Stopping Sepsis in Virginia Hospitals and Nursing Homes · 2017-10-10 · Stopping Sepsis in Virginia . Hospitals and Nursing Homes. Hospital Webinar #5-Thursday, September 21, 2017

Stopping Sepsis in Virginia Hospitals and Nursing Homes

Hospital Webinar #5- Thursday, September 21, 2017

Welcome and Introductions

Today’s Objectives:

• Discuss Post Sepsis Syndrome and Post ICU Syndrome

• Address Handouts and Improving Communications (verbal and written)

• Stopping Sepsis Project Updates• Next Steps

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John Lawrence, RN, BSNStroke & Sepsis Coordinator

INOVA Mount Vernon HospitalAlexandria, VA

Collaboration Spotlight

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Your Sepsis Support Team

Deborah Smith, MTL(ASCP),

BSN,CIC, CPHQImprovement

Consultant

Candy Hamner,RN, BA, MA

Improvement Consultant

Betsy Cole Archer ,MS, ASCP

Sr. Director, Performance Improvement

Joyce Dayvault, RN, BBA

Director, Performance Improvement

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Lisa Mark,RN, BSN

Improvement Consultant

Your Sepsis Content Expert

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Kathleen M. Vollman RN, MSN, CCNS, FCCM, FAAN

Clinical Nurse Specialist/Educator/ConsultantADVANCING NURSING LLC

Sepsis Solutions International LLC [email protected]

Northville, Michiganwww.vollman.com

Disclosures for Kathleen Vollman

• Consultant-Michigan Hospital Association Keystone Center

• Consultant/Faculty for CUSP for MVP—AHRQ funded national study

• Subject matter expert for CAUTI and CLABSI for CMS/HEN 1.0 & 2.0

• Consultant and speaker bureau for Sage Products, LLC

• Consultant and speaker bureau for Hill-Rom, Inc.

• Consultant and speaker bureau for Eloquest Healthcare

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Let’s Get Started

Post Sepsis Syndrome(PSS) and Post ICU Syndrome (PICS) What You Need to Know to Impact Outcomes

Starts with Your ABC’s…

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• Define Post Sepsis Syndrome (PSS) and Post ICU Syndrome (PICS) in the patients.

• Identify current practice and begin to build the will to reduce cognitive and physical dysfunction harm that occurs as a result of sepsis or in patients with an ICU stay.

• Discussion current evidence based practice that can help reduce PICS

Learning Objectives

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Describes physical and/or long-term effects that affects up to 50% of people who survive sepsis.Longer term effects of sepsis include:• Sleep disturbance including insomnia• Experiencing nightmares, hallucinations,

flashbacks and panic attacks• Muscle and joint pains which can be severe

and disabling• Extreme tiredness and fatigue• Inability to concentrate• Impaired mental (cognitive) functioning• Loss of confidence and self-belief

Post-Sepsis Syndrome

Iwashyna, T. JAMA 2010; Mukherjee, S SHOCK 20129

Post Sepsis Syndrome

• People who have suffered from severe sepsis and especially those treated in an intensive care unit are at greatest risk of suffering post-sepsis syndrome.

• “60 percent of hospitalizations for severe sepsis were associated with worsened cognitive and physical function among surviving older adults. The odds of acquiring moderate to severe cognitive impairment were 3.3 times higher following an episode of sepsis than for other hospitalizations.”

• Sepsis survivors may be more at risk for developing other infections both viral and bacterial

Iwashyna, T. JAMA 2010; Mukherjee, S SHOCK 201210

Mild Cognitive Impairment

Moderate/Severe Cog Impairment

20

15

10

5

0

% survivors cognitively impaired

-3 years -1 year +1 year + 3 years

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p<0.001After SepsisBefore Sepsis

Iwashyna T, JAMA 2010;304:1787-1794

Cognitive Impairment: Sepsis

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Functional Trajectories by Baseline Functioning

ADL: walking, dressing, bathing, eating, getting into and out of bed and toiletingIADL: preparing a hot meal, shopping for groceries, making telephone calls, taking medicines, and managing money

