MHA 2015 Fall Regional Meetings Strategies to Reduce Harms and Infections

Welcome and Agenda  Introductions  Missouri harms and infections data review  Infection prevention focus areas: sepsis, hand

hygiene, antimicrobial stewardship programming  Shared best practices  Workshop activity  Networking!!!

Missouri’s Performance STATE LEVEL NUMBER OF INFECTIONS FROM STATE LEVEL RAW DATA FOR TOTAL HARM FROM Q4CY2013TOTAL HARM BY OUTCOME MEASURE Q4CY2013 -Q1CY2015 Q1CY2015

Falls = 38% increase

800 1600

20

15

10

5

0

9.4% 42%

700 1400

NUMBER OF INFECTIONS

NUMBER OF HARM EVENTS

25

250

200

600 1200 500

150

1000

400

800

100

300

600 200

50

400 100

200 0 Total Harm

0

Q4CY2013

Q1CY2014

Q2CY2014

Q3CY2014

Q4CY2014

Q1CY2015

667

630

564

582

324

352

0

Q4CY2013 Total Infections 1323 Falls & Trauma Pressure Rates

Q1CY2014 Q2CY2014 Q3CY2014 Q4CY2014 Q1CY2015 1381 1366 Death Rate 1117 1146DRG's 1198 REPORTING TIMEFRAME in Low Mortality DVT Rate

DVT RATE

30

Antibiotic/Antimicrobial Stewardship

Stewardship Program Goals Goal #1: Optimize clinical outcomes while minimizing the unintended consequences of antimicrobial use

Goal #2: Reduce health care costs without adversely affecting the quality of care

Antibiotic Resistance  Antibiotic resistance is not a new phenomenon  Within 10 years of penicillin’s discovery in 1928,

group A streptococci and pneumococci had already developed modes of resistance  What is new?  the growing magnitude of the problem  the speed with which new resistant pathogens are emerging  the decline in new antibiotic research and development

Antibiotic Resistance  At least some clinical

isolates of many pathogenic bacterial species are now resistant to most antibiotics  Most new antibiotic developments have failed to expand on the “golden era” of antibiotics  Poses a significant patient safety and public health issue

Antibiotic Resistance  Root-Causes   

Prescribing incorrectly Over-prescribing Unnecessarily prescribing

 Stats 



• Patient harm, morbidity, mortality • Cost of care • Cross-transmission

In a survey of 505 acute care hospitals, 78% had evidence of redundant antibiotic usage Antibiotic exposure is the single most important risk factor for the development of C. difficile

Outside Pressures and Future Payfor-Performance??  Antibiotic stewardship programs

currently voluntary  CDC urging CMS to “put teeth” to it and include as part of pay-forperformance  “10 x ’20 initiative,” a call to action to develop 10 new antimicrobial drugs by the year 2020 (IDSA)  Strategies to Address Antimicrobial Resistance Act (H.R. 2400 known as STAAR) — introduced in May 2009

Components of an AR Program*  Leadership commitment  Accountability via an

interprofessional team with a designated leader  Designated pharmacy leader  Tracking of antibiotic use  Regular reporting on antibiotic use and resistance

 Educating providers on

use and resistance  Guidelines for management of common infection syndromes  Computer decision support  Specific improvement interventions

*2014 CDC Core Elements of Hospital Antibiotic Stewardship Programs and 2007 Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship

Ensure the “Basics”

Anderson DJ, Kaye KS. Controlling antimicrobial resistance in the hospital. Infect Dis Clin North Am. 2009; 23:847-64, vii-viii.

Triple Threat Infection Preventionist + Infectious Disease Specialist + Pharmacist Source: A Hospital Pharmacist’s Guide to Antimicrobial Stewardship Programs

Recommended Strategies • Hard stops • Care bundles • Antibiotic “timeouts” • Committee structure • Antibiotic cycling • Education feedback strategies

High Reliability Organization Principles!!

