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Surviving SEPsis90 Campaign - HRO Saves Lives!
Share PrintOur Surviving SEPsis90 Campaign provides an adaptable framework to develop a comprehensive program to monitor and improve outcomes in our veterans with sepsis. Using quality improvement tools and implementation science principles, we have created a standard process to screen for sepsis on presentation to the ED, tailorable order sets for the management of sepsis, and templated notes to document sepsis diagnosis and treatment interventions to ensure effective hand-offs. This systematic approach to sepsis care has improved veterans’ access to timely, high-quality care and led to a trend in reduced veteran mortality and increased discharges home alive from the hospital.
Origin:
July 2022, James J. Peters Department of Veterans Affairs Medical Center (Bronx)
Adoptions:
3 successful, 10 in-progress
Awards and Recognition:
VHA Shark Tank Winner
Recent Updates
Overview
Problem
Sepsis accounts for one-third of hospital deaths. The Surviving Sepsis Campaign (SSC) provides protocol-driven, goal-oriented guidance for resuscitation within the first six hours of sepsis. Evidence suggests that adherence to these guidelines decreases mortality.
In 2015, the Centers for Medicare & Medicaid Services (CMS) added the Severe Sepsis and Sep ... Sepsis accounts for one-third of hospital deaths. The Surviving Sepsis Campaign (SSC) provides protocol-driven, goal-oriented guidance for resuscitation within the first six hours of sepsis. Evidence suggests that adherence to these guidelines decreases mortality.
In 2015, the Centers for Medicare & Medicaid Services (CMS) added the Severe Sepsis and Septic Shock: Management Bundle (SEP-1) to its core measures, which evaluates the proportion of patients with sepsis who receive early, guideline-directed management. These early interventions include administering IV antibiotics, drawing blood cultures prior to antibiotics, and obtaining a lactate within three hours of sepsis recognition.
Despite guidelines and mandated metric reporting, morbidity and mortality from sepsis has remained unacceptably high. In response, the CDC recently published the Hospital Sepsis Program Core Elements to provide guidance to develop a comprehensive program to monitor and improve sepsis outcomes.
Nationally, only 38% of veterans with sepsis or septic shock received appropriate early management in FY22 compared to 58% of all institutions reporting SEP-1 data to CMS. Devoting VHA resources to systematically improving early management of sepsis will save veteran lives. See more
In 2015, the Centers for Medicare & Medicaid Services (CMS) added the Severe Sepsis and Sep ... Sepsis accounts for one-third of hospital deaths. The Surviving Sepsis Campaign (SSC) provides protocol-driven, goal-oriented guidance for resuscitation within the first six hours of sepsis. Evidence suggests that adherence to these guidelines decreases mortality.
In 2015, the Centers for Medicare & Medicaid Services (CMS) added the Severe Sepsis and Septic Shock: Management Bundle (SEP-1) to its core measures, which evaluates the proportion of patients with sepsis who receive early, guideline-directed management. These early interventions include administering IV antibiotics, drawing blood cultures prior to antibiotics, and obtaining a lactate within three hours of sepsis recognition.
Despite guidelines and mandated metric reporting, morbidity and mortality from sepsis has remained unacceptably high. In response, the CDC recently published the Hospital Sepsis Program Core Elements to provide guidance to develop a comprehensive program to monitor and improve sepsis outcomes.
Nationally, only 38% of veterans with sepsis or septic shock received appropriate early management in FY22 compared to 58% of all institutions reporting SEP-1 data to CMS. Devoting VHA resources to systematically improving early management of sepsis will save veteran lives. See more
Images
Credit: CDC
SEP90: all-or-nothing composite score of SEP-1 made up of SEP1a, SEP1b, SEP1c, and SEP1d metrics
Links
- See attached link to access the CDC's Hospital Sepsis Program Core Elements website. CDC's Hospital Sepsis Program Core Elements Website
Solution
Our interdisciplinary team established an adaptable framework to standardize the management of sepsis using clinical documentation templates that trigger a computerized sepsis order set pathway in CPRS. The computerized sepsis order set defaults to immediate administration of new antimicrobials and bundles blood culture and lab orders with one click, includi
...
Our interdisciplinary team established an adaptable framework to standardize the management of sepsis using clinical documentation templates that trigger a computerized sepsis order set pathway in CPRS. The computerized sepsis order set defaults to immediate administration of new antimicrobials and bundles blood culture and lab orders with one click, including auto-ordering a repeat lactate. Templated notes ensure documentation of sepsis diagnosis and treatment interventions to facilitate effective hand-offs. Generic orders are embedded into order sets and health factors into templated notes, which trigger CPRS alerts to notify sepsis champions of real-time sepsis recognition. This allows for proactive interventions within the three- and six-hour management windows.
