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Sepsis and VenousThromboembolism
Sepsis and Venous Thromboembolism• Why we did it ?• What we embarked to do?• How we are doing presently?
The Sepsis / VTE Collaborative:Why we did it?
Why is it important?
Courtesy of Dr IRoberts
SEVERE SEPSIS AND HAI MORTALITY•   SEVERE SEPSIS                        •   MRSA & CDI•   2004: 14000 DEATHS              ...
A U.K. Perspective               40               30  AnnualUK mortality  (2003),      20thousands               10       ...
Surgical SepsisSepsis in General Surgery: The 2005-2007 NationalSurgical Quality Improvement Program Perspective.Moore, La...
Variation In Sepsis Care
15,022 Patients165 Hospitals Median of 14     Mortality Decreased from                     37 to 30.8 Percent             ...
STAG Sepsis Management in Scotland                 • Signs of sepsis < 2                   days                 • 2% of em...
Why is implementation so difficult?•   Too many elements in the bundle•   Some are controversial•   Time Sensitive Process...
Complacency, Education & Trying Harder            isn’t enough
New ways of thinking
New ways of thinking• Front line engagement• Segmentation• Real Time Data Collection• Early Feed Back of Metrics• Early Ca...
“He who must not be named”
Reliable Recognition, Assessment &              Rescue
VTE – the facts• Up to 25,000 deaths each year in England & Wales• No reason to believe that Scotland is any better• Numbe...
What are the consequences?• Some VTE are silent• Some VTE kill• Often are associated with long term poor health   – Post t...
Why should we care?• VTE is underestimated – many are diagnosed  after discharge from hospital  (Sweetland S et al BMJ 200...
What should we be doing ?         •Assessment of patient and admission         related risk of VTE         •Assessment of ...
The Sepsis / VTE Collaborative:What we embarked to do?
Will, Ideas and Execution
Complacency, Education & Trying Harder             isn‟t enough 17 years to apply 14% of research     knowledge to patient...
Team Scotland
How has the frontline done it?• Get goals.          •   Get the facts.• Get bold.           •   Get to the field.• Get tog...
The Collaborative Model                                  P                  P                P      Organisational        ...
Driver            Change          Measurement    Diagram            Package            Plan                       Learning...
The Model for Improvement „This model is not magic, but it is probably the most useful single framework I have encountered...
Learn from Experience• Segmentation• Real Time Data Collection• Early Feed Back of Metrics• Early Case Review and Feedback...
Having the best professionals in the world is no longer enoughSupport                 Responsibility• Collaborative       ...
Building Will
Community of Practicehttp://www.knowledge.scot.nhs.uk/sepsisvte.aspx
The Sepsis / VTE Collaborative:
• “The NHS is….. not good at capturing, using and sharing  information. Lots of data, a lot less information and even  les...
• Signs of sepsis < 2  days• 2% of emergency     Scottish  admissions (~5000)• 71% had aRate   Defect EWS• 34% had severe ...
•Assessment of patient and admissionrelated risk of VTE•Assessment of contra-indications to anti-coagulant and mechanical ...
Bridging the Knowledge-Practice Gap                “Knowing is not                enough; we must                apply. Wi...
Transfer of Knowledge intoQuality Healthcare                              Clinical Knowledge (Evidence                    ...
Example of Knowledge into Action support     package: Sepsis and VTE Collaborative     Aim: Define and Implement a Change ...
Driver Diagrams, Change Packages &            Measurement Plans• Subject experts• Improvement experts• A facilitated after...
The Result
The Sepsis / VTE Collaborative:How are we doing ?
Action Period 1• Community of Practice• Monthly Conference Calls and WebEx• Site Visits• Measurement• Learning Session 2
% Board participation in Conference Calls/WebEx                     Sepsis Collaborative100% 90% 80% 70% 60% 50% 40% 30%  ...
The Sepsis / VTE Collaborative:Ayrshire & Arran - Sepsis
What we are trying to accomplish?• All patients in an in the pilot area with a MEWS  score of 4 or more will be assessed f...
