Northern California Mortality Reduction Getting Results to Scale Dr. Carmen Adams.

Northern California Mortality Reduction

Getting Results to Scale

Dr. Carmen Adams

Connecting to Our Potential

© Copyright Kaiser Permanente, 2009 | For Internal Use Only National Quality Conference | Page 2

Step 1- Identify, Document and Code Sepsis

EARLY

RECOGN I T I ON

Identify at triage if suspected infection and 2 SIRS criteria

To < 96.8 (36.0) or > 100.4 (38.0)HR > 90RR > 20WBC > 12K or < 4K or > 10% bands(OR Altered LOC)

CBC, Lactate, BC

Consider IV fluids and ABX

SBP ≤ 90?

yesno

Lactate high?

20 ml/kg fluid bolus

2-3.9 IV fluidsConsider ABX

Repeat lactate in 6 hrs

<2

Document Septic Shock (Time Zero)

Document Septic Shock (Time Zero)

≥ 4

SBP ≤ 90

SBP >90

stop

Suspected Sepsis

Document Severe Sepsis (Time Zero)

Document Severe Sepsis (Time Zero)

Developing a Common Framework for Identification and Treatment



Step 2: Meet EGDT Goals in 6 Hours

Aggressive fluid resuscitation

Within 1 hr: Start ABX

Within 2 hrs:Central Line Placed




CVP 8-12?

MAP ≥ 65?

ScvO2 ≥70?

8-12

≥ 65

≥ 70

500 to 1000 ml Fluid boluses q 30 min

Norepinephrine

If Hct low, transfuse to 30

<8-12

< 65

<70

<70

Dobutamine

DIRECTED

THERAPY

E A R L Y G O A L

Diagnosis of Severe Sepsis or Septic Shock


Lower Lactate




Treatment Plan for Severe Sepsis & Shock

Time Zero

1 hour

2 hours

6 hours

6-12 hours

Diagnosis Severe

Sepsis or Septic Shock

ABX startedIV Fluid

Central Line

Placed 1st CVP or SvcO2

MAP

CVP

ScvO2 at Goal

Repeat Lactate is

Lower than First Lactate

Screen all patients at

risk

Bundle Elements




Taking Action: (1) May Mortality Summit (2) November Sepsis Summit

Room / Bed # ____________

ADDRESSOGRAPH

EARLY GOAL DIRECTED THERAPY (EGDT) ED AND ICU ORDERSET Page 1 of 4

X Check box to activate an order

Kaiser Foundation Hospital - San Jose

Mark chart: Allergic to ___________________________________________ No Known Allergies Weight _______(kg) Height______ Check if applies: Pregnant Lactating ED ORDERS ICU ORDERS Administer oxygen titrate FiO2 to maintain SpO2 between 90-94%. Notify physician if patient requires over 50% FiO2 via face mask or more than 10% increase in 1 hour to achieve needed goal

___________________, RN ______________(Date/Time)

Insert Foley catheter

___________________, RN ______________(Date/Time)

VITAL SIGNS Measure intake and output hourly

___________________, RN ______________(Date/Time)

Record vital signs (heart rate, blood pressure, respiratory rate, SpO2) per unit standards and as needed

___________________, RN ______________(Date/Time)

Measure central venous pressure (CVP) every 30 minutes until goal has been achieved and for at least 2 hours after goal has been reached, then monitor per unit standards and as needed

___________________, RN ______________(Date/Time)

Monitor mixed venous oxygen saturation (ScvO2) continuously

___________________, RN ______________(Date/Time)

Continue Discontinue






EMERGENCY DEPARTMENT DRAFTED NURSES FLOW SHEET

Date _________________________________ Pg__ of __

Time BP P R T GCS* MAP* FiO2/ CVP RASS* Intervention

Score Character(EMV)

SCVO2SpO2 mm/Hg Score Note actions taken in response to the findings on

the left.

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

INTAKE PARENTERAL FLUIDS

Time TYPE AMOUNT Time TYPE AMOUNT Time #SITE

GAUGE TYPE STARTED ABSORBED

TOTALS

Initals Signature/Title Initials Signature/Title Initials Signature/Title

OUTPUT

Pain*

Addressograph

Develop Teams

Tools and Equipment

Adopt Algorithms

Train







CVP 8-12?

MAP ≥ 65?

ScvO2 ≥70?

8-12

≥ 65

≥ 70

500 to 1000 ml Fluid boluses q 30 min

Norepinephrine

If Hct low, transfuse to 30

<8-12

< 65

<70

<70

Dobutamine

DIRECTED

THERAPY

E A R L Y G O A L



Lower Lactate

Sepsis Care Surgical Care Improvement Program

Lactates Sepsis Implementation

Lactates on ED Blood Cultures Te

am

Trai

ning

Abx

in 1

hr

CL

in 2

hrs

55%

47% 44% 84% 37% 69% 91% 29% 85% 32% 77% 37% 99% 80% 36% 63% 66%

58%

56% 100% 0% 0% 0%

DENOM

Measure



Sepsis Collaborative and Site Visits

Focus areas of site visits:

• Evidence of Engagement

• Quality of Team’s Functioning

• Interviews with Frontline Staff Members



The Regional Lens on Environment

Evidence of engagement (sepsis cart, posters, bulletin board)

Regulatory lens (emergency equipment, locked cart)

Observation of patterns of delivery of care

Relevant data is posted and current



Quality of Team’s Functioning

Participation in Sepsis Multidisciplinary Team meetings

Discuss status of unit ( what’s going well; what could be improved; huddles)

Sepsis Team meeting minutes (barriers are discussed)

Review of performance data



Interviews with Frontline Staff

Can they verbalize sepsis screening criteriaDo they exhibit awareness of EGDT bundle elements and are they comfortable advocating for this treatmentAre they knowledgeable about performance outcomes in their unitDo they feel valued as a member of this staff



The ‘Win – Win’ of Site Visits

Attention

Focus

Relationships

Commitment



Work to Come: Prevention/Detection

Decrease Sepsis Mortality and Morbidity29% of all mortalities

Decrease Sepsis Mortality and Morbidity29% of all mortalities

Sepsis on admission

1385 deaths (24% rate)

AIM Primary Drivers Secondary Driver Initiative

1761 deaths/yr Detection

Treatment Timely ABX, EGDT bundle

16% of POA Sepsis is associated with complication from prior medical or surgical care

386 deaths (47% rate)

DetectionDetection

PreventionPrevention

Sepsis During Hospitalization

6% of all mortalities

Sepsis During Hospitalization

6% of all mortalitiesBSI, VAP, ?HAP, ?

C diff, ?SSI

BSI, VAP, ?HAP, ?C diff, ?SSI

Lactate protocols ? Rounding ? Early

warning

Order lactates!



More to Come…

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