How to Use an Early Warning System for Sepsis in the Emergency Department

By Christopher Cheney

An early warning system for sepsis embedded in an electronic health record (EHR) can have a significant impact on sepsis care, according to a recent research article.

Sepsis is a life-threatening condition caused by the body’s extreme reaction to an infection. Annually, at least 1.7 million American adults develop sepsis and about 270,000 Americans die due to sepsis, according to the Centers for Disease Control and Prevention.

The recent research article, which was published by Critical Care Medicine, describes the results of a randomized, controlled quality improvement initiative conducted at The MetroHealth System in Cleveland. The article features data collected from 598 patients, with 285 patients in the intervention group and 313 in the standard care group.

The intervention involved using a sepsis early warning system embedded in the health system’s EHR. The early warning system is based on structured EHR variables used to predict whether a patient will develop sepsis during their hospitalization. The variables include demographic data, vital signs, laboratory results, orders, and comorbidities.

When the early warning system determined there was a likelihood of sepsis, two actions were triggered: an alert appeared in the EHR, and a message was sent to emergency department pharmacists. The pharmacist would review the chart and huddle with the primary ED provider. If sepsis was suspected, the pharmacist would expedite ordering and collection of blood work as well as ordering and administration of antibiotics and fluid boluses.

The research article features two primary data points.

  • The time to antibiotic administration from ED arrival was shorter for the intervention group compared to the standard care group (2.3 hours versus 3.0 hours). It is widely accepted that timely administration of antibiotics results in better outcomes for sepsis patients.
  • Days alive and out of hospital at 28 days was greater for the intervention group compared to the standard care group (24.1 days versus 22.5 days).

“In this single-center randomized quality improvement initiative, the display of an electronic health record–based sepsis early warning system–triggered flag combined with electronic health record–based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions,” the research article’s co-authors wrote.

Assessing the sepsis early warning system

Although the research article documented modest improvements in the timeliness of antibiotics administration as well as days alive and out of hospital, the early warning system intervention’s benefits were significant, the lead author of the study told HealthLeaders.

“While earlier research on the management of sepsis led to major improvements in sepsis-related outcomes, there have not been any major breakthroughs in the past decade. As a result, healthcare systems looking to improve their sepsis outcomes are more likely to do so by focusing on improving their current processes, with an attention to appropriate and rapid antibiotic usage. Our study shows exactly how one could use a sepsis early warning system to make such a change,” said Yasir Tarabichi, MD, director of Clinical Informatics for Research Support at The MetroHealth System.

There were no negative consequences from using the sepsis early warning system, he said. “The potential downsides of such a system include alert fatigue, antibiotic overuse, and misdiagnosis. We did not see any evidence of antibiotic overuse or sepsis misdiagnosis. Our alert did not interrupt providers’ workflows and alert fatigue was not reported during our intervention. Our pharmacists also felt that the early warning system did not add any substantial time stress on top of the numerous other responsibilities they have in the ED setting.”

ED pharmacists were a key component of the early warning system intervention, Tarabichi said. “In their role, they are well-positioned to hasten the selection, preparation, and administration of an antibiotic to patients with sepsis. This was reflected in our analysis that showed that the time from the provider ordering an antibiotic to the time it was delivered was significantly hastened when the early warning system was available.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.