Volume 16 Supplement 3

Sepsis 2012

Open Access

Kaiser Permanente Northern California sepsis mortality reduction initiative

  • B Crawford1,
  • M Skeath1 and
  • A Whippy1
Critical Care201216(Suppl 3):P12

DOI: 10.1186/cc11699

Published: 14 November 2012

Background

In 2008, Kaiser Permanente Northern California (KPNC), which provides care to 3.3 million members in 21 hospitals, implemented an initiative to improve sepsis care, a critical step to reduce hospital mortality. The goals of the program were threefold: improve identification of sepsis patients, appropriately stratify risk, and reliably provide treatment, focusing on spread and sustainability across all medical centers.

Methods

In spring 2008, all hospitals reviewed the last 50 deaths and sepsis was identified as a significant improvement opportunity. In May 2008, two hospitals began rapid cycle pilot testing, resulting in the development of a playbook containing treatment algorithms, standardized order sets and flow charts, and chart abstraction tools. These tools, along with expectations for implementation, were shared with leaders and champions from all 21 hospitals at the November 2008 Sepsis Summit. The summit closed with a young mother sharing the story of how her life was saved as a result of the work at the pilot hospital. Subsequently, all hospitals convened multidisciplinary sepsis teams and began training and tool adoption, focusing immediately on improving sepsis identification. Regional mentors and medical center improvement advisors supported team-building and rapid implementation; timely and actionable data allowed ongoing identification of improvement opportunities. Identification and performance monitoring were supported by the development of a web-based tool that pulled information directly from the electronic medical record.

Results

The number of sepsis diagnoses per 1,000 admissions increased from a baseline of 35.7 (March 2008) to 98.3 (December 2010). For septic shock patients, bundle performance increased from 7.3% (Q3 2009) to 55.1% (December 2010), and EGDT population mortality decreased from 29.7% (July to August 2009) to 20.2% (Q4 2010). Overall sepsis mortality decreased from a baseline of 24.6% (March 2008) to 11.5% (December 2010); mortality rates continued to drop to below 9% in May 2012. This was associated with a 14% overall drop in raw hospital mortality. Subsequent performance improvement programs encompass care of the intermediate lactate population, pediatric patients and surgical patients. See Figure 1 and Table 1.
https://static-content.springer.com/image/art%3A10.1186%2Fcc11699/MediaObjects/13054_2012_Article_779_Fig1_HTML.jpg
Figure 1

Sepsis EGDT mortality rate compared with overall bundle compliance. Kaiser Permanente Northern California Hospitals. As bundle performance passed 30%, a sharp decline in mortality was observed for septic shock patients who qualify for EGDT.

Table 1

Key results of the KPNC sepsis mortality reduction initiative (aggregate data for all 21 hospitals)

Measure

Baseline

Rapid adoption (December 2010)a

Sustainability (May 2012)a

Sepsis diagnoses per 1,000 admits

35.7 (2006 to early 2008)

98.3

137.9

Admitted patients with blood cultures in ED have lactate test in ED

27% (early 2008)

96.5%

95.6%

ABX w/in 60 minutes of dx of shock

69.5% (Q3 2009)

90.4%

91.8%

CL w/in 2 hours of dx (first CVP of ScvO2 in 2 hours)

41.5% (Q3 2009)

78.6%

89.6%

Mean BP (MAP) at target

52% (Q3 2009)

90.4%

93.8%

CVP at target

41.5% (Q3 2009)

83.8%

92.8%

ScvO2 at target

30.8% (Q3 2009)

74.3%

81.4%

Lactate lower within 6 hours for EGDT

52% (Q3 2009)

91.2%

95.9%

EGDT bundle

7.3% (Q3 2009)

55.1%

70.1%

Sepsis raw mortality

24.6% (2006 to early 2008)

11.5%

8.7%

Sepsis observed/expected (O/E) mortality

1.07 (rolling year ending Q1 2008)

0.82

0.56

Sepsis O/E LOS

1.07 (rolling year ending Q1 2008)

0.89

0.75

EGDT population mortality (only patients with refractory shock or lactate ≥4)

29.7% (239 cases, July to August 2009)

20.2% (391 cases, Q4 2010)

18.6% (323 cases, March-May 2012)

Raw all cause adult non-OB KPNC hospital mortality

3.63% (2006 to 2007)

3.11% (2010)

3.07% (year ending Q2 2012)

HSMR-Medicate only

0.92 (rolling year ending Q2 2008)

0.60 (YE 2010)

0.52 (YE 2011)

Balancing measures: EGDT associated harm

July to December 2009

July to December 2010

December 2011 to May 2012

   BSI

0

0

0

   Retained guidewires

3

0

0

   Pneumothorax

1

2

4

aRapid adoption and sustainability data reflect December 2010 and May 2012, respectively, unless otherwise noted.

Conclusion

The KPNC program is unique in its rapid rate of improvement in sepsis measures, adoption of a single standard of care across an entire 21-hospital system, sustainability well beyond the rapid adoption period, and the quantification of mortality risk beyond the shock population to the intermediate sepsis population. These results demonstrate that a strong performance improvement engine can drive large-scale, sustained improvements in care within a short duration.

Authors’ Affiliations

(1)
Kaiser Permanente

Copyright

© Crawford et al.; licensee BioMed Central Ltd. 2012

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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