Iwashyna T, JAMA 2010;304:1787-1794

1.57 new limitations among patients who had no limitations

before

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Cause of Post Sepsis Syndrome

• Response to systemic inflammation• Brain, muscle and nerve injury from

inflammation, ischemia and ischemia-reperfusion

• Poor perfusion, blood clots• End organ damage

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Quote from Husband of 32 year Old Sepsis Survivor

“Doctor, she’s not all there. The wit, the comprehension, the concentration. It’s all haphazard at best. To most, it is unrecognizable. The best way to describe it is mental disorganization, like there is a connection missing or a synapse not firing. It has been 10 months, and I just keep waiting for it to straighten itself out. Is this it?”

http://www.icudelirium.org/testimonials.html

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http://www.icudelirium.org/testimonials.html

Post Intensive Care Syndrome

Harvey M, Davidson J. Crit Care Med, 2016;44(2):381-38515

Definition

PICS is defined as new or worsening impairment in physical, cognitive, or mental health status arising and persisting after hospitalization for critical illness


PICS-Physical Dysfunction

• Less than 10% of patients on mechanical ventilation • for >4 d are alive and fully independent 1 yr later• Caregiver assistance ranging from assistance with activities

of daily living to full care is required by patients 1 yr later• Half of patients with adult respiratory distress syndrome

have not returned to work 1 yr later• ICU-acquired weakness that can persist for years can

develop in 25–80% of those with sepsis or on mechanical ventilation for > 4 d

Desai SV, Law TJ, Needham DM:. Crit Care Med 2011; 39:371–379Brummel NE, Balas MC, Morandi A, et al: Crit Care Med 2015; 43:1265–1275Briegel I, Dolch M, Irlbeck M, et al:Anaesthesist 2013; 62:261–270

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PICS: Cognition & Mental Illness

• Cognitive impairment that can persist for years develops in 30–80% of patients

• Symptoms of depression occur 1/3 of patient and persist for a year

• Symptoms of anxiety occur in 23–48% have symptoms of anxiety

• Symptoms of posttraumatic distress syndrome occur in 10–50% of patients and may persist for years

Desai SV, Law TJ, Needham DM:. Crit Care Med 2011; 39:371–379Brummel NE, Balas MC, Morandi A, et al: Crit Care Med 2015; 43:1265–1275Briegel I, Dolch M, Irlbeck M, et al:Anaesthesist 2013; 62:261–270Rabiee A, et al. Crit Care Med, 2016, May 5th online

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Epidemiology of ICU Delirium• 20 - 80% of ICU patients have delirium during ICU• Frequently unrecognized or misdiagnosed by

clinicians• Subtypes

o Hyperactive (agitated, increased motor activity) 1%o Hypoactive (sleepy, inattentive, decreased motor

activity) 44%o Mixed 55%

• Onset: ICU Day 2 (+/- 2)• Duration: 4 (+/- 2) days• 50% & 10% of ARDS pts delirious at ICU &

hospital d/cEly, EW, et al. JAMA 2001; 286, 2703-2710Ely, EW, et al. CCM 2001; 9:1370-1379Peterson, et al JAGS 2006: 54:479-484 McNicoll L, JAGS 2003;51:591-98;Fan, et al CCM 2008:94-99.

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Brain-ICU Study

• Multicenter RCT- medical-surgical ICU’s• 821 patients with ARF or Shock• Evaluated in-hospital delirium and cognitive

impact 3-12 months post d/c

Results:• 74% of patients developed

delirium during hospital stay• 1/3 & 1/4 had cognitive scores at

1 year follow-up c/w moderate TBI & mild Alzheimers, respectively

• Affected both older and younger

Pandharipande, PP. et al. N Engl J Med;369:1306:1316

1 out of 4 cognitive

Impairment at 12

months

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Delirium and Patient Outcomes

• Independently associated with increased risk of death: Each day of delirium increase 1 yr mortality by 10%

• Duration assoc. with short & long term cognitive impairment

• 1 out of 4 patients had cognitive impairment at 12 months• Mech Vent duration• ICU & Hospital Length of Stay• Estimated national costs $4 to $16 Billion• ?Post-d/c anxiety/ PTSD symptom from delirious memory

