Health05 oktober, 2021

Standardizing sepsis protocols across settings optimizes sepsis prevention

As hospitals work to improve their sepsis programs, they look to tools and technology to support them in these efforts. But as any organization understands, technology is but one piece of the puzzle. It must go hand-in-hand with standardized, evidence-based sepsis protocols to ensure that patients who receive sepsis care achieve the best possible outcomes.

Guidelines provide sepsis protocol foundations

The two most prominent sources to use as a basis for hospital-specific protocols come from the Centers for Medicare and Medicaid Services (CMS) and The Society for Critical Care Medicine (SCCM).

According to a 2019 New York State study, patients treated according to the SEP-1  CMS 3- and 6- hour sepsis care bundles were 15% less likely to die than those patients whose care did not follow protocols. The patients undergoing protocolized care also experienced shorter lengths for stay (three days LOS reduction on average for the 3-hour bundle, and more than a day shorter LOS with the 6-hour bundle). The SCCM’s Surviving Sepsis Campaign, conducted in collaboration with the Institute for Healthcare Improvement, has considerable overlap with CMS guidelines. The primary difference is that the Campaign updates its guidelines more frequently than CMS, based on the latest evidence.

Despite these widely respected guidelines, there is no single absolute care standard for sepsis today, and some variations exist. Therefore, hospitals will have to decide for themselves how closely to follow these guidelines as they develop protocols tailored to their particular settings.

The consistent pieces of any sepsis protocol

While protocols appropriately differ from one hospital to the next, the best sepsis prevention programs flesh out each step in the process for each care setting in the hospital. As we’ve noted in prior articles, most hospitals’ sepsis protocols focus on the initial admission of patients with sepsis who present to the emergency department and the intensive care unit. Most hospitals have already implemented effective sepsis detection and treatment programs in those settings, but they stop there rather than considering other hospital areas where sepsis appears. The two settings we’ve noted in prior articles – patients boarding in the ED and the medical-surgical ward – are particularly ripe for the use of standardized “mini” order sets that consider the training and staffing in each of these units.

The best sepsis prevention programs also create different versions of the order sets to focus on additional sepsis treatments as it progresses during a hospital stay. A rule-out sepsis protocol, or one for a patient that develops nosocomial sepsis with hypotension or shock, are important examples. Furthermore, in addition to provider order sets, exemplary programs delineate screening order sets for nursing staff or rapid response team members.

All along the way, each of these protocols should clearly delineate several steps, including:

  • Who should be alerted first
  • Which “mini” order set should be used when
  • Who can order the set
  • When to call the rapid response team 

The protocols should also consider ways to overcome the common cultural barriers to communication between bedside nurses and physicians. Everyone must be on the same page with so many teams involved – including the sepsis coordinator, charge nurse, rapid response team, and providers. 

It’s also essential that the electronic alert-based system in each setting generates clinician trust through transparency about the provenance of the alerts, demonstrated sensitivity and specificity, and the delivery of explicit, patient-specific, evidence-based, actionable care guidance to the care team. Such alerts should embed the facility-specific policies and protocols you’ve developed to promote adherence further and reduce variations in care among your clinical staff.  

Change management is critical

Developing the protocols is one thing, but as most hospitals have come to learn, successful change only happens when organizations deploy an effective change management methodology. The following elements are essential:

Senior leadership must be on board

The visible support of senior leadership secures staff buy-in, as does visible support from clinical leaders such as the chief medical officer, chief nursing officer, and key administrative nurses.

Engage clinical staff from the outset

Clinicians must be included in planning and technology selection. They also must have adequate representation and a respected voice on sepsis committees, sepsis teams, and management.

Establish relevant metrics

Potential measures include CMS bundle compliance rate, alert response times, the use of order sets, compliance with protocols, length of stay, and mortality. Work with hospital staff and existing guidelines to determine the proper metrics.

Gather and use data

Data gathered with help from the informatics, IT, and quality departments are essential to determine if you are meeting your metrics. It is a powerful way to demonstrate why change needs to happen and to document successes. Absent the data, many hospitals and health systems don’t know or believe they are underperforming; nor can they see where the concerns are or how to address them. In contrast, data collection around key metrics enables hospitals to analyze all components of sepsis care and determine how to institute life- and money-saving changes. The data also inform reports for regulatory compliance.

Delineate roles

As noted above, all team members must understand what they need to do, why they need to do it, and when and who to call for each of the key points in the plan. Depending on each hospital’s individual situation, the team members will typically include bedside nurses and/or charge nurses at the point of care, providers, providers-in-training, and members of the rapid response team; all should be represented when devising the plans.

Empower clinical staff, particularly nurses, to practice to the top of their license

Empowering nurses to become more involved in sepsis screening and ordering appropriate tests can expedite early sepsis detection and treatment; it is a proven model for improving sepsis care. To overcome any resistance, nursing leadership can approach provider colleagues and hospital governance with a concrete plan that draws on peer-reviewed research and outlines a nurse-driven, provider-approved protocol for nurses to initiate testing under specific circumstances. In addition, the best programs empower all clinical staff, including new personnel, with precise training requirements around sepsis detection and treatment.

Hard problems demand rigorous responses

Despite significant improvements in detection and treatment over the past couple of decades, sepsis still accounts for nearly 270,000 deaths each year in the United States—about 1 in 3 of all hospital deaths. Corresponding financial costs are $24 billion a year. What’s more, the reimbursement rate for each sepsis incident typically leaves hospitals holding the bag for somewhere between $7,100 – $12,000. And according to The Lancet’s 2020 Global Burden of Disease Study, sepsis accounts for almost 20 percent of all deaths in 2017 worldwide.

Given these numbers and the waning of the COVID-19 pandemic, now is an ideal time for hospitals to turn their attention back to sepsis detection and treatment. Bringing together AI-informed sepsis surveillance technology with readily accessible sepsis-specific order sets for different situations and detailed policies and procedures tailored to each hospital setting is an essential piece of any sepsis improvement program.

To learn more about all of the challenges hospitals face to improve sepsis outcomes and how to address those challenges, download our guide, titled: Best Practices For Improving Sepsis Care and Outcomes.

Download the guide
Dr. Itay Klaz is responsible for directing clinical efforts toward the development, implementation and support of Wolters Kluwer Sepsis Surveillance software solutions.
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