stepping up on sepsis
TRANSCRIPT
infectioncontrol
Stepping up against SEPSIST h ese h osp ita ls h av e sh o w n th a t a co o rd in a ted , lo w -c o s t s tra te g y d ra m a tic a lly
reduces in fection and m o rta lity . It ’s an ap p ro ach o th e rs m a y w a n t to a d o p t
The introduction of a controversial new core measure for sepsis bundles is refocusing attention on one of health care's most vexing conditions.
The Centers for Medicare & Medicaid Services has wanted to launch a core measure for sepsis care for years, but emergency department physicians
and others have opposed it, saying some elements of the core measure bundle are not evidence-based.
Nonetheless, use of the sepsis bundle has reduced the death toll from the condition, and CMS is trying to standardize
care for the huge population of patients who acquire it. Every year, 750,000 Americans are diagnosed with the condition and 220,000 of them
’ * * * * ’ * * * * * * die, according to the Joint Commission.In 2014, 11 percent of patients discharged from an acute
care hospital had a sepsis diagnosis — and 48 percent of patients who died in a hospital suffered from sepsis. Nationally, the mor
BY LOLA BUTCHER
tality rate for sepsis is between 25 and 50 percent, but health systems that have made sepsis a priority have demonstrated that it can be much lower.
Diagnosing and treating earlyNorth Shore-Long Island Jewish Health System in New York is one of them. The 15-hospital system received a 2014 John M. Eisenberg Patient Safety and Quality Award from the Joint Commission and the National Quality Forum for reducing sepsis mortalities by 50 percent since 2009.
That success stems from a total overhaul in the way North Shore-LIJ approaches sepsis diagnosis and treatment. Traditionally, says Martin Doerfler, M.D., senior vice president of clinical strategy and development, sepsis was considered the purview of the intensive care department and the goal was to keep patients with septic shock from dying.
When CEO Michael Dowling highlighted sepsis mortality
38 H&HN / JANUARY 2016 / www.hhnmag.com I l l u s t r a t i o n by K a t e r y n a Kon
as an organizational priority, about a dozen clinical leaders — emergency physicians, critical care physicians, nurse leaders and quality officers — convened to figure out what to do.
“That group came to the conclusion that if we were really going to make a difference, the best way was to move upstream,” Doerfler says. “Instead of focusing on the specific subgroup that was dying, we should try to minimize the number of individuals who went downstream and, therefore, were at risk of dying."
The multidisciplinary group, which started its work in 2010, identified the need to develop triage criteria to screen emergency department patients for sepsis and re-engineer processes to speed:• Administering early antibiotics to septic patients.• Returning serum lactate test results to physicians so they know
whether a patient has severe sepsis.• Starting fluids appropriately.
“Doing that with a variety of folks with different viewpoints in the room and having a consensus on where to start were critical to the success we've since demonstrated and hope to continue," Doerfler says.
Today, all New York hospitals are subject to regulations, enacted in 2013, that require protocols for the early diagnosis and treatment of sepsis. The New York Department of Health estimates that the regulations will save at least 5,000 lives each year.
Rory's Regulations, as they are called, became law after 12-year-old Rory Staunton died of sepsis that went unrecognized by his pediatrician and ED clinicians. Doerfler serves on the medical advisory board of the Rory Staunton Foundation, which advocated for the New York law and seeks to raise awareness of sepsis and improve the diagnosis and treatment of sepsis broadly.
At N orth Shore-LIJ, two departm ents — quality and improvement science — collaborated with a systemwide task force to develop new care algorithms. Those include antibiotics that will be administered within 180 minutes of sepsis diagnosis and within 60 minutes of severe sepsis diagnosis. The group also determined the metrics used to track compliance and monitor progress.
Each hospital has its own sepsis task force, and the processes used to carry out the work are determined at the departm ent level w ithin each facility. "We allow each different environment to figure out how they will best accomplish it, because they have unique challenges and unique resources, as well as sometimes different patient populations that they will encounter," Doerfler says. "Allowing the frontline team to understand ‘This is the goal, but we can decide how w e're going to get there and own that' has been a piece of our success."
North Shore-LIJ partnered with the Institute for Healthcare Improvement to address sepsis and used IHI's methodology to support process re-engineering. The work also was supported by quarterly off-site learning sessions at which front-line teams received education about the science of sepsis care and
w w w . h h n m a g . c o m / JANUARY 2016 / H&HN 39
S e p s is P r im e r
S epsis is an injury to the body resulting from the immune system’s attempt to
eradicate an infection. “ Think of it as collateral damage in a m ilitary sense,
where you’ re try ing to get the enemy but, in the meantime, you are destroy
ing whatever else is in town because it just happens to be in the same area,” says
Martin Doerfler, M.D., senior vice president of clinical strategy and development at North Shore-LIJ Health System in New York.
