When staff at Charleston Area Medical Center (CAMC) dug into benchmark mortality data, they found an obvious place to focus their quality improvement efforts: severe sepsis, a complex and life-threatening reaction to infection. Severe sepsis can be difficult to identify and manage, and is recognized as the leading cause of death in noncoronary ICUs (Surviving Sepsis Campaign).
In 2005, about 38 percent of CAMC patients who developed severe sepsis died. CAMC's sepsis mortality rate was better than the national average; however, in this case, being better than average was not good enough for CAMC staff.
"Sepsis was our largest cause of mortality, representing close to 33 percent of our deaths," says Glenn Crotty, Jr., MD, chief operating officer at CAMC, an academic medical center with three hospital locations in southern West Virginia. Sepsis was also costly to treat and added days to patients' hospital stays.
A target was set: Lower sepsis-related mortality to 25 percent, and save $1 million in associated costs. By 2009, CAMC had surpassed these targets, attaining a sepsis mortality rate of 17 percent.
A Standardized Approach
To begin tackling sepsis mortality, CAMC formed a multidisciplinary steering committee that included physicians and staff from the ICU, ED, and pharmacy. One key to success: CAMC's participation in QUEST, an improvement collaborative, says Crotty. "It was extremely important for us to be able to benchmark against our peers and share information with them regarding best practices."
Two standardized tools were developed:
- An early recognition tool that helps clinical staff identify septic patients in the ED and elsewhere
- A standard order set that spells out one-hour, six-hour, and 24-hour goals for septic patients
"The first thing our team members did was gain an understanding of the data so they could better recognize patients who were potentially septic in the ED," says Crotty. "Once identified, these ED patients could then be moved to the ICU under the care of an intensivist, which was another positive step."
Also key: Educating CAMC residents, medical staff, and rural referring physicians on the standardized approach. CAMC's simulation teaching lab-with a mock ICU and other units-helped physicians learn the new approaches. The steering committee also arranged for Emanuel Rivers, MD, MPH, a respected physician/researcher, to give a presentation on goal-directed therapy for sepsis.
CAMC instituted several other improvements to reduce sepsis mortality. For example, rapid response teams are now in place, and a critical care nurse rounds on every floor to help other nurses identify patients who may fit sepsis criteria.
The Dark Green Savings
The finance representative on the steering committee helped clinical members identify potential savings. "We always include the finance people on these teams," says Crotty. "They allow us to capture the hard, green dollars-or real dollars saved, not costs avoided. For example, did we use fewer or different (and less costly) resources?"
CAMC has saved $1 million through the sepsis initiative primarily from reducing LOS. Most sepsis patients at CAMC are Medicare patients, and Medicare pays a fixed rate regardless of LOS.
At CAMC, the average Medicare LOS is 5.2 days; whereas the average sepsis patient has an LOS of >10 days. CAMC was able to reduce sepsis LOS down to <10 days, which translated into a cost savings of $600 a day. Other cost savings came from reducing ventilator days, reducing ICU days, and reducing the number of medications delivered.
Kip Rice, cost accounting manager, details how savings were calculated.
- Specific patient encounters were identified based on two criteria: A primary or secondary diagnosis of septic shock (ICD-9-CM code 785.52) or severe sepsis (ICD-9-CM code 995.95), and use of ICU care during admission.
- A baseline direct variable cost per case was established on a department/procedure level for a given time frame by extracting demographic and financial information for each encounter.
- Cost information on a department/procedure level was again extracted and calculated after the improvements were made to determine the cost savings.
The following formula was used: Cost Savings = # of Patients X Direct Variable Cost Savings per Case Prior to Change - Cost after Change
Decreased reimbursement from commercial insurers was factored into savings calculations, says Rice. "Historically, commercially insured sepsis patients represent only 9.5 percent of our patient population," he says. "We felt that any decrease in reimbursement would be offset by increased throughput from rural referral centers and by decreasing diversions to competing hospitals."
Keys to Success
In addition to dramatically improving sepsis mortality, CAMC has slashed surgical site infection rates and improved the delivery of medications. One key to CAMC's success is the adoption of Six Sigma and Lean manufacturing approaches-or what Crotty calls an "industrial strength methodology" for improvement. Crotty also recommends getting finance involved early in projects, having physicians champion quality efforts, and developing a control plan to ensure sustained improvement.
Interviewed for this case study: Glenn Crotty, Jr., MD, is COO at Charleston Area Medical Center (CAMC) in southern W. Va. (glenn.crotty@camc.org). Kip Rice, who is a cost accounting manager at CAMC, also contributed to this case study (Kip.Rice@camc.org).
Publication Date: Wednesday, January 06, 2010