Klouwenberg BMJ 2014;349:g6652; Ely. ICM 2001; 27, 1892-1900 Ely, JAMA 2004; 291: 1753-1762 ; Lin, SM CCM 2004; 32: 2254-2259Girard CCM 38(7):1513-1520; Milbrandt E.,CCM 2004; 32:955-962. Jackson. Neuropsychology Review 2004; 14: 87-98.Oimet ICM 2007; 33:1007-1013; Davydow Gen. Hosp. Psych 2008;30:421-434Pandharipande, PP. et al. N Engl J Med;369:1306:1316

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Patient Risk Factors

• Immobility• Number of days on mechanical ventilation• Length of stay in the ICU• Heavy sedation• Delirium• Hypoglycemia• Hypoxia• Sepsis• ARDS

Desai SV, Law TJ, Needham DM:. Crit Care Med 2011; 39:371–379Brummel NE, Balas MC, Morandi A, et al: Crit Care Med 2015; 43:1265–1275Briegel I, Dolch M, Irlbeck M, et al:Anaesthesist 2013; 62:261–27022

Prevention is Key

Minimizing Risk Factors23

Reduction of Risk Factors for PICS

• ABCDEF bundle• Early psychological intervention• ICU diaries• Healing environments of care• Post-discharge follow-up programs


“Four Cornerstones for Success”

Evidence Based

Practice

Inter-Professional

Teams

System Collaboration

Reduction of Practice Variation

ASSESS, PREVENT & MANAGE PAIN

BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY

FAMILY ENGAGEMENT & EMPOWERMENT/FOLLOW UP REFERRALS/

FUNCTIONAL CHECKLIST

GOOD HANDOFF COMMUNICATION

HANDOUT MATERIALS FOR PICS & PICS-F

A

DEF

BC

COORDINATION & COMPREHENSIVE

ORAL CARE

GH

Harvey M, Davidson J. Crit Care Med, 2016;44(2):381-385Balas M, et al. Crit Care Med. 2014 May;42(5):1024-36. www.iculiberation.org

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http://www.iculiberation.org/

Pain, Agitation and Delirium (PAD)

• Agitation in critically ill patients may result from inadequately treated pain, anxiety, delirium, and/or ventilator desynchrony

• Detection and treatment of pain, agitation, and delirium should be reassessed often in these patients

• Patients should be awake and able to purposely follow commands in order to participate in their care unless a clinical indication for deeper sedation exists

Website to help organizations implement the PAD guidelines and reverse immobility:www.iculiberation.org; www.icudelirium.org

Barr J. Crit Care Med. 2013;41:263-30627

http://www.iculiberation.org/


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Society of Critical Care Medicine PAD Guidelines 2013

CPOT and BPS most valid and reliable

The American Society of Pain Management Nursing July 2011

CPOT is acceptable for the critically ill/unconscious

Critical Care Pain Observation Tool (CPOT)

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ICU Liberation Program Based on PAD Guidelines

www.iculiberation.org30


BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY





A

DEF

BC


ORAL CARE

GH


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Agitation

• Avoid deep sedation/coma: • Sedative medications should be titrated to maintain lighter

levels of sedation, unless clinically contraindicated. (+1B)• Use daily awakening or a titrated sedation strategy to

maintain patient wakefulness. (1B)• Choice of sedative:

• Non-benzodiazepines may be preferred over benzodiazepines to improve clinical outcomes in mechanically ventilated ICU patients. (+2B)

• Reduction in sedation requirements:• Use of an analgesia-first (i.e., analog-sedation) strategy is

recommended in mechanically ventilated patients. (+ 2B)Barr J. Crit Care Med. 2013;41:263-306.

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Non-Benzodiazepine Sedative Medications Yield Better ICU Outcomes

• Systematic review and meta-analysis of 6 RCTs comparing benzodiazepine vs. non-benzodiazepine ICU sedation regimens:↓ICU LOS (6 studies)• Difference of 1.6 days, P= 0.0007• ↓ Duration of mechanical ventilation (4 studies)

• Difference of 1.9 days, P< 0.00001• Similar delirium prevalence and short-term

mortality.