Sepsis is a tricky topic because there are three stages o f the condition, diag
nosis can be d ifficu lt and definitions may be changing. At the moment:
• Sepsis is defined as infection plus the presence of at least two systemic inflam
matory response syndrome criteria, such as rapid heart rate, high or low body
temperature, low blood pressure, unexplained altered mental state and others.
• Severe sepsis means there is organ dysfunction caused by sepsis.
• Septic shock is severe sepsis plus low blood pressure or high serum lactate not
reversed w ith flu id resuscitation.
The defin ition of basic sepsis is under attack by some specialists who th ink
it is too broad, prompting patients to be treated unnecessarily, and by others who
th ink the defin ition misses some patients who should be treated immediately. A
debate about the definition is playing out in medical literature.
Nevertheless, everyone agrees that early diagnosis and treatment are essen
tia l to prevent a patient’s condition from deteriorating to the more advanced stages,
where death is common. More than 220,000 people in the United States die from
sepsis each year, and it is the most expensive disease to treat in the hospital, cost
ing about $24 billion annually, according to the Agency for Healthcare Research and Quality.
Despite its burden on patients and the health care system, sepsis has not
received as much attention as some other treatable conditions. That is because it is more challenging in a few ways.
Surgical-site infections, for example, can be targeted by interventions along the
well-defined path from preoperative evaluation through rehabilitation that every surgery
patient travels. By contrast, sepsis can attack anyone, but is most common in patients
who are very young or very old, have a compromised immune sys
tem, have wounds or injuries, have serious comorbidities or
have invasive devices. That means that just about every acute
inpatient throughout a hospital is at risk.
“ I th in k many people thought for a long tim e tha t
sepsis was such a big, hairy problem that we m ight not
have the capacity to deal w ith it using traditional process
improvement m ethods,” says Todd Allen, M.D., an emer
gency physician who has helped to spearhead sepsis protocols
at Intermountain Healthcare. “ That turns out not to be the case, but I th ink it took
the culture of medicine a while to come to tha t.”
It’s fairly obvious who should be part of the clinical team responsible for tack
ling surgical-site infections because o f the patients they serve. The team to address
sepsis, on the other hand, needs to include emergency departm ent and critica l
care physicians, hospita lists, nurses and others who m ight not immediately come
to mind. “ One o f the most important lessons that I learned leading th is effort was
that I had to have a phlebotomist on all of my teams if I really wanted to maximize our ab ility to make a difference,” Allen says.
Another challenge: Because there is litt le awareness o f sepsis among the
public, patients and fam ily members rarely recognize symptoms tha t m ight point
to that diagnosis in a more tim ely fashion.
And, while treatment guidelines do exist, the knowledge base about sepsis
includes major gaps. For example, there is no consensus definition for septic shock
in diffe rent care settings, and there is uncertainty about optim al treatm ent [see
“ Septic Shock: Advances in Diagnosis and Treatment” in the Aug. 18, 2015, issue
o f the Journal o f the American Medical Association. - lola butcher •
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with Andrea Kabcenell, IHI
When the Institute for Healthcare Improvement began working on critical care two decades ago,
sepsis management was not on its h it list. But over time, the sepsis to ll on patients became
clear and IHI spent several years focused on reducing sepsis mortality. “ We are very excited
to see tha t th is top ic has taken hold and it has become a widespread concern and another
opportunity to reduce unnecessary deaths,” says Andrea Kabcenell, R.N., an IHI vice president.
Why is the new sepsis bundle core measure, which is debuting this year, controversial?
KABCENELL: A lo t of people who haven’t had experience with the sepsis resuscitation bundle
fear it is not safe science yet and it’ s out of reach. So, having a core measure about it feels like
a push too soon. Creating a core measure is a strong way to [get hospitals to focus on sepsis
mortality], but it ’s an effective way to do it. When something becomes a core measure, it gets
attention. But there may be unexpected consequences along the way as people struggle to
get up to speed.
Sepsis management used to be considered an intensive care unit problem, but now there is a
wide range o f approaches to improving sepsis care. What do you advise?KABCENELL: The quickest way to reduce sepsis mortality is to start in the emergency department
and focus on early diagnosis and adherence to the sepsis bundle as an all-or-none bundle, not
just one or two elements of it. That’s been productive for almost everyone because if you can
catch people w ith sepsis early in the ir ED stay and before they are sent to a unit, they have a
good start. The discipline to get that diagnosis right and, under those circumstances, have the
confidence to get the communication right and load upon fluids when needed serves well when
you move to other parts o f the hospital.
