Here are early insights from the first year of CHA's pediatric sepsis collaborative.
The Improving Pediatric Sepsis Outcomes (IPSO) collaborative gained momentum in 2016, with more than 40 children's hospitals of all sizes starting work on a multi-year improvement initiative. This initiative takes known best practices and uses improvement science to implement these best practices.
As teams mobilized to implement bundles and track outcomes, important lessons have emerged that can benefit any children's hospital working toward better sepsis care. These insights were revealed in the Steal Shamelessly: Early Lessons from the Improving Pediatric Sepsis Outcomes Collaborative session at the 2017 Quality & Safety in Children's Health Conference.
In its first year, IPSO has uncovered topics that show promise in changing sepsis outcomes: understanding sepsis incidence; workable approaches to sepsis screening in paper-based and EMR-enabled environments; creating sepsis order sets; Code Sepsis practices; mapping sepsis care processes; and training resources.
"We ultimately want to master recognition of non-severe sepsis and prevent deterioration to severe sepsis," says Richard Brilli, M.D., chief medical officer, Nationwide Children's Hospital, and one of the IPSO national co-chairs. "The collaborative will help teams put in a system that reduces variation to the get the outcomes we're looking for."
Six key drivers
The work coming out of this collaborative is based on six elements:
- Prevention: Avoid hospital-onset severe sepsis by recognizing patients who might potentially have sepsis later.
- Recognition: Create a systematic approach to identify at-risk patients. Building this into a system can redefine how to know if a patient may develop sepsis.
- Diagnosis: Standardize the order set to minimize variation and deliver timely care, as well as recognize the potential for deterioration.
- Resuscitation: Standardize the order sets for management of specific patients, so there is consistency for which provider comes to bedside, what labs were ordered and what medications were administered. It also allows for interventions to be tailored.
- De-escalation: Stop the over delivery of sepsis interventions when a patient no longer needs them.
- Patient and family engagement: Encourage families to share a concern and trigger escalation of care.
- Optimize performance: Couple content knowledge with specific knowledge of quality improvement.
This collaborative is focused on reliably implementing known best practices to create effective hospital-wide response systems. Because sepsis presents differently with every patient, it can be difficult to know the exact incidences in a hospital without data or processes. Just months after starting the work, hospitals started sharing their experiences, which led to these early lessons learned.
Lesson 1: Sepsis incidence is underestimated
Do you know your mortality rates? It can be challenging to identify patients to understand incidence. IPSO hospitals estimate 40 percent to 60 percent of cases are missing in their estimates. Learning how to identify and label these patients will help hospitals see patients who otherwise wouldn't have been identified. Building infrastructure to identify these children is critical to capturing true incidence.
Lesson 2: Systems are recognizing gaps in care delivery
Sepsis has historically been championed in silos or individual units, but that doesn't allow learning across the larger system. Process mapping across the continuum of care has identified these gaps for delivery systems.
Lesson 3: Scale best practices from microsystem to enterprise
Sepsis work has been focused largely in single-care settings. In IPSO, hospitals have the opportunity to not only take best practices from one venue of care to the next, but also empower those who aren't typically champions of sepsis by providing resources and education.
Lesson 4: Prevent deterioration by recognizing risk
It's critical to standardize terminology, along with guidelines for preventable sepsis. "In my own backyard, we found the language that would empower the move from recognizing to managing sepsis shock was so weak and non-standardized, it required clinicians to do a deep dive into more than 15 guidelines," says Charles Macias, M.D., executive director, chief clinical systems integration officer, Texas Children's Hospital, and an IPSO national co-chair. "We needed to move out of looking at all these different disease processes and start managing patients differently."
Lesson 5: Timeline source control prevents sepsis
IPSO engages surgical colleagues to identify conditions that could lead to severe sepsis and drive timeline source control to prevent those cases.
Lesson 6: Sepsis screening without alarm fatigue
The high volume of false alarms is a common concern when implementing automated sepsis screening practices. Hospitals have developed sepsis screening criteria and tools that are rapid (within seconds) and specific (low volume of alarms per day).
Lesson 7: Screening doesn't require a large technology investment
EMR-enabled sepsis screening tools are ideal, but teams can successfully use a paper-based screening system to identify sepsis in patients. A paper-based screening can be valuable where EMR support is delayed or not possible.
Lesson 8: Best practices exist
Collaborators can gain important skills from a pool of expertise and proven tools and methods: screening tools, order sets, bundles, training materials and EMR tips—all in real time. "Where does this work lead? To the parent, to the provider, to the institutions that have changed their infrastructure—and to the nation," Brilli says. "We intend to save thousands of kids' lives through the collaborative."
Children's hospitals can join those focused on defeating the leading killer of hospitalized children. This collaborative will reduce morbidity and mortality across all levels of care. Enrollment for July 2017 ends June 30.
To learn more about these early lessons learned or for a recap of what was presented at the conference, view a recording of the webinar, Steal Shamelessly: Early Lessons From the Improving Pediatric Sepsis Outcomes Collaborative.
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