SOS! Spotlight on Sepsis at Inova Mount Vernon Hospital High Reliability Organization (HRO) Brown Bag Presented by Inova Mount Vernon Hosted by Virginia Hospital & Healthcare Association September 23, 2019
SOS! Spotlight on Sepsis at Inova Mount Vernon Hospital
SOS! Spotlight on Sepsis John Lawrence, RN, BSN, SCRN RN Sepsis Coordinator Inova Mount Vernon Hospital Alexandria, VA
SOS! Spotlight on Sepsis Founded in 1976, Inova Mount Vernon Hospital is a 237-bed community hospital offering patients convenience and state-of-the-art care in a unique healing environment.
SOS! Spotlight on Sepsis • Our Opportunity • Process Improvement & Interventions • Our Results • Next Steps
SOS! Spotlight on Sepsis • Our Opportunity • Process Improvement & Interventions • Our Results • Next Steps
Our Opportunity 2016 Q4 Inova Sepsis Mortality Performance (Acute Inpatient Only) 2.00 1.50 O/E Ratio 0.99 1.00 0.85 0.81 0.80 0.80 Premier Top 0.68 Quartile .68 0.50 0.00 IAH IFOH IFMC ILH IMVH Inova Q4 2016 PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17
Our Opportunity 1/1/16 - 8/20/16 Sepsis Cases 1,200 1,000 800 600 400 200 0 IFH IAH ILH IFOH IMVH Cases Deaths Hospital Beds
Our Opportunity • In 2016, our SEP-1 compliance was 49%, which was the lowest in our health system.
SOS! Spotlight on Sepsis • Our Opportunity • Process Improvement & Interventions • Our Results • Next Steps
Process Improvement & Interventions Critical Success Factors • Executive Sponsorship: CEO, CMO, CNO • A Coordinated System-wide, Multi-disciplinary Approach – 90-day clinical effectiveness sprint at end of 2016 • Dedicated Sepsis Coordinator (0.5 FTE) • Real-time Focused Feedback & Education • Following the Principles of HRO
Process Improvement & Interventions Staff Education Is Key • Education rollout beginning of 2017 across the entire health system – for both RNs and clinical technicians • Annual nursing and clin tech skills fair • 30 minutes at new employee orientation • Ongoing coaching of front-line staff • All new providers receive sepsis orientation Top : Sepsis simulation during annual nursing skills fair Bottom : Staff and students heard from a sepsis survivor at our 2018 Sepsis Lunch & Learn
Process Improvement & Interventions Standardized Tools • Our nurses and providers use a “ Code Sepsis ” checklist whenever they suspect sepsis. • This ensures patients receive a standardized “ bundle ” of care. • Each nurse also has a sepsis “ badge buddy. ”
Process Improvement & Interventions Sepsis Order Sets for Providers
Process Improvement & Interventions Centralized 24/7 eICU Support
Process Improvement & Interventions Modified Early Warning Score • The MEWS tool is built into Epic, our EMR. – Helps nurses monitor their patients and more quickly recognize a patient experiencing a sudden decline. 3 2 1 0 1 2 3 Respiratory Rate Less than 9 9-14 15-20 21-29 30 or more Heart Rate Less than 40 40-50 51-100 101-110 111-129 130 or more Systolic Blood 70 or less 71-80 81-100 101-199 200 or more Pressure New Level of Unrespon- Responds to Responds to Alert agitation, Consciousness sive Pain Voice confusion 101.4 or Temperature (F) 95 or less 95.1-96.8 96.9-100.4 100.5-101.3 more
Process Improvement & Interventions MEWS Color MEWS Score Action Continue to Green 0-2 monitor Re-assess Yellow 3 patient and VS Orange 4 Notify RRT RN or call RRT Red 5+
Process Improvement & Interventions
Process Improvement & Interventions Focused Feedback & Recognition PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17
Process Improvement & Interventions Focused Feedback & Recognition
Process Improvement & Interventions Focused Feedback & Recognition
Celebrating Our Sepsis Stars! • Nurse A. screened patient positive for sepsis. • “Pt positive sepsis screen, low bp. hr increased low grade fever, o2 91 on RA pt only complained of decreased sensation to the right side. MD notified awaiting for new orders.” • Escalated to provider who ordered lactic, cultures and increased fluids. Lactic was in fact elevated at 2.7. • Infectious disease and medical service were consulted and antibiotics ordered for prostatitis and possible other potential infection. • Patient transferred to medical unit for closer observation and further management as he is unable to participate in therapies.
