3/20/2013 1 IHI Expedition Treating Maternal Sepsis Thursday, March 21 These presenters have nothing to disclose Pete Cherouny, MD Kevin Rooney, MBChB, FRCA Sue Leavitt Gullo, RN, BSN, MS Today’s Host 2 Jesse McCall, Project Manager, Institute for Healthcare Improvement (IHI), currently manages Expeditions (2 – 4 month web-based educational programs) and various other projects including Passport, The $10 Million Saved Seminar, and the Co-Operative Education Program in partnership with Northeastern University. He began his career at IHI as the Project Coordinator for the 5 Million Lives Campaign. Mr. McCall is a graduate of Northeastern University in Boston, MA with a specialization in marketing. He enjoys music, trivia, the beach, and cooking.
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3/20/2013
1
IHI ExpeditionTreating Maternal Sepsis
Thursday, March 21
These presenters have nothing to disclose
Pete Cherouny, MD
Kevin Rooney, MBChB, FRCA
Sue Leavitt Gullo, RN, BSN, MS
Today’s Host2
Jesse McCall, Project Manager, Institute for Healthcare Improvement (IHI), currently manages Expeditions (2 – 4 month web-based educational programs) and various other projects including Passport, The $10 Million Saved Seminar, and the Co-Operative Education Program in partnership with Northeastern University. He began his career at IHI as the Project Coordinator for the 5 Million Lives Campaign. Mr. McCall is a graduate of Northeastern University in Boston, MA with a specialization in marketing. He enjoys music, trivia, the beach, and cooking.
3/20/2013
2
WebEx Quick Reference
• Welcome to today’s session!
• Please use chat to “All Participants” for questions
• For technology issues only, please chat to “Host”
• WebEx Technical Support: 866-569-3239
• Dial-in Info: Communicate / Join Teleconference (in menu)
3
Raise your hand
Select Chat recipient
Enter Text
4
When Chatting…
Please send your message to
All Participants
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5
Chat Time!
What is your goal for participating in this Expedition?
5
6
Join Passport to:
• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-
line teams make rapid improvements.
• Train your middle managers to effectively lead quality improvement initiatives.
Sue Leavitt Gullo, RN, BSN, MS, Managing Director, Institute for Healthcare Improvement (IHI), brings 30 years of health care experience to her current roles, which include work in IHI's national and international patient safety work, and IHI's faculty for leadership and patient safety. She is the Director of the Perinatal Improvement Community and The Safer Patient Project in Denmark. Prior to joining IHI, Ms. Gullo was the Director of Women's Services at Elliot Hospital in New Hampshire. Her prior nursing roles included experience in the frontline clinical areas of maternal-child health, oncology, and medical-surgical nursing. Ms. Gullo has also been active as national faculty in obstetrical care for the last 15 years. Her involvement with IHI dates back to 1995 as a participant in the IHI Breakthrough Series on Improving Maternal and Neonatal Outcomes and continued as IHI faculty until she joined the IHI staff in 2005.
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Today’s Agenda11
Ground Rules & Introductions
What is Sepsis?
The Golden Hour – Sepsis Doesn’t Wait
Review Maternal Sepsis at Your Organization
Case Study of Maternal Sepsis
Developing a Measurement System
Next Steps
Ground Rules12
We learn from one another – “All teach, all learn”
Why reinvent the wheel? - Steal shamelessly
This is a transparent learning environment
All ideas/feedback are welcome and encouraged!
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Overall Program Aim
The program aims to help participants learn how to identify and treat maternal sepsis by sharing
screening techniques and treatment protocols geared toward maternal populations.
13
Expedition Objectives
At the end of the Expedition, participants will be able to:Identify maternal and perinatal morbidities and mortalities associated with infectionExplain the known strategies to prevent infection in the maternal patient during and following pregnancyDescribe the process of recognizing and managing of infection in order to minimize morbidity and mortalityDefine the critical points in mitigating the advancement of shock and septic shock, with a focus on the Golden HourDesign a reliable early response system to decrease morbidity, mortality and cost
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Schedule of Calls
Session 1 – Prevention, Identification, and Mitigation of Maternal
Sepsis
Date: Thursday, March 21 1:00 PM – 4:00 PM ET
Session 2 – Designing a Reliable Process to Identify and Treat
Maternal Sepsis
Date: Friday, April 26, 1:00 – 2:30 PM ET
15
Faculty16
Peter H. Cherouny, MD, Professor of Obstetrics and Gynecology, University of Vermont College of Medicine, has strong clinical interests in obstetric health care quality improvement and is currently serving as Chair of the Institute for Healthcare Improvement's Perinatal Improvement Community. He was also the lead author of the IHI white paper, "Idealized Design of Perinatal Care." He has been Chair of Quality Assurance and Improvement and Credentialing for the Women's Health Care Service of Fletcher Allen Heathcare for the last 15 years. His recent research and work in obstetric quality improvement is as Chair of the March of Dimes collaborative, "Improving Prenatal Care in Vermont," and as co-investigator of the MedTeams project.
