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SEPSIS COLLABORATIVE
JUNE 2016 – JULY 2018
TABLE OF CONTENTS
Contents
CHATQualityCollaboratives____________________________________________________________________________ 1
SepsisInitiative__________________________________________________________________________________________ 3
CollaborativeDesign_____________________________________________________________________________________ 4
PatientPopulation_______________________________________________________________________________________ 5
InterventionStrategies__________________________________________________________________________________ 6
EducationStrategies_____________________________________________________________________________________ 8
Measurement____________________________________________________________________________________________10
Data______________________________________________________________________________________________________11
VariableList_____________________________________________________________________________________________15
VariableList_____________________________________________________________________________________________16
TimeZero________________________________________________________________________________________________17
MakingConnections____________________________________________________________________________________18
Appendix ________________________________________________________________________________________________19
Appendix1.1:ICD‐10Codes________________________________________________________________________20
Appendix1.2: PDSAPlanning_______________________________________________________________________22
Appendix1.3: TemplateforLearningSessions_____________________________________________________23
___________________________________________________________________________________________________________25
ImplementationChecklist______________________________________________________________________________27
References(comingsoon)______________________________________________________________________________28
CHAT QUALITY COLLABORATIVES
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CHATQualityCollaboratives
PURPOSE
To improve the quality and safety of care and outcomes for children throughout participating children’s hospitals and their affiliated healthcare systems in Texas through collaboration and continuous quality improvement efforts.
OVERARCHING PHILOSOPHY
Utilizing the clinical systems integration model, analytics and QI methodology for design and implementation, CHAT member hospitals and children’s healthcare systems will improve outcomes for children in Texas across the continuum of care. Our guiding tenants include: • Providing a patient and family-centered focus
• Collaborating on quality and safety
• Sharing transparently for process and outcome improvements internally and externally
• Creating and driving quality and safety for the pediatric population across the state
• Improving health and wellness for pediatric patients
• Developing and implementing QI and safety initiatives
• Performing data collection and analyses that inform clinical and operational decision-making
• Disseminating QI reports and sharing best practices for rapid cycle improvement
• Supporting implementation and adoption of best practices
• Providing a collective voice and advocacy for pediatric healthcare improvement
• Establishing and fostering engagement and collaboration with pediatric care entities outside of CHAT hospitals
KEY ELEMENTS
• Evidence-based development
• Quality education
• Improvement science
• Quality improvement methodologies
• Analytics
CHAT QUALITY COLLABORATIVES
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• Efficiency and synchronicity with other current initiatives
• Inclusion of dissemination pilots
PARTICIPATING SITES
SEPSIS INITIATIVE
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SepsisInitiative
Goal: Improve diagnostic recognition of pediatric patients with septic shock (through utilization of an identification tool) and escalation of care (through education and infrastructure improvements) for more timely resuscitation efforts. Key Drivers: Developed by systematically integrating best evidence with the most recent American College of Critical Care Medicine’s clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. These clinical practice parameters will be translated into care across the continuum—from ED triage assessments to inpatient and critical care units. Deliverables: Standard-care pathways for ED/urgent care and inpatient areas; endorsed metrics and scorecard; monthly progress reports, and standard educational materials Methods: Iterative change and improvement over time will include educational outreach, standardized pathways, and standardize methods of intervention to encourage timely attainment of goals and providing personalized feedback using emails, run charts and statistical process control (SPC) charts. Webpage: http://chatexas.com/quality-collaboratives/ DISLAIMER: The CHAT-S collaborative has adopted key concepts (i.e., with respect to interventions and data strategies) from the Pediatric Septic Shock Collaborative (American Academy of Pediatrics) and the Improving Pediatric Sepsis Outcomes (Children’s Hospital Association).
