Sepsis: The Basics Part 1 Pragmatic Sepsis Care For Providers€¦ · many as 27 different languages. The latest version of this ransomware variant, known as WannaCry, WCry, or Wanna

1 © 2017 TMIT

May 18, 2017 Webinar Month 102

For resource downloads go to: www.safetyleaders.org

Sepsis: The Basics Part 1

Pragmatic Sepsis Care For Providers:

2 © 2017 TMIT

Charles Denham, MD Chairman, TMIT TMIT High Performer Webinar May 18, 2017

Welcome

3 © 2017 TMIT

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TMIT Purpose Statement Our Purpose: We will measure our success by how we protect and enrich the lives of families…patients AND caregivers. Our Mission: To accelerate performance solutions that save lives, save money, and create value in the communities we serve and ventures we undertake.

8 © 2017 TMIT

Disclosure Statement The following panelists certify: that unless otherwise noted below, each presenter provided full disclosure information; does not intend to discuss an unapproved/investigative use of a commercial product/device; and has no significant financial relationship(s) to disclose. If unapproved uses of products are discussed, presenters are expected to disclose this to participants. None of the participants have any relationship medication or device companies discussed in their presentations.

Jeanne M. Huddleston, MD, FACP, FHM, is a past President of the Society of Hospital Medicine, the founder of Hospital Medicine and past Program Director of the Hospital Medicine Fellowship at Mayo Clinic, Rochester, MN. She is Chairperson of Mayo Clinic's Mortality Review Subcommittee, a multi-disciplinary group of providers that review every death in search of where the health care delivery system may have failed the providers and/or the patient. She has nothing to disclose. Ryan Arnold, MD, is an emergency medicine physician at Christiana Care Health System and is the Director of Research, participating in over 60 different research projects. He has nothing to disclose. Charles Denham, MD, is the Chairman of TMIT; a former TMIT education grantee of CareFusion and AORN with co-production by Discovery Channel for Chasing Zero documentary and Toolbox including models; and an education grantee of GE with co-production by Discovery Channel for Surfing the Healthcare Tsunami documentary and Toolbox, including models. HCC is a former contractor for GE and CareFusion, and a former contractor with Siemens and Nanosonics, which produces a sterilization device, Trophon. HCC is a former contractor with Senior Care Centers. HCC is a former contractor for ByoPlanet, a producer of sanitation devices for multiple industries. He does not currently work with any pharmaceutical or device company. His current area of research is in threat management to institutions and continuing professional education and consumer education. Dr. Denham is a collaborator with Professor Christensen.

9 © 2017 TMIT

Speakers and Reactors

Jeanne Huddleston Ryan Arnold, MD Charles Denham MD

10 © 2017 TMIT

Charles Denham, MD Chairman, TMIT TMIT High Performer Webinar May 18, 2017

In the News and National Survey Highlights: News Update and

March 2017 Webinar National Survey

© 2006 HCC, Inc. CD000000-0000XX 11 © 2017 TMIT

In The News …

Source: Propublica May 12, 2017

May 12, 2017

© 2006 HCC, Inc. CD000000-0000XX 12 © 2017 TMIT

In The News …

Among the 2855 patients who were 30-day survivors of an out-of-hospital cardiac arrest during the period from 2001 through 2012, a total of 10.5% had brain damage or were admitted to a nursing home and 9.7% died during the 1-year follow-up period. During the study period, among the 2084 patients who had cardiac arrests that were not witnessed by emergency medical services (EMS) personnel, the rate of bystander CPR increased from 66.7% to 80.6% (P<0.001), the rate of bystander defibrillation increased from 2.1% to 16.8% (P<0.001), the rate of brain damage or nursing home admission decreased from 10.0% to 7.6% (P<0.001), and all-cause mortality decreased from 18.0% to 7.9% (P = 0.002). In adjusted analyses, bystander CPR was associated with a risk of brain damage or nursing home admission that was significantly lower than that associated with no bystander resuscitation (hazard ratio, 0.62; 95% confidence interval [CI], 0.47 to 0.82), as well as a lower risk of death from any cause (hazard ratio, 0.70; 95% CI, 0.50 to 0.99) and a lower risk of the composite end point of brain damage, nursing home admission, or death (hazard ratio, 0.67; 95% CI, 0.53 to 0.84). The risks of these outcomes were even lower among patients who received bystander defibrillation as compared with no bystander resuscitation… In our study, we found that bystander CPR and defibrillation were associated with risks of brain damage or nursing home admission and of death from any cause that were significantly lower than those associated with no bystander resuscitation. (Funded by TrygFonden and the Danish Heart Foundation.)