Managing the septic patient• Within the general ward areas an Advanced  Nurse practitioner is on duty, with a roving  mand...
First series of small tests
Worksheet for Testing ChangeAim:              Every goal will require multiple smaller tests of change              Descri...
Tested Documentation and     First Full Testing
Situation- Audit of SIRS/Sepsis assessment and implementation of the Sepsis 6                              bundle on pts w...
Initial data•   First live testing within Respiratory ward.•   Baseline data for 4 weeks commenced 9.1.12•   Patients with...
00:00                                            00:14                                                    00:28           ...
•   Pre intervention median time 1hr 25 min•   Post intervention median time 37 minutes•   Area chosen due to high probabl...
Balancing measures• Antibiotic usage- area now compliant with  empirical antibiotic use.• Blood culture contamination- non...
Currently• Cardiology• Surgical• Orthopaedics (all three wards)
Baseline data for Cardiology,Orthopaedic Department (ward x3) and      one general surgical ward• Baseline data being coll...
Time to first antiobiotic- cardiology, orthopaedics and general surgery10:4809:36                                         ...
Challenges• Acute baseline assessment and implementation.• Dual site response – Ayr Hospital baseline data  collection com...
The Sepsis / VTE Collaborative:Grampian – VTE
Plan Do Study Act (PDSA)       In Practice
Testing the validity of the VTE screening tool                                                             Change Seven: D...
VTE DATA
Patient Information Leaflet  “Quite impressive. Very good and  very interesting. Never knew about  dehydration and that ca...
Next Steps Taken• Orthopaedics now on test 2 of form with compliance data being collected.• General Surgical on test 5 of ...
Success…..
The Sepsis / VTE Collaborative:Conclusion
“Each of you ... All of us”“ The key is collective   impact !”“ working together means  that you should never  worry alone.”
http://www.cec.health.nsw.gov.au/programs/sepsishttp://www.thrombosis-charity.org.uk/cms/index.php?option=com_content&task...
Our journey has begun?• 10% reduction in mortality  from sepsis by 2014• Reliable risk assessment  and appropriate  thromb...
Thank You
Parallel Session 2.8 SEPSIS and VTE Collaborative – Breakthrough Series Collaborative within a Collaborative
Parallel Session 2.8 SEPSIS and VTE Collaborative – Breakthrough Series Collaborative within a Collaborative
Parallel Session 2.8 SEPSIS and VTE Collaborative – Breakthrough Series Collaborative within a Collaborative
Parallel Session 2.8 SEPSIS and VTE Collaborative – Breakthrough Series Collaborative within a Collaborative
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Parallel Session 2.8 SEPSIS and VTE Collaborative – Breakthrough Series Collaborative within a Collaborative

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Parallel Session 2.8 SEPSIS and VTE Collaborative – Breakthrough Series Collaborative within a Collaborative

  1. 1. Sepsis and VenousThromboembolism
  2. 2. Sepsis and Venous Thromboembolism• Why we did it ?• What we embarked to do?• How we are doing presently?
  3. 3. The Sepsis / VTE Collaborative:Why we did it?
  4. 4. Why is it important?
  5. 5. Courtesy of Dr IRoberts
  6. 6. SEVERE SEPSIS AND HAI MORTALITY• SEVERE SEPSIS • MRSA & CDI• 2004: 14000 DEATHS • 2006: 8132 DEATHS• 300 per million of dying of severe • 91 per million of dying of MRSA or sepsis in any one year CDI in any one year. • ODDS: 1 in 11,000.• ODDS: 1 in 3333 – For those aged under 45 years : 1 in 250,000.• SEPSIS in UK: 37000 DEATHS – For those aged 85 years or• ODDS 1 in 125 older, 1 in 300. www.statistics.gov.uk); ; UK Sepsis Group Harrison D et al Critical Care 2006; 10:R42
  7. 7. A U.K. Perspective 40 30 AnnualUK mortality (2003), 20thousands 10 0 Lung1 Colon2 Breast3 Sepsis4 1,2,3 www.statistics.gov.uk, cancers 4 Intensive Care National Audit Research Centre (2006) © Ron Daniels 2010
  8. 8. Surgical SepsisSepsis in General Surgery: The 2005-2007 NationalSurgical Quality Improvement Program Perspective.Moore, Laura; Moore, Frederick; Todd, S; Jones, Stephen;Turner, Krista; Bass, BarbaraArchives of Surgery. 145(7):695-700, July 2010. Copyright 2010 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions 2 Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. Published by American Medical Association.
