• Sepsis Outcomes Improve Through Clinical Collaboration

    Ray Valek Dec 12, 2014

    Quality-conscious hospitals are achieving dramatic reductions in sepsis mortality rates while reducing related costs.

    Rory Staunton was an active, athletic 12 year old who cut his arm diving for a basketball at his school’s gym. The next day, he arrived at a hospital emergency department (ED) in pain, feverish, and vomiting. ED doctors administered fluids, prescribed acetaminophen, and sent him home. Three nights later, Rory died in the ICU from sepsis.

    Stories similar to Rory Staunton’s have become all too common. Sepsis affects 750,000 hospitalized patients in the United States every year, according to the Centers for Disease Control and Prevention. In addition, a survey of California hospitals by Kaiser Permanente found that sepsis was a factor in approximately 44-55 percent of hospital deaths between 2010 and 2012.

    In addition to causing immense suffering, sepsis cost the U.S. healthcare system $20 billion in 2011, according to the Agency for Healthcare Research and Quality. Yet, many sepsis complications and deaths could be prevented with earlier and more coordinated attention (see the exhibit below).

    Exhibit 1 Sepsis Article

    Two health systems and a coalition of nine hospitals are among the progressive organizations improving sepsis outcomes and reducing related costs:

    • Intermountain Healthcare
    • North Shore–Long Island Jewish Health System (North Shore-LIJ)
    • Nine San Francisco-area hospitals that took part in the University of California, San Francisco, Integrative Nurse Leadership Program (UCSF Collaborative)

    To fast-track their sepsis improvement efforts, these early adopters built on existing knowledge and best practices—disseminated by the Surviving Sepsis Campaign (SSC) and the Institute for Healthcare Improvement (IHI)—to standardize how sepsis is diagnosed and treated. The three programs averaged 50 percent reductions in mortality rates for sepsis patients in approximately six years.

    Screening and Diagnosis

    The best practices encouraged by SSC and IHI focus on screening a broad set of patients for sepsis risk factors and symptoms, providing early resuscitation, and diagnosing patients as quickly as possible.

    For example, Intermountain developed an early-detection screening protocol for sepsis, which is adapted from standard systemic inflammatory response syndrome (SIRS) criteria for body temperature, heart rate, respiratory rate, and white blood cell count:

    • Sepsis: When there’s an infection accompanied by two SIRS criteria outside the acceptable range.
    • Severe sepsis: When a patient has sepsis plus organ dysfunction.
    • Septic shock: When a patient has severe sepsis plus low blood pressure or a lactate value greater than 4 millimoles/liter.

    This computerized protocol can be accessed and implemented by physicians and registered nurses.

    North Shore-LIJ also uses early detection and diagnosis protocols in its 12 EDs. These processes include early administration of antibiotics and fluids when warranted and lactate tests that can detect sepsis. This proactive treatment has decreased ED door-to-doctor time for patients suspected to have sepsis. The system’s medical/surgical units have implemented similar processes.

    The UCSF Collaborative’s screening and diagnosis process requires clinical staff to check vital signs and review a patient’s history of infection and consciousness level. In addition to receiving formal training on screening and diagnosis, the delivery care teams are given on-the-job assignments to solidify their ability to perform the processes. For example, participating hospitals developed specific nurse-driven protocols, which allow the treating nurse to order a lactic-acid test based on a positive sepsis screen or initiate other elements of the protocol.

    “The thinking was that you have to use the knowledge in the real setting and understand what works and what doesn’t work to make strides,” says Julie Kliger, the UCSF Collaborative program director.

    Sepsis Treatment

    The 2012 SSC International Guidelines for Management of Severe Sepsis and Septic Shock recommend the use of evidence-based protocols and order sets to treat sepsis as quickly as possible. Such guidelines help clinicians choose appropriate antibiotics and other treatments and track each patient's progress against goals for systolic blood pressure, mean arterial pressure, central venous pressure, and venous oxygen saturation.

    Intermountain critical care specialist Terry P. Clemmer, MD, worked with colleagues to adapt SSC recommendations into a evidence-based treatment bundle?—that works best in Intermountain’s care settings (see the exhibit below). “In our opinion, this local adaptation is a key to quality improvement success,” says Todd L. Allen, MD, an Intermountain emergency medicine specialist.

    Exhibit 2 Sepsis Article

    In addition to aligning the SSC guidelines with its internal processes, North Shore-LIJ put a major focus on detecting patients in earlier stages of the sepsis spectrum. “Our guidelines address how to better identify and aggressively treat potential cases of severe sepsis prior to definitive diagnosis,” says John D'Angelo, MD, executive director and senior vice president, North Shore-LIJ’s emergency medicine service line, emphasizing the word “potential.”