Source: Kragholm K., Wissenberg, M., et al. Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest. The NEJM. 2017 May 4.

May 4, 2017

Bystander Efforts And 1-year Outcomes In Out-of-hospital Cardiac Arrest

© 2006 HCC, Inc. CD000000-0000XX 13 © 2017 TMIT

In The News …

According to numerous open-source reports, a widespread ransomware campaign is affecting various organizations with reports of tens of thousands of infections in as many as 150 countries, including the United States, United Kingdom, Spain, Russia, Taiwan, France, and Japan. The software can run in as many as 27 different languages. The latest version of this ransomware variant, known as WannaCry, WCry, or Wanna Decryptor, was discovered the morning of May 12, 2017, by an independent security researcher and has spread rapidly over several hours, with initial reports beginning around 4:00 AM EDT, May 12, 2017. Open-source reporting indicates a requested ransom of .1781 bitcoins, roughly $300 U.S.

Source: FBI Flash: Indicators associated with WannaCry ransomware. FBI and DHS. 2017 May 13.

May 13, 2017

FBI Flash: indicators associated with WannaCry Ransomware

© 2006 HCC, Inc. CD000000-0000XX 14 © 2017 TMIT

In The News …

The 2017 Identity Fraud Study, released by Javelin Strategy & Research, found that $16 billion was stolen from 15.4 million U.S. consumers in 2016, compared with $15.3 billion and 13.1 million victims a year earlier. In the past six years identity thieves have stolen over $107 billion. Following the introduction of microchip equipped credit cards in 2015 in the United States, which make the cards difficult to counterfeit, criminals focused on new account fraud. New account fraud occurs when a thief opens a credit card or other financial account using a victim’s name and other stolen personal information … Medical/healthcare organizations were affected by 377 breaches (34.5 percent of total breaches).

Source: Source for Javelin 2017 Report: Identity Theft Research Center Report and website. Available at: http://www.iii.org/fact-statistic/identity-theft-and-cybercrime

2017

Identity Theft and Cybercrime

15 © 2016 TMIT

I am interested in MORE DETAIL ON FAILURE TO RESCUE.

100%

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10%

15%

Very Strongly

Agree

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Strongly Agree

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Agree

8

Agree

7

Very Strongly Disagree

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Disagree

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Neutral

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Negative to Neutral

4

99% Agreed and 76% Strongly or Very Strongly Agreed, and 59% Very Strongly Agreed

59%

17%

1%

Source: TMIT High Performer Webinar Series; 2017 Threats & Safety Failure to Rescue: Bedside Patient Rescue A Great Opportunity – April 20, 2017

Anonymous Survey Questions

8%

16 © 2016 TMIT

• Best players on the team! • Bowel obstructions • Building efficiency in nursing staffing and work patterns to

obtain data that feed "nurse worry" • Clinical alarm fatigue • Device integration to aide in real time documentation for

improved decision support using a ews model • Discussion of most common failure points • Early identification of sepsis • Geriatric patients • How to implement in a smaller facility • How to manage in smaller, rural hospitals • How to use a portion of this research in a small community

hospital (no residents) where nursing has to escalate because there is no "real time" supervising MD

• Implementation of an EWS in a smaller hospital • More detail on these types of EWS • More details on triage • More on sepsis Nursing intuition on patient care • Outcome measurements of RRT performance • Sepsis - qsofa • Slow bleeds

• What are best effective recognition activities when an early warning system is not in place

• What is the next step to utilized this information • What type of training do nurses receive on MEWS and other

early warning systems? • Worry factor scoring

FAILURE TO RESCUE topics I would like to be FURTHER covered include:


17 © 2016 TMIT

I am interested in FAILURE TO RESCUE performance improvement topics.

