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

2. 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

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

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

5. 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)

6. 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

7. 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

8. 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

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

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

11. 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

12. 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

13. 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)

14. 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

15. 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

16. Thank You Dr. Redwood!

17. Break
15 minutes

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

19. 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.

20. Resources WHA Quality Center MHA Community Page
Patients/Sepsis.aspx
Sepsis Starter Pack
Sepsis IAN information and details
Archived Webinars
Discussion Board

21. 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

22. Evaluation +/-

23. Contacts Beth Dibbert Improvement Advisor/Quality Director
Shruthi Murali
Improvement Advisor
Jill Hanson
Bobby Redwood
Physician Improvement
Advisor
Nadine Allen
Kelly Court
Chief Quality Officer