COLLABORATIVE DESIGN
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CollaborativeDesign
•Virtual Complete•Kick‐offMeetinginSanAntonio Complete
Initiation
•Convenedworkgroups•DesignInterventionBundle Complete•DataStrategy InProgress•EducationalResources InProgress
•OptimizeDataPortal
PlanningPhase‐ Collaborative
•Vetcollaborativecomponents
•Ensurebuy‐infromrelevantstakeholders
•Establishsite‐specificgoals
•Formallyintroducecollaborativetosite(specificallytheED,IP,ICUareas)
•Identifyplansfor1stinterventioncycle
•Mapdatasources
•Submitbaselinedata
PlanningPhase‐ ParticipatingSites‐ NEXTSTEPS
•Addresseducationalneeds
•SitesimplementchangesusingPlan‐Do‐Study‐Actcyclesinwhichtheyinvestigatequalityproblems,developandimplementsmall‐scalechanges,measuretheeffects,andmakevariouschangesforimprovement.
•Submit1stroundofimplementationdata
•Duringmonthlylearningsessionssiteswilllearnimprovementtechniques,sharetheirexperiencesimplementingnewpracticeswithoneanother,reviewdata,andaddressbarriers)
Execution/ImplementationPhase
Closure(TBD)
PATIENT POPULATION
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PatientPopulation
NON‐SEVERE SEPSIS CRITERIA
Inclusion: PatientswhoseencounterstartsintheEDandthereisanintenttoadmitto
hospital; Patientsinaninpatientorcriticalcareunit; Aforementionedpatientsmusthavereceivedanantibioticandbloodculture
collectedwithin24hoursofeachotherExclusion:
Patientsthatmeetcriteriaforseveresepsis/septicshock
SEVERE SEPSIS/SEPTIC SHOCK CRITERIA
Inclusion: Patientswithapositivesepsishuddle; Patientsthatreceivedcareusingasepsisorderset; Patientswithapositivesepsisscreenthatreceived2fluidbolusesandantibiotics
within24hoursandbloodculturewithin72hours Patientswithapositivesepsisscreenthatreceived1fluidbolus,pressor,and
antibioticswithin24hoursandbloodculturewithin72hours ICD-10 codes are listed in the Appendix. Please be cognizant that ICD-10 coding can be unreliable. Your site should consider augmenting other methods of patient identification with ICD-10 codes rather than relying solely on coding.
INTERVENTION STRATEGIES
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InterventionStrategies
Goal: By December 2017, the CHAT-S collaborative will improve the timeliness of fluid and antibiotic administration by 50%. By July 2017, we expect a 50% reduction in sepsis-related deaths.
KEY DRIVERS CHANGE STRATEGIES Early Recognition
Utilizeascreeningtooltoidentifypatientso Toolcanbeelectronicorpaperformo Suggestedcomponentsincludeage‐adjustedvitalsigns(PALSi);
temperatureabnormality;hypotension;tachycardia;tachypnea;capillaryrefillabnormality;mentalstatusabnormality;pulseabnormality;skinabnormality
Careteamshouldconductahuddletodeveloptreatmentplano Teamshouldbeinterdisciplinary
Placepatientswithsuspectedsepsisonasurveillancepathway. Conductclinicalassessmentandlaboratoryscreening
o Obtainbloodcultureaccordingtobodyweightiio SuggestedInitialLabs:WBC;creatinine;platelets.Optional:VBG/ABG;
procalcitonin;glucoseo Performfrequentvitalsignassessment(suggested:every10minutes)o Assessperfusionandmentalstatus
Escalation of Care (hospital-based interventions)
Activatenotificationsystem/activationplan
1st Hour of Resuscitation
Begincardiopulmonarymonitoring Frequentvitalsignmonitoring Administeroxygenindependentofsaturation EstablishIV/IOaccess Administer1stfluidboluswithin20minutesofrecognition
o Viapush‐pull,pressurebag,orrapidinfusermethod Administer3rdfluidboluswithin60minutesofrecognition(contingentuponpatient’scondition)
Administerbroadspectrumantibioticswithin60minutesofrecognition Considerinitiationofvasoactivemedicationsforfluid‐refractoryshock(considernorepinephrineforwarmshock|epinephrineforcoldshock)
Eachsiteshouldestablishcriteriaforinpatientandcriticalcareadmissionandtimelineforadmission
INTERVENTION STRATEGIES
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Ongoing Management
Continuevitalsignmonitoring Identifyandcontrolinfectionsource Assessfororgandysfunctionandcorrect Obtainchestx‐raysasidentifiedbypatientstatus Assessneedforongoingfluidtherapy Consultspecialtyteamsasneeded
Transfers (hospital-based interventions)
Establishcriteriafortransferstohigherlevelofcare
EDUCATION STRATEGIES
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EducationStrategies
Goal: To ensure all members of the care team possess core knowledge to identify and treat patients with and at-risk for sepsis.
