SEP-1 Early Management Bundle,

1 Welcome! Audio for this event is available viaReadyTalk Internet Streaming. No telephone line is required. Computer speakers or headphones are necessary to listen to streaming audio. Limited dial-in lines are send a chat message if needed. This event is being AudioAudio from computer speakers breaking up? Audio suddenly stop? Click Refreshicon or Click F52F5 KeyTop Row of KeyboardLocation of ButtonsRefresh7/17/2018 Troubleshooting Echo Hear a bad echo on the call? Echo is caused by multiple browsers/tabs open to a single event (multiple audio feeds). Close all but one browser/tab and the echo will of Two Browsers/Tabs Open in Same Event7/17/2018 Submitting QuestionsType questions in the Chat with presenter section, located in the bottom-left corner ofyour Early Management bundle , Severe Sepsis/Septic Shock: Providence Tarzana Medical Center s Sepsis Journey and Frequently Asked QuestionsJuly 17, 2018 Speakers6 Our Sepsis JourneyJamie Eng, MDSteve Perry, RNAssociate Director Emergency MedicinePerformance Improvement Review NurseProvidence Tarzana Medical Center Providence Tarzana Medical Center Howard Davis, MD, MBAA ndre Vovan, MD, MBAC hief Medical OfficerRegional Chief of Clinical EffectivenessProvidence Tarzana Medical Center Providence Tarzana Medical Center SEP-1 Early Management bundle , Severe Sepsis/ Septic Shock.

2 Measure FAQsNoel Albritton, MSN, RNJennifer Witt, RNLead Solutions SpecialistSenior Health Informatics Solutions CoordinatorHospital Inpatient and Outpatient Hospital Inpatient and Outpatient Process and Structural Measure Process and Structural Measure Outpatient Development and MaintenanceOutpatient Development and Maintenance Support Contractor Support Contractor7/17/2018 AcronymsObjectivesAt the end of the presentation, participants will be able to: Better understand the sepsis journey of Providence Tarzana Medical Center. Better understand and interpret the guidance in version of the specifications manual to ensure successful reporting for the SEP-1 and Abbreviations87/17/2018 Back9 Jamie Eng, Director Emergency Medicine, PTMCS teve Perry, RNPerformance Improvement Review Nurse, PTMCOur Sepsis Journey7/17/2018 AcronymsProvidence Tarzana Medical Center10 249-bed acute care hospital accredited by The Joint Commission 24/7 emergency department with ~45,000 annual visits STEMI receiving center Primary stroke center Pediatric medical center The Valley Heart and Vascular Institute Women and Children Services7/17/2018 Acronyms7/17/201811 AcronymsCare Timeline 2005 20112005 EGDT Strong leadership by physicians Case review based on EGDT recommendations with referral to peer review2008 Development of a multi-disciplinary team.

3 Sepsis Study Group Formal integration into the IOP Adoption of 2008 IHI sepsis guidelines by study group as new standard of care Creation of Sepsis Coordinator position Development of Sepsis Rate-Based Report 2009 2011 Creation andimplementation of ED and inpatient Sepsis Order Sets Sepsis integrated into annual nursing education update Participated in SCPSC Development of educational tool for sepsis continuum (physician/nurses) Participants in 2011 IHI Sepsis Detection and Initial Management ExpeditionCare Timeline 20127/17/201812 Acronyms Adoptio n of 2012 IHI guideli nes as updated standard of care Updated Sepsis Order Set Development and implementation ED physician sepsis template for documentation Creation of Antibiotics by Source Order Set for sepsis patients based on antibiogram with pharmacy Stocked key antibiotics in ED pharmacy Included phlebotomy as part of RRT code Developed policy and procedure f or dedicated RRT Expansion of Sepsis Study Group to include hospitalist group Providence System audit-high performer complia nce with sepsis abstraction guidelinesCare Timeline 2013 20157/17/201813 Acronyms Participation in PSCSC ED and hospitalist sepsis presentations to general medical staff Educational reminders to ED and Department of Medicine regarding sepsis Close collaboration among CMO, hospitalists.