Data Needed!  Measurement methodology is not exact Example: defined daily doses  Health care informatics focus areas and goal  Hospitals can measure antimicrobial use, track changes in antimicrobial use and resistance over time, compare to similar institutions, and provide data to regional and national databases to allow largescale tracking of trends  Encourage reporting through NHSN (HIDI Group) Source: A Hospital Pharmacist’s Guide to Antimicrobial 

Stewardship Programs

Quality – Finance Link: ASP Program Return on Investment • Calculation of anticipated savings may be based on current use and practices and estimates of the impact of proposed interventions. Such calculations may be useful in obtaining initial support for the development of an ASP. • Calculation of actual savings can be based on the results of specific patientlevel interventions or on aggregate data for the entire hospital/facility from preand post-intervention periods. Such calculations may be one method of demonstrating the value of the ASP and justifying requests for additional financial support (e.g., personnel resources) for the program.

Cost Savings Opportunities  Direct Savings  





IV:PO Conversions Reductions in use of high-cost antimicrobials Reductions in performing therapeutic drug monitoring (TDM) lab tests Reduction in overall antimicrobial use

 Associated Savings   



Reduced LOS Reduced incidence of

C. difficile

Reductions in rates of antibiotic resistance among health care facility–associated pathogens Reduced incidence of toxicity

Population Health Implications  Care Coordination  



Cross-transmission among hospitals, LTC, and the community Lack of systemic control of antibiotic use across domains of care Increase in outpatient and LTC setting antibiotic usage

Population Health Implications  Antibiotic use in animal medicine/food animal  





production Antibiotic use in agriculture for food production Growing body of evidence noting link between antibiotic use in food/animals to antibiotic resistance in humans Includes the direct acquisition of resistant pathogens through the food supply as well as the transfer of resistance genes to human bacterial populations Recommendations to decrease/eliminate use

ASP Resources          

CDC IDSA LeadStewardship.org APIC SHEA ASHP Society of Infectious Disease Pharmacists The Ohio State University UCLA Health System The Nebraska Medical Center

ASP Resources

Trending: HAI

HAI Overview  Every day, 1 in 25 hospital patients suffer from

 

 

at least one health care-associated infection An estimate of 4,037 people died in Missouri hospitals because of an HAI in 2014 Pay-for-Performance  HAC Reduction Program penalty  VBP reimbursement Costly Substandard/not evidence based care

Link between HAI and Handwashing  Difficult to prove but studies with increasing

hand hygiene show decreased infection rates

Key Structures to Hand Hygiene Programs  Successful hand hygiene educational programs should

incorporate:  reinforcement of hand hygiene messages  knowledge of health care workers’ perceived importance of hand hygiene and its role in prevention of HAIs  monitoring and feedback of hand hygiene practices  practical education tools  role modeling by senior staff  supportive infrastructure and management

Meet Infection Control Barbie, Ami Links to Hand Washing Resources Centers for Disease Control and Prevention Institute for Healthcare Improvement The Joint Commission World Health Organization

Trending: Sepsis

Update  Effective October 1, 2015, CMS will enforce its

new bundle measure for severe sepsis and septic shock as part of the Hospital Inpatient Quality Reporting (Hospital IQR) program  The new bundle is based on two time periods:  the first three hours of diagnosis  six hours of diagnosis  the clock starts as soon as presumed or confirmed severe sepsis is documented by diagnosis or criteria are met.

Sepsis Bundle Project: New CMS Guidelines  New measure beginning with 10/1/2015

     

discharges Collected for CMS Process measure Added to align with CY 2015 IPPS Final Rule Includes SEP-1 – Early Management Bundle, Severe Sepsis/Septic Shock 63 new data elements Improvement noted as an increase in the rate

SEP Initial Patient Population  Population determined using five data elements     

ICD-10-CM Principal Diagnosis Code ICD-10-CM Other Diagnosis Code Admission Date Birthdate Discharge Date

SEP Initial Patient Population  Patients admitted to the hospital for acute

inpatient care with a PDC or ODC for sepsis as defined in Appendix A, Table 4.01  Age > or = to 18 years  LOS < or = to 120 days

SEP Sampling  Option of sampling quarterly or monthly 

Hospitals selecting sample cases must ensure that the population and sample size meets the conditions

SEP Sampling  Quarterly Sample Size Based on Hospital’s Initial Patient Population Size for the Sepsis Measure

SEP Sampling  Monthly Sample Size Based on Hospital’s Initial Patient Population Size for the Sepsis Measure

It’s all about the lactate Lactate Level (mmol/L)

