Improving Pediatric Sepsis Outcomes (IPSO)
A Multicenter Quality Improvement Collaborative Hosted by The Children’s Hospital Association
1
Pacific Northwest Sepsis Conference – 6/16/2020Dr. Matthew Niedner, MD
2(CHA has >220 Children’s Hospitals)
IPSO Co-Chairs
3
Rich Brilli, MDNationwide Children’s
HospitalIPSO Co-Chair
Emeritus
Charles Macias, MDUH Rainbow Babies &
Children’s Hospital
Raina Paul, MDAdvocate Children’s
Hospital
Matthew Niedner, MDPediatric Intensivist
CHA IPSO Team
Ruth RiggsData Analyst
Jayne StuartDirector, QI
Mary HeadleyProgram Manager
Troy RichardsonManager, Biostatistician
Lowrie WardQI Consultant
(QIC)
Heidi Gruhler
Statistics
Patty KohnRecruitment
Carol RosenbergClinical QI Consultant
(QIC)
Jennifer ColdrenQI Consultant (QIC)
+ Over 50 National Experts in IPSO Leadership &
Advisory Roles
IPSO High-level Overview
4
Form teams
Partnerships
Resources
Train staff
Data sources
Validate
Submit data
Reports
IPSO bundles
5 key processes
Rapid cycle improvement
Peer-to-peer sharing
Web-based libraryDirect
coaching
March 2020 – Inclusion in Aggregate Status
5
50 Sites Actively Submitting Data
47 Sites Included in Aggregate
3 Sites Excluded from Aggregate
April 2018 Reports# of Data Quality Issues
0 1 2 317 4 2 2
16 3 3
1 3
March 2020 Reports# of Data Quality Issues
0 1 2 3Minimum Data Submission Met 47
Minimum Baseline Submission Not Met
Minimum Prospective Submission Not Met 2Neither Baseline nor Prospective Minimum Met 1
TerminologyBlood culture & antibiotic within 24 hours
and inpatients or intent to admit (ED)IPSO Suspected
Infection (ISI)8 ways to meet inclusion from treatments to ICD
(sensitivity>specificity)
IPSO Sepsis
Subset with Treatment Criteria AND 3rd Bolus OR Pressor
IPSO Critical Sepsis (ICS)
Subset not meeting IPSO Critical criteria
IPSO Non-Critical Sepsis (INS)
6
>200k
>15k
>30kn over3 yrs
Highly correlated to Goldstein Criteria for
Severe Sepsis / Shock
IPSO Key Driver Diagram (sans 2o drivers)
7
Reduce Sepsis-Attributable
“IPSO Critical Sepsis”
Mortality by 25%
II Recognition: Sensitive, specific, efficient, and timely recognition of IPSO Sepsis III Diagnostic Evaluation: Appropriate and timely diagnostic evaluation of IPSO SepsisIV Resuscitation / Stabilization: Appropriate, timely, and effective treatment of IPSO SepsisV De-escalation: Appropriate and timely de-escalation of careVI Patient and Family Engagement
I Prevention: Appropriate & timely treatment of IPSO Suspected Infection that may progress to IPSO Sepsis
VII Optimize Performance
Reduce Hospital-Onset“IPSO Critical
Sepsis” by 25%
0
50,000
100,000
150,000
200,000
250,000
300,000
2017
-06
2017
-07
2017
-08
2017
-09
2017
-10
2017
-11
2017
-12
2018
-01
2018
-02
2018
-03
2018
-04
2018
-05
2018
-06
2018
-07
2018
-08
2018
-09
2018
-10
2018
-11
2018
-12
2019
-01
2019
-02
2019
-03
2019
-04
2019
-05
2019
