SEPSIS: GETTING STARTED Ohio Sepsis Initiative July 15, 2015
SEPSIS INCIDENCE Definition: the number of severe sepsis or septic shock encounters using the following ICD-9 codes (995.91 Sepsis, 995.92 severe sepsis, 785.52 septic shock) per month Numerator: the number of patients admitted to the acute care setting with severe sepsis or septic shock Denominator: Total number of inpatient encounters July 15, 2015 2
Severe Sepsis & Septic Shock Incidence and Mortality, 2012Q1-2014Q3 Encounters 25000 Incidence Deaths 4000 Mortality 3500 20000 3000 15000 2500 2000 10000 1500 5000 1000 500 0 0 Sepsis POA Sepsis Not POA Sepsis POA Sepsis Not POA July 24, 2015 3
SEPSIS MORTALITY Definition: Percent of patients with severe sepsis or septic shock using the following ICD-9 codes (995.91 Sepsis, 995.92 severe sepsis, 785.52 septic shock) who expire during a hospital admission Numerator: the number of patients admitted to the acute care setting with severe sepsis or septic shock who died (discharge code of 20) during the hospital stay. Denominator: the number of patients admitted to the acute care setting with severe sepsis or septic shock July 15, 2015 4
Rate (%) 35 SEVERE SEPSIS & SEPTIC SHOCK MORTALITY, 2013Q4-2014Q3 30 25 20 15 Lower is better, 15.5 is the statewide mean 10 Statewide improvement target is 10.86 5 0 25 hospitals (4 OHA Sepsis Initiative) have a rate of 0 OHA Sepsis Initiative Hospitals Other Ohio/OHA Member Hospitals July 15, 2015 5
Rate (%) 60 SEVERE SEPSIS & SEPTIC SHOCK NOT POA MORTALITY, 2013Q4-2014Q3 50 40 Lower is better, 31.96 is the statewide mean 30 Statewide improvement target is 22.37 20 10 0 19 hospitals (3 OHA Sepsis Initiative) have a rate of 0 OHA Sepsis Initiative Hospitals Other Ohio/OHA Member Hospitals NOTE: Eleven hospitals participating in the OHA Sespsis Initiative did not have sepsis not POA encounters for the period 2013Q4-2014Q3. July 15, 2015 6
Rate (%) 35 SEVERE SEPSIS & SEPTIC SHOCK MORTALITY, 2013Q4-2014Q3 0-100 Beds 30 25 20 15 Lower is better, 15.5 is the statewide mean 10 Statewide improvement target is 10.86 5 0 20 hospitals (4 OHA Sepsis Initiative) have a rate of 0 OHA Sepsis Initiative Hospitals Other Ohio/OHA Member Hospitals July 15, 2015 7
Rate (%) 35 SEVERE SEPSIS & SEPTIC SHOCK MORTALITY, 2013Q4-2014Q3 101-300 Beds 30 25 20 15 Lower is better, 15.5 is the statewide mean Statewide improvement target is 10.86 10 5 hospitals have a rate of 0 5 0 OHA Sepsis Initiative Hospitals Other Ohio/OHA Member Hospitals July 15, 2015 8
Rate (%) 35 SEVERE SEPSIS & SEPTIC SHOCK MORTALITY, 2013Q4-2014Q3 300+ Beds 30 25 20 15 Lower is better, 15.5 is the statewide mean Statewide improvement target is 10.86 10 5 0 OHA Sepsis Initiative Hospitals Other Ohio/OHA Member Hospitals July 15 2015 9
PROCESS MEASURES July 15, 2015 10
SAMPLE SIZE Prefer a minimum of 10 discharge charts per month but more would be desirable. You can use sepsis charts used for core measure submission or any charts from other populations. Excluded populations are patients with Palliative care order prior to 180 minutes from arrival. July 15, 2015 11
CMS SEPSIS ALGORITHM July 15, 2015 12
INITIAL LACTATE LEVEL (Yes) An initial lactate level was drawn in the time window between 6 hours prior to and 3 hours following the presentation of severe sepsis. July 15, 2015 13
Yes for initial Lactate level July 15, 2015 14
BLOOD CULTURE COLLECTION Allowable Values: 1 (Yes) A blood culture was drawn in the time window between 48 hours prior to and 3 hours following the presentation of severe sepsis July 15, 2015 15