    For example, North Shore-LIJ set a standard to administer antibiotics to patients with severe sepsis within 60 minutes?a more aggressive goal than the SSC guideline of 180 minutes.

    Meanwhile the UCSF Collaborative has adopted practical strategies to expedite sepsis treatment, including paging a hospitalist when a patient screens positive for sepsis, stocking antibiotics on the floors, immediately transferring severe sepsis patients to the ICU, promptly arranging a critical care consult, and developing or expanding a rapid response team.

    The Same Page

    Creating structures, goals, and processes to spur quality improvement was an important aspect of all three programs.

    For example, Intermountain created the Intensive Medicine Clinical Program to organize improvement efforts around clinical processes and support services rather than around traditional clinical departments, says Allen. This program created a nonhierarchical environment in which team members from the system’s 22 EDs, 15 intensive care units (ICUs), and other settings could promote cross-disciplinary learning about sepsis, says Allen. “We tried to find best practices and common ground rather than to seek out someone to blame,” he explains. “Everyone has different strengths and weaknesses. Everyone has something to learn and to teach,” he states. Working as a team, the sepsis program participants aligned goals, organized with proper resources and data streams, and were able to “dial in on performance improvement,” Allen said.

    North Shore-LIJ created systemwide expectations and measures around sepsis. “We not only agreed on what the performance measures should be but on the specific definitions so everyone was on the same page, and there was comfort in the integrity of the data as we compared venues and locations,” says Martin E. Doerfler, MD, senior VP, clinical strategy and development, and associate chief medical officer.

    Another important change has been the emphasis on “teamwork is paramount,” adds D'Angelo. “We are becoming self-aware, self-critical, and self-correcting as a clinical community regarding improvement,” he observes.

    The UCSF Collaborative gathered decision makers from its participating hospitals at eight full-day training days over the course of 22 months. Early in this process, leaders determined the program’s four core strategies.

    • Educating leaders at each hospital about program goals, standards, and outcomes measures, as well as about strategic communications, using data to determine next steps in improvement and training on becoming high-performance teams
    • Training unit care providers on how to identify severe sepsis and septic shock
    • Consistently providing treatment according to a sepsis bundle
    • Capturing and submitting an expanded set of ICD-9 coded diagnostic data to measure performance

    Hospital leaders also agreed to two project goals: a 15 percent reduction in the sepsis baseline mortality rate and 80 percent compliance with using the sepsis bundle, says Kliger.

    Results

    USCF Collaborative achieved its goal in a little under three years: The sepsis mortality rate across the nine hospitals declined from 28 percent in June 2008 to 15 percent in April 2011. In July 2013, the rate stood at 14 percent. The program’s analysis indicated a 56 percent ROI.

    North Shore-LIJ has achieved similar results, lowering its sepsis mortality rate to the current 15.1 percent from 31.5 percent in 2009.

    Meanwhile, Intermountain has achieved single-digit mortality rates, which are among the best documented in a peer-review process, Allen says. By achieving about 80 percent compliance with the system’s treatment bundle, Intermountain decreased the mortality rate to about 9 percent in 2011, saving 362 lives against baseline during the four-year span. Believing that further improvement is possible, the Salt Lake City-based health system is now focused on improving its 80 percent compliance rate, says Allen.

    A National Trend

    Emblematic of many tragic stories, Rory Staunton’s death from sepsis spurred “Rory’s Regulations” in New York?the first state to require the use of sepsis best practices. Meanwhile, throughout the nation, increasing numbers of hospitals are undertaking sepsis-related quality improvement initiatives, using the experiences of Intermountain, North Shore-LIJ, and the UCSF Collaborative as guides.

    These efforts bode well for patients who otherwise would not survive sepsis and for hospitals looking to reduce unnecessary costs.

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    Ray Valek is president of Valek & Company, Inc., LaGrange, Ill.

    Interviewed for this article:
    Todd L. Allen, MD, is assistant quality officer and medical director of the Emergency Department Development Team, Intermountain Healthcare, Salt Lake City.

    Julie Kliger is senior director, Alvarez and Marsal, and former program director, University of California, San Francisco, Integrative Nurse Leadership Program, San Francisco.

    Martin E. Doerfler, MD, is senior VP, clinical strategy and development, and associate chief medical officer, North Shore-LIJ, Great Neck, N.Y.

    John D'Angelo, MD, is executive director and senior VP, emergency medicine service line, North Shore-LIJ.

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