Closer Monitoring Reduces Sepsis Death
This work can’t be done alone. It has to be interdisciplinary and inter-professional if we are going to make a difference.Clinical Affairs | CU School of Medicine Nov 1, 2019
Sepsis is a common threat and a tough problem to solve in a hospital. Nicole (Nicky) Huntley, CNS RN, Med/Surg Division CNS, and Sepsis Coordinator at the University of Colorado Hospital, is determined to solve it with the help of colleagues across the UCH system.
“You can’t do this alone. It has to be interdisciplinary and interprofessional if we’re going to make a difference with a problem like sepsis,” says Huntley.
The challenge of reducing sepsis deaths
Sepsis is a problem because it is surprisingly common and potentially deadly, yet can manifest in a variety of ways. In the early stages, common symptoms are fever, chills, rapid breathing and heart rate, and disorientation. Unfortunately, these symptoms are shared by many other conditions as well, including many less dangerous than sepsis. This makes sepsis hard to detect when treatment is most effective.
The key is putting all of the patient’s signs and symptoms together to create a picture that suggests sepsis, and ensuring that a provider can correctly interpret that picture in enough time to deliver life-saving treatment.
Persistence and progress
Huntley and two other UCH sepsis coordinators, Elise McKnight and Leighann Jock, are committed to decreasing the rate of sepsis death throughout the UCH system. In the last five years, sepsis coordinators have raised awareness about sepsis and helped bedside nurses learn to identify its signs. They have worked with hospital pharmacists to improve the speed of antibiotic treatment once sepsis is identified. Importantly, they have also focused on improving sepsis identification in the medical-surgical unit, where sepsis cases went unidentified more often than in the ICU or critical care unit. As a result, med-surg has had the highest rate of mortality from sepsis.
They also led the effort to implement an Early Warning System, which uses the data in the EHR to alert the bedside nurse when a patient is at risk for sepsis.
Their work is making a difference: the hospital is saving 93 more lives per year than when they started their work. But the goal is to save at least 77 additional lives per year, and that’s going to take a new approach.
Technology and virtual health center nurses improve sepsis detection
The Early Warning System was an important step but had some limitations. Only bedside nurses could see the alert, and the nurse had to be in the patient’s medical record to see it. If the nurse wasn’t in the patient’s record for a few hours, the window of opportunity to treat could be missed entirely. Another problem was that the system frequently triggered an alert because sepsis has a wide range of common symptoms.
“The alert created a lot of noise for bedside nurses,” explains Huntley, “and they were on their own to evaluate the alert and decide what to do.”
The team’s latest initiative is designed to address these problems. Their latest partner in preventing sepsis death is the virtual health center, which is staffed by an ICU nurse who receives the early warning alerts as soon as they are triggered, along with a physician who collaborates with the bedside team to coordinate the care plan. Based on data from sources like charting, lab values, respiratory therapy and wearables that collect vital signs, the patient is given a deterioration score that the virtual care ICU nurse can assess.
By evaluating the alerts first, the ICU nurse can reduce the amount of noise for bedside nurses and focus on cases that truly require action. The virtual care ICU nurse alerts the bedside nurse when sepsis is likely, and the two work together to assess the case. The ICU nurse “holds the clock,” keeping track of the time elapsed to ensure that the patient does not miss the window for effective treatment. The physician at the virtual health center works with the care team to get the patient timely antibiotics or fluid resuscitation if necessary.
“The ICU nurse is another layer of care, someone who brings needed expertise. The bedside nurse is the expert on what’s happening the patient. The ICU nurse has a slightly different skill set so it’s complementary. Both are needed to successfully treat sepsis in time,” says Huntley.
Using an interdisciplinary approach
For the past six months, Huntley and her colleagues have been doing a slow, phased rollout across the whole UCH system. Huntley stresses the importance of including a wide variety of providers and site representatives when implementing a broad initiative like this.
What works in theory may not fit into the existing workflow. Or, what works at the University of Colorado Hospital may not work in rural areas, where resources and staffing are different. Successful implementation requires both standardization and flexibility: keep the standards, process, and platform largely the same across the system, but adapt the training, messaging, and specific strategies to the unique needs of the site.
Support from leadership across the system is also essential. “Solving the sepsis problem across the system requires investment and accountability from leaders in all our regions,” says Chris Davis, MD, Medical Director of the Virtual Health Center. “The success we have had thus far in reducing sepsis deaths is a result of this collaboration, and our continued success depends on it.”
Looking forward, Huntley and her colleagues plan to continue to roll out the virtual care center initiative. They also plan to turn their attention to transitions from the emergency department to inpatient care, to ensure that information collected in the emergency department follows the patient and is included in their inpatient record. Patients sometimes arrive at the hospital in early sepsis stages, so the information from the emergency department can make a crucial difference in timely treatment. Continuity of care, always important for high care quality, can be life saving in this case.
“We’re saving patients’ lives. We want to improve care systems so no one gets missed and harm is prevented. Our goal is to be the very best and to make sure our patient experience and falling mortality rates reflect that.”