Tomah Memorial Hospital Thursday, June 15th 2017 Improvement Action Network (IAN) Sepsis Tomah Memorial Hospital Thursday, June 15th 2017

Agenda 9:00 – 9:10 a.m. Welcome and Introductions Express Goals for the day, goal of an IAN and importance in the HIIN journey 9:10 – 9:30 a.m. Round Robin – Gap Analysis and Goals Each hospital team reports off on the completed gap analysis and goal to accomplish today. 9:30 – 10:00 a.m. The Hospital and Physician Perspective Divine Savior, Portage Robert Redwood, MD, MPH (Emergency Physician, Preventive Medicine Physician, Antimicrobial Stewardship Committee Chairperson) 10:00 – 10:15 a.m. Break 10:15 – 11:15 a.m. Workgroup Activities Work with other hospitals and your hospital team to brainstorm and develop action plans on how to move forward with Sepsis initiatives. 11:15 – 12:00 p.m. Report out – Action Plans Hospital teams describe what they worked on, communicate action plans and if you have the support and necessary tools to move forward. 12:00 – 12:15 p.m. Next Steps Agenda

Round Robin – Gap Analysis and Goals Each hospital team reports off on the completed gap analysis and goal to accomplish today.

Bobby Redwood, MD, MPH Sepsis: from the Greek σῆψις: the state of putrefaction and decay

Definition: Sepsis My definitions: Really sick (septic w/ lactate ≥4 = 30% mortality) Ready to crump (septic w/ <BP = 36.7% mortality) Transfer please! (<BP + lactate ≥4 = 46.1% mortality)

Critical Elements of the 3 Hour Bundle Measure lactate level Obtain blood cultures prior to administration of antibiotics Administer broad spectrum antibiotics Administer 30cc/kg crystalloid for hypotension or lactate greater than or equal to 4mmol/L

Critical Elements of the 6 Hour Bundle Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) greater than or equal to 65mmHg Reassess fluid volume status and tissue perfusion (for persistent hypotension or elevated lactate level) Re-measure lactate if initial lactate elevated

Other Best Practices from the Gap Tool Create/Activate an interdisciplinary team (include ED and ICU) Establish process for routine screening in all patient areas with a standardized screening tool Design automated alerts for severe sepsis/septic shock Standardize care protocols for patients who screen positive

Divine Savior Healthcare SE-1 Data Core Measure Met by Month (%)

Divine Savior Healthcare SE-1 Data Component Breakdown by Quarter (%)

PDSA/Small Tests of Change Started looking at monthly instead of quarterly data Initiated Triage RN screening protocol Created Blood cultures before antibiotics order (Fail) Created sepsis order set Repeat lactate didactics/meetings (Fail) Created reflex 2 hour lactate if 1° lactate >2 order Made sepsis order set an RN-initiated protocol (Fail) Created suggested antibiotic resource and order set Posted ED Scoreboard in central location

Challenges Accurate abstraction RN buy-in Influenza season / Screening accuracy 30 cc/kg bolus in CHF patients (emergency physicians) Repeat Lactate <6 hrs (hospitalist staffing) Antibiotic nuances (esp. allergies) Balancing antibiotic stewardship and proper sepsis care

Highlight on the 30cc/kg Bolus Your patient may well need more than 30cc/kg, use defined endpoints to guide further fluid resuscitation U/O >0.5cc/kg/hr MAP >65 Normalization of lactate In CHF, prioritize fluid resuscitation over respiratory status Iatrogenic fluid overload is rare in severe sepsis (even in CHF) Think long term (lose the pulmonary edema battle and win the sepsis war) Do not fear BiPap/intubation (positive pressure is your friend)

Current Issues and Next Steps Failures occur more “downstream” in the bundle with each PDSA At the point where our failures are few enough that we can examine them individually (x2 abx failures in June) Skin source. Patient only received vancomycin. Provider felt he knew it was MRSA and chose targeted therapy. Community-acquired pneumonia with pleural effusion. Only received azithromycin. Ceftriaxone had been ordered but was inexplicably cancelled. Planning to initiate monthly provider and RN peer review on bundle and screening compliance. Incorporate pro-calcitonin lab into our sepsis protocol

Key Opportunities for Physician Leadership in Sepsis Care Help your quality department understand the processes of care and provide a clinical perspective Convince yourself that you believe in the measure and then motivate your peers to do the same Set an example by going first and (politely) holding your peers accountable Showcase your successes to med staff and administration Analyze your failures and share lessons learned

Thank You Dr. Redwood!

Break 15 minutes

Workgroup Activity Work with other hospitals and your hospital team to brainstorm and develop action plans on how to move forward with Sepsis initiatives.

Report Out – Action Plans Hospital teams describe what they worked on, communicate action plans and if you have the support and necessary tools to move forward.

Resources WHA Quality Center MHA Community Page http://www.whaqualitycenter.org/Partnersfor Patients/Sepsis.aspx Sepsis Starter Pack Sepsis IAN information and details http://community.mha.org/home Archived Webinars Discussion Board

Next Steps… Scanning of your Action Plans 30 day follow up: Phone call with Improvement Advisor on your action plans and small tests of change 60 day follow up: Virtual event/call with all hospitals to highlighting hospitals successes. Details to come. Date: August 17th 12-1pm Resources from IAN link on WHA Quality Center Website’s Partners Page

Evaluation +/-

Contacts Beth Dibbert Improvement Advisor/Quality Director bdibbert@wha.org 608-268-1817 Shruthi Murali Improvement Advisor smurali@wha.org 608-268-1825 Jill Hanson jhanson@wha.org 608-268-1842 Bobby Redwood Physician Improvement Advisor rredwood@wha.org   Nadine Allen nallen@wha.org 608-268-1823 Kelly Court Chief Quality Officer kcourt@wha.org 608-274-1820