Fraser G. Crit Care Med. 2013; 41:S30-8www.ICUliberation.org

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Agitation

• Assess q 2-4hrs or prn with change in dose or patients condition

• Use validated tool (RASS or SAS)

• RASS target -1 to +1

• SAS target 3 to 4

www.iculiberation.org34

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ABC Trial (RCT Paired Sedation & Vent Weaning Protocols)

Girard, et al, Lancet. 2008;371:126-3436

ABC Trail: Mortality at 1 Year

Girard, et al, Lancet. 2008;371:126-3437

Perform the Safety Screen

• Pass safety screen? Turn off all sedatives• Observe for 5 min, continuously for up to 4 hrs.• If patient awakens: follow 3 out of 4 commands

(open eyes, look at you, squeeze hand, push out tongue)

• Leave sedation off! Tell RT so SBT can be completed.

• The patient fails based on:Try

intermittent dosing or

restart at ½ rate

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DAILY SBT Process

• Coordinate timing with RT• Conduct safety screen

• Is the patient on vasopressors? This is not automatic exclusion. Must be a discussion with the medical team.

• Pass the safety screen? RT will perform and document SBT and results of SBT.

• RT will notify team if patient passes.• Failure of SBT is based on:

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CDC Prevention Epicenters’Wake Up and Breathe Collaborative• Prospective quality improvement collaborative• Goal: prevent VAEs through less sedation and

earlier liberation from mechanical ventilation• Mechanism: increase performance of paired daily

spontaneous awakening trials and breathing trials (SATs and SBTs)

• 12 ICUs affiliated with 7 hospitals

Klompas M. (CDC ABCDE Collaborative), Am J Respir Crit Care Med. 2015;191:292-301.

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CDC Prevention Epicenters’Wake Up and Breathe Collaborative

a. 63% in SATs

b. 16% in SBTs

c. 81% in SBTs done with sedatives off

a. 37% in VACs

b. 65% in IVACs

SATs / SBTs VAEs

Klompas M. (CDC ABCDE Collaborative) Am J Respir Crit Care Med. 2015;191:292-301.

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Outcome of SAT/SBT

• Decreased days of mechanical ventilation• Reduced weaning time• Reduced re-intubation rates• Fewer days with delirium• Decreased length of ICU stay• Decreased length of hospital stay

Ely E. N Engl J Med.1999;335:1864-9.Girard T. Lancet.2008;371:126-34.Esteban A. Am J Respir Crit Care Med.1997;156:459-65.Esteban A. Am J Respir Crit Care Med.1999;159:512-8www.ICUliberation.org

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Interdisciplinary Rounds: Nursing Objective Card

VAP

SEPSIS

Pain, Agitation &

Delirium

CAUTI/CLABSI

Mobility

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BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY





A

DEF

BC


ORAL CARE

GH


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Delirium: First Focus on Prevention

• Pain and sedation scores• Analgesia and Sedative Algorithm

• Control pain first, then anxiety

• Use intermittent meds first before continuous

• Target RASS + 1 to -1• Daily SAT (spontaneous awakening trial)• Daily SBT (spontaneous breathing trial)• Screen for Delirium---minimum q12hrs; can do it more

frequently• Implement non-pharmacological strategies

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For Nursing Home Participants:

Polling Question #1

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Are you screening for delirium at a minimum of every 12 hours using a validated tool?

Check if the lights are on

Is anyone home?

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Non-Pharmacological Strategies

a. Appropriate Medicationsb. Bath during dayc. Chair positiond. Lightinge. Televisionf. Hearing/Vision Aids/Denturesg. Control Noiseh. Ear plugs/eye maski. Minimizing care related disruptions

j. Cognitive Stimulation/Musick. Reorientationl. Familiar objects in room/pictures

Sleep Promotion Mobility Promotiona. Evaluate for Physical Therapyb. Range of Motionc. Sleepd. Work with PTe. Spontaneous Awakening Trial

Sedation Awakening

Other

• Sleep Promotion• Mobility

Pandharipande P et al. (Lorazepam) Anesthesiology 2006;104:21–26;Oimet ICM 2007; 33:1007-1013;Pandharipande P et al. (Midazolam) J Trauma 2008Dubois MJ et al., (Morphine) Intensive Care Med 2001; 27:1297Abraha I, et al. Plos One. 2015;DOI:10.1371/journal.pone.0123090Gathecha E, et al. J of Hosp Med, 2016 online

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For Hospital & Nursing Home Participants:

Polling Question #2

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Do your ICUs and nursing care units have a sleep protocol?

