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

2. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 2 Step 1- Identify, Document and Code Sepsis EARLYRECOGNITIONEARLYRECOGNITION Identify at triage if suspected infection and 2 SIRS criteria T o 100.4 (38.0) HR > 90 RR > 20 WBC > 12K or 10% bands (OR Altered LOC) CBC, Lactate, BC Consider IV fluids and ABX SBP ≤ 90? yes no Lactate high? 20 ml/kg fluid bolus 2-3.9 IV fluids Consider ABX Repeat lactate in 6 hrs <2 Document Septic Shock (Time Zero) ≥ 4 SBP ≤ 90 SBP >90 stop Suspected Sepsis Document Severe Sepsis (Time Zero) Developing a Common Framework for Identification and Treatment

3. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 3 Step 2: Meet EGDT Goals in 6 Hours Developing a Common Framework for Identification and Treatment

4. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 4 Treatment Plan for Severe Sepsis & Shock Time Zero 1 hour 2 hours 6 hours 6-12 hours Diagnosis Severe Sepsis or Septic Shock ABX started IV Fluid Central Line Placed 1 st CVP or SvcO2 MAP CVP ScvO 2 at Goal Repeat Lactate is Lower than First Lactate Screen all patients at risk Bundle Elements Developing a Common Framework for Identification and Treatment

5. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 5 Taking Action: (1) May Mortality Summit (2) November Sepsis Summit Develop Teams Tools and Equipment Adopt Algorithms Train Measure

6. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 6 Sepsis Collaborative and Site Visits Focus areas of site visits: Evidence of Engagement Quality of Team’s Functioning Interviews with Frontline Staff Members

7. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 7 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

8. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 8 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

9. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 9 Interviews with Frontline Staff Can they verbalize sepsis screening criteria Do they exhibit awareness of EGDT bundle elements and are they comfortable advocating for this treatment Are they knowledgeable about performance outcomes in their unit Do they feel valued as a member of this staff

10. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 10 The ‘Win – Win’ of Site Visits Attention Focus Relationships Commitment

11. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 11 Work to Come: Prevention/Detection Decrease Sepsis Mortality and Morbidity 29% of all mortalities Decrease Sepsis Mortality and Morbidity 29% 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) Detection Prevention Sepsis During Hospitalization 6% of all mortalities BSI, VAP, ?HAP, ?C diff, ?SSI Lactate protocols ? Rounding ? Early warning Order lactates!

12. Connecting to Our Potential © Copyright Kaiser Permanente, 2009 | For Internal Use OnlyNational Quality Conference | Page 12 More to Come…