Do’s and Don’ts of Data Display Sepsis/CLABSI Collaborative

April 15, 2013

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Jared Quinton Jim Stotts

Susan Garritson

Michael McElroy

Joe Clement

Kim Delahanty

Kathleen Quan

Debbie Thompson

Jennifer Yim

Data, Data, and More Data

Default NHSN Graph Output

NHSN Resource Guide: http://www.cdc.gov/nhsn/pdfs/training/Resource-book.pdf

Peer to Peer Data Tips

Kim Delahanty from UC San Diego

California Confidential Evidence Code

1157

• UC San Diego DSRIP House wide CLABSI Goals:

2012-2013

• Target: 1.52

• Threshold: 1.55

• Maximum: 1.51

Curos, CHG

bath, 2 x a day

environ clean

California Confidential Evidence Code

1157

Curos, CHG

bath, 2x a day

environ

cleaning

• UC San Diego DSRIP House wide CLABSI Goals:

2012-2013

• Target: 1.52

• Threshold: 1.55

• Maximum: 1.51

Telling a Story with Data

1. CL Insertion Kit proposed 6. Start CL PPE Insertion Kit

2. CL Dressing Kit start 7. Start Insertion Kit

3. CLBSI SICU Study start 8. Standardized Education and

4. HC ED Insertion Kit pilot Compete CL Insertion

5. CL PPE Insertion Kit piloted 9. CHG Bathing

• Data is not just the output of a mechanical process. There is a real human dimension in your work. The numbers represent individuals, so you should approach the data in that way.

• It’s also not just a graph, but a graphic.

• Labels and annotations provide context, while color direct your attention to what’s important.

• Chart and graph design isn’t just about statistical visualizations, but also explaining what the visualization shows.

Susan Garritson from UC San Francisco

* = change in denominator to include inpatient

and observation days per NHSN criteria

Hospital Onset- defined as specimen collected > 3

days after admission to the facility ( on or after day

4).

• C.dificile Toxin-positive C.difficile stool assay for

a patients in inpatient location in with no prior

toxin positive C.difficile stool assay reported

within 14 days for the same patient/location

• MRSA and VRE positive blood cultures for a

patient in a location with no prior MRSA positive

blood culture reported within 14 days interval

between specimens.

Jim Stotts from UC San Francisco

(Unit) Sepsis Dashboard July 2012 – January 2013

0%

20%

40%

60%

80%

100%

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Lactate Compliance

0%

20%

40%

60%

80%

100%

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

BCx Compliance

0%

20%

40%

60%

80%

100%

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

ABX Compliance

0%

20%

40%

60%

80%

100%

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Fluids Compliance

0%

20%

40%

60%

80%

100%

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Bundle Compliance (UCSF IAP Target 70%)

0

20

40

60

80

100

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Average

Days

Nights

Target

% C

om

plia

nce

(Unit) Sepsis Screening Compliance

Blood culture before ABX administration

ABX within 1 hour of TOP of severe sepsis

At least 1L NS or 20-30 cc/kg bolus NS for severe sepsis

Compliance with all 4 bundle elements.

Abbreviations: Abx = antibiotic; BCx = blood culture; TOP = time of presentation of severe sepsis; NS = Normal Saline

This decrease in lactate compliance is due

to 1 out of 4 patients in whom a lactate

wasn’t obtained within 6 hours from TOP.

Though this shows that BCxs were obtained

before antibiotics in 4 out of 4 cases, the

average time it took to get BCxs was 198 mins

in this cohort. Our goal is to obtained BCx

within 60 mins from order.

This drop in antibiotic compliance is due a

delay in initiating orders to treat severe

sepsis. The average time it took to administer

antibiotics once an order was written was 29

mins in this cohort. Call a code sepsis to

expedite antibiotic treatment.

This compliance is based on 14 L patients

only. The drop in compliance is due to the

drop in compliance with lactates and ABxs.

Bundle compliance for all patients on all

pilot units taken together is 81% for

January.

No patients required this fluids month for

hypotension or a lactate greater than 4.

Screening compliance is at 98% for this

month. Overall goals for this month are

to draw lactates for every positive screen

and call code sepsis for every patient that

meets code sepsis criteria.