Prospective data related to the sep90 composite score are also collected and updated daily via a local dashboard created by our data analytics team. Displayed data include lactate level and time of blood culture collection and antibiotic administration. The dashboard also pulls data from embedded generic order and health factors to allow for next-day feedback to care teams to ensure order sets and documentation templates are used consistently.
An education campaign is paramount to promote use of standardized sepsis management tools and ensure prompt recognition. Physician and nursing sepsis champions were identified in all care units and educated by subject matter experts from the sepsis program’s interdisciplinary team. Unit-level sepsis champions, in turn, educated their peers. Staff are continually educated about sepsis management and documentation tools during daily safety huddles.
In August 2023, the CDC published the Hospital Sepsis Program Core Elements, which outline structural and procedural components that are associated with the multidisciplinary expertise required to support the care of patients with sepsis. Core elements include:
(1) hospital leadership commitment to ensure hospital clinician engagement and sufficient resources to run the program,
(2) designation of a sepsis program leader,
(3) creation of an interdisciplinary team of subject matter experts, clinicians caring for patients with sepsis, medical informatics, and quality management to spearhead the sepsis program,
(4) development of standardized processes to screen for sepsis, order sets for sepsis management, and templated notes to document sepsis diagnosis and treatment information,
(5) tracking of sepsis management and outcomes to identify improvement opportunities,
(6) reporting of sepsis management and outcomes to motivate behavior change and facilitate improvement in sepsis treatment and outcomes, and
(7) education of hospital staff caring for patients with sepsis.
Our innovation embodies a successful sepsis program that implements the CDC’s Hospital Sepsis Program Core Elements. By using continuous process improvement methods, creating a culture of safety on sepsis reporting, and obtaining full support from executive leadership, which are the three main pillars of HRO, we were able to sustain improvement and streamline the evaluation and management of veterans with sepsis and septic shock. See more
Prospective data related to the sep90 composite score are also collected and updated daily via a local dashboard created by our data analytics team. Displayed data include lactate level and time of blood culture collection and antibiotic administration. The dashboard also pulls data from embedded generic order and health factors to allow for next-day feedback to care teams to ensure order sets and documentation templates are used consistently.
An education campaign is paramount to promote use of standardized sepsis management tools and ensure prompt recognition. Physician and nursing sepsis champions were identified in all care units and educated by subject matter experts from the sepsis program’s interdisciplinary team. Unit-level sepsis champions, in turn, educated their peers. Staff are continually educated about sepsis management and documentation tools during daily safety huddles.
In August 2023, the CDC published the Hospital Sepsis Program Core Elements, which outline structural and procedural components that are associated with the multidisciplinary expertise required to support the care of patients with sepsis. Core elements include:
(1) hospital leadership commitment to ensure hospital clinician engagement and sufficient resources to run the program,
(2) designation of a sepsis program leader,
(3) creation of an interdisciplinary team of subject matter experts, clinicians caring for patients with sepsis, medical informatics, and quality management to spearhead the sepsis program,
(4) development of standardized processes to screen for sepsis, order sets for sepsis management, and templated notes to document sepsis diagnosis and treatment information,
(5) tracking of sepsis management and outcomes to identify improvement opportunities,
(6) reporting of sepsis management and outcomes to motivate behavior change and facilitate improvement in sepsis treatment and outcomes, and
(7) education of hospital staff caring for patients with sepsis.
Our innovation embodies a successful sepsis program that implements the CDC’s Hospital Sepsis Program Core Elements. By using continuous process improvement methods, creating a culture of safety on sepsis reporting, and obtaining full support from executive leadership, which are the three main pillars of HRO, we were able to sustain improvement and streamline the evaluation and management of veterans with sepsis and septic shock. See more
Images
Credit: CDC
Links
- Watch this video to see a live demonstration of sepsis documentation note templates for physicians in CPRS Sepsis Physician Documentation Templates Demo in CPRS
- Watch this video to see a live demonstration of sepsis clinical pathway order set in CPRS Sepsis Clinical Pathway Order Set Demo in CPRS
- Watch this video to see a live demonstration of sepsis documentation note templates for nurses in CPRS Sepsis Nursing Documentation Templates Demo in CPRS
Results
Our SEP90 SAIL score increased from 14% in FY22 to 67% in FY23 after implementation of our comprehensive sepsis program (p=0.0001).
