Fighting sepsis: A clinical, technological and cultural initiative

Sepsis is a significant problem for patients and hospitals, as the condition is often deadly and a major burden to hospitals' bottom line. Despite hospitals' best efforts to curb this inflammatory response to infection, the prevalence of sepsis has increased over the last several years.

Between 2000 and 2008, the latest range of years for which data is available, the rate of patients who acquired sepsis in the hospital increased by 15.6 percent, and the rate of patients who were admitted to the hospital for sepsis increased by 12.4 percent, according to the Centers for Disease Control And Prevention.

Across all age groups, in 2008 the average length of stay for patients with sepsis was nearly twice that of patients in the hospital for other reasons, at 4.8 days and 8.4 days respectively.

These statistics illustrate the need for greater prevention and intervention processes for sepsis. Retrospective data analysis is helpful for refining sepsis protocols, but it fails to provide clinicians with guidance at the point of care. Sepsis is uniquely time-sensitive, so failure to identify and treat the condition can quickly prove fatal.

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"Left unchecked, the cascade of resulting inflammatory responses that occur can result in multi-system organ failure and death," Stacy Pur, vice president of clinical intelligence at VigiLanz, a real-time intelligence and predictive analytics solutions provider, said during a webinar hosted by Becker's Hospital Review. "As patients progress from no infection to end-stage sepsis, morbidity and mortality, length of stay and cost all increase."

In addition to sepsis' costs and safety implications, the condition is also one for which hospitals face greater scrutiny from insurers. CMS has added the Severe Sepsis and Septic Shock Early Management Bundle to the fiscal year 2016 Inpatient Prospective Payment System Final Rule. This added financial pressure has driven many hospitals to seek more advanced intelligence and analytics to better prevent and manage sepsis.

About the new sepsis core measure
"What's driven much of CMS' response to sepsis is the gradual increase in sepsis across the nation," said Edward O. Blews III, MD, assistant professor of infectious disease and associate medical director of hospital epidemiology at Loma Linda (Calif.) University Medical Center.

The CMS core measure applies to adults 18 and over. It stipulates specific tests across a three- and six-hour timeline. According to Dr. Blews, within three hours of severe sepsis presentation, patients should receive the following tests: initial lactate level management, blood cultures prior to antibiotics and broad spectrum or other antibiotics administered. Within six hours of severe sepsis presentation, clinicians should repeat lactate level measurement only if the initial lactate level was elevated. Guidelines for septic shock are also given on a three- and six-hour basis.

Compliance with the new bundle is critical for reducing mortality, as well as lowering the substantial costs associated with sepsis. Studies have shown that just a 30 percent compliance rate with the sepsis bundle lead to a 4 percent to 6 percent reduction in mortality, while a compliance rate of 52 percent lead to a 20 percent reduction, according to Dr. Blews.

A new solution: Predictive analytics
In the best case scenario, clinicians can use predictive intelligence to prevent infections before they result in sepsis. VigiLanz offers a suite of real-time predictive analytics to empower clinicians to prevent infections from the start. Modern software solutions like VigiLanz Infection Prevention and VigiLanz Quality and Care Management "do not simply count and report infections, [but] also contain features to help prevent them," said Ms. Pur. 

However, if an infection does develop in a patient, VigiLanz's tools use real-time surveillance of the patient's condition and provide timely notifications and guided treatment alerts. According to Ms. Pur, alerts should not focus on the medication intervention alone. Instead, it's important to consider how to remove barriers to healing, which may be indicated by the patient's nutrition status or whether a device needs to be removed.

"Systems that are able to deploy alerts to specialized departments, such as dietary or IV management teams, are able to stay ahead of the game," said Ms. Pur. "In some cases, removal of a device such as a contaminated urinary catheter is all that is needed to prevent sepsis. Ignoring this type of intervention opportunity is ignoring an early, very low-cost opportunity."

The promise of real-time alerts
Sometimes, despite early intervention efforts, infections get worse. In this case, modern, real-time intelligence solutions can provide guidance around new needs automatically, according to Ms. Pur. For example, if the bacteria causing a patient's infection become resistant to the antibiotic administered, a pharmacy or stewardship alert around a bug/drug mismatch can ensure the patient's treatment is adjusted to match the organism's new drug resistance pattern.

At Loma Linda University Medical Center, Dr. Blews said the clinicians and administration were unhappy with the mortality rate for sepsis. This prompted them to launch an early intervention system that uses best practices alerts through the EHR system when any element of systematic inflammatory response syndrome criteria are noted in the chart.

These real-time alerts activate a nurse standing order for lactate and blood cultures with lactate drawn, and a physician is then immediately paged to assess the patient. If the physician does not respond within 30 minutes, there is a standing order for antibiotics. Dr. Blews said the physicians have responded aggressively to this best practice alert and intervening as to whether or not antibiotics are needed. However, he did note one flaw in the alert system that his team is working to resolve.

"Because we expanded our own criteria for when best practice alerts should fire, we had a tremendous amount — over 1,500 activations in the first month. So we are actively in the process right now of refining our best practice alerts to have more specificity for the clinicians."

Ms. Pur discussed the dangers of over-alerting, saying alert fatigue is the enemy to efficient bedside care.

"The best intelligence technologies will not only recognize the time when sepsis testing should occur, but it also should only alert to those conditions where blood cultures, lactic acid and other tests are indicated and the clinician has not yet acted," she said. With VigiLanz's tools, facilities have the flexibility to determine how much time clinical groups should have before an alert is escalated. 

Putting the CMS core measure in practice
Implementing a sepsis program to meet the requirements of the CMS core measure is challenging for hospitals. According to Michael Cheatham, MD, chief surgical quality officer at Orlando (Fla.) Regional Medical Center, there are three main reasons for this.

First, incorporating any change that requires clinicians to change their behavior requires effective communication and education efforts. If these needs are not met, the change effort is probably doomed from the start.

"We learned team member engagement is essential to the success of an implementation project," he said in regards to Orlando Health's experience implementing a systemewide structure for quality improvement.

The second biggest challenge results from hospitals' tendency to spend too long planning, and not enough time doing. "Most of us are really good at spending months in committee meetings designing perfect implementation plans," said Dr. Cheatham. "We are afraid of failure. In the meantime, we have patients that are not having good outcomes and perhaps dying."

To avoid getting stuck in the planning phase, Dr. Cheatham recommends using a "plan, do, study, act" cycle. In this cycle, you spend a brief period designing a plan, then try it on a small scale, study the outcomes, modify it and try it again. This is a much more effective way to "perfect" a plan than sitting in committee, removed from the clinical environment.

Finally, the goal behind implementing a sepsis — or any — initiative should be easily defined, measurable and achievable. While "reducing mortality from sepsis" is the global aim, a more specific and measurable goal is documenting implementation of the "Big Four" within three hours, he says. The Big Four includes testing lactate, fluids, administering appropriate antibiotics and cultures.

Creating "unit triads," which include a unit triad medical director, a nurse operations manager and a unit practice council chair, can monitor the sepsis initiative, assess progress and provide feedback on a weekly basis.

Sepsis is a healthcare emergency, as it affects all age groups and carries a high risk of death. However, with refined guidelines, financial incentives and real-time predictive technology, hospitals can become better equipped to fight back.

To download the webinar as a PDF, click here.

To view the webinar on YouTube, click here.

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