100%

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9

Agree

8

Agree

7


1

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3

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2

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6

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Negative to Neutral

4


73%

16%



4%

18 © 2016 TMIT

• Change management and nursing involvement • How to implement in a smaller facility • Process breakdown detection • Real time documentation entry to improve accuracy of the

scores • Building inter professional communication pathways to improve

responsiveness to alerts • Same • Training the nurse of <1 year to increase perception of patient

deterioration • More detail about evidence based computerized early warning

tools and alerting,; what elements are important; and other opportunities to address other common failures

• How does the RRT integrate into the alert system described

FAILURE TO RESCUE topics I would like to be covered first include:


19 © 2016 TMIT

I am interested in TRIAGE performance improvement topics.

100%

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Agree

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43%

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8%



8% 3%

20 © 2016 TMIT

• How to pick which patients go to which floor • Sepsis • Care team efficiency and ensuring that the patient is admitted to

the correct area more on admission to appropriate location from the ED

• Wrong level of care or inappropriate level of care and how to make sure patients are admitted to the floor that can care for them appropriately

• Direct admissions • Directing end stage disease process patient to better resources

such as hospice and palliative directing end stage disease process patient to better resources such as hospice and palliative care

• Stroke versus MI patient • CVAs, ectopic pregnancies, aortic aneurisms • Admission triage

TRIAGE topics I would like to be covered first include:


21 © 2017 TMIT

Meaningful Use is dead. Long live something better! High Impact Care Hazards to Patients, Students, and Employees

A Medical-Tactical Approach undertaken by clinical and non-clinical people can have enormous impact on loss of life and harm from very common hazards:

• High Impact Care Hazards are

frequent, severe, preventable, and measurable.

• Lifeline Behaviors undertaken by anyone can save lives.

The Program: • Free afterschool courses for grade

three and above. • Courses for Boy and Girl Scouts,

Clubs, and Communities. • Courses for non-clinical staff and

families ideal for healthcare institutions.

• Continuing Education for Clinical Caregivers (CME, CEU, and continuing ed for most caregivers)

Cardiac Arrest

Opioid Overdose

Common Accidents

Bullying

Choking & Drowning

Anaphylaxis

Major Trauma

Transportation Accidents

© 2006 HCC, Inc. CD000000-0000XX 22 © 2016 TMIT

Meaningful Use is dead. Long live something better! High Impact Care Hazards to Patients, Students, and Employees

A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury

Source: National Academies of Sciences, Engineering, and Medicine. 2016. A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press.

Dr. Don Berwick Chairman

The Opportunity for YOU SAFETY

LEADERS

23 © 2016 TMIT

I am interested in helping develop a MED TAC PROGRAM in my community.

100%

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9

Agree

8

Agree

7


1

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3

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2

Neutral

6

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Negative to Neutral

4


32%

2%

11%

Source: TMIT High Performer Webinar Series; 2017 Threats & Safety Why Hospitals Should Fly: Mortality Reviews & Harm from Omission, Med Tac, and Healthcare Violence– March 16, 2017


5%

12% 9%

4% 2% 7%

24 © 2016 TMIT

• Already have a committee going • Cardiac arrest • Continued diagnosis and treatment in the ED hold area • How to begin a med tac program • How to do it • How to get my institution and community to understand the

need for Med Tac • If we have a county search and rescue program would they be

the ones to oversee/incorporate this program or would it be under our local EMS service?

• Means of organizing misc. Medical personnel for emergency responses from main hospital areas. How can lpn's and medical assistants become part of volunteer, community TAC unit in case of major disasters and national emergencies.

• N/a • Not qualified to help develop Med Tac program, but interested in

every TMIT topic presented • Not sure, need to learn more overall first • Not yet • Opioid crisis; infection prevention • Public school education • Workplace violence

The topics I would like to know more about starting a MED TAC PROGRAM include:

Source: TMIT High Performer Webinar Series; 2017 Threats & Safety Why Hospitals Should Fly: Mortality Reviews & Harm from Omission, Med Tac, and Healthcare Violence– March 16, 2017

25 © 2017 TMIT

Sepsis Introduction What we Learned from Mortality Reviews

Jeanne M. Huddleston, MD, FACP, FHM Hospitalist Chairperson of Mortality Review Subcommittee Mayo Clinic Rochester, MN TMIT High Performer Webinar May 18, 2017

26 © 2017 TMIT

Pragmatic Sepsis Care For Providers: Aligning evidence, guidelines, mandates and policy to inform your daily practice.

