Who Moved My Sepsis? Understanding Sepsis Changes in Terry P. Clemmer, MD

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1 Who Moved My Sepsis? Understanding Sepsis Changes in 2015 Terry P. Clemmer, MD Danny R. Probst, MS, BSN, RN Data Manager, Intensive Medicine Clinical Program, Objectives: Identify the continued need to focus on Sever Sepsis and Septic Shock Relate the new CMS SEP-1 Measure Describe Intermountain s strategy moving forward with Severe Sepsis and Septic Shock

2 Who moved my Sepsis Understanding Sepsis Changes in 2015 Terry Clemmer Daniel R. Probst Lydia Dong

3 Sepsis History Greeks & Romans Word Sepsis is derived from the Greek which refers to the decomposition of animal, or vegetable or organic matter in the presence of bacteria. The term sepsis is found in his writings, was one of the first to examine antisepsis properties of potential medicinal compounds Revered Historical figure in the study of sepsis his passion was the use of medications to treat disease. His collection of medicinals ( apotheca ) was the forerunner of today s apothecary (pharmacy Convinced that within swamps, sepsis resulted from the production of invisible creatures Formed public health initiatives, early health initiatives were directed at eliminating these swamps and the creation of safe and elaborate water delivery systems

4 Sepsis History Golden Era (19 th Century) Maternity Ward Puerperal Sepsis 16% Implemented Hand washing and Sepsis dropped to 3% Mandate to reduce deaths from postoperative sepsis initial efforts resulted in 45% to 50% of patients dying from infections Germ Theory of Disease, demonstrated that putrefaction required living organisms, presented data demonstrating streptococci as the cause of puerperal sepsis. One of the fathers of microbiology, developed modern microbiology techniques

5 Setting the Stage Antibiotics Michael Heidelberger & Walter A. Jacobs 1917 Alexander Flemming Ernst Florey -- Howard Chain Aromatic arsenicals, for the treatment for infectious diseases, in particular syphilis.

6 Intermountain Sepsis History Pre 2004 to Baseline Study Phase Clinical Program Goal Period Planning Phase Implementation Phase Board Goal Period

7 Sepsis History Summary The early descriptions of sepsis date back to antiquity. The initial theories of infectious disease espoused by Hippocrates and Galen remained largely unchallenged until Lister, Koch and Pasteur rapidly advanced the field and resulted in a paradigm shift in the way we view sepsis.. Continued research into sepsis has resulted in a decrease in mortality when compared to historical controls, and results will no doubt continue to improve.

8 Sepsis Rationale According to the Agency for Healthcare Research and Quality (AHRQ), Sepsis is the most expensive cause of hospitalizations in the United States, accounting for more than $24 billion annually Number of hospitalizations with a principal diagnosis of sepsis increased by 148% from 2000 to 2010, with a secondary diagnosis increased by 66% Sepsis is the sixth most common principal diagnosis in the inpatient setting accounting for one out of every 23 hospitalized patients Of all hospital deaths nationally, as many as 52% were among patients diagnosed with sepsis. Sepsis hospitalization also contributed to 21.2% of all hospital charges. Multiple studies have shown that, for patients with severe sepsis, standardized order sets, enhanced bedside monitor display, telemedicine, and comprehensive CQI feedback is feasible, modifies clinician behavior, and is associated with decreased hospital mortality (Thiel, 2009; Micek, 2006; Winterbottom, 2011; Schramm, 2011; Nguyen, 2007; Loyola, 2011).

9 Current Sepsis Goal Progress

10 SEP-1 CMS reporting begins October 1 st 2015

11 SEP-1 Patient Population (Cohort)

12 SEP-1 Patient Population (Cohort)

13 Cohort Impact

14 SEP-1 Patient Population (Cohort) Key Take Away Compliance and mortality will be tracked on all patients who are coded as severe sepsis or septic shock regardless of transfer to ICU.

