The document discusses the Sepsis/VTE Collaborative. It explains that the collaborative was formed to improve sepsis and venous thromboembolism (VTE) management. It describes initial tests of changing documentation and assessing patients for sepsis that were conducted. Baseline data was collected on 18 patients with high early warning scores, of which 9 had new septic episodes. The median time to first antibiotics for septic patients was reduced from 1 hour and 25 minutes pre-intervention to 37 minutes post-intervention with the introduction of a dual response system in one respiratory ward area. Balancing measures such as antibiotic usage were also tracked.

1. Sepsis and Venous
Thromboembolism

2. Sepsis and Venous Thromboembolism
• Why we did it ?
• What we embarked to do?
• How we are doing presently?

3. The Sepsis / VTE Collaborative:
Why we did it?

4. Why is it important?

5. Courtesy of Dr I
Roberts

7. 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

8. A U.K. Perspective
40
30
Annual
UK mortality
(2003), 20
thousands
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

9. Surgical Sepsis
Sepsis in General Surgery: The 2005-2007 National
Surgical Quality Improvement Program Perspective.
Moore, Laura; Moore, Frederick; Todd, S; Jones, Stephen;
Turner, Krista; Bass, Barbara
Archives 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.

10. Variation In Sepsis Care

11. 15,022 Patients
165 Hospitals
Median of 14 Mortality Decreased from
37 to 30.8 Percent
6.2% Absolute
Months 16% Relative

12. 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

13. 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??

14. Complacency, Education & Trying Harder
isn’t enough

15. New ways of thinking

16. 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

17. “He who must not be named”

18. Reliable Recognition, Assessment &
Rescue

19. 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

20. 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

21. 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 )

22. 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

23. The Sepsis / VTE Collaborative:
What we embarked to do?

24. Will, Ideas and Execution

26. 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

27. Team Scotland

28. 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

29. The Collaborative Model
P P P
Organisational
A D D A D
Self Assessment A
S S S
1.5 day LS Continued
Alignment 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

30. Driver Change Measurement
Diagram Package Plan
Learning
Session
Action Period
Monitoring &
Measurement
Monthly Conference Monthly Site
Calls & WebEx Visits

31. 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. Berwick
Former Administrator of the Centres for Medicare &
Medicaid Services
Professor of Paediatrics and Health Care Policy at
the Harvard Medical School

32. Learn from Experience
• Segmentation
• Real Time Data Collection
• Early Feed Back of Metrics
• Early Case Review and Feedback
• Use Level 2 Reliability Tools

33. Having the best professionals in
the world is no longer enough
Support Responsibility
• Collaborative • Leadership
• Leadership • Participation
• Political attention • Outcomes
• Prioritisation
• Measurement

34. Building Will

35. Community of Practice
http://www.knowledge.scot.nhs.uk/sepsisvte.aspx

36. The Sepsis / VTE Collaborative:

37. • “The NHS is….. not good at capturing, using and sharing
information. Lots of data, a lot less information and even
less knowledge, and that's bad for patients and their
families, it's 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.

38. • 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

39. •Assessment of patient and admission
related risk of VTE
•Assessment of contra-indications to anti-
coagulant and mechanical Interventions
•Treat according to outcome of assessnt
and recommended action
•Plan for timely re-assessment
•Documented evidence that the risks and
benefits of thromboprophylaxis have been
discussed with the patient

40. 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‟”

41. Transfer of Knowledge into
Quality 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

42. 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

44. Driver Diagrams, Change Packages &
Measurement Plans
• Subject experts
• Improvement experts
• A facilitated afternoon session to agree content

45. The Result

46. The Sepsis / VTE Collaborative:
How are we doing ?

47. Action Period 1
• Community of Practice
• Monthly Conference Calls and WebEx
• Site Visits
• Measurement
• Learning Session 2

49. % Board participation in Conference Calls/WebEx
Sepsis Collaborative
100%
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

50. The Sepsis / VTE Collaborative:
Ayrshire & Arran - Sepsis

51. 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

52. 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

53. First series of small tests

54. Worksheet for Testing Change
Aim:
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 hospital
Plan
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 documentation
Do 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 (first
night 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 as
effective (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

55. Tested Documentation and
First Full Testing

56. 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……………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………..................
..........................................................................................................................................
..........................................................................................................................................
.......................................................................................................................................

57. 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

58. 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 11
Consecutive 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

59. • 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

60. Balancing measures
• Antibiotic usage- area now compliant with
empirical antibiotic use.
• Blood culture contamination- non significant
levels noted
• ERT ANP workload – ongoing review

61. Currently
• Cardiology
• Surgical
• Orthopaedics (all three wards)

62. 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

63. Time to first antiobiotic- cardiology, orthopaedics and general surgery
10:48
09:36
dual response pt not handed over
08:24 commenced
07:12
06:00
04:48
03:36
02:24
01:12
00:00
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

64. Challenges
• Acute baseline assessment and implementation.
• Dual site response – Ayr Hospital baseline data
collection commencing. ERT on both sites.

65. The Sepsis / VTE Collaborative:
Grampian – VTE

66. Plan Do Study Act (PDSA)
In Practice

67. 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 form
was too busy as it included consideration of medical, surgical and orthopaedic admissions. This was seen to be
confusing, take extra time to complete and may lead to no-compliance.

68. VTE DATA

69. 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

70. 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.

71. Success…..

72. The Sepsis / VTE Collaborative:
Conclusion

73. “Each of you ... All of us”
“ The key is collective
impact !”
“ working together means
that you should never
worry alone.”

74. http://www.cec.health.nsw.gov.au/programs/sepsis
http://www.thrombosis-charity.org.uk/cms/index.php?option=com_content&task=view&id=65&Itemid=13

75. 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

76. Thank You