Yes for Blood Culture July 15, 2015 16
ANTIBIOTIC ADMINISTRATION Allowable Values: (Yes) A broad spectrum or other antibiotic was administered intravenously in the time window 24 hours prior to and 3 hours following the presentation of severe sepsis. An antibiotic listed on CMS Data dictionary Table 5.0, 5.1, or in data element Broad Spectrum or Other Antibiotic Selection July 15, 2015 17
Yes for Antibiotic Administration July 15, 2015 18
CRYSTALLOID FLUID Allowable Values: ADMINISTRATION (Yes) Crystalloid fluids were administered after the presentation of septic shock, or crystalloid fluids were being administered at the time of presentation of septic shock AND the volume ordered was 30 ml/kg. ONLY 0.9% Normal Saline or Lactated Ringers Solution. July 15, 2015 19
Yes for crystalloid fluids July 15, 2015 20
DATA ENTRY July 15, 2015 21
LOG-IN www.qualityinstitute.org/cops July 15, 2015 22
DATA ENTRY OHA will upload mortality data Hospitals enter data Be sure to save data before leaving page
DATA REPORTS Select measure Select Timeframe Click view to see results
DATA REPORTS July 15, 2015 25
EARLY GAP SURVEY RESULTS July 15, 2015 26
EARLY GAP ANALYSIS RESULTS Have Sepsis Screening Tool Screening Location 80 100 70 90 60 80 70 50 60 40 50 30 40 20 30 20 10 10 0 Have Sepsis Screening Tool 0 ED M/S Unit ICU Other Yes No Yes No July 15, 2015 27
EARLY GAP ANALYSIS RESULTS Screening Frequency Alert Mechanism in Place 90 100 80 90 70 80 60 70 50 60 40 50 30 20 10 0 Triage Q shift Inpatient 40 30 20 10 0 Yes No Yes No July 15, 2015 28
EARLY GAP ANALYSIS RESULTS Have Sepsis Order Set/Protocol 100 3 Hour Bundle 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Lactate Level Bld Culture Antibiotic Fluids Yes No Yes No July 15, 2015 29
EARLY GAP ANALYSIS RESULTS Antibiotic Dispensing System W/I 1 hour Time Zero Method for Visual Cue 90 100 80 90 70 80 60 70 50 60 40 50 30 20 10 0 ED Inpatient 40 30 20 10 0 Yes No Yes No July 15, 2015 30
EARLY GAP ANALYSIS RESULTS 70 60 50 40 30 20 10 0 Track Clinician Adherence 45 40 35 30 25 20 15 10 5 0 Meetings for Sepsis Review Yes No Yes Partly No July 15, 2015 31
HOW TO PRIORITIZE EFFORTS To Do over next month Complete Gap Analysis Identify areas where you differ from recommended Form an interdisciplinary team to address Sepsis Identify executive champion Identify clinical champion Set Aims (be specific) July 15, 2015 32
HOW TO PRIORITIZE EFFORTS To do over next month Develop an action plan Align with organization goals Determine target vs. broad approach Look for and focus on low hanging fruit Implement action plan Collect and submit data monthly Do small tests of change July 15, 2015 33
NEXT MONTH August 12 Three Hour Bundle James O Brien, MD, MS Vice President, Quality & Patient Safety OhioHealth Riverside Methodist Hospital Data due Aug 15 July 15, 2015 34
OHA collaborates with member hospitals and health systems to ensure a healthy Ohio James V. Guliano, MSN, RN-BC Vice President, Quality Programs james.guliano@ohiohospitals.org Rosalie Weakland, MSN, RN, CPHQ, FACHE Senior Director, Quality Programs rosalie.weakland@ohiohospitals.org Ryan Everett Director, Population Health Ryan.Everett@ohiohospitals.org Ellen Hughes, RN Quality Coordinator Ellen.hughes@ohiohospitals.org Ohio Hospital Association 155 E. Broad St., Suite 301 Columbus, OH 43215-3640 T 614.221.7614 ohiohospitals.org