PAD Treatment of Delirium Recommendations

• There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients (No Evidence).

• Atypical antipsychotics may reduce the duration of delirium in adult ICU patients (C).

• We do not recommend administering rivastigmine to reduce the duration of delirium in ICU patients (–1B).

Barr J, et al. Crit Care Med 2013; 41:263–306 51

Perceptions and Practices Regarding Sleep in the ICU*1

• 1223 surveys of providers• 59% nurses• 39% physicians

• 24 countries• 75% indicate ICU

patients sleep poor or very poor

• 83% to 97% felt poor sleep was associated with negative ICU outcomes

• 32% had sleep promoting protocols

1.Kamdar BB, et al. Ann Am Thorac Soc. 2016 Apr 22,The Sleep in the ICU Task Force2. Presented at Euroanaesthia 2016 accessed 07/14/2016 http://www.medicaldaily.com/noise-levels-icu-who-recommendations-388073

ICU noise at 45dBA & ½ the time at 54 dBA2

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Perceptions and Practices Regarding Sleep in the ICU

Kamdar BB, et al. Ann Am Thorac Soc. 2016 Apr 22, The Sleep in the ICU Task Force53


BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY





A

DEF

BC


ORAL CARE

GH


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Outcomes of Early Mobility Programs

• incidence of VAP• time on the ventilator• days of sedation• incidence of skin injury• delirium• ambulatory distance• Improved function• in hospital readmissions• ICU & Hospital LOS

Staudinger t, et al. Crit Care Med, 2010;38.Abroung F, et al. Critical Care, 2011;15:R6Morris PE, et al. Crit Care Med, 2008;36:2238-2243 Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094Schweickert WD, et al. Lancet, 373(9678):1874-82. Thomsen GE, et al. CCM 2008;36;1119-1124Winkelman C et al, CCN,2010;30:36-60Azuh O, et al. The American Journal of Medicine, 2016, doi:10.106/jmjmed.2016.03.032Corcoran JR, et al. PMR J, 2016 in press

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Systematic Review of Early Rehabilitation in the ICU

• 14 studies/1753 patients

• 880 patients in intervention group

• 873 patient in control group

• Varying methodologies

• Results• No difference in

short or long term mortality

Tipping CJ, et al. ICM, 2017;43:171-18356

a. Results of Active Rehaba. ↑ muscle mass at ICU d/cb. ↑ probability of walking without assistance at hospital d/cc. ↑ more days alive and out of hospital 180 days

b. Limitationsa. Variation in dosage, small sample sizes of individual studies

Tipping CJ, et al. ICM, 2017;43:171-183

Systematic Review of Early Rehabilitation in the ICU

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Consensus on Safe Criteria for Active MobilizationSystematic review performed than 23 international experts gather to reach consensus

• Respiratory• Cardiovascular• Neurological• Other Considerations

Categories: Consensus reach on all criteria. If no other contraindications; vasoactives, endotracheal tube, FIO2 < 60% with SaO2 90% & RR < 30/min were considered safe criteriaHodgson CL, et. al Critical Care, 2014;18:658

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Can We Do It?Is it Safe?

Early Mobility

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• 7,546 patients with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions (2.6%)

• Meta-analysis: hemodynamic changes, 3.8 (1.3–11.4) and desaturation 1.9 (0.9–4.3) per 1000 mobilization sessions

• Events that could not be meta-analyzed-• 11 falls , 2 removals of ETT, 35 removal or dysfunctions of

intravascular catheters, 15 removals of other tube/catheter, 4 cardiac arrest in a single study (not during mobilization).

