By Megan Headley
Since 2007, the Sepsis Alliance has worked to build awareness among healthcare organizations and professionals about the signs of this danger infection. And with growing awareness, many organizations are taking year-round steps to ensure their staff is able to identify symptoms early on and make dramatic strides in reducing mortality from sepsis.
According to data from the Centers for Disease Control and Prevention (CDC), more than 1.5 million Americans get sepsis each year, and for at least 250,000 of those individuals the infection proves fatal. It’s particularly dangerous for children under one and adults over 65 years old.
CDC notes that the symptoms might include any combination of the following:
- Confusion or disorientation.
- Shortness of breath.
- High heart rate.
- Fever, shivering or feeling very cold.
- Extreme pain or discomfort.
- Clammy or sweaty skin.
While organizations around the nation work to build awareness of sepsis, many healthcare networks are building specific plans around reducing mortality from this condition.
Early Identification and Staff Commitment Prove Vital at Lehigh Valley Health Network
The rising population age in Pennsylvania is being cited as one reason Lehigh Valley Hospital saw an 89 percent increase in admissions for sepsis from 2008-2016, according to a report released in September.
But better early identification of sepsis is also contributing to the high numbers—and now Lehigh Valley Health Network has a program in place to reduce mortality from the infection.
According to Dr. Matthew McCambridge, chief quality officer for Lehigh Valley Health Network in Pennsylvania, the system began its program to reduce sepsis mortality rates in January 2016 as a result of the dire numbers on sepsis mortality tracked by Vizient, a health services company helping the system apply data to improving processes.
McCambridge describes the protocols put in place to reduce sepsis rates:
- Creation of an ED sepsis pathway.
- Sepsis alerts, including code sepsis for septic shock and sepsis alerts for systemic inflammatory response syndrome (SIRS) with source of infection.
- Sepsis order sets (initiation and continuation), that include checking vital signs every four hours.
- Inclusion of a Modified Early Warning sign in EPIC to alert nursing/providers of patients who have a change in their vital signs.
- Including a Recent Best Practice Advisory in EPIC to notify staff of modified SIRs criteria, indicating possible sepsis-order set imbedded in the advisory.
The protocols have made a difference. From an observed-to-expected ratio of 1.42 in the second quarter of 2015, sepsis rates dropped to an O/E of -0.9 in third quarter 2016.
McCambridge acknowledges that the new protocols have taken some adjustment from nursing staff. “It’s time-consuming, so [nurses attending sepsis patients] need other nurses to care for their patients during the alerts.”
In addition, he says, the Best Practice Advisory initially fired too frequently, so modifications are being made to make it more specific and less sensitive.
Education on the reasons why early identification and treatment are necessary has proved critical in building staff engagement. McCambridge explains that the system uses multiple education opportunities ranging from grand rounds to TLC modules for providers and nursing (required for residents and nursing), as well as infographics posted on each unit and unit leaders who drive these improvement efforts.
Now the organization is determined to drive education efforts for even earlier identification of sepsis.
“Community-acquired sepsis was our first focus, since 85 percent of patients are identified in the ED. We now need to focus on the hospital-acquired sepsis since this population has higher mortality rates,” McCambridge says.
McCambridge encourages other organizations to further improve identification of community-acquired sepsis by involving EMS providers in education effort so that they can identify at-risk patients in the field and begin treatment prior to arrival.
But McCambridge also points to collaboration with other hospitals as a valuable strategy for driving improvements in sepsis programs. The system has worked closely with other hospitals in Pennsylvania and around the country. “While attending a recent Vizient conference, we were able to collaborate with another hospital that created a visual dashboard that pulls EPIC data,” he explains. “We also created a Tableau sepsis dashboard to identify mortalities, readmissions, length of stay and compliance by department with the ability to drill down to patient level data.”
Ongoing Education Drives Pottstown Hospital’s Reduction in Sepsis Rates
Pottstown Hospital in Pottstown, Penn., put its sepsis reduction program in place around April 2016.
“We formed a multidisciplinary committee to start taking a look at our sepsis program and protocols as well as opportunities for improvement,” explains. Susan Keown, chief quality officer with Pottstown Hospital. A few months later the hospital brought Jennifer Catagnus onboard as sepsis coordinator to support programs, protocols and education for staff on overall sepsis awareness.
