Your hospitals managed to achieve a notable reduction in sepsis rates. How did you do this?
We do have a great story to tell. Back in 2007, which was very early for standardized sepsis protocols, we looked at our baseline ICU septic shock mortality rate. It was over 50%. We did not have the ability to draw a lactate level and result the value internally. This is one measure to evaluate while determining if a patient has sepsis.
We have developed a robust, structured screening and treatment protocol process between the ER, ICU and general medical surgical units. We have reduced our ICU septic shock mortality rate to 9%. Each month sepsis process measures are reported and we look for any opportunities for process improvement.
We have a database that tracks back to 2007 for all of our septic shock patients and severe sepsis patients.
How do you keep this initiative going?
Over the years, we have seen many patterns. Here is a hypothetical. We track every metric for sepsis. Let’s say a patient didn’t receive a lactate level, or didn’t receive antibiotics in 3 hours. We drill down into that patient record to see if there is any trend. We then look to see what the similarities are, and we work hand in hand with them to develop new processes.
If there are significant fallouts, we would go to that unit and work with them to improve the process and compliance.
Most recently, AMITA Health has had a platform that is an early indicator system of changes in a patient’s condition on the general medical floor. That tool fires off color-coded alerts that show us a patient at risk and the severity of that risk. It is a great predictor of patients in sepsis and highlights changes in acuity. The goal is to treat those patients proactively.
The TeleICU clinicians are centrally monitoring that platform for five of our sites. We use live video technology to visually assess a patient. We work with the bedside nurse to evaluate the patient and discuss the plan of care. Together the bedside and TeleICU RN’s collaborate with one another to improve the health status of our patients.
Telehealth ICU of Presence Health system, (now AMITA Health), Bolingbrook, Illinois. Two critical care nurses watch patient data streams from Presence hospital ICUs.
Does clinical decision support have any role to play in improving treatment of sepsis?
Without clinical decision support, we wouldn’t have the ability to report outcomes. They are a key piece in measuring and reporting process and outcomes measures for sepsis care delivery. Decision support helps doctors and nurses to know what to do next. The screening tools are done by nurses. It is a checklist. Does that patient have this? If they have this, do they have that? They are great tools.
It’s a guide; it doesn’t change the clinician’s clinical judgment. It gives them something to think about: What is best for that particular patient?
Are there any major developments in recent years in fighting sepsis?
There is a lot of evidence-based research on innovative ways to fight sepsis. Being able to evaluate a blood sample and pinpoint the exact antibiotic that will treat that infection, you couldn’t do that before.
Electronic acuity risk-adjusted systems give us early warnings of patients at risk. We have seen different blood tests that have come on the market. In 2007 we could draw the blood, but it would have to be sent out of the hospital for results. That was pretty common throughout the US. That added 12 to 24 hours to the diagnostic timeline. We know the patient’s chances of dying increases every hour they don’t receive treatment.
What about changes in protocols or guidelines?
There have been changes in the guidelines over the course of years. That's improving sepsis care delivery.
To be fair, the focus on sepsis protocols really started when the first guidelines came out in the early 2000s. Prior to facilities adopting sepsis protocols there was great variability in care delivery.
What has happened, there has been a concerted effort by the medical community to adopt evidence- based care and screening protocols for the treatment of patients with sepsis.
It has standardized the care delivery. Variability has been reduced. We created structured processes built in our EMR, standardized physician order sets, and robust reporting to show outcomes on a monthly basis. All that has created a standard approach for sepsis screening and care delivery which has reduced clinical variation.
Read part 3 of our interview with Laura Messineo next week.