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Faculty17
Kevin Rooney, MBChB, FRCA, Professor of Care Improvement, University of the West of Scotland was appointed as a consultant in Intensive Care and Anaesthesia at the Royal Alexandra Hospital in Paisley in July 2003. From February 2009 to January 2011, he was the Lead Clinician in Critical Care for Greater Glasgow & Clyde Health Board, the largest strategic health authority in Scotland serving a population of 1.2 million people and providing tertiary referral services to over 50% of Scotland’s 5.2 million population. In January 2011, Kevin was made a Professor of Care Improvement at the University of the West of Scotland, where he leads the Institute for Care and Practice Improvement. He continues to practice in Intensive Care & Anaesthesia at the Royal Alexandra Hospital where he can pursue his interests of patient safety and healthcare quality improvement. Professor Rooney is the National Clinical Adviser on Sepsis to Healthcare Improvement Scotland and is leading their breakthrough series collaborative on Sepsis. He is also the National Clinical Lead for Knowledge into Action for NHS Education for Scotland, where he helps to align the use of knowledge in NHS Scotland with care that is safe, effective and person-centred.
What is Sepsis?IHI Expedition: Treating Maternal Sepsis
March 21, 2013
These presenters have nothing to disclose
Kevin Rooney, MBChB, FRCA
3/20/2013
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Background
ICU ConsultantRoyal Alexandra Hospital, PaisleyProfessor of Care ImprovementNational Clinical Lead for SepsisHealthcare Improvement Scotland
Conflicts of Interest
In the last 5 years I have acted as consultant, or received honoraria / research grants from:
Abbott, Baxter, Eli Lilly
What is Sepsis?
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Diagnostic Criteria for Sepsis:
Crit Care Med 2013; 41:580-647
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Severe Sepsis
Crit Care Med 2013; 41:580-637
Severe Sepsis And HAI Mortality
SEVERE SEPSIS
2004: 14000 DEATHS
300 per million dying of severe sepsis in any one year
ODDS: 1 in 3333
SEPSIS in UK: 37000 DEATHS
ODDS 1 in 125
MRSA & CDI
2006: 8132 DEATHS
91 per million dying of MRSA or CDI in any one year.
ODDS: 1 in 11,000.– For those aged under 45
years : 1 in 250,000.
– For those aged 85 years or older, 1 in 300.
www.statistics.gov.uk
UK Sepsis Group, Harrison D et al Critical Care 2006; 10:R42
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Acute MI & Trauma
5% Mortality 3% Mortality
“Similar to polytrauma, acute myocardial infarction, or
stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome.”
“Most of these recommendations are appropriate for the severe sepsis patient in the ICU and non-ICU settings.”
During the 2006 – 2008 triennium, sepsis was the leading cause of direct maternal deaths, accounting for 26 direct deaths and a further 3 deaths classified as ‘Late Direct’Whilst maternal mortality is declining overall, maternal deaths due to sepsis have risen in recent triennia, particularly those associated with Group A streptococcal infection (GAS)
2000-2002 2003-2005 2006-2008
Rate per 100000 maternities
0.65 0.85 1.13
Numbers (all organisms)
13 21 29
Numbers (GAS) 3 8 13
Sepsis Deaths and Fetal Outcomes
29 Deaths altogether
Before 24 weeks, (n=8 ) women died of sepsis
– 100% fetal loss
After 24 weeks (n=21)
12 women had vaginal delivery
9 women had caesarean section
Antenatal Sepsis
9 women developed sepsis antenatally @ >24wks
– 4 c-section/ 5 vaginal deliveries
Fetal outcome : 16 survived5 stillbirths
5 in-utero deaths
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Why do Obstetric Patients Die?