  9. 9. Variation In Sepsis Care
  10. 10. 15,022 Patients165 Hospitals Median of 14 Mortality Decreased from 37 to 30.8 Percent 6.2% Absolute Months 16% Relative
  11. 11. STAG Sepsis Management in Scotland • Signs of sepsis < 2 days • 2% of emergency Scottish admissions (~5000) • Defect a EWS 71% had Rate • was had severe 34% 18-74% sepsis • 21% blood cultures • 32% IV Antibiotics • 70% IV fluids
  12. 12. Why is implementation so difficult?• Too many elements in the bundle• Some are controversial• Time Sensitive Process• Difficult To Diagnosis Sepsis Early• Human Factors Get In The Way• Invasive procedures needed• ICU stuff??
  13. 13. Complacency, Education & Trying Harder isn’t enough
  14. 14. New ways of thinking
  15. 15. New ways of thinking• Front line engagement• Segmentation• Real Time Data Collection• Early Feed Back of Metrics• Early Case Review and Feedback• Use Level 2 Reliability Tools
  16. 16. “He who must not be named”
  17. 17. Reliable Recognition, Assessment & Rescue
  18. 18. VTE – the facts• Up to 25,000 deaths each year in England & Wales• No reason to believe that Scotland is any better• Numbers likely to increase in line with risk factors• Known and significant gap in delivery of evidence based interventions• Process and outcome are disparate• Patient‟s clinical condition change• Patient‟s location changes
  19. 19. What are the consequences?• Some VTE are silent• Some VTE kill• Often are associated with long term poor health – Post thrombotic syndrome – Chronic thromboembolic pulmonary hypertension
  20. 20. Why should we care?• VTE is underestimated – many are diagnosed after discharge from hospital (Sweetland S et al BMJ 2009,339:b4583)• Around 25 to 50% of episodes relate to admission to hospital (Heit JA et al Arch Int Med 2002, 162:1245-8; Wiseman DN & Harrison J NZ Med J 2010, 123:37-90)• Adherence to thromboprophylaxis recommendations is incomplete, especially in medical in-patients (Cohen A et al Lancet 2008, 371:387; Bergman JF et al Thrombos Haemostas 2010, 103:736 )
  21. 21. What should we be doing ? •Assessment of patient and admission related risk of VTE •Assessment of contra-indications to anti- coagulant and mechanical Interventions •Treat according to outcome of assessment and recommended action •Plan for timely re-assessment •Documented evidence that the risks and benefits of thromboprophylaxis have been discussed with the patient
  22. 22. The Sepsis / VTE Collaborative:What we embarked to do?