• Consequences of Potential Safety Events Were reported in23 publications, with 3,329 patients & 13,974 mobilization sessions, 308 potential safety events, for incidence of 2% with consequences 0.6% (78 events)

Safety of Patient Mobilization & Rehab in ICU: Systematic Review & Meta-Analysis

Nydahl P, et al. Annals ATS, 2017;14(5):766-77660


BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY





A

DEF

BC


ORAL CARE

GH


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FGood communication with the family is critical at every step of a patient’s clinical course, and empowering the family to be part of the team to ensure best care is adhered to diligently will improve many aspects of the patient’s experience. The F was recently added to help to keep patients and families as the center and focus of care.

www.icudelirium.org

Family Engagement and Empowerment

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Families are the heart of

patient-centered

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Families are the Heart of Patient-Centered

“I have learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” Maya Angelou

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ICU Diaries

• Used routinely in Europe• Diaries are kept by families and

staff to describe the patients experience during the ICU stay

• Pictures are sometimes included• When read post discharge diaries

can fill in memory gaps, replace false memories and delusions

Ullman AJ, et al. Cochrane Database Syst Rev, 2014;12:CD010468Garrouste-Orgeas M, et al. Crit Care Med, 2012;40:2033-2040Jones C, et al. Am J Crit Care, 2012;21:172-176

Outcomes of ICU Diaries:• Decrease anxiety, depression and PTSD symptoms• Decrease PTSD symptoms in families

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Early Psychologic Intervention

• Psychologists as members of the critical care team

• Early patient & family support, counseling and education on stress management and coping skills

• Psychologist involvement has shown to cut the prevalence of anxiety, depression and PTSD in half

Peris A , et al. Crit Care, 2011;15:R41Czerwonka Al, et al. J Crit Care 2015;30:242-249Petrinec AM, et al. Crit Care Med, 2015;43:1205-1212

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BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY





A

DEF

BC


ORAL CARE

GH


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Functional Reconciliation Checklist

• Communication throughout the continuum of care—each transfer to ensure all areas are aware of the patients current physical function• ROM• Bed mobility• Chair• Ambulation• ADL

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BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY





A

DEF

BC


ORAL CARE

GH


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Good Handoff Communication

Each Phase Requires Different Levels of Support & Effective Handoff Communication

Czerwonka AI, et al. J of Crit Care, 2015;30:242-249

Major Theme: Survivors do not experience continuity of medical care during recovery after critical illness

• Informational needs change across the care continuum• Fear and worry persist when families don’t know what to expect• Survivors transition from dependence to independence

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BOTH SAT & SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY





A

DEF

BC


ORAL CARE

GH


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PICS Resources

Self help rehabilitation manual showed ↓ In PTSD symptoms. Jones C, et al. Crit Care Med, 2003;31:2456-2461

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ResourcesWebsite Selected information available at the site

www.sepsisalliance.org • signs/symptoms of sepsis• description of common sequelae• over 400 “Faces of Sepsis” – written tributes to lost loved ones and stories of

survivors

www.myicucare.org/thrive • several white-board videos for patient an families, including videos on preparing for hospital discharge after critical illness, post-intensive care syndrome, and wellness after critical illness

• information on virtual and in-person peer support groups for critical illness survivors

www.icusteps.org • information on in-person support groups in the United Kingdom• informational pamphlets for patients and families, including a guide to the ICU

www.healthtalk.org • video interviews describing patient and family experiences of the ICU

www.icudelirium.org/patients • information about common sequelae of critical illness, including patient testimonials

• information about the Vanderbilt ICU recovery center

http://www.aftertheicu.org • Site for information to help patients and families after their ICU stay• Blog to share journeys

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First US Post ICU Clinics- Indiana University & Vanderbilt

• Critical Care Recovery Center at Indiana University (2011)• ICU recovery Center at Vanderbilt (2012)

• Team consists of medical ICU nurse practitioner, a pharmacist, pulmonary intensivists, a case manager and neurocognitive psychologist

• Any member of the ICU teams can make a referral for patients to the clinic• Screening for inclusion and exclusion criteria are performed• Exclusion criteria