Associated Mortality Rate

≥ 4.0 2.5-4.0 20 or PaCO2 12,000 or 10% bands

(Systemic Inflammatory Response Syndrome)

• Severe Sepsis + Hypotension

Progress lags despite 13 year campaign  Surviving sepsis campaign yet to curb rising sepsis mortality rates

17%

Increase in sepsis inpatient hospital death rates in the past decade

19%

Physicians who follow pediatric sepsis guidelines

31%

Physicians who adhere to 6-hour sepsis resuscitation bundle The Advisory Board Group Company, 2014

Many Hurdles Along Path to Delivering Sepsis Care Triage  Suspect sepsis  Screen for sepsis  Identify positive screens  Inform physician  Kick-off 6 hr bundle  Order sepsis panel

47%

Fail to order lactate with blood culture

Early Resuscitation  Draw cultures and lactate  Give antibiotics  Collect test results  Alert ICU or RRT  Central line insertion  EGDT monitoring

50%

Fail to administer antibiotics within 6 hrs

Ongoing Management  ICU/Floor transfer  Hand-off remaining bundle steps  Repeat lactate  Collect culture results  Adjust antibiotics

72%

Fail to document specific microbe The Advisory Board Group Company, 2014

4-Tier Process for Severe Sepsis Program Implementation Measuring Success and CI Implementation of the Sepsis Bundle Early Screening with Tools and Triggers Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively Sepsis Solutions International 2006

Tier 1: Organizational Consensus and Support  Define Sepsis Program Goal and aligned with   

  

Measuring Success and CI

organizational goals Implementation of the Sepsis Bundle Identify Executive sponsor Early Screening with Tools and Triggers Collect Baseline Data—essential step Organizational Consensus that Severe Sepsis Must be Managed Develop sepsis team Early and Aggressively (do we have all the right people here?) and schedule monthly (minimum) meetings for at least 6 months Complete Team Charter Identify nursing and physician champions in ED and ICU and ensure champions attend team meeting Begin to define action plan and timeline for program development and implementation Sepsis Solutions International 2006

Tier 1: Challenges and Barriers  Scheduling meetings and consistent

attendance  Time  Skipping key steps  Charter  Communication plan (accountability)  Align within organization  Baseline data

Sepsis Solutions International 2006

Tier 2: Screening for Severe Sepsis Define the Disease Continuum  Sepsis: presence of infection (suspected or confirmed) with systemic manifestations of infection  Severe Sepsis: Sepsis-induced tissue hypoperfusion or organ dysfunction  Septic Shock: Hypotension that persists despite adequate fluid resuscitation

Measuring Success and CI

Implementation of the Sepsis Bundle

Early Screening with Tools and Triggers

Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Sepsis Solutions International 2006

Tier 2: Screening for Severe Sepsis  Develop screening process for ED, rapid

response team and ICU (eventually housewide)  Develop audit process to evaluate compliance and effectiveness  Ensure screening process has clear “next steps” defined for nursing staff

Sepsis Solutions International 2006

Tier 3: Sepsis Bundle Implementation  Develop easy to use order sets (ED and ICU  

 

 

Measuring Success and CI

should be the same), organized by bundle Implementation of the Sepsis Bundle Order sets approved by appropriate medical Early Screening with Tools and Triggers and nursing leadership/committees Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively Identify resistance and barriers to bundle implementation and develop solutions  Ex: ability to get lactate quickly Identify equipment needs and make capital requests Develop triggers/processes to alert staff when time to move from first 3 hrs to shock bundle Define educational plan for all staff Develop implementation plan Sepsis Solutions International 2006

Tier 3: Sepsis Bundle Implementation  Hospital resources often focus on planning phase and

then back off after implementation.  The implementation phase is the most critical.  Frequent rounds by project champion recommended on unit to support staff and answer questions.  Defined resources for bedside nurse  Project champion has pager to be available 24/7 initially  Clinical nurse champions identified on each ICU unit and ED to be resources to bedside staff (these staff should be members of the sepsis team/committee from the beginning) Sepsis Solutions International 2006

