Every September, during Sepsis Awareness Month, the Centers for Disease Control and Prevention and other health organizations focus on raising awareness and education about sepsis, a life-threatening illness that develops as a result of a serious infection.
Sepsis is the 10th leading overall cause of death in the United States, yet fewer than half of Americans know anything about the illness. We spoke to experts at two of America’s Essential Hospitals’ members, Parkland Health & Hospital System, in Dallas, and UNM Health Sciences Center, in Albuquerque, N.M., about their efforts related to sepsis prevention and care.
What are the challenges in tackling sepsis?
Pranavi Sreeramoju, MD, MPH, Parkland Chief of Infection Prevention: For sepsis, early treatment leads to better outcomes. Early signs of sepsis are very subtle. They include increase in heart rate, decrease in blood pressure, increase in white blood cell count, fever, chills, or low body temperature. It takes some time for these symptoms to become full blown, but as these vital signs are getting worse, patients are already in the process of developing sepsis.
Another thing is that it’s not so much that we don’t know what needs to be done, but it’s a matter of doing it. It is a challenge for complex health systems such as Parkland and other major hospital systems to provide treatment in a timely fashion. There are so many players involved in sepsis care. Getting everybody on the same page on standardization of care is a major challenge.
Richard Crowell, MD, UNM vice chair of quality and safety: Early recognition and starting bundle intervention as soon as possible — particularly antibiotics and fluids.
What sepsis-related initiatives has your hospital implemented?
Sreeramoju: Parkland launched a sepsis initiative in early 2013 as part of our Section 1115 waiver program to prevent health care-associated infections and sepsis mortality. As part of that, we implemented a predictive analysis software in the emergency department. The program overlays the electronic medical records.
When patients come in and are getting their usual care — vitals, history, labs — this software gathers that information and puts key information into a tested, statistical model that creates a sepsis risk code. Then, the software generates an initial best practice advisory that says, “your patient could have sepsis; please draw these labs.” When the labs become available, there’s a second alert that goes to the physicians. The physician then checks steps of the sepsis order set that are pertinent to the care of that patient.
Last year, the Centers for Medicare & Medicare Services implemented inpatient quality reporting, which includes sepsis reporting as a core measure. The definitions are a little different from our initial project. That initiative involves sepsis patients anywhere in the hospital, not just the emergency department (ED). So this year, we implemented the best practices advisory in all parts of the hospital.
Crowell: The Sepsis Mortality Improvement Team initiative is a joint, multidisciplinary effort started in 2009 between the emergency medicine and internal medicine — particularly the division of pulmonary and critical care — departments. This close collaboration is ongoing, with twice-monthly meetings to review data and re-evaluate processes for continuous improvement. The multidisciplinary team consists of representatives from nursing, pharmacy, physicians, and quality representatives from both departments and the health system.
We train staff on the importance of early treatment and bundle compliance for patients with severe sepsis. One of the biggest early successes was recognizing that the treatment bundle for severe sepsis patients also is time dependent, so they are treated in a similar, streamlined fashion on arrival into the ED. We have managed to reduce mortality in severe sepsis and septic shock patients who end up in the ED by about 45 to 50 percent.
How do you engage staff in sepsis education?
Sreeramajo: We developed a standardized curriculum and training for eligible clinicians who will potentially take care of patients with sepsis. Systemwide, we held training with more than 500 unit-level leaders at Parkland. Staff created a sepsis video to engage clinicians in the ED. We’ve also had articles in our monthly newsletter for all employees.
Crowell: Each case is tracked by faculty attending, resident, fellow, and primary nurse, and feedback provided regarding bundle compliance and clinical outcomes for that patient. This is also shared at the department level. In addition, there are regular seminars, education processes included as part of training for nursing staff, residents, and pharmacy.
How do you engage patients in sepsis awareness and education?
Sreeramajo: Right now, our sepsis education extends to those diagnosed with sepsis. Our next level would be to educate all patients on sepsis. We do a lot of community education initiatives through Parkland. We also are planning a public press release to distribute to all media to address family member awareness of signs of sepsis.
What have you learned about sepsis care through your initiatives?
Sreeramajo: We’ve learned the definitions really matter for accurate data collection. We ended up spending a lot of time on figuring out the definitions and getting data reports right. That’s something I would recommend other hospitals to pay attention to.
We had to make several tweaks to our work environment and the workflow to make care available to the patient in a timely manner. For example, instead of bringing antibiotics from the pharmacy to the ED to give the patient, we had to place the antibiotics in the ED.
There is a lot of communication and standardizing care and training that is always something that we need to pay attention to. It’s very hard to disseminate information through a complex health care system.
Crowell: One, develop early detection approaches that fit with your hospital’s culture. We put the emphasis for this on nurse screening tools, which we have found to be quite effective. Second, collect the appropriate data, review it regularly, and relentlessly pursue continuous improvement.
[It’s also important to] develop effective feedback strategies sensitive to hospital’s culture and clinical realities. For example, we are a level I trauma center, so our ED is well-attuned to early intervention bundles (trauma patients, acute myocardial infections, and acute strokes all have time-dependent bundles of care for patients on arrival).