-06
2019
-07
2019
-08
2019
-09
2019
-10
2019
-11
2019
-12
2020
-01
2020
-02
2020
-03
2020
-04
Epis
odes
Submission Month
by Episode Type
Baseline IPSO Sepsis IPSO Sepsis (not critical) IPSO Critical Sepsis IPSO Suspected Infection
Baseline IPSO Sepsis Episodes - 12,426Prospective IPSO Sepsis Episodes - 45,038
IPSO Critical Sepsis Episodes - 15,290
Total Episodes - 259,324IPSO Suspected Infection Episodes - 201,860
IPSO Sepsis (not critical) Episodes - 29,748
Cumulative Sepsis Episodes Submitted
8
2017 2018 2019 2020
91.1%
92.5%
81.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2017
-06
2017
-07
2017
-08
2017
-09
2017
-10
2017
-11
2017
-12
2018
-01
2018
-02
2018
-03
2018
-04
2018
-05
2018
-06
2018
-07
2018
-08
2018
-09
2018
-10
2018
-11
2018
-12
2019
-01
2019
-02
2019
-03
2019
-04
2019
-05
2019
-06
2019
-07
2019
-08
2019
-09
2019
-10
2019
-11
2019
-12
2020
-01
2020
-02
2020
-03
2020
-04
% o
f Mon
ths
Subm
itted
Submission Month
Target Baseline IPSO Sepsis Prospective IPSO Sepsis IPSO Suspected Infection
% Overall Submission Progress 4.25.20
9
> 90% of total IPSO Sepsis months possible have been submitted
2017 2018 2019 2020
IPSO’s 5 Key Processes
10
62% 65% 63% 58% 50%94%
0%
20%
40%
60%
80%
100%
ScreenImproving
HuddleImproving
Order SetImproving
BolusImproving
ABXImproving
Improvingin at leastone keyprocess
Perc
ent o
f Hos
pita
ls
% of Hospitals Showing Improvement*
*Last 12 data points improved over first 12 data points
11
49 43 33 19 1005
101520253035404550
improved inat least 1
improved inat least 2
improved inat least 3
improved inat least 4
improved inall 5
Num
ber o
f Hos
pita
ls
Number of Hospitals Showing Improvement*
IPSO’s 5 Key Processes
*Last 12 data points improved over first 12 data points
12
2017 2018 2019
13
2017 2018 2019 2020
14
2017 2018 2019 2020
15
2017 2018 2019 2020
16
2017 2018 2019 2020
17
2017 2018 2019 20202016
18
2017 2018 2019 20202016
19
2017 2018 2019 20202016
Treatment
Within 6 Hours
Antibiotic
2 Boluses OR
1 Bolus + Pressor
Third Bolus OR Pressor
IPSO Critical Sepsis
What do we mean by “IPSO Critical Sepsis”?
20
[Third Bolus or Pressor] Plus Treatment
Note: “IPSO Critical Sepsis” cannot be identified from IPSO baseline data set; baseline for IPSO Critical Sepsis is defined as the first 12 months of IPSO prospective data set (2017 for Wave 1).
Incidence Comparison (per 1000 admissions)
21
0
5
10
15
20
25Ja
n 20
17Fe
b 20
17M
ar 2
017
Apr 2
017
May
201
7Ju
n 20
17Ju
l 201
7Au
g 20
17Se
p 20
17O
ct 2
017
Nov
201
7D
ec 2
017
Jan
2018
Feb
2018
Mar
201
8Ap
r 201
8M
ay 2
018
Jun
2018
Jul 2
018
Aug
2018
Sep
2018
Oct
201
8N
ov 2
018
Dec
201
8Ja
n 20
19Fe
b 20
19M
ar 2
019
Apr 2
019
May
201
9Ju
n 20
19
18.320.3
14.1
0
5
10
15
20
25
Jan
2017
Feb
2017
Mar
201
7Ap
r 201
7M
ay 2
017
Jun
2017
Jul 2
017
Aug
2017
Sep
2017
Oct
201
7N
ov 2
017
Dec
201
7Ja
n 20
18Fe
b 20
18M
ar 2
