2 Key Sepsis Steps Hospitals Should Use

Adopting an early warning system and deploying care bundles for the infection are keys to treating sepsis patients.

A pair of health systems have made strides in improving their treatment of sepsis with new screening protocols and standardized bundles of care for the deadly infection.

More than 1.7 million people contract sepsis annually in the United States, with 270,000 fatalities, according to the Centers for Disease Control and Prevention. About 1 in 3 of patients who die in a hospital have sepsis, the CDC says.

In response to the sepsis threat to patients and the sepsis core measure established in 2015 by the Centers for Medicare & Medicaid Services, DeKalb Medical in Decatur, Georgia, and AHMC Healthcare in Alhambra, California, have adopted early warning intervention systems for the infection and sepsis care bundles.

The early warning invention systems feature electronic alerts and staff training to heighten awareness of sepsis signs and symptoms. The sepsis care bundles feature treatment protocols for three hours and six hours after diagnosis.

1. Early detection screening

DeKalb launched its sepsis initiative in early 2017, beginning the process by examining data to determine care gaps.

"It became apparent that the majority of our sepsis population was coming through our emergency room, with some sort of infectious process already starting. So, we focused on our emergency room locations, and took time to look at sepsis as an organization in terms of how it presented," says Christina English, RN, performance improvement coordinator at DeKalb.

DeKalb adopted an approach that leveraged both data and clinical care team capabilities, with the help of IBM Watson Health CareDiscovery.

"We looked at different chief complaints associated with sepsis and some of the clinical presentations, then developed electronic alerts, nursing processes, and physician order sets to address these patients when they come through the door," she says.

Electronic alerts are generated through DeKalb's electronic health record.

"We hardwired alerts that are based off a combination of chief complaint and presenting vital signs comprised of SIRS criteria. So, once a patient meets several SIRS criteria and they have a chief complaint associated with an infection process, the nurse and the physician get an alert," English says.

Staff training and coordination are critical components of DeKalb's early warning intervention system for sepsis.

"We made sure pharmacy and the labs department [were] looped in, we had a lot of collaborative effort with the physician staff, and there was a clinical education component," she says.

AHMC started its sepsis care initiative in 2015. Educating staff is an essential element of the health system's screening processes for sepsis, says Jonathan Aquino, MHA, corporate chief quality officer of AMHC and CEO of San Gabriel Valley Medical Center in California.

"We have done a lot of training in all areas of the hospital—our emergency department frontline staff, physicians, floor nurses, and our leadership team. We have a number of screening protocols that are now in place; we check for sepsis at almost every juncture," he says.

Sepsis screening occurs in several settings, Aquino says. "There is a sepsis screening protocol in triage, at the time of admission, [and] for shift changes."

The AMHC nursing staff plays a key role in screening and intervention, he says. "Once we get indications from the screening process, our nursing teams start a process to initiate the sepsis bundle of care."

AMHC physicians have empowered the nursing staff to initiate sepsis interventions, Aquino says.

"Our physicians have allowed us to use nurse-driven protocols to initiate the bundle. Our medical executive committees have said that if the nurses see signs of sepsis or catch it in triage, we should execute the bundle right away. We don't wait for the doctors," Aquino says.

2. Sepsis care bundles
 

The treatment of sepsis patients at AHMC and DeKalb mirrors the recommendations of the CMS sepsis core measure.

The sepsis core measure features intervention sets that clinicians should initiate in three-hour and six-hour timeframes for patients who have reached severe sepsis or septic shock.

For example, in the first three hours after a patient has presented with severe sepsis, interventions include administration of antibiotics and lactate testing.

The care clock starts ticking as soon as a patient is identified with severe sepsis or septic shock, Aquino says.

"We know that if we can manage these patients aggressively and improve the continuum of care for sepsis, these patients will go home sooner. We know if we delay lab draws, antibiotics, an X-ray, an EKG, or whatever it may be, a patient's medical condition can progress for the worse. What that means is affecting the length of stay in the hospital and affecting our ability to treat the patient," he says.

Sepsis care impact
 

For some months and annual quarters, AHMC has achieved 100% compliance with the CMS sepsis core measure, Aquino says. "We didn't get to a success rate of 100% sepsis core measure compliance in some months and quarters overnight. We showed our staff that the clock starts ticking."

From 2016 to 2017, DeKalb has achieved sepsis care gains in several metrics:

• The compliance rate for the CMS sepsis core measure increased 27%
   
• Average length of stay for sepsis patients fell 2.3 days
   
• Cost avoidance savings totaled $2.7 million
   
• Mortality rate for sepsis patients decreased 30%, with about 48 lives saved

Although effective sepsis care requires aggressive interventions, the cost of care is justifiable clinically and financially, English and Aquino say.

"Implementing the sepsis core measure has a cost to it—there are medications, labs, and other resources; but it is very easy to justify being proactive when you look at how much sepsis costs on the back end when it progresses to an inpatient stay, or the patient is in shock or ventilated," English says.

Aggressive screening efforts also are clinically and financially effective, she says. "When you catch sepsis early, the treatment is antibiotics and a couple bags of IV fluid. If you don't catch it early, you could have several days in the ICU and ventilation."

Lessons learned
 

In launching and implementing its sepsis care initiative, DeKalb has learned about the importance of raising awareness and promoting care coordination, English says.

"The most beneficial component to the early warning system is not necessarily that the EHR catches 100% of the cases, but we have seen a positive shift in our nursing practice and awareness of sepsis. We have seen examples where the alert did not go off, but a nurse was already suspicious about sepsis. They can catch sepsis that may have been borderline under the rigid criteria of the electronic screening," she says.

Care coordination is critical to executing effective sepsis care, English says.

"We have also learned that the care of sepsis patients requires a lot of communication and collaboration between the different disciplines. So, it has tested our care continuum model and how we are able to work together in nursing, physicians, and labs."

AMHC's sepsis care initiative has succeeded in part through physician leadership, Aquino says.

"You need physician champions. For sepsis, you need infectious disease physician champions. You need to be able to lean on the leadership for infectious diseases and help them spread the message to the medical staff," he says.