Immunosuppressed
Uncommon
Bad signs very late
Low index of suspicion
Factors affecting Mortality
Subtle signs and symptoms
Lack of recognition of disease severity
Delay in diagnosis
Delay in treatment
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Q&A - Challenges in managing septic patients (tick all that apply/clinical unit level responses)
38%
33%
30%
26%
18%
18%
17%
13%
8%
0% 10% 20% 30% 40% 50%
Deficits in skill and knowledge e.g. lack offamiliarity with assessment / screening tools
Time / workload constraints
Issues relating to referrals / consultation
Multiple physicians admit to the unit, such thatcare processes and teams are fragmented
Absent or unclear procedures / protocols
Lack of supervision of junior clinicians(details)
None
Other (provide details)
Access to relevant information, assistance orother resources (provide details)
The 3 delays model38
DEMAND:
Delays in
deciding to
seek care
SUPPLY:
Delays in
receiving
routine and
emergency
high quality
care
LINKAGE:
Delays in
identifying and
reaching
appropriate
care setting
Delay 1 Delay 2 Delay 3
Designing an integrated care system that accounts for the patient journey
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Why all septic patients?
Sepsis Disease Continuum:
15% → 30% → 50%
Sepsis Deterioration
SIRS
Sepsis
Severe Sepsis
Septic Shock
Action
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Risk Factors for Maternal / Genital Sepsis
ObesityImpaired glucose tolerance / diabetesImmunosuppressionAnaemiaVaginal DischargeHistory of pelvic infectionHistory of Group B Streptococcal InfectionGroup A Strep in close contacts
Invasive intrauterine proceduresProlonged Spontaneous Rupture of MembranesPyrexia in LabourRetained products of conceptionC-Section/MidcavityforcepsPoverty & Minority ethnic groups
Variation In Sepsis Care
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15,022 Patients
165 Hospitals
Median of 14
Months
Mortality Decreased from
37 to 30.8 Percent
6.2% Absolute
16% Relative
Stages of Facing Reality
“The data are wrong”
“The data are right, but it’s not a problem”
“The data are right; it is a problem; but it is not my problem.”
Adapted from: Glasziou, P et al. Can evidence-based
medicine and clinical quality improvement learn from
each other? 2011. BMJ QualSaf 20 (suppl 1): i13-i17
89
Evidence for the Change Package90
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91
“He who must not be named”92
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Socio-economic Factors93
Type of physiological abnormality at time of ED patient inclusion in audit (first signs of sepsis) n=626 – median age 73 years
Gray et al Emerg Med J (2012) doi:10.1136/emermed-2012-201361
94
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Reliable Recognition, Assessment & Rescue95
What can we do?
Early recognition
Early resuscitation
Early antibiotics
Review
Appropriate help
96
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Screening for Sepsis and Performance Improvement
We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy (grade 1C).
Performance improvement efforts in severe sepsis should be used to improve patient outcomes (UG).
2. Take blood cultures and consider source control
3. Give IV antibiotics according to local protocol
4. Start IV fluid resuscitation (min 500ml) and reassess
5. Check serum lactate & FBC
6. Commence accurate urine output measurement and consider urinary catheterisation
All within one hour
104
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History
Diarrhoea +/- vomiting
Severe lower abdominal pain/ severe “after pains”requiring frequent analgesia
Sore throat
Myalgia
Fever
Productive cough, shortness of breath
Urinary symptoms
Vaginal discharge/ wound pain and redness
105
History
“diarrhoea is an important sign of pelvic sepsis, the combination of abdominal pain and fetal loss should alert the clinician to the possibility of sepsis as well as consideration
of abruption””””
106
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Clinical Features Suggestive of Sepsis
Fever or rigors
Diarrhoea or Vomiting
Rash
Abdominal / Pelvic pain & tenderness
Offensive vaginal discharge
Productive cough
Urinary symptoms
Breast Engorgement
Wound infection
Heavy Lochia
Delay in Uterine involution
Non-specific
– Lethargy
– Reduced appetite
Investigations
FBC, U&Es, LFTs, glucose
Coagulation
Blood Cultures
ABGs
Blood lactate
CRP
HVS, MSSU, throat swab, wound swab
108
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Investigations-Severe Sepsis
BP <90mmHg or MAP<65mmHg or systolic 40 mmHg below normal
Urine output <30 mls/hr for 2 hours
New altered mental state
New oxygen requirement
Serum creatinine >120mmol/l
Lactate >4 mmol/l
Unexplained coagulopathy
109
Common organisms causing Puerperal Sepsis
GAS, also known as Streptococcus pyogenes
Escherichia coli
Staphylococcus aureus
Streptococcus pneumoniae
meticillin-resistant S. aureus (MRSA), Clostridium septicum and Morganella morganii.