  23. 23. Will, Ideas and Execution
  24. 24. Complacency, Education & Trying Harder isn‟t enough 17 years to apply 14% of research knowledge to patient care! Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
  25. 25. Team Scotland
  26. 26. How has the frontline done it?• Get goals. • Get the facts.• Get bold. • Get to the field.• Get together. • Get a clock.• Get a model (and • Get the numbers. stick with it) • Get the stories.• Get patients and families
  27. 27. The Collaborative Model P P P Organisational A D D A D Self Assessment A S S S 1.5 day LS ContinuedAlignment with Kickoff LS LS Supports national work Supports Key Changes Expert clinical faculty Listserv Site Visit Improvement Phone conf Assessments Measures Monthly Reports via web
  28. 28. Driver Change Measurement Diagram Package Plan Learning Session Action Period Monitoring & MeasurementMonthly Conference Monthly Site Calls & WebEx Visits
  29. 29. The Model for Improvement „This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement‟ Dr Donald M. BerwickFormer Administrator of the Centres for Medicare & Medicaid Services Professor of Paediatrics and Health Care Policy at the Harvard Medical School
  30. 30. Learn from Experience• Segmentation• Real Time Data Collection• Early Feed Back of Metrics• Early Case Review and Feedback• Use Level 2 Reliability Tools
  31. 31. Having the best professionals in the world is no longer enoughSupport Responsibility• Collaborative • Leadership• Leadership • Participation• Political attention • Outcomes• Prioritisation• Measurement
  32. 32. Building Will
  33. 33. Community of Practicehttp://www.knowledge.scot.nhs.uk/sepsisvte.aspx
  34. 34. The Sepsis / VTE Collaborative:
  35. 35. • “The NHS is….. not good at capturing, using and sharing information. Lots of data, a lot less information and even less knowledge, and thats bad for patients and their families, its bad for clinicians, bad for managers, bad for regulators and bad for policy-makers.” Ann Abraham, Parliamentary and Health Service Ombudsman, reporting on Mid-Staffordshire Inquiry.
  36. 36. • Signs of sepsis < 2 days• 2% of emergency Scottish admissions (~5000)• 71% had aRate Defect EWS• 34% had severe was 24-79% sepsis• 21% blood cultures• 32% IV Antibiotics• 70% IV fluids
  37. 37. •Assessment of patient and admissionrelated risk of VTE•Assessment of contra-indications to anti-coagulant and mechanical Interventions•Treat according to outcome of assessntand recommended action•Plan for timely re-assessment•Documented evidence that the risks andbenefits of thromboprophylaxis have beendiscussed with the patient
  38. 38. Bridging the Knowledge-Practice Gap “Knowing is not enough; we must apply. Willing is not enough; we must do” „The transfer of knowledge is care‟”
  39. 39. Transfer of Knowledge intoQuality Healthcare Clinical Knowledge (Evidence Based Practice): MEDLINE, Cochrane etc Doing the Clinical Decisions Know-What right thing Improvement Knowledge: System, context, process, Doing it right Process/System patient Changes Know-How Adapted from: Glasziou, P et al. Can evidence-based medicine and clinical quality improvement learn Quality from each other? 2011. BMJ Qual Saf 20 (suppl 1): i13-i17 Patient Care
  40. 40. Example of Knowledge into Action support package: Sepsis and VTE Collaborative Aim: Define and Implement a Change Package for Management of Sepsis and VTE Knowledge Management Support• Know-What, Know-How, Know-Who• Evidence for intervention and implementation• Community of practice support
  41. 41. Driver Diagrams, Change Packages & Measurement Plans• Subject experts• Improvement experts• A facilitated afternoon session to agree content
  42. 42. The Result
  43. 43. The Sepsis / VTE Collaborative:How are we doing ?