There are reasons people want to start in the ICU — there’s a team there and it ’ s easier
to control the work, and often emergency departments are so beleaguered tha t people don’t
want to start there w ith a new in itiative. But ultimately, if they want to reduce mortality in the
organization, the biggest bang for the buck is in the ED.
Hospitals typically have sepsis mortality rates between 20 and 5o percent What should lead
ers set as the target?KABCENELL: They should not start w ith the idea, ‘Oh, well, we’re already at 20 percent, so we
don’t have to worry.’ That’s not the right attitude. The right attitude is that, unless you have an
unusually low mortality rate — like 10 percent or lower — you can make big gains wherever you
are. In fact, you’ ll probably cut the rate in half over a couple of years.
Start by looking at compliance rates to make sure the individual elements o f the sepsis
resuscitation bundle are im proving and compliance is approaching 100 percent. Then look
for high compliance w ith the entire bundle. Then you’ ll start to see the sepsis mortality move.
What makes sepsis management so challenging ?KABCENELL: Getting sepsis mortality down in most hospitals requires a lot o f cross-boundary
communication. When a patient who has sepsis leaves the ED and goes to the unit, coordina
tion is really tough, and the ability to take care o f those patients across boundaries challenges
everyone. There is lots of tension because treatment sometimes also involves loading people
w ith flu ids — something that seems unsafe to many clinicians.
“ A ll o f tha t cross-boundary work requires leaders to be very supportive and insistent on
good clinical communication, very good handoffs, taking the time to get th is right and maybe
put some more trivia l things aside in order to address a bigger need. So, it takes leadership and
empathy w ith the people who are working hard on change.” - LOLA butcher •
improvement science.To keep sepsis care as a priority, Doer-
fler's department hosts a biweekly all-sepsis collaborative conference call during which staff throughout the system discuss their progress and challenges.
The 50 percent reduction in sepsis mortalities has come without an expensive infrastructure, he says. A nurse manager in the improvement science department dedicates 40 percent of her time to support the sepsis project, and an industrial engineer spends 20 percent of her time helping local hospital teams to identify and remove barriers to compliance with the system's sepsis care protocols.
“For everybody else, this is embedded into their day jobs because it's how we want to care for patients,” Doerfler says. "This is something that is scalable and can be picked up in other organizations, because we did not create a big addition to the budget to do this work."
Data — the best medicineIntermountain Healthcare also deployed protocols for the aggressive detection and treatment of sepsis, starting in the ED, to reduce its sepsis mortality rate by more than 50 percent. Over a six-year period beginning in 2004, Intermountain cut the rate from 20.2 percent — already one of the best in the nation — to less than 9 percent, where it remains.
Success was tied directly to an intensive implementation at 15 Intermountain hospitals that have both an ED and an intensive care unit, achieving 80 percent compliance with a bundle of 11 clinical elements — four specific to the ED, four for the ICU and three that could be applied in either setting — during the first 24 hours of treatment.
In 2011, the bundle was reduced to seven elements; two were eliminated based on new medical evidence and two were removed for reporting purposes, but not for practice.
Intermountain's sepsis protocols are saving more than 100 lives each year, and there is still room for progress, says Todd Allen, M.D., who chairs the emergency department development team in Intermountain's Intensive Medicine Clinical Program.
For one thing, Intermountain is trying to identify patients with sepsis earlier and more consistently by working with urgent care centers and non-intensive care inpatient units to improve sepsis screening, detection and early treatment.
40 H&HN / JANUARY 2016 / www.hhnmag.com P h o t o g r a p h c o u r t e s y o f I H I
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"The second effort is to continue to refine our data systems and our reporting so that they become more accurate and more real-time, assuring that we have good data upon which we can make good administrative and clinical decisions," M en says.
Indeed, the use of data is an important part of Intermountain's success in curtailing deaths from sepsis. For starters, Intermountain leaders use a scoreboard to monitor each facility's compliance with the entire bundle and each individual element in the bundle. They also track three main outcome measures: mortality, inpatient length of stay and cost.
Those data points support continuous improvement efforts in two ways.
“I can look at the dashboard and say, 'Hey McKay-Dee Hospital, you're doing great on the element of antibiotics in three hours — how are you doing this?'" M en says. 'What can we share? How can we make those learning opportunities transparent across the system?'"
Additionally, the performance variation among Intermountain hospitals can be analyzed to determine what elements of the bundle are most significant to good outcomes or where root- cause analysis may be needed to identify barriers to good performance.