Lactate within 6 hrs from time of presentation of severe sepsis

UCSF Physician letter UCSF Letter to Clinical Staff – ED

Sent via Secure Email

From: ED Attending

Sent: Date/Time

To: MD (names), RN (names), Pharmacists (names)

Cc: Sepsis Champions, ED Quality Physician Chair

Subject: ePHI: ED severe sepsis/septic shock QI case review

Names et al: As part of the UCSF Medical Center's initiative to improve the care of patients with severe sepsis/septic shock, we are reviewing each case seen in the ED that has failed to meet compliance with the following bundle of interventions (which are tracked closely by the Med Center and used in QI reporting). There are 2

sets of criteria to which we are being held (DSRIP and SNI). Please see below for details. The following patient was seen by you and did not meet the full bundle criteria as noted below: Patient name: Last name, first MR #: XXXXXXXXX Date of visit: Date/time Initial lactate: 9.2 Organ dysfunction: elevated lactate (<2)

Timeline for Sepsis Bundle Elements (time is the x-axis, bars represent time intervals, numbers on either end of bars represent time event occurred):

*Time of presentation (TOP) = time that patient meets the following 3 criteria (all 3 must be present, TOP = time of the last criteria to be met):

1. 2 or more SIRS criteria 2. Clinical suspicion for infection 3. Evidence of organ dysfunction

Bundle Element Compliance (green = compliant, red = not in compliance) Sepsis Bundle Component DSRIP criteria (lenient) SNI criteria (stringent) Lactate Within 6hrs of TOP 4hrs before-6hrs after TOP Blood Culture Before antibiotics Before antibiotics Broad Spectrum Antibiotics Within 3hrs (for ED) of TOP Within 1hr of TOP Fluid Bolus 20ml/kg or 1000ml crystalloid or 300-

500ml colloid if SBP<90 or MAP<66 or lactate >4, within 6hrs of TOP

20ml/kg or 1000ml crystalloid or 300-500ml colloid within 1hr of TOP, regardless of BP or lactate

Vasopressor Pressors started within 6h of TOP if SBP failed to respond to initial fluid resuscitation

N/A

Full Bundle Compliance All of the above All of the above *As an aside, we understand the controversy around fluid bolus administration in the SNI criteria. Notes: This was a patient with (disease) who had a (significant event) at home. The patient had received ACLS in the field by EMS prior to arrival in the ED and was intubated, tachycardic, hypoxic, and hypothermic on ED arrival. The patient was admitted to ICU (service) with (service) involved for therapeutic hypothermia. After transfer to the ICU, it appears that the admission team ordered antibiotics which triggered this case for our review (I.e. Possible sepsis case). There is no mention in the ED note of a concern for infection as the underlying etiology and it's not clear to me that her underlying etiology was infectious. However, to be complete, I am forwarding this on to you all (including the admission team). Any thoughts on the delayed antibiotics (163 mins after TOP) and absence of a fluid bolus (presumably due to this patient being (disease))? Please let us know if there were systems issues or other impediments that played a role in meeting these bundle elements. Physician Sepsis Champions

Michael McElroy from SFGH

Joe Clement from SFGH

Kathleen Quan, Debbie Thompson, Jennifer Yim UC Irvine

SIR

Nurse-Sensitive Quality Indicators

Unit: SICU

Unit Specific Dashboard

Understanding SIR

Jared Quinton from UC Davis

The Usual Suspects…

baseline DY-8

actual DY-8 goal

DY-9 goal

DY-10 goal

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

Bu

nd

le C

om

plia

nce

(%

)

Boxplots Dashboard

s

0.70.60.50.40.30.2

Median

Mean

0.700.650.600.550.500.45

1st Q uartile 0.45163

Median 0.55769

3rd Q uartile 0.67803

Maximum 0.73314

0.46833 0.63203

0.45469 0.67691

0.11857 0.24229

A -Squared 0.51

P-V alue 0.171

Mean 0.55018

StDev 0.15920

V ariance 0.02534

Skewness -0.984283

Kurtosis 0.819763

N 17

Minimum 0.15152

A nderson-Darling Normality Test

95% C onfidence Interv al for Mean

95% C onfidence Interv al for Median

95% C onfidence Interv al for StDev95% Confidence Intervals

Descriptive Statistics Process Maps Planning Grant Process Map Sepsis Improvement CollaborativeAs of 07/11/2011

Phase 1

[Completed 11/03/2010]

Phase 2[Completed 12/01/2010]

Phase 3

[Completed 01/05/2011]

Phase 4

[Completed 02/16/2011]

ED / ACU ICU

Primary Screen

Secondary Screen

Early Recognition

Alert Screen

Sepsis Screening Order Set**

Notification ofPotential EGDT

Activation

SepsisTreatmentProtocol

Treatment

Sepsis Treatment Order Set**

EMR

Met Criteria?