following onset of septic shock-associated hypotension
and associated survival. The x-axis represents time (hrs)
following first documentation of septic shock-associated
hypotension. Black bars represent the fraction of
patients surviving to hospital discharge for effective
therapy initiated within the given time interval. The gray
bars represent the cumulative fraction of patients having
received effective antimicrobials at any given time point.
Why within an hour?111
The Sepsis Six
1. Deliver O2 (>94% SpO2 or >88% in COPD)
2. Take blood cultures and consider source control
3. Give IV antibiotics according to local protocol
4. Start IV fluid resuscitation (min 500ml) and reassess
5. Check serum lactate & FBC
6. Commence accurate urine output measurement and consider urinary catheterisation
All within one hour
112
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Surviving Sepsis 2012
We recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (> 45 minutes) in the start of antimicrobial(s) administration(grade1C).
The administration of effective IV antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) should be the goal of therapy.
The antimicrobial regimen should be reassessed daily for potential de-escalation to prevent the development of resistance, to reduce toxicity, and to reduce costs (grade 1B).
Activity – Review Maternal Sepsis at Your Organization
IHI Expedition: Treating Maternal Sepsis
March 21, 2013
These presenters have nothing to disclose
Sue Leavitt Gullo,
RN, BSN, MS
3/20/2013
66
Case Example of Maternal SepsisIHI Expedition: Treating Maternal Sepsis
March 21, 2013
These presenters have nothing to disclose
Cheri Johnson, RN
Questions?132
Raise your hand
Use the Chat
3/20/2013
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Designing a Measurement Strategy IHI Expedition: Treating Maternal Sepsis
March 21, 2013
These presenters have nothing to disclose
Sue Leavitt Gullo,
RN, BSN, MS
What are we trying toAccomplish?
How will we know that a
change is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Act Plan
Study Do
Source:
Langley, et al. The Improvement Guide, 1996.
Aim
The three
questions
provide
the
strategy
The PDSA cycle
provides the
tactical approach
to work
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Always ask…
What is the real problem we are trying to solve?
135
136
Aim Statement Worksheet
Team name:
How good?
By when?
Aim statement (What’s the problem? Why is it important? What are we going to do about it?)
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137
Check Points in Developing an Aim Statement
AIM Content
• Explicit over arching description
• Specific actions or focus
• Goals
AIM Characteristics
• Measurable (How good?)
• Time specific (By when?)
• Define participants and customers
What are we trying toAccomplish?
How will we know that a
change is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Act Plan
Study Do
Source:
Langley, et al. The Improvement Guide, 1996.
Measure
The three
questions
provide
the
strategy
The PDSA cycle
provides the
tactical approach
to work
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Question #2: How Do We Know that a Change is an Improvement?
“When you can measure what you are speaking about
and express it in numbers, you know something about it;
but when you cannot measure it, when you cannot
express it in numbers, your knowledge is of a meager
and unsatisfactory kind.”
Lord Kelvin, May 3, 1883
“In God we trust.
All others bring data.”
W. E. Deming
The purpose of measurement in QI work is for learning not judgment!
All measures have limitations, but the limitations do not negate their value for learning.
You need a balanced set of measures reported daily, weekly or monthly to determine if the process has improved, stayed the same or become worse.
These measures should be linked to the team’s Aim.
Measures should be used to guide improvement and test changes.
Measures should be integrated into the team’s daily routine.
Data should be plotted over time on annotate graphs.
Focus on the Vital Few!
Measurement is Central to the Team’s Ability to Improve
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Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result?
Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?
Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)?
Three Types of Measures
� Outcome Measures:Percent of patients alive at 30 days or discharged alive < 30 days, sampled patients
� Process Measures:
- Percent of patient with elevated EWS score who had documented SIRS score
- Median Time to First Antibiotic Dose
- Percent of patients with blood culture performed within 1 hour of time zero
- Percent of patients with Sepsis Six performed within 1 hour of time zero (Bundle)
Three Types of Measures
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143How do we analyze variation for quality improvement?