  44. 44. Action Period 1• Community of Practice• Monthly Conference Calls and WebEx• Site Visits• Measurement• Learning Session 2
  45. 45. % Board participation in Conference Calls/WebEx Sepsis Collaborative100% 90% 80% 70% 60% 50% 40% 30% % calls attended 20% 10% 0% Participation on conference calls/WebEx VTE Collaborative 25 20 email reminder 20 No. attended 17 15 Boards 13 12 10 11 Participants 10 9 9 8 8 Clinicians 7 7 5 5 4 4 0 Jan-12 Feb-12 Mar-12 Apr-12 May-12
  46. 46. The Sepsis / VTE Collaborative:Ayrshire & Arran - Sepsis
  47. 47. What we are trying to accomplish?• All patients in an in the pilot area with a MEWS score of 4 or more will be assessed for SIRS within 30 minutes by July 2012• 95% of patients identified as septic using the SIRS criteria will receive the sepsis six within one hour of confirmation, by July 2012• Full hospital spread to be confirmed
  48. 48. Managing the septic patient• Within the general ward areas an Advanced Nurse practitioner is on duty, with a roving mandate, 24 hrs a day 7 days per week, for the Emergency Response Team / H@N• To meet the time sensitive need of the septic pt within these areas a dual response was planned
  49. 49. First series of small tests
  50. 50. Worksheet for Testing ChangeAim: Every goal will require multiple smaller tests of change Describe your first (or next) test of change: Person When to Where to responsible be done be done H@N ANP (not in Sepsis group) to review next MEWS4 pts using ED Now Pan sepsis documentation and implement Sepsis6 for one weekend hospitalPlan List the tasks needed to set up this test of change Person When to Where to responsible be done be done Non sepsis group ANPs identified on shift, to test ED now Pan Sepsis group ANP to support hospital Predict what will happen when the test is carried Measures to determine if prediction succeeds out Pt assessed appropriately. Case note review on pts Monday am If SIRS/Sepsis +ve implement sepsis 6. Review of times required for implementation If SIRS +ve but NOT septic- no antibiotics etc Staff comments on documentationDo Describe what actually happened when you ran the test 4 Pts reviewed at MEWS 4. One pt not SIRS positive. Three SIRS +ve. One SIRS +ve but not septic (firstnight post op).Study Describe the measured results and how they compared to the predictions System worked appropriately. Non septic pts did not receive sepsis 6. Documentation agreed aseffective (finally)Act Describe what modifications to the plan will be made for the next cycle from what you learned Re do test with new documentation. Also test for MEWS 4 pt who is SIRS +ve but NOT septic
  51. 51. Tested Documentation and First Full Testing
  52. 52. Situation- Audit of SIRS/Sepsis assessment and implementation of the Sepsis 6 bundle on pts with MEWS score of 4 and above Purpose As part of the work to improve Sepsis management we require to obtain base line data prior to implementation. Therefore we require:- Case note review of all respiratory patients within the confines of ward 3b who have scored MEWS 4 or above. The ERT ANP should liaise with nursing staff and medical staff(if available) to• Base line audit of SIRS identify ANY respiratory patient who has triggered MEWS 4 and above. This should take place during first trawl if possible. Reviewing the case note entry for that clinical episode the following assessment should take place:- review and and Sepsis Date and time of MEWS trigger…………………………………… Date and time of clinician response………………………………… intervention Was there evidence that the patient was assessed using SIRS criteria? Y N If NO, would patients have been SIRS positive at time of MEWS trigger? commenced within Was patients identified as having SEPSIS, with or without SIRS criteria review? If no- was SEPSIS present? area If SEPSIS was present, were the following reviewed or implemented? :- Documented as:- REVIEWED IMPLEMENTED SEPSIS 6 Y N Y N Oxygen Fluid challenge Antibiotic Blood culture Lactate & Full Blood Count Urine output review Comments…………………………………………………………………………… ………………………………………………………………………………………… ……………………………………………………………………………….................. .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................
