Assistant Clinical Professor Sepsis Day 2016 Russell Kerbel MD MBA Assistant Clinical Professor Hospital Medicine UCLA Health

In Last Years Episode…

New in 2016 for UCLA Sepsis: CMS: SEP-1 Bundle New Sepsis Team Structure for UCLA Health Sepsis 3.0 Guidelines Early SEP-1 Data

Assistant Clinical Professor Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment UCLA Sepsis Day 2016 Russell Kerbel MD MBA Assistant Clinical Professor Hospital Medicine UCLA Health

Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment UCLA Sepsis Day 2016

Mission: “Deliver Leading-Edge Patient Care, Research and Education” Sepsis Executive Committee Sepsis Quality and ValU Teams Sepsis Nursing Champions

Defining: SIRS, Sepsis, Severe Sepsis & Septic Shock Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment Defining: SIRS, Sepsis, Severe Sepsis & Septic Shock

Why initiate the bundle at Severe Sepsis? The Sepsis Continuum Why initiate the bundle at Severe Sepsis?

Wait…I thought SIRS & Severe Sepsis were obsolete? Utilization of the SOFA and qSOFA Scores Not recognized by CMS or ICD-10

Mean Arterial Pressure = Cardiac Output X Systemic Vascular Resistance MAP = CO x SVR Mean Arterial Pressure = Cardiac Output X Systemic Vascular Resistance Why is does the SVR fall in Severe Sepsis?

Severe Sepsis and Septic Shock Derek C. Angus, M.D., M.P.H., and Tom van der Poll, M.D., Ph.D. N Engl J Med 2013; 369:840-851August 29, 2013DOI: 10.1056/NEJMra1208623

Microcirculation Tissue Severe Sepsis and Septic Shock Derek C. Angus, M.D., M.P.H., and Tom van der Poll, M.D., Ph.D. N Engl J Med 2013; 369:840-851August 29, 2013DOI: 10.1056/NEJMra1208623

Severe Sepsis (2 SIRS Criteria + Infection Source + Any One of these) Vasodilation SBP < 90 or MAP <65 SBP drop of greater than 40mmHg from last “normal” blood pressure Tissue Hypoperfusion Bilirubin > 2 mg/dL Creatinine > 2 or Urine Output <0.5 mL/kf/hg for 2hrs Lactate > 2 mmol/L Coagulability Issues INR 1.5 or aPTT > 60 seconds Platelets < 100,000

The Sequential Organ Failure Assessment (SOFA)

Future Sepsis Physiology Research

Identify Clinical Deterioration Creating a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment Identify Clinical Deterioration

Doctor and Nurse Bedside Collaboration Rapid Response Team or A.C.T. Clinical Deterioration Call Primary Team? Doctor and Nurse Bedside Collaboration Clinical Stability Call Primary Team? Stable Vitals Rapid Response Team or A.C.T. SIRS / Sepsis Severe Sepsis Code Blue Team Septic Shock Time

How Can We Identify Patients on the Sepsis Continuum? Current Methods: Nurse Sepsis Screening Tool Physician and RN Clinical Skills Rapid Response Team at SM Pilots Projects: A.C.T. Pilot (8E and 8W at RR) Clinical Triggers Pilots (4MN & 5MN at SM) Clinical Surveillance Team (RR) Sepsis ED RN Best Practice Alert (Planned for 2017)

The Severe Sepsis & Septic Shock Bundles Creating a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment The Severe Sepsis & Septic Shock Bundles

Severe Sepsis Bundle Evidence? Severe Sepsis Bundle Compliance Rates < 30% 4-6% Absolute Reduction in Mortality Severe Sepsis Bundle Compliance Rates of 52% 20% Absolute Reduction in Mortality Bundle Completion vs Non-Bundle Completion ~14% in Mortality Difference

High-Reliability Organizations Continuing to Create a Highly-Reliable Academic Medical Center in Severe Sepsis & Septic Shock Identification and Treatment High-Reliability Organizations

The Granular Elements of a Highly Reliable Organization (1) (2) (3) (4)

Collective Drive: Sepsis Day! Preoccupation with Severe Sepsis Failure Achieving Highly-Reliable Severe Sepsis Identification and Treatment at UCLA (1) No Sepsis Guidelines or Protocols Sepsis Screenings and Bundles Integrated Order Sets and Protocols Backup and Redundant Systems (2) No way to measure errors Event Reports & Severe Sepsis Dashboards Severe Sepsis Process and Outcome Benchmarking Continuous Real-Time Severe Sepsis Screenings Individual Autonomy for Severe Sepsis Sepsis Safety and Quality Teams Centralized Severe Sepsis Control Organizational Severe Sepsis Awareness (3) (4) Trial and Error Defining Roles In Severe Sepsis Collective Drive: Sepsis Day! Preoccupation with Severe Sepsis Failure

Continuing to Create a Highly-Reliable Academic Medical Center in Sepsis Identification and Treatment You!

PLEASE EMAIL ME WITH IDEAS rkerbel@mednet.ucla.edu Your Eyes Your Clinical Skills Your Innovations PLEASE EMAIL ME WITH IDEAS rkerbel@mednet.ucla.edu

Thank You Questions?

Current RR SEP-1 Data

Current SM SEP-1 Data

December 2014: Case #1 85F Dementia, presents to ED with fever, WBC 21K, AKI, + supra-pubic tenderness, + UA. Documentation: # Severe Sepsis Secondary to Bacterial UTI with Acute Renal Failure: The pt received IVF, has been started on broad spectrum abx. The pt had a lactate drawn as well as two sets of blood cultures draw in the ED. Fallout: The Lactate was drawn 4:25 minutes BEFORE the Time of Presentation for Severe Sepsis

January 2015: Case #2 63F presents to the ED with leukocytosis, abdominal pain, transaminitis. Documentation: # Severe Sepsis: Possible intra-abdominal source, concern for cholangitis given nature of abdominal pain and lactate of 33 Fallout: No blood cultures, lactate (in window) or IVF bolus.

How could an Attending Hospitalist not know to draw a lactate? Why would an Attending Hospitalist not draw Blood Cultures, Bolus IVF?

They Need More Education Solution: They Need More Education

Lots of Clinician Education December 2014 – February 2015 Lectures regarding Sepsis Bundle to: 5 Nursing Groups on 4MN and 5MN Family Medicine Residents Hospitalists Private Physicians Nursing Leadership Administration Leadership

Who was the Attending Hospitalist for Cases 1 & 2? Dr. Russell Kerbel

Did my patients “Fall-Out” of the Sepsis Bundle on purpose? No This is a Systems-Error

Where was the Systems-Error?

Lets use the Sepsis Bundle as an Example 50% Overall Bundle Compliance

Looking Closer at October 2014 82% + 11% = 50%

Breaking Down the Inpatient Bundle: The 4 Components:

2 of 8 Rapid Responses were Called October 2014 Sepsis Fallouts 1. Lactate Not Drawn 2. Abx Not Given 2 of 8 Rapid Responses were Called 3. Blood Cultures Not Taken 4. IVF Bolus

Will Fish Diagrams Solve the Problem?: Lactate Abx Lactate Real-Time Severe Sepsis Recognition and Documentation is Not Occurring Blood Cultures Fluid Bolus

4MN & 5MN Clinical Triggers Pilot Clinical Deterioration Primary Team Communication? 4MN & 5MN Clinical Triggers Pilot Clinical Stability Primary Team Communication? Stable Vitals Rapid Response Team SIRS / Sepsis Severe Sepsis Code Blue Team Septic Shock Time