SURVIVING SEPSIS: SIX SIGMA APPROACH TO REDUCE MORTALITY AND COST

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SURVIVING SEPSIS SIX SIGMA APPROACH TO REDUCE
MORTALITY AND COST

• WCBFS 8TH ANNUAL LEAN,SIX SIGMA, AND PROCESS
  IMPROVEMENT IN HEALTH CARE SUMMIT
• Glenn Crotty Jr, MD, COO CAMC

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Sepsis

• Sepsis is a bloodstream infection that begins in
  one organ system and is transferred to other
  organ systems via the blood.
• High Mortality over 50
• One of the leading causes of death in US
  hospitals

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Definitions

• Sepsis Inflammatory Markers Site of Infection
• Severe Sepsis Sepsis Organ Dysfunction (one
  or more)
• Kidney impairment
• Lung impairment
• Confusion
• Blood disorders
• Septic Shock Severe Sepsis Unrelenting
• Shock

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Sepsis Symptoms

• Often dependent on the presenting organ system
  involved
• Can cause delirium, confusion, sweating, rapid or
  shallow respirations,high or low blood pressure,
  high or low pulse, high or low temperature
• High WBC count, Left shift of differential, Low
  pH, low PO2, increased lactic acid level

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Top Ten APR-DRG Mortalities
Of 813 deaths at CAMC in 2007, 15 were
attributed to Septicemia Disseminated Infection
(124 patients)
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Define

• 144 deaths at CAMC in 2005 twice the number of
  any other disease process
• Patients who survived stayed an extra 6 days on
  average at cost of 900/day
• Mortality for patients with sepsis both inpatient
  and ED to ICU is 56 consistent with national
  data
• Decision to begin at one ED and one ICU

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Define
Project Description
Improvement in the early identification and
aggressive care of the septic patient will
significantly decrease the mortality rate
associated with severe sepsis and septic shock.
National studies have identified best practice
around sepsis care and CAMC has an opportunity to
improve outcomes by applying this knowledge to
our processes of management of patients with
sepsis.
Project Scope Patients presenting to General
Hospital ED with positive screen for severe
sepsis, and admitted to the ICU (use ICD-9
discharge diagnosis codes of severe sepsis
(995.92) and septic shock (785.52)
Alignment Reduce expense per discharge, achieve
effective care by embedding clinical science into
care processes Strategic Goal Reduction of
Mortality
Target Reduce severe sepsis mortality rates by
25 at GH in 1 year
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Measure Determine Potential Causes
Key Takeaway Process standardization and staff
education will yield the most opportunity for
improvement
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Measure - Segmentation
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Measure - Baseline
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Measure - Baseline
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Analyze
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Improve

• 2006 Severe Sepsis Order Set implemented at
  General Hospital, screening tool
  development/training, dedicated clinical
  pharmacists available for sepsis consults
• 2007 ED nurse triage protocol developed, Philips
  Protocol Watch monitors placed in GH emergency
  department, rapid response teams (MET) engaged at
  both hospitals, Memorial Hospital sepsis team
  started, sepsis simulation training started for
  staff, residents, and medical staff
• 2008 Sepsis Awareness week - Manny Rivers, MD
  visits and talks to many groups about EGDT,
  sepsis clinical coordinator hired to review all
  cases (concurrent vs. retrospective), focus on
  order set usage compliance at MH and roll out to
  Women and Childrens Hospital, algorithms
  developed for central line placement and use of
  PreSep catheter

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FRONT- pg1
BACK- pg1
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FRONT- pg2
BACK- pg2
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FRONT- pg3
BACK- pg3
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Awareness/Early Detection
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Resuscitation Bundle Compliance (EGDT)
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Maintenance Bundle Compliance/ Data
Analysis, Tracking, Reporting
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Education
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Pharmacy Sepsis Consult Data
P values lt 0.05 Statistically significant
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Control GH Mortality Rates
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Control Improved Recognition
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System-wide Mortality Rates
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Reliability

• Unless there is a process capability of 80 there
  is generally not actual process.
• First step is to achieve a process capability of
  80
• Then improve process capability to 95 then to 99

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Steps to 80 Reliabililty

• Standardized order sets and protocols
• Education and training
• Increase process capability of use of order sets
  and protocols
• Create shared vision and need

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Steps to 95 Reliability

• Alerts and Reminders New monitors with this
  capability
• Root cause analysis of cases
• Individual who reviews all cases
• Sepsis ER alert to all care givers like Trauma
  and Cardiac alerts
• Advanced simulation training for care givers and
  for outlining facilities who refer to CAMC
• MET team to help respond to floor cases and who
  do active rounds