15 Numerator: Severe Sepsis Within 3 hours of presentation of severe sepsis Initial lactate level measurement Broad spectrum or other antibiotic administration Blood cultures drawn prior to antibiotics AND Within 6 hours or presentation of severe sepsis Repeat Lactate if initial lactate is elevated (>2)

16 Numerator: ONLY if Septic Shock Within 3 hours of presentation of septic shock Resuscitation with 30 ml/kg crystalloid fluids AND ONLY if hypotension persists Within 6 hours of presentation of septic Vasopressor administration AND ONLY if hypotension persists after fluids OR initial lactate > 4 mmol/l Within 6 hours of presentation of septic shock Repeat volume status and tissue perfusion assessment

17 SEP-1 Severe Sepsis Presentation

18 SEP-1 Severe Sepsis Presentation Key Take Away Time Zero is identified as the time the physician/apn/pa documents presentation time in medical record or when patient manifests severe sepsis criteria. It is not ED Arrival or ICU Admit date/time Preferred data source for presentation is physician/apn/pa notes or ED Record Inclusion Terms Severe Sepsis r/o severe sepsis Differential Diagnosis: Severe Sepsis Possible Severe Sepsis Exclusion Terms Septic Bacteremia Septicemia Possibly Septic If no inclusion terms are contained in the physician/apn/pa documentation then the record will be reviewed to determine if severe sepsis was present

19 SEP-1 Severe Sepsis Presentation Key Take Away Physician Documentation Order sets initiation can be used for presentation time if the documentation clearly indicates the order set is being used for severe sepsis or septic shock and the order is dated and timed Problem list could qualify as an acceptable data source is there is documentation that the problem is current and there is a date and time associated with it A clinical event or alert could not serve as an acceptable data point, the source information that triggered the alert would need to be used.

20 SEP-1 Severe Sepsis Bundle

21 SEP-1 Severe Sepsis Bundle Key Take Away Antibiotic Timing Antibiotic monotherapy vs combo therapy

22 SEP-1 Septic Shock Presentation _

23 SEP-1 Septic Shock Presentation Key Take Away Time Zero is identified as the time the physician/apn/pa documents presentation time in medical record or when patient manifests severe sepsis criteria. It is not ED Arrival or ICU Admit date/time Preferred data source for presentation is physician/apn/pa notes or ED Record Inclusion Terms Septic Shock r/o Septic Shock Differential Diagnosis: Septic Shock Possible Septic Shock Exclusion Terms Septic Bacteremia Septicemia Possibly Septic If no inclusion terms are contained in the physician/apn/pa documentation then the record will be reviewed to determine if severe sepsis was present

24 SEP-1 Septic Shock Presentation Key Take Away Physician Documentation Order sets initiation can be used for presentation time if the documentation clearly indicates the order set is being used for severe sepsis or septic shock Problem list could qualify as an acceptable data source if there is documentation that the problem is current and there is a data and time associated with it A clinical event or alert could not serve as an acceptable data point, the source information that triggered the alert would need to be used.

25 SEP-1 Septic Shock Bundle

26 SEP-1 Septic Shock Bundle Key Take Away Fluid Volume is based upon actual weight vs. ideal body weight Focused Exam, Passive Leg Raise and Fluid Challenge all require assessment and documentation by Physician/APN/PA

27 Intermountain Sepsis Strategy

28 Intermountain vs CMS Patient Count

29 Intermountain Strategy Keep our current Intensive Medicine abstractors and monitor bundle compliance Adopt CMS definitions to decrease confusion on care of sepsis patient In addition to the CMS bundle elements we will continue to monitor the maintenance bundle (Glucose, Steroids, and Lung Protection)

30 The need for facility/region Sepsis Coordinators Severe Sepsis/Shock incidence continues to rise with increased focus locally and nationally Employ Stroke/Trauma coordinators in facilities and sepsis has x times more volume Sepsis Coordinator provides increased education and increased improvement efforts for patient and provider Sepsis Coordinator provides concurrent data abstraction, reporting and tracking of missed opportunities Sepsis Coordinator works across departments to improve efficiency in the care of sepsis patients

31 References Sepsis and Septic Shock: A history (Duane J. Funk, MD, FRCP(C)a, Joseph E. Parrillo, MDb, AnandKumar, MDc,d) Hospital IQR Release Notes version 5.0