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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
B R E A K O U T S E S S I O N
Improving Sepsis Outcomes Through Best Practices and Data Transparency
Assistant Vice President, Medical & Surgical Services, Valley Health System, Ridgewood, New Jersey
Bettyann Kempin DNP, NP-C, MS-HCM, CCRN-K, NEA-BC, FACHE
PRESENTED BY
Vice President, Quality Solutions Healthgrades
Debra Gradick MD, FACEP
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
Learning Objectives
• Implementing process and organizational changes to improve sepsis outcomes
• How to align providers to create clinical and organizational change
• Using data and chart review to corroborate clinical change
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Ridgewood, New Jersey Valley Health System
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Ridgewood, New Jersey Valley Health System
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
Hospital Inhospital Mortality
Star Performance Cases Actual Predicted
Sepsis
Valley Health System, Ridgewood, NJ 1717 22.25% 19.37% ★"
Five-Star Requirement 1717 18.05% 19.37% ★★★★★"
National Average 472 17.18% 17.25% ★★★"
State Average 714 20.43%
Hospital A 1154 18.80% 16.87% ★" "Hospital B 1715 20.82% 23.59% ★★★★★"
Hospital C 894 19.02% 15.54% ★"
Hospital D 1931 19.68% 21.15% ★★★★★" "Hospital E 726 22.87% 16.47% ★"
Benchmarks & comparative data (medpar 2011-2013) Sepsis – 2015 data table (prior outcomes)
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
Why Healthgrades Quality Solutions?
• Partnership dates back to 2006
• Quality Rating Assessments in:
• Cardiac, Orthopedics, GI, Vascular, Pulmonary, Critical Care, etc.
• Intimate knowledge of the organization and its performance
• Team members committed to the effort
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
Solution: Engaged Healthgrades Quality Solutions group
Quality assessment and improvement plans for sepsis
• Assessed efficacy of clinical structure and processes
• Identified opportunities for improvement based on current best practices
• Customized solutions
• Assessed documentation and coding
• Identified metrics for success
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
Strategy for innovation
• Formation of a sepsis subcommittee
• Monthly review of data
• Frequent on-site meetings
• Reports to (and engagement from) C-suite executives on progress
• Accountability (internally and at HG) for making requisite changes
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Focus on Multidisciplinary Approach Teamwork
• Healthcare providers from:
• EMS
• ED
• Inpatient/CC
• Informatics
• Quality
• Community Education
• Medical Records
• Healthgrades
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Process changes: Emergency medical services
• July 1, 2013 — pre-hospital sepsis protocol in effect utilizing SIRS criteria
• Mandatory EMS sepsis education
• Criteria developed in conjunction with ED physicians and EMS medical control
• Patients meeting criteria receive specific clinical interventions
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Process changes: Emergency department
• SWAT nurses
• Real-time triage flag for VS consistent with sepsis
• Sepsis tracker
• Electronic checklist for seamless transition of care
• ED sepsis order set
• Lactic acid reflex order
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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ED Sepsis tracker and checklist
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Process changes: Inpatient
• Sepsis order set – inpatient
• Sepsis surveillance board
• RRT real-time notification paging system
• Lactic acid reflex order in EMR
• Nurse-driven lactic acid order
• Process for repeat focused exam
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
Surveillance Board
Indicator Public Tracker
Multiple ways to monitor sepsis electronically Informatics: Checks and balances
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Palliative care pathway in the ICU Process changes: ICU
• Robust multidisciplinary rounds
• Patient criteria for palliative care
• Nurse-driven palliative consult
• Day 3-5: Have family meeting to establish goals of care