KEY DRIVERS CHANGE STRATEGIES Identify Learners
Allpersonsinvolvedinthecareofchildren(careteam)withsepsisshouldbeeligibletoreceiveeducationalresourcesandsupport.
Thecareteammaybecomprisedofphysicians,mid‐levelproviders,andnursesaswellasancillaryteams(e.g.,rapidresponseteams,pharmacists,transportteams).
Identify Core Knowledge
Thecollaborativewillidentifykeyareasofcompetency–somewhichincludes:
o Abilitytorecognizesignsofearlysepsis(basedonvitalsignsandphysicalexam)
o Understandriskfactorsassociatedwithsepsiso Abilitytodifferentiatecompensatedfromuncompensatedshocko Skillstoinitiatetargetedinterventions(fluid
resuscitation/antibiotics/vasopressorsasindicated)rapidly
Provide Sepsis-Specific Educational Opportunities
Sepsis‐specificeducationalopportunitiesshouldbeofferedthroughouttheyear
Morethanonedeliverymethodshouldbeinstitutedforlearners–thesemethodsinclude:
o Individual(casereview)andaggregateo Learningmodules(computerbasedtrainings),pathwaysaccessiblevia
thewebwithrelevanthyperlinks,newsletters,emailupdates,PowerPointpresentations,SimulationLab,bulletinboardpostings
o Meetings:divisional(educationalconference)anddepartmental(GrandRounds)
o Celebratesuccessesinatimelyfashiono ConsideradoptingtheChildren’snationalSepsisModuleforall
learners Ensurecompletionofmodulesandrelevantliteraturesearch–eachsitewilldeterminetheirpreferred“entry‐level”education
Endorsed/PreferredStrategy:Integratejust‐intimeeducation(i.e.,throughdecisionsupportwithinEMRplatform;graphicaldisplaysincaresetting)
EDUCATION STRATEGIES
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Re‐evaluatecurrenteducationalstrategiesandrefineasneededbasedonKirkpatrickmodel(knowledge‐behavior‐skills)
Integrate Quality Improvement Principles
OfferQI‐specificeducationalopportunitiesthroughoutthecourseofthecollaborative
Providefeedbacktomembersofthecareteamrelatedtotimeliness,efficiency,andeffectivenessofcareprovided(shouldbebasedonCHAT‐Squalitymeasures)
Transformingcareatthebedside Rapidcyclechange
Engage Patients & Families
Engageandeducatefamiliesoftargetedpatientpopulationsinearlysepsisworkup
Writtenmaterialgiventofamiliesofpatientswithsepsis Considerincludingfamiliesinsepsishuddle Supportfamilyawarenesswhenrapidresponseteamisinitiated
MEASUREMENT
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Measurement
CLINICAL MEASURES
Mediantimefromarrivaltorecognition**
PercentageofpatientsthatreturntoED/inpatientunitandmeetinclusioncriteria(48‐hour“bounce‐backs”)
Proportionofpatientsthatreceived1stfluidboluswithin20minutesof
recognition*
Proportionofpatientsthatreceived3rdfluidboluswithin60minutesofrecognition*
Proportionofpatientsthatreceivedfirstantibioticwithin60minutes**
Proportionofpatientsrequiringrapidtransferstocriticalcareunit**
Hospitallengthofstay*;IntensiveCareUnitlengthofstay**
Falsepositiverate
o Falsenegativerate(optionalmeasure)
30‐day,allcause,mortality*
FINANCIAL MEASURES
The goal is to be able to discern any financial impact from the collaborative efforts. APR-DRGS volumes to include variables below and by SOI:
Totaldischarges(EDandInpatient) AverageLOSforthosecategoriesabove AverageChargeperDischarge AverageNetRevenueperDischarge AverageTotalCostperDischarge AverageNetMarginperDischarge
*IPSO Metric **Not IPSO but can calculate using IPSO variables
DATA
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Data
CATEGORY DETAILS METRIC Median time from arrival to recognition TYPE Process GOAL Decrease VARIABLES TO COLLECT
(CHAT-4/IPSO-10): Arrival Time (CHAT-6/IPSO-68): Functional Time Zero
RATIONALE Identify delays in recognition CONSIDERATIONS Time patient arrived at ED or was admitted to hospital
CATEGORY DETAILS METRIC Proportion of patients that received 1st fluid bolus within
20 minutes TYPE Process GOAL Increase VARIABLE TO COLLECT (CHAT-6/IPSO-68): Functional Time Zero
(CHAT-14 / IPSO-20): Bolus 1 Time CONSIDERATIONS Time that first fluid bolus began closest to Time Zero.
(Some patients may receive a bolus prior to time zero.) The target time is within 20 minutes of Time Zero and no more than 6 hours after Time Zero. Volumes less than 5 cc per kg should not be counted as a bolus.
CATEGORY DETAILS METRIC Proportion of patients that received 3rd fluid bolus within
60 minutes TYPE Process GOAL Increase VARIABLE TO COLLECT (CHAT-6/IPSO-68): Functional Time Zero
(CHAT-16/IPSO-24): Bolus 3 Time CONSIDERATIONS Time that third fluid bolus began, after Time Zero. The
target time is within 60 minutes of Time Zero and no more than 6 hours after Time Zero. Volumes less than 5 cc per kg should not be counted as a bolus.
DATA
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CATEGORY DETAILS METRIC Proportion of patients that received first antibiotics within
60 minutes (severe sepsis/septic shock) TYPE Process GOAL Increase VARIABLE TO COLLECT (CHAT-6/IPSO-68): Functional Time Zero
(CHAT-18/IPSO-26): First Antibiotic Time CONSIDERATIONS Patient population: Only report for severe sepsis and
septic shock.Time that first antibiotic was started after Time Zero, whether or not the antibiotic was effective. The target time is within 6 hours before or 24 hours after Time Zero.
CATEGORY DETAILS METRIC Time from antibiotic order to antibiotic administration
(non-severe sepsis patients) TYPE Process GOAL Decrease VARIABLE TO COLLECT (CHAT-19/IPSO-59): Time Antibiotic Ordered
(CHAT-20/IPSO-60): Time Antibiotic Administered CONSIDERATIONS Patient population: Only report for non-severe sepsis
cases. This variable does not apply if IV antibiotic and blood culture are not both ordered within 24 hours.
CATEGORY DETAILS METRIC Proportion of patients requiring rapid transfers to critical
care unit in less than 6 hours TYPE Outcome GOAL Decrease VARIABLE TO COLLECT (CHAT-11/IPSO-12): Time to Gen Care from ED Time
(CHAT-12/IPSO-13): Time to ICU from ED Time (CHAT-13/IPSO-14): Time to ICU from Gen Care Time (CHAT-5/IPSO-10): Arrival Time
RATIONALE CONSIDERATIONS Exclude patients from home without an EC stay
Exclude patients arrived at your hospital from an “outside hospital” in the 24 hours before time zero.