Tier 3: Sepsis Bundle Implementation  Identify who will oversee the implementation and the

expectations of that person(sepsis nurse or program coordinator)  Define ICU/ED resources for staff that they can call at any time for questions and assistance  Create rounding schedule and process  Should begin as daily in the ICU and ED  Keep master list of all patients who go on the bundles (and those who should have but didn’t if possible)  Do real time interventions to ensure patients get the evidence based practices  Define follow up process for review and evaluate missed opportunities

Sepsis Solutions International 2006

Tier 4: Measure Success and Continuous Improvement  Define outcome and process data

Measuring Success and CI

elements that will be collected  Develop and implement a data collection process  Revise and update goals and action plan as needed  Execute implementation plan

Implementation of the Sepsis Bundle

Early Screening with Tools and Triggers

Organizational Consensus that Severe Sepsis Must be Managed Early and Aggressively

Sepsis Solutions International 2006

Tier 4: Measure Success and Continuous Improvement  Data Collection  Patient Log Define how will find all patients that receive the bundles  Real time data collection is optimal—then used as checklist to ensure patient receives all appropriate interventions  Outcome  Mortality (ICU and Hosp)  Hosp LOS  Cost per case (total and direct)  Process  SSC database  Data elements that measure process achievement of the 3 & 6 hour bundles & outcome measures of the 6hrs 

Sepsis Solutions International 2006

Strategies for Keeping Sepsis Front and Center  Align team with clinical and quality structures in     

 

organization Sepsis program/goals part of hospital quality plan Reporting progress and data quarterly to executive leadership Report to hospital board annually Standing agenda item on department meetings Communication plan – includes flyers, newsletters, postings in units etc. Code sepsis Real time data measurement and feedback Sepsis Solutions International 2006

Question  Where is your sepsis recognition priority 

 

ED/EMS Critical Care Floors

Case Study 1 Establishing an Emergency Department Sepsis Screen at St. Claire Regional Medical Center, Kentucky

Discovering a Need at St. Claire Regional Medical Center  Chart reviews of patients with primary diagnosis

of sepsis for the months of January-March 2012.  42 patients with primary diagnosis of sepsis.  21 patients met SIRS criteria at triage  13 of those 21 patients met SIRS criteria based on vital signs alone.  Only 3 of those 21 patients had the established sepsis order set initiated.

Bailey, P. (2014). St Claire Regional Medical Center.

Next Step at St. Claire  Sepsis screening tool created and added into ED

triage assessment.  Performed on every adult patient upon arrival to emergency department.

 If patient meets the criteria, the Triage Sepsis order set is initiated by the nurse and the patient is flagged on the tracker.

Bailey, P. (2014). St Claire Regional Medical Center.

Triage Sepsis Order Set at St. Claire        

CBC CMP Magnesium PTT, PT/INR Lactate Troponin BNP Blood culture x 2

 CXR - portable  EKG  IV initiation and normal

saline bolus  Bedside telemetry, noninvasive blood pressure, and continuous pulse oximetry monitoring

Bailey, P. (2014). St Claire Regional Medical Center.

Post-Intervention Data at St. Claire  Screening initiated on January 15th, 2013  235 positive screens from January 15th,2013

through June 30th, 2013  113 (48% of patients with positive screen) met criteria for diagnosis of sepsis  Main sources  Sepsis of urinary origin  Sepsis of pulmonary origin

Bailey, P. (2014). St Claire Regional Medical Center.

Case Study 2 Reducing Sepsis Mortality at Wake Health

Case Study at Wake Forest:

A Gradual Rollout to the Floors, ED, and ICU Stepwise Approach Allows Initiative Refinement Along the Way

The Advisory Board Group Company, 2014

Wake Health’s Barriers to Optimal Sepsis Care Reflect Industry-wide Challenges Multidisciplinary Staff Meeting to Uncover Barriers to Optimal Sepsis Care at Wake Health

Meeting Attendees  Performance improvement experts

 Faculty and house staff from medical, surgery, and neurology departments

    

ICU physicians

Respiratory therapy leaders Frontline nurses Pharmacists Rapid response team

Barriers Identified  Guidelines not consistently followed in time-sensitive window

 Responsibilities for identifying and treating sepsis in rapid timeframe not well-defined