Run and Control Charts are the best
tools to determine if our improvement
strategies have had the desired effect.
The Problem144
Aggregated data presented in tabular formats or with summary statistics, will not
help you measure the impact of process improvement/redesign efforts. Aggregated
data can only lead to judgment, not to improvement!
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Measure Over Time
0
1
2
3
4
5
6
7
8
9
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14
De
lay t
ime
(h
ou
rs)
Weeks
What are we trying toAccomplish?
How will we know that a
change is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Act Plan
Study Do
Source:
Langley, et al. The Improvement Guide, 1996.
Changes
The three
questions
provide
the
strategy
The PDSA cycle
provides the
tactical approach
to work
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Changes
Design reliable processes
Reduce variation
Limit waste
Discover through applied learning
147
Guidance for Testing a Change Concept
Test over a wide range of conditions in the sequence of tests, for example test at different times of day, different days, different patients
Celebrate your failures and learn from them.─ Do not try to design the perfect test─ Some theories are wrong
Don’t confuse a task with a test!
A test means that you are changing something: thus a test of change
148
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149
A test of change should answer a specific question!
A test of change requires a theory and a prediction!
Test on a small scale and collect data over time.
Build knowledge sequentially with multiple PDSA
cycles for each change idea.
Include a wide range of conditions in the sequence of tests.
Don’t confuse a task with a test!
Guidance for Testing a Change Concept
Why Rapid Cycle Testing
• Minimal investment to learn what works
• Engages individuals
• Being able to test leads to willingness to adopt
• “Just do it” does not work for large changes
150
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Testing
Test on a small scale and collect data over time.
Test with one nurse, one doctor, one patient 1----3----5----ALL
Build knowledge sequentially with multiple PDSA cycles for each change idea.
Test multiple times, with different changes
151
Don’t confuse a task with a test!
They are closely related.
In order to run a PDSA test, you need to perform a number of tasks or activities
152
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A PDSA and related Tasks
Examples of Tasks
� Scheduling a meeting
� Creating a form to collect data
� Printing a survey
� Developing an educational program
� Writing a policy or procedure
� Deciding which form to use
� Determining when the test will be done
� Identifying who will run the test, where it will be done and when
153
Tests and related task
Test Tasks (activities) we need to do in order
to run this test
In this test we plan to: 1.
2.
3.
In this test we plan to : 1.
2.
3.
4.
154
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How quickly can you test?
─ Depends on design of the test
─ Availability of situation to test
─ Can test many times a day
─ Test at least once a day or every two days
─ Based on level of ambition
155
Source: The Improvement Guide, API
Model for Improvement
Now, let’s focus
on the PDSA
part of the MFI
and tests of
change
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The PDSA Cycle for Learning and Improvement
Plan• Objective
• Questions &
predictions
• Plan to carry out:
Who?When?
How? Where?
Do• Carry out plan
• Document
problems
• Begin data
analysis
Act• Ready to
implement?
• Try something
else?
• Next cycle
Study• Complete data
analysis
• Compare to
predictions
• Summarize
What will happen if we try something different?
Let’s try it!Did it work?
What’s next?
Testing v. Implementation
Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system.
Implementation – Making this change a part of the day-to-day operation of the system
Would the change persist even if its champion were to leave the organization?
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Factors that Determine SuccessCurrent Situation Resistant Indifferent Ready
Low Confidence that current change idea will lead to Improvement
Cost of failure large
Very Small
Scale Test
Very Small
Scale Test
Very Small
Scale Test
Cost of failure small
Very Small
Scale Test
Very Small
Scale Test
Small Scale
Test
High Confidence that current change idea will lead to Improvement
Cost of failure large
Very Small
Scale Test Small Scale
Test
Large Scale
Test
Cost of failure small
Small Scale
Test
Large Scale
TestImplement
What are the next steps…
As a Team, what will be your plan?
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Proposed Measures
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Next StepsIHI Expedition: Treating Maternal Sepsis
March 21, 2013
These presenters have nothing to disclose
Sue Leavitt Gullo,
RN, BSN, MS
Will, Ideas, Execution
Will
Ideas
Execution
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Execution- What Will You Do?
What are you trying to accomplish?
How will you know a change is an improvement?
What changes will you make that will result in improvement?
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Action Period Assignment
Answer the 3 questions and begin your PDSA’s
Share your plan over the Listserv - faculty and other participants will provide feedback.
Be prepared to answer the following questions on Session 2