Beyond that, data about all Intermountain's sepsis patients — laboratory and X-ray results, length of stay, intervention results, comorbidities and more — have been systematically collected for the past 11 years. The sepsis "datamart” includes information about thousands of patients, and it grows with every new sepsis diagnosis.
"We can do our own research, using formal or informal research methods, to discover new information about questions that we come up with," M en says.
That rich data set also allows Intermountain to embed its electronic health record system with decision support “alerts" that notify the care team when a patient's condition is beginning to match those of previous patients who have suffered sepsis.
"If we are successful in identifying patients who are on a path to sepsis, and we intervene appropriately and in a timely fashion, we make them — as we use the term here — ineligible for developing septic shock,” Allen says. “The key is to use this robust database of thousands of patients to have a maximally sensitive, maximally specific alerting
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system that prevents patients from populating that database in the future."
Bringing everybody on boardWake Forest Baptist Health put sepsis on the front burner when analysis of benchmarking data showed that its sepsis mortality index was significantly higher than those of its comparative institutions.
Its sepsis initiative worked. Within two years, the average amount of time to start antibiotics for a septic patient on an inpatient floor fell from 396 minutes to 53 minutes, and total compliance with a four-element bundle of care for sepsis patients went from 13 to 71 percent.
The result: Wake Forest Baptist's sepsis mortality index dropped below that at benchmark health systems, and has remained there for nearly three years.
The keys to success, says Ryan LeFebvre, performance improvement adviser, were executive leadership support and multidisciplinary collaboration. “When it's something that the folks at the top really believe in, and they're willing to put themselves out there as advocates, it's going to happen," he says.
Historically, diagnosing and treating sepsis had not been urgent concerns. The medical center's protocol was to use the four-element bundle developed by the Surviving Sepsis Campaign, but "there was a whole lot of 'let's wait and see,' before labeling a patient as potentially septic," LeFebvre says.
As part of the approach, an hour-long educational session, featuring patient stories and a review of protocols, was mandatory for everyone from physicians to receptionists. “It wasn't a silo of physicians and a silo of nurses," he says. "It was true multidisciplinary education with everybody receiving the same message."
For the first six months of the initiative, Cathy Messick-Jones, M.D., the physician champion for sepsis care at that time, tracked the response to every Code Sepsis incident. If any element of the sepsis bundle was not completed within the appropriate time frame, she used a phone call or email message to find out why.
"Dr. Jones would actually reach out to physicians individually and say, 'What happened here? Why weren't we compliant?"' LeFebvre says. "Having that level of executive support was huge. It made people feel like this was an important thing to do." — Lola Butcher is a contributing writer for H&HN. •
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EXECUTIVE CORNERWhat every health care executive should know about sepsis:
• A ccurate ly tra c k in g com pliance w ith seps
care protocols is cha lleng ing , even for organ
zations that are sophisticated and experience'
in the use of data. Investing in a clinical nurse
specialist who makes sure those data are com
plete and accurate is worthwhile, says Todd
Allen, M.D., an emergency physician at Inter
mountain Healthcare.“ It makes a world of d iff
ence in having the clinicians trust the data an<
be w illing to make actionable choices based o
what the data are revealing,” he says.
• H ig h -q u a lity care pays fo r its e lf. Prevent
ing a patient from moving from severe sepsis i septic shock saves about $3,000 per case — a
dramatically improves the likelihood the patie
w ill survive. “ Added up over time, that’s an ea
return on investment,” Allen says. “That relati
ship plays itself out again and again in these
quality improvement initiatives.”
• The p rim ary outcom e m easure is th e morl
ity ra te fo r p a tie n ts w ith severe sepsis - bu
an effective sepsis control program may make t l
rate increase initially. “ If I have fewer people get
severe sepsis because they didn’t progress to tf
stage, my sepsis mortality rate — the number of
deaths per the number of people who have the
condition — may go up because the denominate
is smaller,” says Martin Doerfler, M.D., senior vt
president of clinical strategy and development a
North Shore-LIJ Health System.
• While Intermountain Health has a sepsis
mortality rate of just 9 percent, that may be ar
unrealistic benchmark for many health systen
in the short term. A better g oal m ay be to cut
th e sepsis m o rta lity ra te by 50 p ercent w ith
tw o y ears , which is something many organiz;
tions have done.
• E lim inating sepsis is not rea lis tic . “ For
patients with advanced lung cancer or leukerr
or other things that we cannot treat, part of th
process that results in those individuals dying
is sepsis,” Doerfler says. “ But, by appropriate
treatment, we can minimize the organ injury
that causes suffering unrelated to their main
problem.” *