 Lack of education on sepsis and sepsis initiative among frontline staff

 Clinicians took often take ad-

hoc approach to screening and miss diagnoses

The Advisory Board Group Company, 2014

Reducing Sepsis Mortality at Wake Health

Eight Tactics for Promoting Consistent, High-Quality Sepsis Care

I

II

III

Formalize Identification

Accelerate Treatment

Hardwire Accountability

1. Inpatient early

warning sepsis screen 2. Acuity-sensitive ICU sepsis trigger

3. Simplified sepsis bundle 4. Top-of-license sepsis roles 5. Rapid response sepsis kit 6. Comfort care decision prompt

7. Real-time

protocol checklist 8. Phased bundle adherence accountability

The Advisory Board Group Company, 2014

Wake Health Roadmap I: Formalize Identification (Immersion Project coming Fall 2015!)

Signaling Initiative Importance with a Brand “Code Sepsis” Logo

Definition of “Code Sepsis” at Wake Health A patient emergency requiring immediate action for the treatment of potential sepsis and septic shock.  Early identification, communication, and intervention for patients with sepsis  Implementing the sepsis bundle (including antibiotics) within one hour The Advisory Board Group Company, 2014

Wake Health Addresses Barriers to Identification Sepsis Identification Process Across Inpatient Floor, ED, and ICU

Barriers to Early Identification  Subtle symptoms often fly under the radar

Site of Care

Screen Used

Provider Responsible for Screening

Screening Frequency

Inpatient Floor

Early Warning System

Nursing assistant checks vitals and RN patient alertness

• Every 4 hours for first 24 hours • If patient is stable after 24 hours, every hours • Is EWS is between 5-7, every four hours

ICU

SIRS and “snooze criteria”

Bedside nurse

• Upon ICU admission • Every 12 hours as needed

ED

EWS

RN

During ED triage

 Floor nurses not

exposed to many sepsis cases

 Nurses reluctant to sound alarm because of false positive

 All clinicians

extremely busy

The Advisory Board Group Company, 2014

Sepsis Screen Tells Nurses When to Sound the Alarm Early Warning Score Criteria

Used on inpatient floors and ED

The Advisory Board Group Company, 2014

Sepsis Trigger in ICU Reduces False Alarms ICU sepsis screen accounts for high acuity Hitting the “Snooze” to Reduce False Alarms

“The sepsis trigger needs to be like an alarm clock when you hit the snooze alarm. ICU patients will meet SIRS criteria for a period of time and it shouldn’t always trigger an alert.”

ICU Physician, Wake Forest Baptist Health

Patient Timeline in ICU

“Snooze Phase” Patients expected to meet SIRS criteria, but not have sepsis: nurses do not trigger sepsis alert

“Post-Snooze Phase” Nurses conduct sepsis screen every 12 hours or as needed: if positive for SIRES nurse draws lactate: if abnormal lactate and/or potential infection, nurse calls “Code Sepsis”

The Advisory Board Group Company, 2014

Complete “Snooze” Criteria Length of Time per “Snooze” Based on Diagnosis “Snooze” time must elapse before triggering a sepsis alert for patient who meet SIRS Criteria If a patient is…

Snooze them for…

On ABX for Sepsis

96 hrs from new ABX start/change in ABX

Post-Arrest Hypothermia Protocol 72 hours from arrival to facility Patients DNR/Comfort Care

Permanent, unless order changed

Trauma Patient

48 hours from arrival to facility

Patient has CT Surgery

48 hours from return to unit

AMI patients (including STEMIs)

48 hours from return to unit

TAVR Value

24 hours from return to unit

Intracranial bleed

24 hours from arrival to ED

Surgery

24 hours from return to unit The Advisory Board Group Company, 2014

Wake Health Roadmap II: Accelerate Treatment

Rapid Treatment Crucial to Reduce Mortality Impact of Compliance with 6-hour Sepsis Bundle on Hospital Mortality

The Advisory Board Group Company, 2014

Drawing the Link from Staff Activities to Mortality

The Advisory Board Group Company, 2014

Simplifying Guidelines to a FourComponent Bundle Simplified, Time-Sensitive Sepsis Resuscitation Bundle at Wake Forest Health

1. Measure serum lactate 2. Obtain blood cultures prior to antibiotic administration

3. Administer broad-spectrum antibiotics within one hour

4. Fluid resuscitation if MAP