4 And ED providers regarding target metrics Educational lecture regarding SEP-1 core measure to general medical staff Development of 3 and 6 hour severe sepsis and septic shock algorithm Refinement of RRT s role in Early identification Key antibiotics to floors to expedite care (Pyxis) Collaboration with CDS to ensure accurate documentation in sepsis patients Hosted the Sepsis Simulator Mobile classroom Started collecting ROM and SOI data on all cases Participated in Premier analytics webinar regarding calculation of O/E mortality June 2015 CMS Webinar: Early Management bundle , Severe Sepsis/Septic ShockCare Timeline 2015 Today7/17/201814 SEP-1 bundle Data collection beginning 2015 Q4 by PI department Second update of SEP-1 measure to general medical staff Weekly work group including nursing, lab, radiology and ED MD s regarding core measure compliance Addition of SEP-1 measures to nursing resource binder Education letter regarding SEP-1 guidelines and changes developed for medical staff Development of standardized ED documentation template2015 Today Refinement of ED Sepsis Order Set and Antibiotics by Source Order Set Development of CODE SEPSIS in the ED Development of sepsis checklist for ED nursing to ensure completion of bundle components Developed sepsis watch list Refinement of template to address CMS requirements for recognition time and septic shock reassessment Participation in PSJSCA cronyms15 Sepsis Study Group CMO Hospitalists Laboratory Nursing Leadership Quality and PI Respiratory ED Leadership Coding and CDI Sepsis Coordinator7/17/2018 Acronyms16 Sepsis Study Group7/17/2018 Acronyms Multi-disciplinary Key stakeholders Regular monthly meetings under medical staff Review of system data and internal data Review of trends and processes

5 Actionable items, reportable to the next meeting17 Sepsis Coordinator Position created to monitor and improve treatment and chart documentation Increasing role through the years Assists in providing nursing education Daily sepsis screening with inpatient charge nurses Does inter-rater reliability with abstractor Contemporaneous chart review Collaboration with key stakeholders to ensure timely treatment and management7/17/2018 Acronyms18 Sepsis Rate Base Report ED Patients and Inpatients - 2017 JanFebMarAprMayJunJulAugSepOctNovDecTota lSample size 161215161214121213161517170ER RESUSCITATION bundle BMKN1612151612141212131615171701. % of patients met lactate % Blood culture before ABX94%100%100%100%100%100%100% 100% 100% 100% 100% 100% % ABX timeliness (ED = 180 min)94%100%100%100%92%100%92%100%100%100 %100%100% % Correct Antibiotic Selection100%100%100%100%100%100%92%92%1 00%94%100%94% % repeat lactate done100%100%100%100%100%100%100%100%100% 100%100%91% % Fluids administered (30 ml/kg.)

6 75%100%75%100%100%67%100%83%50%89%80%80% % Vasopressors % Post fluid administration reassessment Rate Base Report ED Patients and Inpatients - 2017 OUTCOME SUMMARY (ER CM)JanFebMarAprMayJunJulAugSepOctNovDecT otalN1612151612141212131615171701. % That Passed The Measure69%92%93%100%92%93%83%83%92%94%93 %82% # Survived severe sepsis and/or septic Mortality Quarterly mortality rate7%2%8%2%OUTCOME SUMMARY (ALL patients ER + inpat)1. Total # of Cases (CM)1714151615151415151817181892. # Patients that Survived (CM)1513141615141313131517181763. # Patients that Expired (CM)211001222300144. Total Mortality Rate (all CM Patients) # Severe Sepsis Patients Expired (CM)01000120120076. Severe Sepsis Mortality Rate (CM)0%8%0%0%0%8%15%0%8%17%0%0% # of Patients With Septic Shock (CM)824433232645468. Septic Shock Mortality Rate (CM) Mortality rate for allcoded with Severe sepsis or Septic shock. (Info-view)21%17%14%13%7%24%16%12%21%23% 16%8% Line 7 under outcome summary is a sub-set of line 1.