Trends in individual SEP90 metrics from FY22 to FY23 were as follows:
SEP1a: 57% in FY22 vs. 85% in FY23 (p=0.0349)
SEP1b: 50% in FY22 vs. 95% in FY23 (p=0.0666)
SEP1c: 50% in FY22 vs. 89% in FY23 (p=0.0577)
SEP1d: 0 ... Our SEP90 SAIL score increased from 14% in FY22 to 67% in FY23 after implementation of our comprehensive sepsis program (p=0.0001).
Trends in individual SEP90 metrics from FY22 to FY23 were as follows:
SEP1a: 57% in FY22 vs. 85% in FY23 (p=0.0349)
SEP1b: 50% in FY22 vs. 95% in FY23 (p=0.0666)
SEP1c: 50% in FY22 vs. 89% in FY23 (p=0.0577)
SEP1d: 0% in FY22 vs. 75% in FY23 (p=0.3333)
For reference, SEP90 is a composite, all-or-nothing score comprised of four individual metrics:
- SEP1a: percentage of patients who received an IV antibiotic, had blood cultures drawn prior to antibiotics, and had a lactate level drawn all within 3 hours of sepsis presentation
- SEP1b: percentage of patients who had an elevated initial lactate level result (> 2 mmol/L), and had a repeat lactate drawn within 6 hours of sepsis presentation
- SEP1c: percentage of patients who had initial hypotension or septic shock, and 30 mL/kg of IV crystalloid fluids were started within 3 hours of septic shock or initial hypotension presentation
- SEP1d: percentage of patients who received a vasopressor, if persistent hypotension was present, and who had a repeat volume status and tissue perfusion assessment completed within 6 hours of persistent hypotension or septic shock presentation See more
Trends in individual SEP90 metrics from FY22 to FY23 were as follows:
SEP1a: 57% in FY22 vs. 85% in FY23 (p=0.0349)
SEP1b: 50% in FY22 vs. 95% in FY23 (p=0.0666)
SEP1c: 50% in FY22 vs. 89% in FY23 (p=0.0577)
SEP1d: 0 ... Our SEP90 SAIL score increased from 14% in FY22 to 67% in FY23 after implementation of our comprehensive sepsis program (p=0.0001).
Trends in individual SEP90 metrics from FY22 to FY23 were as follows:
SEP1a: 57% in FY22 vs. 85% in FY23 (p=0.0349)
SEP1b: 50% in FY22 vs. 95% in FY23 (p=0.0666)
SEP1c: 50% in FY22 vs. 89% in FY23 (p=0.0577)
SEP1d: 0% in FY22 vs. 75% in FY23 (p=0.3333)
For reference, SEP90 is a composite, all-or-nothing score comprised of four individual metrics:
- SEP1a: percentage of patients who received an IV antibiotic, had blood cultures drawn prior to antibiotics, and had a lactate level drawn all within 3 hours of sepsis presentation
- SEP1b: percentage of patients who had an elevated initial lactate level result (> 2 mmol/L), and had a repeat lactate drawn within 6 hours of sepsis presentation
- SEP1c: percentage of patients who had initial hypotension or septic shock, and 30 mL/kg of IV crystalloid fluids were started within 3 hours of septic shock or initial hypotension presentation
- SEP1d: percentage of patients who received a vasopressor, if persistent hypotension was present, and who had a repeat volume status and tissue perfusion assessment completed within 6 hours of persistent hypotension or septic shock presentation See more
Images
Trend in SEP90 composite score before & after practice implementation
Trend in individual SEP90 metrics compared to VHA
Sepsis-related outcomes pre-implementation (FY21+FY22) vs. post-implementation (FY23+FY24)
Metrics
- In-Hospital Mortality: 12% (4/33) pre-implementation vs. 11% (4/37) post-implementation (p=1.0000)
- 30-Day Mortality After Discharge: 12% (4/29) pre-implementation vs. 0% (0/33) post-implementation (p=0.0426)
- 90-Day Mortality After Discharge: 21% (6/29) pre-implementation vs. 3% (1/33) post-implementation (p=0.0437)
- Composite 90-Day Mortality: 30% (10/33) pre-implementation vs. 15% (5/37) post-implementation (p=0.1434)
- Admitted to ICU: 67% (22/33) pre-implementation vs. 51% (19/37) post-implementation (p=0.1941)
- Discharged Home: 55% (16/29) pre-implementation vs. 64% (21/33) post-implementation (p=0.4978)
- New Discharge to Facility: 34% (10/29) pre-implementation vs. 12% (4/33) post-implementation (p=0.0322)
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
Surviving SEPsis90 Campaign Implementation Roadmap
Thank you to all frontline staff caring for veterans with sepsis
Implementation
Timeline
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4 weeks