Process Improvement & Interventions Multi-disciplinary Approach: Clinical Documentation Improvement
Process Improvement & Interventions Example of Sepsis Education for Providers • Data show that sepsis, especially “early” sepsis and severe sepsis, is under -documented at IMVH • This skews our mortality numbers and does not reflect the care that you provide • IMVH currently has highest sepsis mortality in system! 2016 Q4 Inova Sepsis IMVH Sepsis Diagnosed Compared Mortality Performance to National Trends (2014-2016) Red = 80th %tile Green 20th %tile Blue = IMVH Sepsis Diagnoses Premier Top Quartile .68 O/E Ratio 0.99 0.85 0.81 0.80 0.80 0.68 IMVH IAH IFOH IFMC ILH Inova
Process Improvement & Interventions Multi-disciplinary Approach: Palliative Care • We have a growing and responsive palliative care team to serve patients with serious illness and comorbidities • Clarifying goals of care early on helps everyone involved
Process Improvement & Interventions Following the Principles of High Reliability HRO Principles IMVH Sepsis Process • Preoccupation Every potential core measure fallout is examined, even if it is not sampled • with Failure Even mistakes that did not lead to harm are examined • Staff utilize the “Safety Always” reporting system • Sensitivity to Sepsis coordinator and nursing supervisors monitor several times each day – and at all hours – for potential sepsis patients Operations • Sepsis coordinator has easy access both to front-line staff and those higher up in the chain of command • Reluctance to Our interdisciplinary sepsis committee always asks how we can take things Simplify to the next level • We are never satisfied with our progress or let down our guard • We dig deep to find root causes of failures • We attempt to look at data in new ways or from different angles • Commitment to We view mistakes as opportunities • Resilience Each nurse and provider is made directly aware of potential fallouts as soon as they are identified • We trust and respect each other and strive for a blame-free culture • Deference to Front-line staff are used to develop new processes and protocols • Expertise Sepsis coordinator provides real-time coaching to nurses and providers
Process Improvement & Interventions Working with Our Community Partners to Reduce Readmissions • “The line of communication between the hospital and the nursing home is critical in reducing admissions and mortality from sepsis” (HQI ) • Each month we host a well-attended Continuum of Care Collaboration with our local SNFs, ALFs, home health and more • We conduct Apparent Cause Analyses for readmissions with facilities
SOS! Spotlight on Sepsis • Our Opportunity • Process Improvement & Interventions • Our Results • Next Steps
Our Results Septicemia 80% 70% 60% 50% Target Area Percent 40% 30% 20% 10% 0% Hospital Natl: 80th %ile Juris: 80th %ile State: 80th %ile Natl: 20th %ile Juris: 20th %ile State: 20th %ile
Our Results Focused Population: Severe Sepsis/Septic Shock - Core Measure Mortality results reflect admitted patients (excluding psych, rehab, hospice) and exclude acute transfers in or transfers out PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17
Our Results Source: Medicare.gov Hospital Compare data for Q4 ’17 to Q3 ’18
Our Results IMVH Sepsis Cases 700 600 500 400 300 200 71 100 56 52 44 25 0 2015 2016 2017 2018 2019 (Jan-Jul) Outcome Cases Deaths Focused Population: Severe Sepsis/Septic Shock - Core Measure PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17
Our Results Sepsis Risk-adjusted 30-day Readmissions - CareScience 1.60 1.40 1.20 1.00 O/E 0.80 0.60 0.40 0.20 0.00 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2016 2017 2018 2019 All-Cause Hospital-Wide 30-Day Readmission Methodology with Planned Readmission Algorithm v4.0 Focused Population: Severe Sepsis/Septic Shock - Core Measure PRIVILEGED AND CONFIDENTIAL: Protected under Virginia Code Section 8.01-581.17
SOS! Spotlight on Sepsis • Our Opportunity • Process Improvement & Interventions • Our Results • Next Steps
Next Steps • Maintain SEP-1 core measure and mortality rates • Continue relationship with skilled nursing facilities to reduce readmissions • Focus on reducing complications • Continue patient and family education
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