7 Line 4 is the total mortality for patients included in the core measure. Line 9 is the mortality for all patients coded with Severe Sepsis and Septic Shock, not limited to the core measure Collection Tool for PI Abstraction 2009 3Q 20157/17/2018 Acronyms21 Data Abstraction Prior to the SEP-1 quality measure, all cases with ICD coding of severe sepsis and septic shock (typically 60 80 cases per month) were abstracted. Primary sepsis abstractor frequently submits queries to CMS through QualityNet for the purpose of clarification during case abstraction and for consultation when developing physician and staff documentation tools. For the purpose of inter-rater reliabilityour Sepsis Coordinator abstracted in parallel five of our 22 SEP-1 cases per month to compare results with sepsis primary abstractor. Primary abstractor identifies missed measures monthly and forwards initial write-up to peer review RN for verification before physician review. Primary abstractor completes rate-based report monthly, tracks and trends missed measures, and archives raw Tool Based on 2008 Institute for Healthcare Improvement Guidelines7/17/2018 Systemic Inflammatory Response Syndrome Defined by the presence of two or more of the following: 1.

8 Temperature > 38 degrees C or < 36 degrees C 2. Heart rate > 90 beats/ minute 3. Respiratory rate > 20 breaths / min or PaCO2 < 32 mm Hg 4. Leukocyte count > 12,000, <4,000 or > 10% bands SIRS plus a suspected or confirmed site of infection, Examples: Urinary tract infection, Pneumonia, Decubitus ulceration Defined as: Sepsis with organ system dysfunction (examples below) Altered LOC (increased agitation, confusion, decreased Glasgow Coma Score) Renal failure/ insufficiency (Creatinine > and/ or urine output < ml/kg/hour) Respiratory failure (room air pulse oximetry < 92%, pO2/ FiO2 <300, need for mechanical ventilation) Metabolic/ Hepatic/ Hematologic. (Lactate level > , liver enzymes >2X upper limit of normal, Platelet count < 100k, INR> w/o Warfarin) Order: Lactic acid , Blood Cx prior to ABX, Early fluid ( 20ml/ Kg) and antibiotic Septic Shock and/or Severe Sepsis w/ Lactate > Defined As: Severe sepsis with SBP < 90 unresponsive to initial fluid resuscitation and/ or lactate level > Order: Lactic acid , Blood Cx prior to ABX, Early fluid ( 20ml/ Kg) and antibiotic Acronyms23 Sepsis Continuum7/17/2018 Acronyms24 3 Hour Sepsis bundle 6 Hour Sepsis bundle OR Providence Tarzana Medical Center 2015 Algorithm7/17/2018 Acronyms25 Dear Member of the Department of Medicine:The medical staff and hospital leadership of PTMC are committed to providing the safest and best care for our patients.

9 As of October 2015 discharges of Severe Sepsis/Septic Shock Management are a Core Measure. On the reverse side of this document we have attached some slides that may be beneficial for your review; Thefirstslide isfrom the Joint Commission/CMSthatsimplifiestherequireme ntsof the3 hourand6 note that the measureis an allor nothing measure. The secondslidedescribes the continuum of symptoms fromSIRS toSeptic Shock. And the thirdslidedescribes how the start time is determined. Afterreview ofmultiplecases startinginOctober/2015the following items/issueshavebeen recognized and foundtobeproblematic and have resultedin fallouts: Youwill note that on thethirdslide listedon thebackthe starttimecan be determined twoways: The starttime iswheneitherthe third element of clinical criteriaisdocumented withina 6hourtimeframe or theMDdocumentsa diagnosis of severesepsis or septicshock . During review we have noted the absence of clinical criteriabeingmetin the chart,if thephysiciandocumentsa diagnosisofseveresepsis/septicshock thestarttime isthetimethephysicianopensthe note that containsthediagnosis.

10 (Pleasenote:if the physiciansspecifiesa timeofdiagnosiswithinthedocument then thattimeis thestarttime).If thephysiciandocuments severesepsis/septic shock he/she must start treatment as described on the firstslideon the reverse of blood cultures were not drawn within 24 hours of diagnosis they must be a lactate has notbeen donewithin6 hours ofdiagnosis,youmust ordera lactate and repeat within6 hoursif not onIVantibiotics the antibiotic must be ordered and administered within 180 minutes of a patient experiences hypotension orlactategreater than or afluid bolus of normal saline orlactated ringersin the amount of 30ml/kg isrequired. The most common patienttofailthemanagementbundleisapatie nt thatisdiagnosedafter admissiononthemedical/surgical/telemetry ,whenyouareeither contactedbythe stafformakethediagnosisofseveresepsis/se pticshock askthat theRapidResponse team (RRT)becalled to manage the patientis alreadyin a critical care unit notify the nurseto initiatethe sepsis hopethis informationisofvaluetoyou.