DATA
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CATEGORY DETAILS METRIC Hospital length of stay TYPE Outcome GOAL Decrease VARIABLE TO COLLECT (CHAT-6/IPSO-68): Functional Time Zero
(CHAT-21/IPSO-53): Disposition Date CONSIDERATIONS Exclude episodes where functional time zero could not be
determined.
CATEGORY DETAILS METRIC Percentage of patients that return to ED/inpatient area and
meet inclusion criteria TYPE Outcome GOAL Decrease VARIABLE TO COLLECT (CHAT-24): Previous ED or IP Visit
(CHAT-6/IPSO-68): Functional Time Zero RATIONALE Highlight missed opportunities for early recognition CONSIDERATIONS For IPSO sites, this will be an extra variable to collect.
Manual chart review to check for previous ED/IP discharge within last 48 hours [determine whether sepsis-related]
CATEGORY DETAILS METRIC False positive rate TYPE Balance GOAL Site-Specific VARIABLE TO COLLECT (CHAT-25): # of cases that electronic screening tool was
activated/triggered as a sepsis patient (CHAT-26): # of positive sepsis cases
RATIONALE Indicates degree of specificity with respect to screening procedures
CONSIDERATIONS Only requesting monthly aggregate data – not patient specific
CHAT Variable No. IPSO
Variable No.
Variable Name Data Type Data Format Value Options Description Required
1 V‐01 id_sepsis_episode alphanumeric HospitalPrefix_uniqueidentifier Your hospital's unique identifier for this sepsis episode record. Y
2 V‐02 dateofbirth date yyyy‐mm‐dd 1900‐01‐01 = Not Known Patient’s date of birth. Y
3 V‐16 weight numeric 000.0 0‐300.0
999= Not known
Patient's weight, in kilograms. Use the weight taken closest to Time Zero, whether before or after. Y
4 V‐11 outsidehospital numeric 1 = Yes
0 = No
99 = Not specified
Indicates if patient arrived at your hospital from another hospital, that is, from an "outside hospital" in the 24 hours
before Time Zero. May require manual chart review to determine.
Y
5 V‐10 arrivaltime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = Not known Time patient arrived at ED or was admitted to hospital. Y
6 V‐68 functionaltimezero numeric 1 = ScreenTime
2 = HuddleTime
3 = OrderSetTime
4 = FirstAntibioticTime5 = Bolus1Time6 = Could not be determined
FunctionalTimeZero is the declaration of which potential time zero variable was used by the hospital as the date and
time of functional prospective time zero for the sepsis episode. The logic for determining FunctionalTimeZero evaluates
ScreenTime, then the earlier of HuddleTime or OrderSetTime. If none of these are reported, the earlier of
FirstAntibioticTime and Bolus1Time is set as FunctionalTimeZero. | First antibiotic time and bolus 1 time have not been endorsed by CHAT as viable time zeros.
Y
7 V‐06 screentime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = Screen occurred but time not known
1900‐01‐02 = Not applicable, no screen occurred
1900‐01‐03 = Do not know if screen occurred
Time of initial screening process to identify possible severe sepsis in patient, where screen was positive. Note: The
initial screening process may consist of an electronic alert, a checklist, PEWS scores (absolute value and/or change),
bedside nursing screens, or other identification tools. The initial screening process may use paper‐ based tools or
electronic tools.
Y
8 V‐07 huddletime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = Huddle occurred but time not known
1900‐01‐02 = Not applicable, no huddle occurred
1900‐01‐03 = Do not know if huddle occurred
Time of sepsis team huddle to review clinical findings and determine whether that patient is on a severe sepsis
pathway, where the huddle result was positive.
Y
9 V‐08 ordersettime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = Order set used but time not known
1900‐01‐02 = Not applicable, no order set used
1900‐01‐03 = Do not know if order set used
Time of first use of either (a) any component of a severe sepsis order set or (b) a related infection‐specific order set that
includes core severe sepsis components
Y
10 V‐66 timezerolocation numeric 1 = ED
2 = ICU
3 = General Floor
4 = Hem/Onc
5 = Other
99 = Not specified
Location of patient at the functional time zero. To choose the value for TimeZeroLocation, evaluate ScreenTime, then
HuddleTime if no ScreenTime reported, then OrderSetTime if no HuddleTime is reported. If none of these are reported,
choose the location of the earlier of FirstAntibioticTime and Bolus1Time.