018
Apr 2
018
May
201
8Ju
n 20
18Ju
l 201
8Au
g 20
18Se
p 20
18O
ct 2
018
Nov
201
8D
ec 2
018
Jan
2019
Feb
2019
Mar
201
9Ap
r 201
9M
ay 2
019
Jun
2019
8.8 9.6
IPSO Critical Sepsis (ICS)IPSO Non-Critical Sepsis (INS)
IPSO Suspected Infection (ISI) = 120/1000 admissions
Better and/or earlier recognition of sepsis syndrome earlier in continuum
Relatively stable baseline
30-Day Sepsis-Attributable Mortality Comparison
22
0%
1%
2%
3%
4%
5%
6%
7%
8%Ja
n 20
17Fe
b 20
17M
ar 2
017
Apr 2
017
May
201
7Ju
n 20
17Ju
l 201
7Au
g 20
17Se
p 20
17O
ct 2
017
Nov
201
7D
ec 2
017
Jan
2018
Feb
2018
Mar
201
8Ap
r 201
8M
ay 2
018
Jun
2018
Jul 2
018
Aug
2018
Sep
2018
Oct
201
8N
ov 2
018
Dec
201
8Ja
n 20
19Fe
b 20
19M
ar 2
019
Apr 2
019
May
201
9Ju
n 20
19
1.8%
0%
1%
2%
3%
4%
5%
6%
7%
8%
Jan
2017
Feb
2017
Mar
201
7Ap
r 201
7M
ay 2
017
Jun
2017
Jul 2
017
Aug
2017
Sep
2017
Oct
201
7N
ov 2
017
Dec
201
7Ja
n 20
18Fe
b 20
18M
ar 2
018
Apr 2
018
May
201
8Ju
n 20
18Ju
l 201
8Au
g 20
18Se
p 20
18O
ct 2
018
Nov
201
8D
ec 2
018
Jan
2019
Feb
2019
Mar
201
9Ap
r 201
9M
ay 2
019
Jun
2019
3.6%
IPSO Critical Sepsis (ICS)IPSO Non-Critical Sepsis (INS)
All-Cause Mortality ~Double
Sepsis-Attributable Mortality (30-Day)By Care Setting Onset/Recognition (1/2017 – 6/2019)
23
IPSO Critical Sepsis
0%1%2%3%4%5%6%7%
Jan
2017
Feb
2017
Mar
201
7Ap
r 201
7M
ay 2
017
Jun
2017
Jul 2
017
Aug
2017
Sep
2017
Oct
201
7N
ov 2
017
Dec
201
7Ja
n 20
18Fe
b 20
18M
ar 2
018
Apr 2
018
May
201
8Ju
n 20
18Ju
l 201
8Au
g 20
18Se
p 20
18O
ct 2
018
Nov
201
8D
ec 2
018
Jan
2019
Feb
2019
Mar
201
9Ap
r 201
9M
ay 2
019
Jun
2019
ED
2.5%
0%
5%
10%
15%
20%
25%
Jan
2017
Feb
2017
Mar
201
7Ap
r 201
7M
ay 2
017
Jun
2017
Jul 2
017
Aug
2017
Sep
2017
Oct
201
7N
ov 2
017
Dec
201
7Ja
n 20
18Fe
b 20
18M
ar 2
018
Apr 2
018
May
201
8Ju
n 20
18Ju
l 201
8Au
g 20
18Se
p 20
18O
ct 2
018
Nov
201
8D
ec 2
018
Jan
2019
Feb
2019
Mar
201
9Ap
r 201
9M
ay 2
019
Jun
2019
ICU
8.5%
0%
10%
20%
30%
40%
Jan
2017
Feb
2017
Mar
201
7Ap
r 201
7M
ay 2
017
Jun
2017
Jul 2
017
Aug
2017
Sep
2017
Oct
201
7N
ov 2
017
Dec
201
7Ja
n 20
18Fe
b 20
18M
ar 2
018
Apr 2
018
May
201
8Ju
n 20
18Ju
l 201
8Au
g 20
18Se
p 20
18O
ct 2
018
Nov
201
8D
ec 2
018
Jan
2019
Feb
2019
Mar
201
9Ap
r 201
9M
ay 2
019
Jun
2019
Gen
Flo
or
5.3%
0%
20%
40%
60%
80%
Jan
2017
Feb
2017
Mar
201
7Ap
r 201
7M
ay 2
017
Jun
2017
Jul 2
017
Aug
2017
Sep
2017
Oct
201
7N
ov 2
017
Dec
201
7Ja
n 20
18Fe
b 20
18M
ar 2
018
Apr 2
018
May
201
8Ju
n 20
18Ju
l 201
8Au
g 20
18Se
p 20
18O
ct 2
018
Nov
201
8D
ec 2
018
Jan
2019
Feb
2019
Mar
201
9Ap
r 201
9M
ay 2
019
Jun
2019
Hem
Onc
10.5%
Hmmmm…
24
So we have evidence-based practices (such as it is)…
And we are improving recognition, process compliance, and timeliness…
But we aren’t seeing the mortality needle move as we had hoped…
So time to revisit if we’re doing the right things and looking at it the right way.
