Sepsis Core Quality Measures Webinar

CMS Core Measures EssentialsAll You Need to Know About Sepsis

Core Quality MeasuresJan 29, 2016 / 10:00 am PST – 10:30 am PST

Sponsored by AcesoCloudhttp://www.acesocloud.com

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Introducing our SpeakerDr. Andre Vovan Chief of Service, Critical Care

15 years as Intensivist 11 years experience running sepsis

program Participated in Original Surviving

Sepsis Campaign Decreased mortality >50% Decreased cost/case of sepsis >50

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Background

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Sepsis Core Measures

January 2016

Sepsis Core Measures & Sepsis Bundles


All about Sepsis Core Measures

January 2016

Effective October 1, 2015 discharges Focused on patients diagnosed with severe sepsis or septic shock Emphasis on early management of SepsisConsistent with the Surviving Sepsis Campaign guidelinesObjective is to lower rates of organ failure, mortality, length of stay, and cost of care Comprises comprehensive two all or none bundles


SEP-1 Definitions

January 2016

Severe Sepsis o suspected source of infectiono 2 SIRS criteria, and o evidence of end-organ dysfunction

Septic Shock o initial lactate greater than or equal

to 4 mmol/Lo Evidence of hypotension in the

first hour following completion of a 30 cc/kg IVF bolus

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How is the new Core Measures different

January 2016

Compared to previous core measures SEP-1 is…o more complicatedo requires more teamwork, and o has the potential to more significantly impact patient outcomes in terms

of mortality, morbidity, and hospital length-of-stayTime of presentationo Unlike most other core measures in which the clock starts upon

admission, for this measure, the clock starts when the patient meets criteria for either severe sepsis or septic shock

Chances are your hospital quality team is still developing a sound understanding of the core measures!


Key Abstractions

January 2016

The course of treatment is dependent on Time of Presentation (TOP) documented by the nurse/PhysicianCare protocol implementation is based on the two clocks:o Three hour o Six hour

Clock starts when Severe Sepsis presentation is documented, either by diagnosis or criteria:o For ED patients the clock begins when the patient is diagnosed with

Severe Sepsiso If Sepsis occurs later, the earliest time all symptoms present or diagnosis

documented is the time when the clock begins.


3 Hour Sepsis Bundles

January 2016

Within 3 hours from TOPo draw a lactate,o draw blood cultures prior to

administration of antibiotics, and start broad-spectrum

antibiotics or approved combination of antibioticso Administer 30ml/kg crystalloid for hypotension or lactate

≥4mmol/L


6 Hour Sepsis Bundles

January 2016

Within 6 hours from TOP, initiate all the above plus: o IVF bolus of 0.9% NS or LR 30ml/kg o If hypotension persists within 1 hour of completion of initial fluid

resuscitation, administer vasopressors to maintain a mean arterial pressure (MAP) ≥65mmHg

o If hypotension persists after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings.

o Re-measure lactate if initial lactate elevated > 2mmol/L or hypotension


Table 1

January 2016

Document reassessment of volume status and tissue perfusion withEither

Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.

OrAny two of the following measures:

o Measure CVPo Measure ScvO2o Bedside cardiovascular ultrasoundo Dynamic assessment of fluid responsiveness with passive leg raise or

fluid challenge

Sepsis Bundle Implementation - Process Map

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Time of Presentation

Screening & Documentation

Initiate Sever Sepsis and/or Septic Shock

Bundle

Initial Lactate Level

Draw Blood Cultures

Complete within 1Hr max

3 Hrs 3+ Hrs

Administer broad-spectrum antibiotics

If <90 or >40below baseline or MAP <65 Or initial lactate

level >36mg/dL

Total bolus of min 30mL/kgIVF bolus of 0.9% NS or LR

30ml/kg

Complete within 6Hr max

If initial lactate >2mmol/L

Repeat serum lactate level

If SBP<90 or MBP<65 within 1 hour of

completing 30ml/kg fluid bolus

If MBP>65 STOP

If lactate is >4mmol/L, perform repeat

volume and tissue perfusion assessment

If hypotensive patient is unresponsive to fluid

bolus of 30mg/dL initiate vasopressors

Repeat volume and tissue perfusion assessment including:• Vital signs• Cardiopulmonary exam• Capillary refill evaluation• Peripheral pulse evaluation• Skin evaluationOR Any two of the following:• Central venous pressure measurement• Central venous oxygen measurement• Cardiovascular ultrasound• Dynamic assessment of fluid responsiveness

with passive leg raise or fluid challenge

Patient meets criteria for Severe Sepsis

and/or Septic Shock


Sepsis Core Measures Exclusions

January 2016

The patient is excluded if …o “comfort care” is ordered for the patient within

3 hours of time of presentation of severe sepsis and 6 hours of septic shock

o Patient expires within 3 hours of severe sepsis or 6 hours of septic shock

o Patient is transferred from outside hospitals and emergency departments

o Patient/decision maker refuse any component of the recommended care

Successful Sepsis Program


Key Components

January 2016

Standardized Identification

o Automated screening tools and alert systemso Definite sepsis processes with clearly laid role

definitions

Evidence Based Treatment

o Physician engagement and accountabilityo Train and empower nurses to use sepsis bundles

Process Improvements

o Identify champions to evaluate sepsis programs o Facilitate, measure and reward physician engagemento Engage frontline clinicians to identify process gapso Execute, monitor and measure process improvementso Facilitate shift in culture towards protocol compliance

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Why so few health systems truly manage quality

Physician empowerment &

engagement

Appropriate analytics & technology solutions

Shifting priorities of governance & leadership

Organizational culture & ability

Executive engagement & awareness

Multiple contrasting priorities

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Four-Tier QI Plan for Sepsis ProgramANALYZEANALYZE PLAN PTIMIZE

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Thank you for joining us!If you would like to obtain additional information or are interested in discussing how AcesoCloud can help please

feel free to contact us.

Contact Email: [email protected]

About AcesoCloud: http://www.acesocloud.com

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Sepsis Core Quality Measures Webinar