Contra Costa Regional Medical Center

Sara Levin, MD, FACPJoelle Kennedy, RNKip Norwood, RN

CCRMC Sepsis Team2

Why Sepsis for Improvement Project? Sepsis accounts for 10% of deaths annually

with a 30% mortality rate Number one cause of multiple-organ failure

and death in patients with critical illness Increased incidence without any significant

change in mortality over past 30 years 750,000 hospitalized cases annually with

210,000 deaths. Many more than Acute MI.

Angus DC, et al. Crit Care Med 2001;29:11303-10.

Why Is Sepsis So Complicated Compared to Other Conditions?

Understanding Sepsis PCI for STEMI

Sepsis Recognition and Treatment A Long Journey Starts at CCRMC 2004 – Physician Education on Early Goal

Directed Therapy

2005-2006 – Implementation of Severe Sepsis Order Set/ Nursing Education

2006-2008 Training workshops for Central line placements and CVP monitoring

Sepsis Recognition and Treatment A Long Journey Continues at CCRMC

Fall 2009 - CCRMC invited to join the INLP cohort on Sepsis

2009 – The sepsis team is made up of nurses, physicians, pharmacists, lab personnel, infection control and quality officers

2009 - A collaboration forms between the ER and Inpatient Units to tackle Sepsis

Project Objectives

Achieve 95% compliance in the use of the severe sepsis screening tool with all patients

Achieve at least 85% compliance in the use of the EGDT bundle

Reduce mortality due to sepsis at CCRMC at least 15%

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Interventions & Innovations

Developed sepsis screening tool and implemented in our ED, ICU, IMCU, Medical/Surgical Units

Automatic Meditech email alerts for every positive screen in the ED

All positive screens on inpatient units are faxed to a central location for data collection

Nurse initiated protocol to order a lactate for every positive screen.

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Interventions & Innovations

• Implemented the iStatlactate collection process in the ED Average turn-around-time

(order – reported) for iStatLactate results (ED)=24 minutes

Average turn-around time (order – reported) for non-iStat Lactate results (Inpatient units)= 54 minutes

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Education & Promotion Staff & MD buy-in◦ Educational Inservices◦ Screensavers◦ Poster boards◦ Unit Huddles◦ Rewards Sense of Pride

Education and Promotion

Unit Huddles/Case Studies

Monthly physician peer-review of septic patients

Required Nursing E-Learning Module

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Data Elements

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Data Elements

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Quantitative Results

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Sustainability Plan Nursing Protocol Policy

Continue monthly team meetings to share data, TOC progress

CAPH Sepsis Initiative

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What Were Our Barriers?The Same Things that Were Necessary for Our Success

◦IndividualsNaysayers; Saboteurs; Late Adopters

◦TeamsBuilding and MaintainingRight People at the table at the Right time for the Right reasons

What Were Our Barriers?The Same Things that Were Necessary for Our Success

◦ Culture Many competing priorities and responsibilities Value what you know over what you can learn Difficulties overcoming the silos that exist within hospital culture

◦ Process Negotiating the best standard process to achieve shared goals Defining how the responsibility and accountability for those processes will be distributed and measured, respectively

How Did We Overcome Our Barriers?

◦ Individuals Individual team members were given the opportunity to develop their skills Individuals on the front line were engaged to be partners in the work

◦ Teams The team as a whole learned how to work more efficiently and effectively as a team and enjoy the fruits of our labors We continually constructed new subgroups of people to work on the components of the project that required their skills and input

How Did We Overcome Our Barriers?

◦ Cultures Ensure that all the subcultures of the hospital environment were represented on the team Value the diverse perspectives and solicit guidance on how to effectively work within their department to meet our shared goals

◦ Process How to modulate and apply different tools and tactics to engage the range of colleagues who we needed: from the early to the late adopters; from the skeptics to the yes (wo)men.

Lessons Learned Attend to the Key Ingredients for Organizational

Change

The importance of tenacity and patience

The importance of building relationships in the workplace to effect change

Overcoming resistance to change by appealing to the values and goals we all share: improving patient care and safety

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Lessons LearnedOrganizational Lessons:◦ Development of team structure to facilitate change◦ Embed the culture of Rapid Improvement into the team structure◦ Provide Support and Tools for Data Collection and Analysis◦ Structured Organizational Commitment to the process of improvement

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How Can We Apply These Learnings To Other Improvement Efforts?

Utilize the structures, skills and relationships developed as a model for future efforts

Reflect on what steps could have been improved and define how

Apply those reflections to future efforts as tests of change

Significance to Organization Early recognition and appropriate treatment

= Decreased mortality ◦ ”GOLDEN HOURS OF SEPSIS – TIME IS TISSUE”

Front line staff = Rapid recognition◦ “SCREENING FOR THE GOLDEN HOURS”

Nurse Empowerment = Earlier Identification Clinical Assessment Necessary

Implementation of evidence-based medicine innovations requires attention to principles of organizational change involving front-line staff

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Many ThanksAnna Roth, CEOJaspreet Benepal, CNOLance Mageno, CQONeil Jayasekera, MDStu Foreman, MDDr. Hye KimMartie MatsonJulie KligerINLP staff

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