Improvement Action Network (IAN)
Sepsis
Tomah Memorial Hospital
Thursday, June 15th 2017
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.
Divine Savior, Portage
Agenda
The Hospital and Physician Perspective
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
Round Robin – Gap Analysis and Goals
Each hospital team reports off on the completed gap analysis and goal to
accomplish today.
Bobby Redwood, MD, MPH
Sepsis: from the Greek σῆψις: the
state of putrefaction and decay
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)
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
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
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

Divine Savior Healthcare SE-1 Data
Core Measure Met by Month (%)
60%
50%
40%
30%
SE1
20%
10%
0%
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Divine Savior Healthcare SE-1 Data
Component Breakdown by Quarter (%)
120.00%
100.00%
SE1
3-hr Bundle
Lactate within 3-hr2
Blood Cx before Abx
Broad Spectrum Abx
Rpt lactate within 6-hr
30cc/kg bolus
Vasopressors
80.00%
60.00%
40.00%
20.00%
0.00%
4th Quarter 2016
(N=50)
1st Quarter 2017
(N=59)
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
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
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)
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
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
Thank You Dr. Redwood!
Break
15 minutes
Workgroup Activity
Work with other hospitals and your hospital team to brainstorm and
develop action plans on how to move forward with Sepsis initiatives.
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.
Resources
WHA Quality Center
http://www.whaqualitycenter.org/Partnersfor
Patients/Sepsis.aspx
•
Sepsis Starter Pack
•
Sepsis IAN information and details
MHA Community Page
http://community.mha.org/home

Archived Webinars

Discussion Board
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
Evaluation +/-
Contacts
Beth Dibbert
Improvement Advisor/Quality
Director
[email protected]
608-268-1817
Shruthi Murali
Improvement Advisor
[email protected]
608-268-1825
Jill Hanson
Improvement Advisor
[email protected]
608-268-1842
Bobby Redwood
Physician Improvement
Advisor
[email protected]
Nadine Allen
Improvement Advisor
[email protected]
608-268-1823
Kelly Court
Chief Quality Officer
[email protected]
608-274-1820