Ryan Arnold, MD Emergency Medicine PhysicianDirector of ResearchChristiana Care Health SystemNewark, Delaware TMIT High Performer Webinar May 18, 2017

Pragmatic sepsis care for providers

Ryan Arnold, MD Director of Research, Department of Emergency Medicine

Clinical Investigator, Value Institute [email protected]

Aligning evidence, guidelines, mandates and policy to inform your daily practice

mailto:[email protected]

Pragmatic sepsis care for providers

Aligning evidence, guidelines, mandates and policy to inform your daily practice

Objectives:

Preaching to the choir: • Summarize challenges in

sepsis definition misalignment

Caring for actual patients: • Provide an operational

approach for sepsis identification and response

Making sepsis an actual emergency: • Outline an ED-based sepsis

alerting and response effort

Objectives:





Making sepsis an actual emergency • Outline an ED-based sepsis


Spectrum of acute organ dysfunction secondary to an infection

Septic Shock Sepsis Infection

Org

an F

ailu

re

0

Renal GI

Respiratory Neuro

Cardiovascular

The Sepsis Spectrum

• Refractory Hypotension

• Vasopressor Initiation • Hypoxia

• Confusion

• Bili > 2.0 • Creat > 2.0


Org

an F

ailu

re

0


CMS

CMS

Org

an F

ailu

re

0

After 30 cc/kg: -SBP < 100 or -Lactate ≥ 4

-RR>22 -New O2 requirement -SBP < 100 -Confusion -Creatinine > 2 -Platelets < 150 -Lactate > 2

• HR > 90 • RR > 20 • Temp >38 or <36 • WBC > 12 or <4 • >10% bands

SIRS Organ Failure


SEPSIS-3

SEPSIS-3

Org

an F

ailu

re

0

-MAP < 70 -P/F Ratio < 400 -GCS < 15 -Bilirub >1.2 -Creatinine > 1.2 -Platelets < 150

-Vasopressor requirement + -Lactate > 2

SOFA


CMS

CMS

SEPSIS-3

SEPSIS-3

Org

an F

ailu

re

0

Metabolic: Lactate > 2.0

Systolic BP < 90 mmHg

Anti-infective treatment

- or -

Viral PCR (+)

Cardiovascular: Shock Index > 1.0

Shared Sepsis-3 definition

Unique Sepsis:IOS

Sepsis Definition Comparison

Infection Organ Failure Shock

Shared CMS definition

MAP < 70 mmHg

Hypo-perfusion

Renal: Urine output = 0 x 12 hours BUN > 20 Creatinine > 50% from base

Respiratory: Hypoxia (SpO2 < 95%) New oxygen requirement SpO2 / FiO2 ratio < 421

Hematopoietic: WBC < 4,000 c/mcL

Gastrointestinal Bilirubin > 1.2 mg/dL

Neurologic: Confusion-acute

Mechanical ventilation

Creatinine > 1.2

GCS ≤ 14

Creatinine > 2.0

Platelets < 150,000 c/mcL

Platelets < 100,000 c/mcL

Bilirubin > 2 mg/dL

End-Organ System Dysfunction

Vasopressor use

Lactate > 4

MAP < 65 mmHg -after IV fluids

-sustained >60 mins

-with lactate > 2.0

Hypotension: sBP < 90 mmHg

Unique CMS definition

Competing objectives…


CMS

CMS

SEPSIS-3

SEPSIS-3

Org

an F

ailu

re

0

Objectives:





Making sepsis an actual emergency • Outline an ED-based sepsis


Trauma

Illne

ss S

ever

ity

Stroke

Acute MI

Sepsis

Sepsis: The perfect patient safety initiative

Day: 1 2 3 0 4 5

S.E.P.S.I.S.: Sepsis Early Prediction Support Implementation System Timeline: 10/2015 –10/2018 Spec Aims: Design and employ data mining, machine learning, predictive analytics and optimization to identify :

1. identify diagnosed patients with sepsis who are deteriorating within the sepsis spectrum

2. corresponding outcomes and personalized therapeutic intervention

Retrospective observational data

– 30 months of consecutive patient visits – 146,552 patients – 244,215 unique visits

46 Program Solicitation NSF 13-543. NSF Proposal ID: 1522072

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCKXv2v2GhskCFQQ5Pgodwn4OYQ&url=http://www.nil.wustl.edu/labs/hornbeck/&psig=AFQjCNGpfmkZkMHnPF1fe2I4xncOsHCdUg&ust=1447251737326388