Y
11 V‐12 timetogencarefromedtime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐02 = Not applicable Time patient arrived on a general care unit from ED. Report this value only once per sepsis episode. Y
12 V‐13 timetoicufromedtime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐02 = Not applicable First time patient arrived in ICU or step‐down unit from ED after Time Zero. Report this value only once per sepsis
episode, for the first transfer, not possible subsequent transfers.
Y
13 V‐14 timetoicufromgencaretime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐02 = Not applicable First time patient arrived in ICU or step‐down unit from a general care unit. Report this value only once per sepsis
episode, for the first transfer, not possible subsequent transfers.
Y
14 V‐20 bolus1time datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = Not known 1900‐01‐02 = Not applicable Time that first fluid bolus began closest to Time Zero. (Some patients may receive a bolus prior to time zero.) The target
time is within 20 minutes of Time Zero and no more than 6 hours after Time Zero. Volumes less than 5 cc per kg should
not be counted as a bolus.
Y
15 V‐21 bolus1volume numeric 99999 = Not known The volume of the first fluid bolus, in milliliters. Do not include volume of flushes in the bolus volume; volumes less
than 5 cc per kg should not be counted as a bolus.
Y
16 V‐24 bolus3time datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = Not known 1900‐01‐02 = Not applicable Time that third fluid bolus began, after Time Zero. The target time is within 60 minutes of Time Zero and no more than
6 hours after Time Zero. Volumes less than 5 cc per kg should not be counted as a bolus.
Y
17 V‐25 bolus3volume numeric 99999 = Not known The volume of the third fluid bolus, in milliliters. Do not include volume of flushes in the bolus volume; volumes less
than 5 cc per kg should not be counted as a bolus.
Y
18 V‐26 firstantibiotictime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = Not known 1900‐01‐02 = Not applicable Time that first antibiotic was started after Time Zero, whether or not the antibiotic was effective. The target time is
within 6 hours before or 24 hours after Time Zero.
Y
19 V‐59 (only
NSS)
timeabxordered datetime yyyy‐mm‐ddThh:mm:ss Time the first IV antibiotic was ordered for a patient with non‐severe sepsis, where both an IV antibiotic order and a
blood culture are ordered within 24 hours of each other and where patient was admitted to the hospital or was in the
ED with an order for inpatient admission. This variable does not apply if IV antibiotic and blood culture are not both
ordered within 24 hours.
Y
20 V‐60 (only
NSS)
timeabxadministered datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = not specified Time the first IV antibiotic was administered for a patient with non‐ severe sepsis, where both IV antibiotic treatment
and a blood culture are ordered within 24 hours of each other and where patient was admitted to the hospital or was
in the ED with an order for inpatient admission. This variable does not apply if IV antibiotic and blood culture are not
both ordered within 24 hours.
Y
21 V‐53 dispositiondate date yyyy‐mm‐dd Date of the patient disposition reported in V‐54 Disposition. If patient is still in hospital 30 days after Time Zero,
DispositionDate=Date of TimeZero+30 days.
Y
22 V‐54 disposition numeric 1 = Home
2 = Rehabilitation Facility
3 = Died
4 = Still in the hospital at day 30
6 = Other
Disposition of the patient at day 30 after Time Zero. If discharged, indicate if discharged to home or rehab. Other
dispositions are Died or Still in Hospital
Y
Page 1 of 2 v1 (3.27.2017)
CHAT Variable No. IPSO
Variable No.