One of the first protocols the hospital instituted was a sepsis process for the rapid response team to follow based on the recommendations of the Surviving Sepsis Campaign, a partnership of the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, and the SEP-1 bundle commitment, Catagnus explains.
In the ER, an initial sepsis screen is conducted in triage. “When a patient is in the triage process, if they screen positive for certain criteria—elevated heart rate, respiratory rate, fever, hypothermia, suspected infection—the nurse is to inform the physician right away to evaluate the patient for inclusion into the sepsis bundle,” Catagnus says. The bundle includes recommendations for checking two sets of blood cultures, lactic acid, CMP, CBC, PTT, PT/INR and then the initiation of broad spectrum antibiotics.
The ER nurses also use a management bundle form to ensure all of the bundle components are included are initiated and nothing gets missed. “We actually use a paper tool, even though we do have an EMR,” Catagnus explains. “They fill out the paper and use it during handoff with the receiving unit.”
If there is a weight-based fluid resuscitation order, Catagnus adds, the ER staff and rapid response team uses a simple sepsis fluid resuscitation sticker. “These wonderful stickers are kind of simple, but they help unify the whole process. Once a sticker is placed on the bag, all the nursing staff knows that these stickers are for the sepsis protocol and the entire dose is to be administered at 30 mL/kg,” she says.
The hospital also has a policy for severe sepsis/septic shock that includes all of these elements. And for inpatient units, nurses perform a sepsis screen every shift and calculate a modified early warning system score—a modified early warning system score—for their patient. Per the policy, the nurse must notify the physician of any positive screens and make recommendations based on the protocol, or potentiate a rapid response if there is no change in vital signs and it’s appropriate.
In addition, the team has incorporated the use of the sepsis protocols into physician order sets, physicians are educated regarding the importance of utilizing order sets and the hospital is able to standardize the sepsis care that it provides.
The protocols have made an impact. From an initial SEP-1 Compliance Rate in early 2016 below 10 percent, the hospital has been consistently above 50 percent in 2017, with a high compliance rate of 78 percent.
The team has also demonstrated an increase in positive sepsis screens within the ER. From 19 sepsis screenings per month in 2016, the hospital has seen increases to as high as 61 sepsis screens in the ER in one month in 2017.
“Mortality rates have also followed the trend of improvement,” Catagnus says. “In 2014 the risk-adjusted analysis of sepsis in relationship to the observed vs expected ratio was 1.26. In 2017, which encompasses January through August, we’ve demonstrated a decrease in the mortality risk adjusted rate to below the threshold of 1, at a rate of 0.77.
Or, to put that in layman’s terms, sepsis-related mortality dropped 26 percent comparative from 2016 and 2017 January to June.
Keown says the key element driving the program’s success is “the constant education, and making staff aware of why sepsis is so important and the effects can have on patients.”
All hospitalists and nursing staff get an education on sepsis through lectures and other means as part of their onboarding process. “Right out the gate we start their employment with an understanding of how we care about sepsis and our emphasis on sepsis” Catagnus adds.
Catagnus also does sepsis rounds with nurses and physicians and, when applicable, identifies opportunities for education and discusses improvement opportunities. During sepsis meetings, the team performs case reviews. More recently, the hospital has implemented a Sepsis Champion program to include participation by the nurses from the various units to the sepsis meetings. The sepsis champions take the information from the committee back to the staff on their clinical units.
The hospital is also leveraging resources such as the Hospital Innovation and Improvement Network (HIIN) collaborative for Severe Sepsis and Septic Shock to boost its education toolbox. “We’re engaged with them to get some ideas of where we want to take our program,” Catagnus says.
Keown explains that one of the next steps is the launch in October of the HIIN Sepsis Readmission Project. The HIIN sepsis project works in conjunction with HIIN’s readmission reduction project to help hospitals prevent sepsis readmissions.
For hospitals looking to take greater control of their sepsis rates, Catagnus points to successful team building as a critical foundation for any program.
“Having a supportive multidisciplinary team in place for sepsis program development is key,” she says. “Sepsis is a very serious condition that ultimately affects many disciplines within the healthcare delivery system, not just nursing, and not just physicians. It affects respiratory, case management, etc., and that whole continuum of care is really important to get the best population outcome.”
About the AuthorMegan Headley is a contributing writer to PSQH.