Suspected Infection?

Yes (BPA Fires)

Yes

BPA lock outACU = 12-hoursICU = 12-hours

ED = 2-hours

BPA lock out24-hours

Met Activation Criteria?

No** See related P&Ps:

· Severe Sepsis Early Recognition and Management Policy

No

Sepsis Reassessment Order Set**

RN RN

RRT

Primary Team

Attending Physician / Primary Team

5 minute response to evaluation

UCDMC Patient Population

Met Activation Criteria?

BPA lock out24-hours

No

5 minute response to EGDT activation after evaluation

Follow-up q2 labs

No

Start

Yes

“Yes (suspected infection)” with Low BP in ACUSepsis Reassessment:

-BP-HR-RR-GCS-Urine Output-CVP (if available)-Lactate-O2 Sat.-ABG / VBG-Documented RN/MD communication

Blood Cultures

ABX

Lactate q4 x2

ScvO2

ABG / VBG

Fluids

Catheter Eval.

Vasopressors

Steroids

Activated Protein C

Glucose Control

Fluids / Blood

Products

Yes

Lactic Acid ABG / VBG

INRCBC

LFTs

Type & Screen

CXR

UA

Sputum Culture

Blood Culture (x2)

BPA lock out7-days

Mini-BAL

Stim. Test

O2

AcuityScoring

30-60 min.

PCR Evaluation

PCT

· Related Standardized Procedure

EMR

Critical Care

Consult

Future element pending laboratory validation

256 patients

H 17 hospitals

Sepsis Collaborative DY-8 Bundle Compliance

Patients by Hospital

DPH w/o Level 1 Trauma Center

DPH w/Level 1 Trauma Center

baseline DY-8

actual DY-8 goal

DY-9 goal

DY-10 goal 0.00

0.20

0.40

0.60

0.80

Bu

nd

le C

om

plia

nce

(%

)

SNI Sepsis Bundle

Compliance

DPH Sepsis Bundle Compliance

This snapshot represents the semi-annual

DY-8 performance of the SNI Sepsis Collaborative

Baseline DY8 DY9 DY10

Three Tips from Your Peers

One size does not fit all

Know Your Audience

Check for Accuracy

Data Tips

• 3D charts

• Pie charts

– Difficult to compare groups; bar charts almost always better

• Deceptive Y-axis scaling

– Are the max and min levels appropriate? How many gridlines are truly necessary?

• Using coded variables

– What does ‘inDateYM’ mean to someone not familiar with NHSN?

• Unnecessary information

– Going out several decimal places

• Lack of benchmarks, comparison groups, goals

More Tips

• No labels

– What units (per 1,000 line-days? Patient days?) are you measuring in? When was the data abstracted? Who collected the data? What’s the data source?

• Too many colors/categories in one chart

– Be careful with color; Red can be a good for a main point if used sparingly

– Small multiples (smaller, side-by-size charts) can get the point across better for multiple categories

• Using serif fonts, especially for small sizes

– San serif fonts like Arial are easier to read

Active Duty Personnel, 1998

Army

35%

Navy

27%

Airforce

26%

Marines

12%

Active Duty Personnel, 1998

Army

35%

Navy

27%

Airforce

26%

Marines

12%

Beware of 3-D

Pie Charts

Resources

• Books – The works of Edward Tufte

• Visual Display of Quantitative Information

• Envisioning Information

• Visual Explanations: Images and Quantities, Evidence and Narrative

• Beautiful Evidence

– Visualize This by Nathan Yau

– Presentation Zen by Garr Reynolds

• Web – New York Times graphics department

• Examples: http://www.nytimes.com/interactive/2012/12/30/multimedia/2012-the-year-in-graphics.html

– www.flowingdata.com

– www.junkcharts.typepad.com

• Scholarly Journals – JAMA, Nature, BMJ, Health Affairs

• Video – The Value of Visualization - http://vimeo.com/29684853

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