1.) Subject matter experts/members of your sepsis interdisciplinary team review physician & nursing sepsis note documentation templates in CPRS and provide modifications based on local orders to the team's Clinical Applications Coordinator (CAC) or Health Informatics Specialist (HIS)2.) Your CAC/HIS imports the reminder dialog template/health factors for the sepsis nursing & physician documentation notes via Reminder Exchange & modifies them accordingly3.) Subject matter experts/members of your sepsis interdisciplinary team review the sepsis clinical pathway order set and provide modifications based on local preferences/institution-specific practices to the team's CAC/HIS4.) Your CAC/HIS builds the sepsis clinical pathway order set in CPRS based on input from the sepsis interdisciplinary team5.) Key frontline nurses and physicians advise the team's CAC/HIS to embed sepsis documentation templates in frequently used notes (i.e., ED Interim Documentation note, ED Physician Note) and determine where the sepsis clinical pathway order set should be located in CPRS (can be placed in multiple menus as per provider preference) -
1 week
1.) Your data analyst will review the provided SQL code to and update accordingly after working with the team's CAC/HIS & clinical staff to identify applicable health factors and orderable items to create a local sepsis dashboard2.) Subject matter experts/members of the sepsis interdisciplinary team will assist the team's data analyst in validating the local sepsis dashboard*this milestone can be started once the team's CAC/HIS has finished the sepsis documentation templates and built the sepsis clinical pathway order set in CPRS -
3 weeks
1.) One facility-wide nursing champion & one facility-wide physician champion educate sepsis nursing & physician champions from each unit regarding early sepsis recognition, management, and the CPRS tools available to provide a streamlined and structured approach to care2.) In-unit sepsis champions, in turn, educate their peers regarding early sepsis recognition, management, and the CPRS tools available to provide a streamlined and structured approach to care*this milestone can be started once the team's CAC/HIS has finished the sepsis documentation templates and built the sepsis clinical pathway order set in CPRS
Core Resources
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Files
- Key "need-to-have" and "nice-to-have" resources to implement & sustain this practice Surviving SEPsis90 Campaign Bid Wish List
Optional Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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Support Resources
| Resource type | Resource description |
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PEOPLE |
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PROCESSES |
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TOOLS |
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Contact
Comment
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Email kirsten.vest@va.gov with questions about this innovation.
About
Origin story
Throughout our VA network, veterans are vulnerable to sepsis or septic shock in multiple clinical settings such as the emergency department, inpatient units, intensive care units, and perioperative spaces. Yet, we did not have a standardized approach to recognition, evaluation, treatment, and quality management of sepsis and septic shock at our institution.
...
Throughout our VA network, veterans are vulnerable to sepsis or septic shock in multiple clinical settings such as the emergency department, inpatient units, intensive care units, and perioperative spaces. Yet, we did not have a standardized approach to recognition, evaluation, treatment, and quality management of sepsis and septic shock at our institution. In fact, review of the SAIL report supported the need for this urgent intervention where our facility placed 101st of 113 VA sites for the SEP90 composite score in FY22. Our team sought to create a facility-wide sepsis clinical pathway with standardized note templates using system redesign and clinical informatics principles that would transition our facility into a high reliability organization (HRO) in sepsis care and management.
Original team
Kirsten Vest, PharmD, BCIDP
Antimicrobial Stewardship Pharmacist
David L. Ng, MD, MS, FACEP
Chief of Emergency Medicine
Bryce Prosper, CPhT, MSW
Clinical Applications Coordinator
Steven Martinez, RN
Emergency Department Nurse Manager
Rodrigo Loza, RN
Emergency Department Clinical Coordinator
Aminatou Famby-Mandjo, RN
Emergency Room Nurse
Nikki McGann, MS, RN
Intensive Care Unit Clinical Coordinator
Bindu Raju, MD, FCCP
Chief of Pulmonary & Critical Care Medicine
Elisabeth Gussenhoven
Management & Program Analyst
Adelina Fuentes-Ramos, MHA
Clinical Applications Coordinator
Meena Zaidi, MD, FACP
Chief of Staff
Lurangee Jimenez, RN-BSN
Clinical Applications Coordinator
Tanya Oden, RN
Quality Management
Ann Phelan, MSN, RN-BC
Quality Management
Shaniqua Raphael, MSA, KT
Chief of Clinical Applications - Medical Informatics Department
great ideas!!
Important and impressive work from this team, as always!
Strong work!!