This first appeared in the June issue of Patient Safety Monitor.
Sepsis mortality rates increase quickly when left untreated, even if it’s only for a few hours. The difficulty facing providers is that there isn’t a simple test for sepsis. Instead, they have to watch for patterns and symptoms that could indicate sepsis. As a result, it’s common to have misdiagnoses or delays in diagnosis.
Sepsis is also the most fatal complication for burn victims, accounting for 50%–60% of burn injury deaths. That last issue is a particular concern for places like Harborview Medical Center in Seattle. The facility is the only designated Level I trauma and burn center in Washington state and is the regional trauma and burn referral center for Alaska, Montana, and Idaho. The 413-bed facility has around 17,000 admissions, 259,000 clinic visits, and 59,000 emergency department visits annually.
Rosemary Grant, BSN, RN, CPHQ, is the sepsis coordinator at Harborview. She says her facility chose to focus their attention on sepsis detection because the condition is “prevalent, expensive, and deadly.”
“When we looked at data from our hospital and others, we saw that patients who develop sepsis in the hospital have a much higher mortality than patients who arrive in the emergency department with sepsis,” says Grant. “So, we knew we needed to focus on faster identification of sepsis in our inpatient population.”
The evidence backs up her concerns. A 2017 study found that while sepsis is only present in 6% of hospitalizations, it accounts for 15% of in-hospital deaths. In 2014 alone, there were 1.7 million sepsis hospitalizations and 270,000 sepsis deaths in the U.S. It’s also one of the most expensive medical conditions, costing tens of billions of dollars annually. And sadly, despite increased awareness of the condition, mortality rates are rising.
In 2011, the Harborview team decided to fight sepsis by changing the way they detected it. Working in-house, they developed an automated flagging system for their electronic health record (EHR).
After a patient is admitted to Harborview, his or her vitals are plugged into the EHR several times each day. The system searches for patterns, trends, and symptoms that might indicate sepsis. If found, a red box appears around the patient’s name and the nurse is assigned a task in the EHR to screen the patient for infection.
The nurse then assesses the patient for non-sepsis causes for the readings. If the nurse thinks the patient could have sepsis, then the physician is alerted. The system is designed so it won’t sound more than once every 12 hours, she says, so nurses won’t get more than one alert per patient per shift.
“I think the most important component of our system is that it incorporates the bedside nurses’ clinical judgment,” says Grant. “The alert is just a computer algorithm, and if it paged the provider every time, they would become tired of it very quickly. Instead, it asks the nurse who is spending his/her shift with a patient whether infection is suspected based on abnormal vitals and the patient’s overall clinical picture.
It’s only if and when the nurse suspects infection that the provider is notified.”
Since the system’s inception, Harborview has seen remarkable results. Sepsis mortality has gone down 41% from 2011–2017, and over 95% of alerts are addressed by a nurse within two hours. There’s also been an increased awareness of the condition and its risks, Grant adds.
Currently, Harborview’s system uses systemic inflammatory response syndrome (SIRS) criteria to determine if a patient has sepsis. SIRS is defined as a combination of the following symptoms:
• Temperature less than 36°C (96.8°F) or greater than 38°C (100.4°F)
• Heart rate greater than 90 beats per minute
• Respiratory rate of more than 20 breaths per minute or an arterial carbon dioxide tension (PaCO2) of less than 32 mmHg
• Abnormal white blood cell count that’s either greater than 12,000/µL, less than 4,000/µL, or greater than 10% immature band forms
• Harborview’s system also looks for:
• Systolic blood pressure less than 90 mmHg
• Lactate level greater than or equal to 2 mmol/L
Grant does note that Harborview has slightly different criteria for burn patients, pediatric patients, and pediatric burn patients.
While sepsis and SIRS are closely linked, sepsis isn’t the only possible cause for SIRS symptoms. A patient could register on the SIRS scale if he or she is more active, is in pain, has a bad cold, etc. That’s why a nurse is needed to make the final call.
“If a patient has two or more of these criteria, the bedside nurse is asked if he or she is concerned for infection,” she says. “If the nurse says ‘yes,’ the provider is automatically paged to come to the bedside. If the nurse says ‘no,’ he or she is asked to explain why the patient has abnormal vitals if it’s not infection.”
Building the system
The original build for the alert system took 12 months, says Grant. That included designing it, getting feedback and buy-in, building it in the EHR, and implementation. Then, in September 2016, Harborview held a weeklong rapid process improvement workshop (RPIW) to further refine the system based on provider feedback.
Approximately 15 team members were in attendance for the RPIW: attending physicians, resident physicians, bedside nurses, APRNs/PAs, data analysts, quality improvement specialists, and IT support. Afterwards, the system was updated, with more back-and-forth between the RPIW team on what changes to keep or drop.
“Since the implementation of those changes in February 2017, we have seen further decreases in mortality for hospital-acquired sepsis as well as increased three-hour [sepsis] bundle compliance,” says Grant.
If your facility is considering setting up its own automated sepsis flagging program (and it should), Grant says that holding an RPIW or similar event with stakeholders is the way to go.
“So much was accomplished having the right people in the room, especially the bedside nurses who will use the system every day,” she says. “They were also able to go back to their units and talk to their colleagues about suggested changes before they were made, and we were able to further refine and improve the system based on that feedback.”
One of the benefits of gathering stakeholders together was convincing them of the system’s merit. Grant says that at the start, there was some pushback from providers who thought their patients were “somehow different than other patients in the hospital.”
“We worked using a ‘pilot’ model where we asked if [the stakeholder] could just try [the system] for three months and see,” she says. “It usually worked out that they realized the benefit of the system.”
In addition to presenting patient safety data from the pilot, Harborview focused on metrics that administrators were beholden to, such as length of stay (LOS). By demonstrating shorter LOS in sepsis patients whose conditions are discovered quickly and treated efficiently, they were able to get the needed leadership support for the program.
The system does have room for improvement—namely in its handling of vital signs, which must be typed in manually. Time is a major factor in treating sepsis, with each hour of delay in administering antibiotics resulting in an average 7.6% decrease in the chance of survival. Having vital signs automatically updated in the EHR would make it easier and faster to notice worrisome changes in a patient’s condition.
“I think it would be great to not have to manually enter the vital signs, and there are some groups working on that, although we haven’t explored much at Harborview—yet!” says Grant. “I think this would be helpful for a lot of reasons. But the system is still very successful even with the sometimes-delayed entry of vitals.”
Get Ahead of Sepsis
Earlier this year, The Centers for Disease Control and Prevention (CDC) launched an anti-sepsis campaign to bring attention to the condition. Called “Get Ahead of Sepsis,” the program was launched last August as an educational initiative to protect Americans from the devastating effects of sepsis, including emphasizing the importance of early recognition and rapid treatment, as well as the importance of preventing infections that could lead to sepsis.