Definition: All-or-None Compliance
Episodes are compliant when:There is a positive screen OR positive huddle OR order set is
used
Bolus was administered in specified timeframe
Antibiotic was administered in specified timeframe
Episodes are non-compliant when:There is no positive screen
AND no positive huddle AND no order set is used
Bolus was not administered in specified timeframe
Antibiotic was not administered in specified timeframe
25
AND
AND
OR
OR
Bundles Evaluated
Bolus 20 min / ABX 60 min / Recognition*
• Reflects Original IPSO-specific targets
Bolus 60 min / ABX 180 min / Recognition*
• Reflects Modified IPSO targets (tripled); also updated to more closely match current Surviving Sepsis Guidelines and Internal Data Analyses
26*Recognition = positive screen, positive huddle or order set use
2019 Compliance by Bundle—IPSO Sepsis
27
BundleN, IPSO Sepsis
Any Recognition
Bolus, < Target
Abx,< Target
Overall Compliance
Bolus 20 min –Antibiotic 60 min –Recognition
12,329 72% 53% 57% 22%
Bolus 60 min –Antibiotic 180 min –Recognition
12,329 72% 78% 83% 49%
2019 Compliance by Bundle—IPSO Critical Sepsis
28
Bundle
N, IPSO Critical Sepsis
Any Recognition
Bolus, < Target
Abx,< Target
Overall Compliance
Bolus 20 min –Antibiotic 60 min –Recognition
3,829 71% 64% 64% 30%
Bolus 60 min –Antibiotic 180 min –Recognition
3,829 71% 88% 88% 58%
Bundle Compliance OutcomesAll Bundles below include
PLUS recognitionIPSO Critical Sepsis
SA Mortality % Diff Hospital Days % Diff
Bol 20 min/ABX 60 min (comp) 3.1%-14%
10.0-11%
Bol 20 min/ABX 60 min (non-comp) 3.6% 11.2
Bol 60 min/ABX 180 min (comp) 2. 5%-49%*
9.5-25%*
Bol 60 min/ABX 180 min (non-comp) 4.8% 12.7
29
* Statistically Significant (p<0.05)
Recognition Compliance TimelinessIPSO Critical Sepsis
Mean Time to ABX % Diff
Mean Time to Bolus % Diff
Screen compliant 73-21%
32-21%
No Screen 93 40
Huddle compliant 73-13%
28-22%
No huddle 84 36
Order Set compliant 63-35%
28-32%
No order set 97 42
Any Recognition compliant 71-37%
30-56%
No recognition 113 68
30
Bundle Compliance
31
Bolus 60 – ABX 180 – Recognition
2017 2018 2019 2017 2018 2019
TakeawaysBundle Compliance Matters
• Mortality & hospital days are lower in more compliant episodes• Time to 1st bolus & IV antibiotic are lower when recognition tools are used• So we believe we’re doing the “right things”
Improvement Opportunities• In aggregate, we have only made modest improvements in key processes• Numerous individual hospitals have made very large improvements in some areas,
demonstrating feasibility and providing an example of how to improve• So there is much more opportunity to improve processes/compliance• We are better powered to detect aggregate improvements in common process measures
that in more rare outcomes (i.e., mortality)• So if we increase “the dose” of the “right things done better” we believe that in time we will
see the needle move on mortality.
32
33This Photo by Unknown Author is licensed under CC BY-NC-ND
Bundle Compliance OutcomesAll Bundles below include
PLUS recognition
IPSO Sepsis IPSO Critical SepsisSA
Mortality % DiffHospital
Days % DiffSA
Mortality % DiffHospital
Days % Diff
Bol 20 min/ABX 60 min (comp) 1.76%-19.5%*
8.5-11.8%
3.12%-13.7%
10.0-11.1%
Bol 20 min/ABX 60 min (non-comp) 2.19% 9.7 3.62% 11.2
Bol 60 min/ABX 180 min (comp) 1.24%-56.9%*
7.9-26.9%*
2.45%-48.9%*
9.5-25.4%*
Bol 60 min/ABX 180 min (non-comp) 2.87% 10.8 4.80% 12.7
35
* Statistically Significant (p<0.05)
Recognition Compliance TimelinessIPSO Sepsis IPSO Critical Sepsis
Mean Time to
ABX % Diff
Mean Time to Bolus %Diff
Mean Time to
ABX % Diff
Mean Time to Bolus % Diff
Screen compliant 92-12.7%
35-13.3%
73-20.8%
32-21.4%
No Screen 106 41 93 40
Huddle compliant 93-6.8%
30-23.6%
73-12.5%
28-21.6%
No huddle 100 40 84 36
Order Set compliant 72-40.4%
33-23.5%
63-35.3%
28-32.3%
No order set 121 43 97 42
Recognition compliant 86-36.6%
34-47.4%
71-37.2%
30-56.0%
No recognition 136 64 113 68
36