  53. 53. Initial data• First live testing within Respiratory ward.• Baseline data for 4 weeks commenced 9.1.12• Patients with MEWS 4 and above n=18• New septic episodes n=9
  54. 54. 00:00 00:14 00:28 00:43 00:57 01:12 01:40 01:55 02:09 01:26 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Patient 11Consecutive Patients commenced Dual response Patient 12 Time to first antibiotic Respiratory Patient 13 Patient 14 Patient 15 Patient 16 Patient 17 Patient 18 Patient 19
  55. 55. • Pre intervention median time 1hr 25 min• Post intervention median time 37 minutes• Area chosen due to high probable compliance.• ANP presence• Consultant SPSP fellow
  56. 56. Balancing measures• Antibiotic usage- area now compliant with empirical antibiotic use.• Blood culture contamination- non significant levels noted• ERT ANP workload – ongoing review
  57. 57. Currently• Cardiology• Surgical• Orthopaedics (all three wards)
  58. 58. Baseline data for Cardiology,Orthopaedic Department (ward x3) and one general surgical ward• Baseline data being collected over 4 week period (3 weeks presented) Commenced 23rd April• Number of patients with MEWS of 4 or above n=21• SIRS assessed n=0• Septic patients n=10• Median time to first antibiotic= 2hrs 30mins
  59. 59. Time to first antiobiotic- cardiology, orthopaedics and general surgery10:4809:36 dual response pt not handed over08:24 commenced07:1206:0004:4803:3602:2401:1200:00 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 Patient 12 Consecutive Patients
  60. 60. Challenges• Acute baseline assessment and implementation.• Dual site response – Ayr Hospital baseline data collection commencing. ERT on both sites.
  61. 61. The Sepsis / VTE Collaborative:Grampian – VTE
  62. 62. Plan Do Study Act (PDSA) In Practice
  63. 63. Testing the validity of the VTE screening tool Change Seven: Data being collected on random sample of all patients being admitted. Form gone to reprographics for initial print run and moving to implementation. Change Six: Form amended and retested by all staff week beginning 16th April 2012. Minor amendment required to the mobility section of the form. Change Five: Layout of the form worked with all staff saying it was clear, easy to follow and to complete. A patient had come in to the Unit on the ACS protocol and currently this was not identified on the form as a risk factor. In addition it was felt that there needed to be the word MEDICA the form to avoid confusion. Change Four: Feedback was that the form was much easier to follow and they liked the tick boxes in terms of risk and bleeding risk factors and found it easy to complete. All forms were completed correctly. Agreed screening and treatment options could be incorporated into one page leaving space for guidance on the back. Change Three: Feedback was that the flowchart was perhaps too complicated. Agreed to test the elements of the flowchart in a table format where staff to “tick all that applied” with a guide then to give or not give prophylaxis based on these results. Feedback was that page 2 of the form was easy to complete. Change Two: Consultants found the flowchart a bit confusing as still referred to surgical patients and included mechanical prophylaxis, which is not advocated in SIGN for medical patients. Having just the medical patient considerations on the back was seen to be easier to complete with more space for writing in follow-up. Agreed to involve others in testing.Change One: Flowchart was easy to follow and that the form contained all relevant information. The issue was that the formwas too busy as it included consideration of medical, surgical and orthopaedic admissions. This was seen to beconfusing, take extra time to complete and may lead to no-compliance.
  64. 64. VTE DATA
  65. 65. Patient Information Leaflet “Quite impressive. Very good and very interesting. Never knew about dehydration and that can cause a blood clot.” “It was very clear and concise, all the abbreviations were explained.” Patients in Aberdeen Royal Infirmary VTEP5 Patient Information Goal 95% 100 80% Compliance 60 40 20 Median 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 5 patient case notes reviewed each day
  66. 66. Next Steps Taken• Orthopaedics now on test 2 of form with compliance data being collected.• General Surgical on test 5 of form with compliance data being collected.• Now focusing on 48hr re-assessment in the step-down medical wards.• Maternity Hospital form being developed in same format for consistency.• Patient information leaflet now as stock order item.• Risk assessment tool tested in ED for patients with long leg plasters.
  67. 67. Success…..
  68. 68. The Sepsis / VTE Collaborative:Conclusion
  69. 69. “Each of you ... All of us”“ The key is collective impact !”“ working together means that you should never worry alone.”
  70. 70. http://www.cec.health.nsw.gov.au/programs/sepsishttp://www.thrombosis-charity.org.uk/cms/index.php?option=com_content&task=view&id=65&Itemid=13
  71. 71. Our journey has begun?• 10% reduction in mortality from sepsis by 2014• Reliable risk assessment and appropriate thromboprophylaxis administration 95% of all adult hospital admissions by December 2014
  72. 72. Thank You

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