• Pre-existing dementia or cognitive defect, life limiting illness, manage primarily by different subspecialty service/eg. liver/renal transplant, already have specialty resources (eg. Stroke or cardiac rehab, long-term resident of a skilled nursing facility

• Initial visit: completes spirometry & a 6 minute walk test• Nurse practitioner completes a detailed history and physical exam• Neuropsychologist meets with the patient to evaluate and screen for

cognitive impairment and PTSD, anxiety and depression• Only anecdotal data to date

Huggins EL, AACN Advances in Critical Care. 2016;27(2):204-21174

SCCM ProgramEvery year, millions of Americans survive critical illness; but despite the efforts of their ICU, many are left with ongoing problems. The current health care system often does not meet the needs of these survivors, or their families, during their weeks to years of recovery. SCCM seeks to improve patient and family support after critical illness through the THRIVE Initiative.

Network of In-Person Support Groups

Survivors as partners in

Professional Societies

Advancing Research &

Improving our Own Practice

Online Support Groups

Educating non-ICU

Clinicians RE Survivorship

TJ Iwashya presented at SCCM Congress 2016 Orlando Fl

https://www.youtube.com/watch?v=aMn8Yd2JInIhttps://www.youtube.com/watch?v=DU7Ax-xaDiwhttps://www.youtube.com/watch?v=Rwch2_9mSQA&index=1&list=PLsb8sp1zaJWoeZ2qY2L_ymyinpn671HS8

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https://www.youtube.com/watch?v=aMn8Yd2JInI

https://www.youtube.com/watch?v=DU7Ax-xaDiw

THE OUTCOME

The Outcome

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ABCDEF Bundle: Improving Survival & Reducing Brain Dysfunction

• Ventilated and non-ventilated medical and surgical ICU patients enrolled between January 1, 2014, and December 31, 2014

• Determine association between ABCDEF bundle compliance/total & partial & outcomes of hospital survival and delirium-free and coma-free days/ adjusting for age, severity of illness, and presence of mechanical ventilation

• Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01–1.04; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001).

10% ↑ in total bundle compliance, patients had a 7% higher odds of hospital survival

Barnes-Daly, CCM 201777

Opportunities Identified in our 1st Cross Setting Meeting between Sepsis Project Hospitals and their Nursing Home Partners:

What have we learned?

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• Improve communication and education of caregivers, patients and families on early signs of Sepsis

• Improve staff communication during handoffs of transfers and discharges

• Arranging for early discharges from acute care to nursing homes so that medical orders and medications can be obtained in a timely manner to eliminate disruption in care especially need for continuation of antibiotic therapy

• Ensure discharge documentation is accurate, timely and complete for continued appropriate plan of post acute care

Save The Date

Friday, September 29, 2017, 10:00AM-12:00NCross Setting Meeting – Richmond/Petersburg SIP Participating Hospitals & Nursing Homes: Friday, September 29, 2017, 10:00AM-12:00N @ VHHA

Thursday, October 26th Webinar 11:00AM-12:00N“Exploring the Long Term Care Regulatory Process”

Regulatory expert Mary Chiles will take our hospital partners on a journey of nursing home state & federal regulatory processes affecting admissions, transfers, discharges and reimbursement. Nursing Homes are welcomed to attend.

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Q and A

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This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network-Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI|11SOW|20170919-144111

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Contact Information

Joyce Dayvault, RN, BBADirector of Performance Improvement, VHHASepsis Innovation Project Lead for Hospitals

Office: (804)297-3402email: [email protected]

Kathleen M. Vollman RN, MSN, CCNS, FCCM, FAAN

Clinical Nurse Specialist/Educator/ConsultantVA Sepsis Innovation Project Content Expert

ADVANCING NURSING LLCSepsis Solutions International LLC

email: [email protected]

Lisa Mark, RN, BSNImprovement Consultant, HQI

Sepsis Innovation Project Lead for Nursing HomesOffice: (804)-289-5331

email: [email protected]

mailto:[email protected]



Stopping Sepsis in Virginia Hospitals and Nursing Homes · 2017-10-10 · Stopping Sepsis in Virginia . Hospitals and Nursing Homes. Hospital Webinar #5-Thursday, September 21, 2017

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