Variable Name Data Type Data Format Value Options Description Required
23 V‐46 lacticacidtime datetime yyyy‐mm‐ddThh:mm:ss 1900‐01‐01 = not specified
1900‐01‐02 = not applicable
Time first lactic acid was obtained within timeframe of 48 hours beforeTime Zero to 48 hours after Time Zero. This
variable is not applicable if lactic acid was obtained more than 48 hours before Time Zero or more than 48 hours after
Time Zero. Do not capture lactic acid from an outside hospital, only the first one at your institution.
OPTIONAL
24 V‐47 lacticacidvalue numeric 0‐30
88 = Not applicable
99 = Not specified
Initial lactic acid value if obtained within timeframe of 48 hours beforeTime Zero to 48 hours after Time Zero. This
variable is not applicable if lactic acid was obtained more than 48 hours before Time Zero or more than 48 hours after
Time Zero.
OPTIONAL
24 ‐ previousEDIPvisit numeric 1 = Yes
0 = No
99 = Not specified
Within 48 hours of index visit OPTIONAL
25 ‐ screeningtoolactivated numeric 0‐500 0‐500
999= Not known
Indicate the number of cases that electronic screening tool activated OPTIONAL
26 ‐ positivesepsiscases numeric 0‐500 0‐500
999= Not known
Indicate the number of positive sepsis cases OPTIONAL
Page 2 of 2 v1 (3.27.2017)
DATA
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CATEGORY DETAILS METRIC Rate of mortality (30-days) TYPE Outcome GOAL Decrease VARIABLE TO COLLECT (CHAT-6/IPSO-68): Functional Time Zero
(CHAT-22/IPSO-54): Disposition (response 3: died) (CHAT-21/IPSO-53): Disposition Date
CONSIDERATIONS Measures all-cause mortality rate of severe sepsis/septic shock episodes per 1,000 hospital admissions from time zero through day 30
TIME ZERO
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TimeZero
Preferred Strategies for Recognizing Target Patients
BestPracticeAlert
• Whenclinicaldecisionsupportindicatesthatpatientmeetscriteriaforsepsis(triggertoolfirest)
• Physicianconfirmsthatactivatedbestpracticealertiscorrect
SepsisHuddle
• Membersofcareteamevaluatepatientanddeterminethatpatientmeetscriteriaforsepsisandinitiatesresuscitationefforts
OrderSet
• Physicianutilizesordersetforsepsis
Version 2: Will include "cheat sheet" for selecting appropriate functional time zero (on encounter basis)
MAKING CONNECTIONS
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MakingConnections
EMR PLATFORMS
EPIC Dallas; Driscoll; Texas Children’s CERNER Dell MEDITECH Cook; Covenant; CHoSA
ESTABLISHED SCREENING TOOLS
EMERGENCY DEPARTMENT Texas Children’s; Covenant; Cook; Dell; Dallas; CHoSA; Driscoll INPATIENT AREAS Covenant; Cook; Dell; Dallas CRITICAL CARE UNIT Covenant
CONTACT INFORMATION
SITE CONTACT PERSON EMAIL Covenant Children’s
KimMcAuley [email protected]
Cook Children’s Quality:StephanieLavin [email protected]
Children’s Health Quality:ChristyPittman
Physician:[email protected]
Dell Children’s Quality:DoryCollette [email protected]
Driscoll Children’s
MeganJackson [email protected]
Children’s Hospital of San Antonio
ClintonWoosley [email protected]
Texas Children’s Quality:TerriBrown
Physician:CharlesMacias
Data:YanShi
APPENDIX
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Appendix
1.1 ICD‐10Codes1.2 TemplateforSitestoDeclareAims&PDSAPlanning1.3 TemplateforLearningSessionUpdates(converttoPDFandinsert)1.4 SiteChecklist
APPENDIX 1.1: ICD‐10 CODES
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Appendix1.1:ICD‐10Codes
STAND ALONE CODES for Severe Sepsis/Septic Shock
Codes below can be used to identify patients with severe sepsis/septic shock.