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCIXnqI-HhskCFYUdPgodFDwFvw&url=http://events.r20.constantcontact.com/register/event?llr=pgcxumfab&oeidk=a07e8z4524v4998f7a9&psig=AFQjCNEqB6aH4iSWJ0cdGvmHj6GkvFu7wQ&ust=1447251768780243

SEPSIS: Operational definition

Objective - To identify an EHR-based approach to allow for real-time

identification of patients with infection and sepsis

Requirements - EHR-based criteria - No requirement for direct chart review - Scalable to allow real-time identification

- e.g. cannot require ICD-10

Infection


Infection - administration of a single dose any anti-infective

(antibiotic, antiviral, or antifungal). - Positive PCR test (viral infection)

Infection

Inflammation


Inflammation - The presence of an abnormality within any of the inflammatory criteria will define a

positive inflammatory state. - Each dysfunction is summative representing an inflammatory burden.

Cellular Response: • WBC > 12,000 • Bandemia > 10% • ESR > 20 mm/hr • CRP > 8 mg/L • Procalcitonin > 0.5

Physiologic Response: • HR ≥ 90 • Resp Rate ≥ 20 • Temp ≥ 38 C (100.4 F) • Temp < 36 C (96.8 F)

Infection

Inflammation

Organ Dysfunction


• Cardiovascular • Metabolic

• Renal • Respiratory • Hematopoietic • Nervous • Gastrointestinal

Organ Dysfunction • The presence of an

abnormality within any of the specified organ systems criteria will define a positive organ failure state

• Each dysfunction is summative representing an organ failure burden.

Hypo-perfusion

End-Organ System Dysfunction


Cardiovascular: • sBP < 90 mmHg • MAP < 65 mmHg • Shock Index > 1.0 Metabolic: • Lactate > 2.0 mmol/L

Renal: • Creatinine > 1.2 mg/dL • Creatinine increase > 50% from baseline • Urine output = 0 x 12 hours • BUN > 20

Respiratory: • Hypoxia (SpO2 < 95%) • New oxygen requirement (FiO2 > 21%) • Mechanical ventilation • SpO2 / FiO2 ratio < 421

Hematopoietic: • Platelets < 150,000 c/mcL • WBC < 4,000 c/mcL

Nervous: • GCS < 14 or GCSverb <5

Gastrointestinal • Bilirubin > 2 mg/dL

Organ Dysfunction

Hypo-perfusion

End Organ System Dysfunction

Infection

Inflammation

Organ Dysfunction

Septic Shock


• SBP < 90 mmHg • MAP < 65 mmHg

Hypotension Septic Shock • Hypotension that occurs:

– At any point after 2L intravenous fluid – Persists for ≥ 60 minutes

independent of IVF administration

• Any administration of a vasopressor

– Independent of blood pressure

Infection

Inflammation

Organ Dysfunction

Septic Shock


Day: 1 2 3 0 4

Infection

Inflammation

Organ Dysfunction

Septic Shock


Infection

Day: 1 2 3 0 4

Sepsis Septic Shock

Infection

Inflammation

Organ Dysfunction

Septic Shock


Case #1 • Patient presents with infection identified on arrival • Develops delayed-onset sepsis (e.g. organ failure) on day 1.5 • Developed septic shock • Discharged with new, chronic organ failure

Day: 1 2 3 0 4

Infection

Inflammation

Organ Dysfunction

Septic Shock


Day: 1 2 3 0 4

Case #2 • Patient presents with infection identified on arrival • Develops sepsis (e.g. organ failure) on day 0.5 (hour 12) • Developed delayed-onset septic shock • Discharged back at baseline health (resolution of organ failure

and shock)

Infection

Inflammation

Organ Dysfunction

Septic Shock


Day: 1 2 3 0 4

Case #3 • Patient arrives in septic shock (infection + organ failure + shock) • Develops sepsis (e.g. organ failure) on day 0.5 (hour 12) • Recovers from shock or organ failure by day 2.5 • Discharged back at baseline health

Infection

Inflammation

Organ Dysfunction

Septic Shock


Day: 1 2 3 0 4

Case #4 • Patient arrives in sepsis (infection + organ failure) • Recovers from sepsis-associated organ failure by day 2.5 • Discharged back at baseline health

Infection

Inflammation

Organ Dysfunction

Septic Shock

Day: 1 2 3 0 4

CMS Sepsis

JAMA Sepsis

CMS Septic Shock

JAMA Septic Shock

One patient…many labels....


