 7 patients treated for severe sepsis and septic shock.

217 patients

WHY?

• In single site study in Hustville Alabama the implementation of an alerting and change management system were associated with a 53% drop in sepsis mortality.

• In relative terms, the mortality rate fell from 9% to 4.2% (P value = .03; 95% confidence interval, 1.06 - 5.25).

Healthcare Information and Management Systems Society (HIMSS) Annual Conference and Exhibition: Presentation 109. Presented April 14, 2015.

WHY?

• Reduced overall sepsis mortality by 44 percent during the study period. One year poststudy, mortality rates declined even further by 54.5 percent. The initiative also generated a positive ROI.

UCL

LCL 0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

12

/13

P1

P2

P3

P4

P5

P6

P7

P8

P9

P1

0

P1

1

P1

2

P1

3

13

/14

P1

P2

P3

P4

P5

P6

P7

P8

P9

P1

0

P1

1

P1

2

P1

3

14

/15

P1

P2

P3

P4

P5

P6

P7

P8

P9

P1

0

P1

1

P1

2

P1

3

Fraser Health 150 Lives Campaign: (Oct–Mar)

Sepsis Mortality – severe sepsis

Why?

The Sepsis Kills toolkit provides significant benefits at both the clinical and system levels, including: • Enhanced clinician skills in sepsis recognition and management • More timely, standardized and effective detection and management

of sepsis • Reduced mortality, morbidity and bed-stays from sepsis-related

conditions • Improved quality and safety of care and a better and safer patient

experience NSW Sepsis Kills In-Patient Program Implementation Guide 2014

Adult Screening tool Draft

Adult CTU screening tool draft

BCCH Pediatrics screening tool on Child Health BC website

Sepsis Kills (Australia) Adult Inpatient Pathways / Screening Tool

Sepsis Kills (Australia) Pediatric Inpatient Pathways / Screening Tool

Sepsis Kills - Tag Cards

Note for Screening Tools

• Adult Screening

• Pediatric Screening

Note for Screening Tools

• CTU

• Rural?

ISBAR Tool

Sepsis Specific SBAR (Providence)

Notes for SBAR Tool

Coffee and Networking

1045 to 1100

PPO Review

1100 to 1215

• Adult and Neonatal / Pediatrics

• Rural, CTU, Urban ?

• Diagnostics

• Nursing orders for monitoring

• Antibiotic orders?

• Plan for 48-72 hours (look at Sepsis Kills example)

Pediatrics – inpatient sepsis orders

Pediatrics – ICU PPO

Antibiotic Guidelines

• Alignment with best practices for antibiotic ordering for initial sepsis treatment and ongoing after cultures received

• What kind of guidance do we want to include in the toolkit?

Adult antibiotic guidelines – Providence

Pediatrics – antibiotic guidelines

Sepsis Kills - 48 hour management plan