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

Editor's Notes

• #10: In the UK, sepsis is the leading cause of direct maternal death. The most recent triennial report (2006-2008) of maternal deaths from the Centre for Maternal and Child Enquiries (CMACE) found that deaths from sepsis have risen rather than declined in recent time, in contrast to the other major causes of direct maternal mortality.
• #12: 10 elements of the bundle:Resuscitation Bundle: Check Lactate, Take Blood Cultures prior to Ab, Give Antibiotics, Fluid (20ml/kg) admin, if not fluid responsive vasopressors to achieve a MAP > 65, CVP≥ 8, ScvO2≥ 70Management Bundle: Steroids, Glycaemic Control, Plateau Pressure < 30, RhAPC
• #13: Looked for signs of sepsis within the first 48 hours of emergency admission to hospital over a 3 month period in 2009.20 participating sites. Over 300,000 admissions. Annual incidence of 21,000 unscheduled care patients. Estimated cost of £79 Million. Vast majority of patients were managed initially by doctors in training.Early Warning System (EWS) charts were commenced on 71% of patients within two hours of initial attendance. When the EWS chart indicated the need for review, documented confirmation that this had occurred was present in 91% of cases. Overall, 34% (1325) of patients with sepsis met the criteria for severe sepsis within two days of initial attendance. Of these patients 48% (637) met the criteria before leaving the ED. Supplementary oxygen was commenced either before or within one hour of the first signs of severe sepsis on 76% of occasions. Blood cultures were taken in 21% of patients either before or within an hour. Intravenous antibiotics were administered on 32% of occasions either before or within one hour, and 66% of occasions within four hours. Lactate was measured within four hours on 55% of occasions.•
• #14: IHI developed the concept of “bundles” to help health care providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks. A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes. It Is At Times Difficult To Diagnosis Sepsis Early: No gold standard marker for disease. Very definition relies on lowest level of evidence, a consensus statementInvasive procedures needed for evaluation and monitoring
• #15: At long-term follow-up, some of the improvements achieved by the educational program had returned to baseline, especially process-of-care measures in the acute phase of treatment. However, it is well-known that quality improvement initiatives should be sustained,especially in areas like the emergency department in which physician turnover is higher than in other areas of the hospital. Applying the“plan-do-study-act” cycles is probably the best approach to sustain the effect of the educational program.
• #17: Segmentation: A/E is the low hanging fruitLevel 2 reliability tools are checklists, protocols, defaults, reminders, redundancyDecision aids and reminders built into the system, Desired action the default (based on scientific evidence), Redundant processes utilized, Habits and patterns known and taken advantage of in the design, Standardisation of process Learn from North Shore LIJ: MEWS, ab within the hour, fluid administration
• #18: He who must not be named. We don’t talk about sepsis. No pattern recognition.
• #19: He who must not be named. We don’t talk about sepsis. No pattern recognition.
• #26: Sepsis and VTE have a stark similarity. Awareness of the condition is low, tens of thousands of people are affected each year, and yet simple screening and rapid intervention can save lives. We don’t talk about it.
• #27: At long-term follow-up, some of the improvements achieved by the educational program had returned to baseline, especially process-of-care measures in the acute phase of treatment. However, it is well-known that quality improvement initiatives should be sustained,especially in areas like the emergency department in which physician turnover is higher than in otherareas of the hospital. Applying the“plan-do-study-act” cycles is probably the best approach to sustain the effect of the educational program.
• #28: Something here about the growing expertise in Scotland – this work is being delivered without external support using fellows, Ias and programme managers
• #33: Segmentation: A/E is the low hanging fruitLevel 2 reliability tools are checklists, protocols, defaults, reminders, redundancyDecision aids and reminders built into the system, Desired action the default (based on scientific evidence), Redundant processes utilized, Habits and patterns known and taken advantage of in the design, Standardisation of process Learn from North Shore LIJ: MEWS, ab within the hour, fluid administration
• #39: Looked for signs of sepsis within the first 48 hours of emergency admission to hospital over a 3 month period in 2009.20 participating sites. Over 300,000 admissions. Annual incidence of 21,000 unscheduled care patients. Estimated cost of £79 Million. Vast majority of patients were managed initially by doctors in training.Early Warning System (EWS) charts were commenced on 71% of patients within two hours of initial attendance. When the EWS chart indicated the need for review, documented confirmation that this had occurred was present in 91% of cases. Overall, 34% (1325) of patients with sepsis met the criteria for severe sepsis within two days of initial attendance. Of these patients 48% (637) met the criteria before leaving the ED. Supplementary oxygen was commenced either before or within one hour of the first signs of severe sepsis on 76% of occasions. Blood cultures were taken in 21% of patients either before or within an hour. Intravenous antibiotics were administered on 32% of occasions either before or within one hour, and 66% of occasions within four hours. Lactate was measured within four hours on 55% of occasions.•
• #41: IOM’s landmark report in 2001: Quality problems are everywhere ….. Between the health care we have and the health care we could have lies not just a gap, but a chasm. The flaws in the current system are indisputable: best-known science is not reliably applied; widespread inefficiencies waste precious resources; and our system, which aims to heal, too often does just the opposite, leading to unintended An important quote from "Crossing the Quality Chasm" is "The transfer of knowledge is care" - one of its 10 principles for improvement. Crossing the Quality Chasm and at least one other of the key Institute of Medicine reports is fronted up with  Goethe's famous quote about "Knowing is not enough; we must apply/Willing is not enough; we must do".  Key point is that use of knowledge and evidence was recognised from the first as a vital part of quality improvement. We very much hope the Knowledge into Action review will give quality improvement in NHS Scotland a unique, leading edge dimension that is rooted in best use of knowledge.Johann Wolfgang von Goethe was an 18th Century German playwright.
• #42: Know-what:Evidence based medicineKnow-how:Data and information from practice and experienceCare processes and systemsWe want to be able to do the right things right.The Knowledge into Action Review is a great opportunity to bring together the worlds of EB practice & QI know what, (research, evidence & guidelines) and know how (tacit knowledge and ideas from experience and practice.
• #72: Quality is one of the 5 key strategies for NHS Grampian. With this in mind, it was decided to create a Quality Improvement Facilitators (QIF’s) role and to have nurses out on secondment to fulfil this role. Initially there were 3 of us and then an additional QIF was appointed.We are the first cohort to be seconded and were given various strands of work: VTE, Sepsis, Falls and Continence.This has meant for VTE that we are available to support the front line staff in the Acute Medical Admission unit (AMAU) in piloting VTE assessment. We are there to listen and get feedback from the staff which means that we are able to make the changes required to the assessment form, collect the data, produce the charts and liaise with the rest of the quality improvement team. This takes the burden away from the clinical staff, enabling them to test the VTE assessment form without taking away too much time from their clinical role.We are supported weekly where we meet with our clinical lead, our nurse manager, our SPSP manager and our nominated executive lead for Quality Improvement. This gives time to discuss progress to date and plan initiatives for the week ahead.I won’t deny that although I put myself forward for this role, it was quite challenging to begin with. I come from a theatre background and it was a big change for me. It has, however, proved to be very interesting and rewarding.We all come from different areas within ARI and the plan is for us, at the end of the secondment, to be able to carry on with quality work in our respective areas.
• #77: At long-term follow-up, some of the improvements achieved by the educational program had returned to baseline, especially process-of-care measures in the acute phase of treatment. However, it is well-known that quality improvement initiatives should be sustained,especially in areas like the emergency department in which physician turnover is higher than in otherareas of the hospital. Applying the“plan-do-study-act” cycles is probably the best approach to sustain the effect of the educational program.