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CMS Core Measures EssentialsAll You Need to Know About Sepsis
Core Quality MeasuresJan 29, 2016 / 10:00 am PST – 10:30 am PST
Sponsored by AcesoCloudhttp://www.acesocloud.com
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Introducing our SpeakerDr. Andre Vovan Chief of Service, Critical Care
15 years as Intensivist 11 years experience running sepsis
program Participated in Original Surviving
Sepsis Campaign Decreased mortality >50% Decreased cost/case of sepsis >50
January 2016 AcesoCloud Webinar
Background
AcesoCloud Webinar 4
Sepsis Core Measures
January 2016
Sepsis Core Measures & Sepsis Bundles
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All about Sepsis Core Measures
January 2016
Effective October 1, 2015 discharges Focused on patients diagnosed with severe sepsis or septic shock Emphasis on early management of SepsisConsistent with the Surviving Sepsis Campaign guidelinesObjective is to lower rates of organ failure, mortality, length of stay, and cost of care Comprises comprehensive two all or none bundles
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SEP-1 Definitions
January 2016
Severe Sepsis o suspected source of infectiono 2 SIRS criteria, and o evidence of end-organ dysfunction
Septic Shock o initial lactate greater than or equal
to 4 mmol/Lo Evidence of hypotension in the
first hour following completion of a 30 cc/kg IVF bolus
8January 2016 AcesoCloud Webinar
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How is the new Core Measures different
January 2016
Compared to previous core measures SEP-1 is…o more complicatedo requires more teamwork, and o has the potential to more significantly impact patient outcomes in terms
of mortality, morbidity, and hospital length-of-stayTime of presentationo Unlike most other core measures in which the clock starts upon
admission, for this measure, the clock starts when the patient meets criteria for either severe sepsis or septic shock
Chances are your hospital quality team is still developing a sound understanding of the core measures!
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Key Abstractions
January 2016
The course of treatment is dependent on Time of Presentation (TOP) documented by the nurse/PhysicianCare protocol implementation is based on the two clocks:o Three hour o Six hour
Clock starts when Severe Sepsis presentation is documented, either by diagnosis or criteria:o For ED patients the clock begins when the patient is diagnosed with
Severe Sepsiso If Sepsis occurs later, the earliest time all symptoms present or diagnosis
documented is the time when the clock begins.
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3 Hour Sepsis Bundles
January 2016
Within 3 hours from TOPo draw a lactate,o draw blood cultures prior to
administration of antibiotics, and start broad-spectrum
antibiotics or approved combination of antibioticso Administer 30ml/kg crystalloid for hypotension or lactate
≥4mmol/L
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6 Hour Sepsis Bundles
January 2016
Within 6 hours from TOP, initiate all the above plus: o IVF bolus of 0.9% NS or LR 30ml/kg o If hypotension persists within 1 hour of completion of initial fluid
resuscitation, administer vasopressors to maintain a mean arterial pressure (MAP) ≥65mmHg
o If hypotension persists after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings.
o Re-measure lactate if initial lactate elevated > 2mmol/L or hypotension
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Table 1
January 2016
Document reassessment of volume status and tissue perfusion withEither
Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.
OrAny two of the following measures:
o Measure CVPo Measure ScvO2o Bedside cardiovascular ultrasoundo Dynamic assessment of fluid responsiveness with passive leg raise or
fluid challenge
Sepsis Bundle Implementation - Process Map
15January 2016 AcesoCloud Webinar
Time of Presentation
Screening & Documentation
Initiate Sever Sepsis and/or Septic Shock
Bundle
Initial Lactate Level
Draw Blood Cultures
Complete within 1Hr max
3 Hrs 3+ Hrs
Administer broad-spectrum antibiotics
If <90 or >40below baseline or MAP <65 Or initial lactate
level >36mg/dL
Total bolus of min 30mL/kgIVF bolus of 0.9% NS or LR
30ml/kg
Complete within 6Hr max
If initial lactate >2mmol/L
Repeat serum lactate level
If SBP<90 or MBP<65 within 1 hour of
completing 30ml/kg fluid bolus
If MBP>65 STOP
If lactate is >4mmol/L, perform repeat
volume and tissue perfusion assessment
If hypotensive patient is unresponsive to fluid
bolus of 30mg/dL initiate vasopressors
Repeat volume and tissue perfusion assessment including:• Vital signs• Cardiopulmonary exam• Capillary refill evaluation• Peripheral pulse evaluation• Skin evaluationOR Any two of the following:• Central venous pressure measurement• Central venous oxygen measurement• Cardiovascular ultrasound• Dynamic assessment of fluid responsiveness
with passive leg raise or fluid challenge
Patient meets criteria for Severe Sepsis
and/or Septic Shock
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Sepsis Core Measures Exclusions
January 2016
The patient is excluded if …o “comfort care” is ordered for the patient within
3 hours of time of presentation of severe sepsis and 6 hours of septic shock
o Patient expires within 3 hours of severe sepsis or 6 hours of septic shock
o Patient is transferred from outside hospitals and emergency departments
o Patient/decision maker refuse any component of the recommended care
Successful Sepsis Program
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Key Components
January 2016
Standardized Identification
o Automated screening tools and alert systemso Definite sepsis processes with clearly laid role
definitions
Evidence Based Treatment
o Physician engagement and accountabilityo Train and empower nurses to use sepsis bundles
Process Improvements
o Identify champions to evaluate sepsis programs o Facilitate, measure and reward physician engagemento Engage frontline clinicians to identify process gapso Execute, monitor and measure process improvementso Facilitate shift in culture towards protocol compliance
19Jan 2016 AcesoCloud Webinar
Why so few health systems truly manage quality
Physician empowerment &
engagement
Appropriate analytics & technology solutions
Shifting priorities of governance & leadership
Organizational culture & ability
Executive engagement & awareness
Multiple contrasting priorities
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Four-Tier QI Plan for Sepsis ProgramANALYZEANALYZE PLAN PTIMIZE
Jan 2016 AcesoCloud Webinar
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Thank you for joining us!If you would like to obtain additional information or are interested in discussing how AcesoCloud can help please
feel free to contact us.
Contact Email: [email protected]
About AcesoCloud: http://www.acesocloud.com
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