Early identification and treatment are the key to reducing the high cost of sepsis care and improving patient outcomes. Frequently, to improve performance, a hospital will use its EHR's sepsis module, alerts and other functionality to accelerate accurate diagnosis and treatment. Unfortunately, the sepsis alert results delivered are marginal at best. The key areas of focus in the fight against sepsis are early recognition and the treatment of infection. The time-sensitive aspect of this disease is crucial because after the onset of severe sepsis, mortality rates increase by 7–10% per hour.
A complex sepsis care continuum
Sepsis is a clinical diagnosis. The delivery of evidence-based care to address the rapid change in biomarkers is the goal. Changing outcomes requires a hospital's commitment to education and change management, adoption of evidence-based consensus guidelines and tools while complying with measures from the Center for Disease Control and other governing bodies. Not only do you have to prevent diagnostic errors, but clinicians also must make the diagnosis quickly and early to save lives.
Where EHRs fall short
Most commonly, EHR sepsis alerting systems utilize Systemic Inflammatory Response Syndrome, or SIRS alert criteria, for sepsis surveillance. The sepsis detection system will trigger a “sepsis alert” if the EHR identifies SIRS criteria. Alternately, sometimes EHR systems deploy alerting systems using the Modified Early Warning System (MEWS) instead of SIRS. Regardless, both SIRS and MEWS-based alerting systems are known to be sensitive but have poor specificity. Today, some systems are starting to use the Sequential Organ Failure Assessment (SOFA) and qSOFA scoring systems for alerting, but these newer systems are already known to have poor sensitivity and a delay in identifying abnormalities.
Because of EHR’s lack of sensitivity and specificity in alerting, each fulfillment of additional sepsis criteria results in the repeat activation of a sepsis alert leading to:
Lack of alert accuracy. Clinicians’ complaints about alert accuracy is warranted since it may be linked to significant patient hazards. A well-cited study revealed that clinicians ignore EHR safety notifications between 49 percent and 96 percent of the time because of alert fatigue. Computerized Physician Order Entry (CPOE) systems in the EHR generate warnings for 3%–6% of all orders that are entered, meaning that a physician could easily receive dozens of warnings each day—putting patients at risk if the accurate alerts are ignored.
Clinical Relevance. Related to alert fatigue are the number of alerts fired on patients that are not septic at all. These are false positives since most of the patients in the hospital have positive SIRS criteria. These include abnormalities in temperature, respiratory rate, heart rate and white blood cell count and can be linked with any number hundreds to thousands of medical conditions. With typical EHR alerting, clinicians ignore ~95% of notifications as they’re typically wrong more than 90% of the time due to the 15% specificity of SIRS based platforms. Only 1 in 10 patients with alerts will have sepsis! Improving clinician utilization of any system is dependent on being able to trust the alert content delivered.
Too late to save lives. Often EHR alerts are fired 6 hours too late to provide effective treatment for septic patients. If alerting criteria includes the presence of organ dysfunction to match the CMS population of patients, the alert will tend to be fired late in the course of disease; possibly too late to save lives.
Although EHR vendors have developed sepsis alerting that appears to be a bargain since it a “free” product, this has not proven to be the case. If one takes a closer look, in-house healthcare teams spend a great deal of energy and time on implementation and integration of the surveillance solution into their workflows in an (unsuccessful) attempt to improve its accuracy, costing time and important clinical resources. There is a better answer. Third-party surveillance technology used with an EHR can offer benefits to offset these gaps.
Surveillance technology that focuses on accurate and timely alerting has moved the dial on detection and treatment by drawing on built-in intelligent clinical content and rules, and by incorporating change management services for hospitals. When accurate enough to account for a wide range of sophisticated clinical scenarios and relevant comorbid medical conditions, surveillance systems that deliver decision support to the point of care can improve outcomes where EHR-based systems have failed.
A 2016 study evaluated the impact of a computerized surveillance algorithm and decision support system such as this on sepsis mortality. The study evaluated - POC Advisor - a highly accurate system that used a combination of change management, computerized surveillance, and mobile point of care alerting to:
- decrease sepsis mortality 53% on hospital units where the sepsis initiative was implemented
- improve alert sensitivity to 95% (effective screening tool) and the specificity to 82% (the sepsis cases were real) when compared to the gold standard of physician chart review
- fire earlier alerts in the course of sepsis so that rapid and effective treatment algorithms could be implemented
- improve clinician utilization by providing a Clinical Decision Support system that incorporates the complexities of a patient’s presentation
A highly-complex condition to diagnose and treat, sepsis is a prime target for technological intervention beyond the EHR. However, as is true in most forms of health IT, not all solutions are equal. Despite the early nature of this market, there are solutions, like POC Advisor, that have a track record of delivering provable and repeatable outcomes reducing sepsis mortality, morbidity and cost of care.