CMS

CMS

SEPSIS-3

SEPSIS-3

Org

an F

ailu

re

0

Omitted population

Goal: CMS compliance

Included Included


CMS

CMS

SEPSIS-3

SEPSIS-3

Org

an F

ailu

re

0

Included Included

Goal: Evidence-based compliance

Omitted population

Objectives:





Making sepsis an actual emergency: • Outline an ED-based sepsis


System Burden

Disease Severity

Disease Label

Resource support

Clinical vigilance Advocacy

Providers Patients & family

Hospital Administration

Awareness

Response

SEPSIS

ED Sepsis Alert 2017

Feedback

• Immediate - ED Process of Care - CMS compliance • Delayed - Patient-centered outcomes “FUTURE”

FUTURES in Sepsis:

Forecasting the Unexpected Transfer to Upgraded REsources in Sepsis

• Method: Gamification of sepsis awareness through the collection of physician and nursing forecasting of a patient’s hospital course at the time of treatment.

FUTURES in Sepsis: • Objectives: Quality improvement effort to 1) increase sepsis awareness and 2) provide direct feedback to the clinical treatment team as to the outcome of individual sepsis patients.

• Data collection: Resuscitation Science Internship, Department of Emergency Medicine

• Patient Follow-up: Resuscitation Science Internship, Department of Emergency Medicine

• Data analytics: CCHS Value Institute • Reports: Monthly reports of aggregate forecasting success and patient

outcomes 1. ED Nursing 2. DFES 3. Sepsis Value Improvement Team 4. Value Institute.

FUTURES in Sepsis:

Forecasting Assessment

o How long will your patient remain in-hospital? o Will an RRT occur at any time? o Will an unanticipated transfer to a higher level

of care occur? o Will an ICU transfer occur? o Will a Code Blue occur? o Will the patient die? o What is your patient’s chance of in-hospital

death?

FUTURES in Sepsis:

http://www.sepsis.org

http://www.sepsis.org/

Concrete Recommendations: 1. Define sepsis

-Institutional agreement on definitions -Location independent!

Infection

Inflammation

Organ Dysfunction

Septic Shock

Infection

Day: 1 2 3 0 4

Sepsis Septic Shock

Concrete Recommendations:

Sepsis IOS: Infection / Organ dysfunction/ Shock





2. Transparent labeling of sepsis

-Nurses, physicians, patients, families, administrators



2. Transparent labeling of sepsis

-Nurses, physicians, patients, families, administrators

3. Make sepsis an emergency -Establish response protocols -Set expectations of care

88 © 2017 TMIT

National Survey Questions

I am interested in MORE DETAIL ON CYBER-HARM AND PT SAFETY.

Very Strongly

Agree

10

Strongly Agree

9

Agree

8

Agree

7


1

Disagree

3

Strongly Disagree

2

Neutral

6

Neutral

5

Negative to Neutral

4

CYBER-HARM AND PT SAFETY topics I would like to be FURTHER covered include:

89 © 2017 TMIT


I am interested in MORE DETAIL REGARDING SEPSIS.

Very Strongly

Agree

10

Strongly Agree

9

Agree

8

Agree

7


1

Disagree

3

Strongly Disagree

2

Neutral

6

Neutral

5

Negative to Neutral

4

Specific SEPSIS TOPICS I would like to be FURTHER covered include:

90 © 2017 TMIT


I am interested in MEDICAL RECORD RECOVERY POST CYBER-HARM.

Very Strongly

Agree

10

Strongly Agree

9

Agree

8

Agree

7


1

Disagree

3

Strongly Disagree

2

Neutral

6

Neutral

5

Negative to Neutral

4

MEDICAL RECORD RECOVERY POST CYBER-HARM topics I would like to be covered first include:

91 © 2017 TMIT

Speakers and Reactors

Jeanne Huddleston Ryan Arnold, MD Charles Denham MD

Documents

Sepsis: The Basics Part 1 Pragmatic Sepsis Care For Providers€¦ · many as 27 different languages. The latest version of this ransomware variant, known as WannaCry, WCry, or Wanna