The overall goal of this project is to utilize process improvement strategies—such as the Toyota Lean method—to implement 3- and 6-hour bundled care as defined by the Surviving Sepsis Campaign to improve care, health, and cost of care for patients with severe sepsis or septic shock.
Improve care: Improve optimal adherence to sepsis bundled care by 5% (relative rate) over three years.
Improve health: Reduce the burden of chronic morbidity from sepsis-associated chronic organ dysfunction, achieving a 5% relative rate reduction over three years in the number of patients requiring long-term acute care or sub-acute nursing care after an incident episode of severe sepsis (where episode refers to events that are bracketed by the admission and discharge from an inpatient acute care facility.)
Reduce cost: Achieve 5% relative rate reduction over three years in the number of patients with sepsis requiring long-term acute care or sub-acute nursing care after an incident episode of severe sepsis; saving $12.24M in Medicare reimbursements at HVHC hospitals over the three years of the study.
Severe sepsis, defined as a clinical syndrome of infection plus organ dysfunction1, affects 1.16 million patients per year in the United States2 and is a major public health challenge with an estimated mortality rate between 20% and 45%.3-6 Care for patients with sepsis is costly and resource-intensive, with many or most patients requiring intensive care during a hospitalization. Survivors experience serious and prolonged long-term morbidities that limit function and economic productivity.
There are few proven specific therapies for sepsis and no single effective therapy. Current guidelines for care highlight the reliance on interventions such as rapid intravenous fluid administration, source control of infection, and initial empiric antibiotic treatment within specific timeframes referred to as “bundled care.” The consequences of ineffective resuscitation and initial management of sepsis are progressive multi-organ failure, severe disability, and death, as well as costly dependence for survivors. Increasingly, delivery of complex care for illnesses like sepsis has been evaluated and reported using composite multi-parameter measures of process and outcome. This “bundle” of composite measures—an aggregate of process interventions connected to outcomes—is commonly used to evaluate the delivery of optimal care (i.e., “perfect bundle”) for certain conditions using “all or none” criteria. Yet a common hurdle in delivering care bundles in these complex environments (ED and ICU) is the potential for wasteful and ineffective care that detracts from the delivery of highly reliable, high value care.
Patient Engagement Interventions
HVHC is implementing sepsis bundled care measures as part of a three-year CMMI award entitled “Optimizing the Treatment of Septicemia and Sepsis through implementation of bundled care interventions with Lean systems improvement strategies.” Year 1 major deliverables and progress to date include a draft sepsis care bundle, Lean training curricula, and Lean implementation and bundle roll out.
A total of ten High Value Healthcare Collaborative members completed the initial survey with eight members participating in the project for year 1. The pilot team conducted an in person working meeting from November 15-16, 2012, with the following decisions:
- Bundle design: The 2012 Surviving Sepsis Campaign (SSC) and National Quality Forum (NQF)9 severe sepsis and septic shock bundles were accepted to be implemented.
- Initial Lean training was delivered to attendees. Attendees proceeded to the Denver Health Emergency Department and conducted a “waste walk” where the entire care process for a current patient in the Emergency Department was profiled and analyzed.
- The draft Lean implementation curricula was accepted by attendees.
- On-site Lean training weeks and bundle rollout were scheduled for all 8 co-lead members.
The pilot sites will implement a standard clinical bundle based upon the 2012 update of the Institute for Health Care Improvement (IHI) Surviving Sepsis Campaign (SSC) and National Quality Forum (NQF) Guidelines for the care of severe sepsis and/or septic shock:
Severe Sepsis 3-Hour Bundle
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate >4mmol/L
Septic Shock 6-Hour Bundle
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure ≥65mmHg)
6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36mg/dl):
- Measure central venous pressure
- Measure central venous oxygen saturation
7. Re-measure lactate if initial lactate was elevated