ICD10 Code Code Description
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
Codes for Sepsis
Codes below can be used to identify patients with sepsis. To be included in the severe sepsis/septic shock cohort they also need to have had interventions for treatment (blood culture/antibiotics/two fluid boluses or a fluid bolus + pressor)
ICD10 Code Code Description
A02.1 Salmonella sepsis
A20.7 Septicemic plague
A21.7 Generalized tularemia
A22.7 Anthrax sepsis
A24.1 Acute and fulminating melioidosis (melioidosis sepsis)
A26.7 Erysipelothrix sepsis
A32.7 Listerial sepsis
A39.2 Acute meningococcemia
A39.3 Chronic meningococcemia
A39.4 Meningococcemia, unspecified
A40.0 Sepsis due to streptococcus, group A
A40.1 Sepsis due to streptococcus, group B
A40.3 Sepsis due to Streptococcus pneumoniae
A40.8 Other streptococcal sepsis
A40.9 Streptococcal sepsis, unspecified
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
A41.1 Sepsis due to other specified staphylococcus
A41.2 Sepsis due to unspecified staphylococcus
A41.3 Sepsis due to Hemophilus influenzae
A41.4 Sepsis due to anaerobes
APPENDIX 1.1: ICD‐10 CODES
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A41.50 Gram‐negative sepsis, unspecified
A41.51 Sepsis due to Escherichia coli [E. coli]
A41.52 Sepsis due to Pseudomonas
A41.53 Sepsis due to Serratia
A41.59 Other Gram‐negative sepsis
A41.81 Sepsis due to Enterococcus
A41.89 Other specified sepsis
A41.9 Sepsis, unspecified organism
A42.7 Actinomycotic sepsis
A54.86 Gonococcal sepsis
B00.7 Disseminated herpesviral disease (herpesviral sepsis)
B37.7 Candidal sepsis
APPENDIX 1.2: PDSA PLANNING
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Appendix1.2: PDSAPlanning
[Organization Name]: Sepsis Collaborative PDSA Worksheet
OVERALL AIM STATEMENT: 90-day goal to achieve: 30-day goal to achieve: Every goal will require multiple smaller tests of change. Describe your first (or next) test of change: Person
Responsible When to Be Done
Where to Be Done
PLAN List the tasks needed to set up this test of change
Person Responsible
When to Be Done
Where to Be Done
Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
DO Describe what actually happened when you ran the test
_
STUDY Describe the measured results and how they compared to the predictions _
ACT Describe what modifications to the plan will be made for the next cycle based on
what was learned _
APPENDIX 1.3: TEMPLATE FOR LEARNING SESSIONS
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Appendix1.3:TemplateforLearningSessions
LEARNING SESSIONS
Hostedeverymonth Allhospitalsarerequiredtosubmitupdates Hospitalswillpresenttheirrecentefforts,successes,barriers,andlessonslearned Anopportunitytoreceivefeedbackandencouragementfrompeers
APPENDIX 1.3: TEMPLATE FOR LEARNING SESSIONS
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IMPLEMENTATION CHECKLIST
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ImplementationChecklist
ADMINISTRATIVE
SignDataUseAgreementwithBaylorCollegeofMedicine
CreateIRBProtocolo SendKrystleBartleyacopyofapproval/waiverletter
Identifyphysicianandnursingchampionso EmergencyDepartmento InpatientUnitso CriticalCareUnits
Compilealistofrepresentativesfromyourhospital(willreceiveinvitesforlearning
sessionsandworkgroupcalls)
QUALITY IMPROVEMENT
Reviewcomponentsofsepsisbinderwithyourcoreteam(i.e.,championsandrepresentatives)
Reviewlistofvariablesandidentifysources/locationwithinyourEMRo Reportmissingvariablesorissueswithformattingtodataworkgroup
CompletethePDSAworksheet
o Definetheglobalaim,30‐day,and90‐dayaimsforyourhospital
Submitbaselinedata
Rolloutinterventions
Submitdatamonthly
Monitorprogress
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