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Process changes: Technology
• Worked with Registration to ensure accurate capture of admission source
• Collaboration between HIM and providers to establish appropriate documentation for capture of palliative care
• Templates developed (with the aid of Informatics) to accurately document repeat focused exams at 3/6 hours
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Process changes: Quality department
• Creation of data collection tool — Sepsis Dashboard
• Shared drive
• Physician communication — feedback to providers on opportunities identified in case reviews
• Intensivist review of outlier cases
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
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Collect process and timing metrics along with labs, palliative care, and EMS alerts
Sepsis dashboard example
Arrival DateArrival Time
Inpatient Sepsis
Order Set Utilized
Inpatient Sepsis
Order set-Time
Ordered
Sepsis Diagnosis
Date
Sepsis Diagnosis
Time
First Order By Intensivist
DateFirst Order By
Intensivist TimeCC
Physician
Serum Lactate
Measured (Y/N)
Date & Time Lactic
OrderedLactic Result
Serum Lactate
Repeated to
Monitor Fluid
Resusitation (Y/N)
Blood Cultures Obtained Prior to
Antibiotic Administr
ation
Broad Spectrum Antibiotics
administered within 3 hrs
of ED Admission
(Y/N)
Date & Time Abx Ordered
(Administered)
Broad Spectrum Antibiotic
s Administ
ered Within 1 Hour Of
ICU Admission (Y/N)
Initial Bolus 30 ml/kg of
Crystalloid or
Colloid Equivalen
t (Y/N)
Patient Respondi
ng To Fluid
Did Patient
Get Started
On Vasopres
sors
Date & Time
Pressors Ordered
8/10/2016 1810 N N/A 8/21/2016 1852 8/21/2016 1408 Suffin Y 8/10/2016@1921 1.9 N Y N8/11/2016@0316 N/A N N Y
8/21/2016@1950
8/24/2016 2250 Y8/25/2016@0105 8/25/2016 0131 8/24/2016 2355 Jacoby Y 08242015@2335 7.3 Y N Y
8/25/2016@0109 N/A Y(notgiven) N Y
8/24/2016@2332
CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
Sepsis review example Chart review
Patient ID/Age/Sex
Admit Date
LOS Presenting Symptoms
Comorbidities Hospital Course
MRN XXXX 80 / M
9/5/XX arrival: 1550 Seen by ED MD: 1609
2 Sent in from SAR with fever, AMS, and SOB CXR -> RLL PN BIB Valley EMS Sepsis Alert in the field
Recent hip fx- s/p repair, Dementia, DVT, Parkinson’s, BPH
• ED triage VS: 139/104, 98, 30, 100.3 ® wbc 7.1, SCr 1.9, lactate 6.5, CXR->bilat infiltrates
• Given ceftriaxone and Zithromax in the ED; 500cc IVF and admitted to med/surg for PN/dehydration
• Developed AF with RVR and became hypotensive
• Transferred to ICU; Amiodarone started and Zosyn added.
• 9/6- Cardiology consulted for management of AF;
• Palliative Care involved to help establish goals of care-> patient made DNR/DNI
• O2 sat now 88%; BiPAP started
• 9/7- Still hypotensive despite IVF boluses; pt. taken off pressors at family’s request; transitioned to comfort care and expired
Considerations: Initial volume resuscitation not as per EGDT; admission to non-ICU bed Exceptional Care: Sepsis alert by EMS; Early involvement of Palliative Care
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
2017 Valley Health System Sepsis Outcomes
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
2012-2017 Healthgrades award years
Valley Health System Healthgrades outcomes (Medicare)
Cohort 2017 2016 2015 2014 2013 2012
Sepsis ««««« ««« « « « « Stroke ««««« ««« « « « « Resp. Failure ««««« ««« « « « «
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
2013-2016 (All payer data) Improvement in sepsis outcomes
19.95% 15.93% 16.96%
16.93%
26.90%
21.06%
33.45%
29.23%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Year 1 Year 2 Year 3 Year 4 (Q3 15 - Q2 16)
Actual
Predicted
18% reduction in mortality rates since 2013!!!
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.
-5.40 -5.07
-2.87
0.56
2.99
-6.00
-5.00
-4.00
-3.00
-2.00
-1.00
0.00
1.00
2.00
3.00
4.00
Medicare Data
2017 Healthgrades outcomes – Sepsis for Valley Health System
5 star in 2017!!!
2012 2013 2014 2015 2016 2017
1 1 1 1 3 5!!!
Z score by year 2013-2017
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CONFIDENTIAL © Copyright 2017 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.