What condition develops quickly, is more common than a heart attack and causes more deaths than cancer?
The answer is the leading cause of death in US hospitals: sepsis. This complex syndrome occurs when the body reacts vigorously to an infection and begins to damage tissues and organs. Unless caught early, this can result in widespread inflammation, organ failure and septic shock.
Nicole Huntley, MS, APN, ACCNS-AG, RN, is a clinical nurse specialist and sepsis coordinator at University of Colorado Hospital (UCH). She has been in nursing for 21 years and has specialized in sepsis since 2015. She explains that it can be difficult to diagnose the syndrome as there is no single diagnostic test.
(Pictured above, Nicole Huntley, MS, APN, ACCNS-AG, RN and Read Pierce, MD)
“Sepsis first presents as very subtle changes in a patient’s vital signs,” she said. “This could be either febrile or hypothermic temperature, heart rate over 90, respiratory rate over 20 or elevated or decreased white blood cell count. Since there are many reasons why a patient’s vitals could change, it could be easy to mistake sepsis for other conditions.”
Mortality from sepsis increases approximately 8% for every hour that treatment is delayed, so early identification and treatment is vital in order to save lives and reduce complications. However, early intervention could also have a significant economic impact. The Agency for Healthcare Research and Quality lists sepsis as the most expensive condition in US hospitals, costing $23.7 billion in 2013 alone.
This startling figure may be one reason why the Centers for Medicare and Medicaid (CMS) made sepsis management a core measure in 2015. In July of that year, UCHealth hired sepsis coordinators – like Huntley – whose goal was to collaborate across the organization to improve sepsis mortality outcomes.
Read Pierce, MD, is assistant professor of medicine at the University of Colorado and associate director for the Institute for Healthcare Quality, Safety and Efficiency. He explained that there has been long-standing interest in improving sepsis care for a number of reasons.
“Over the last decade or so, several organizations have sponsored quality-improvement initiatives related to sepsis care, such as the ‘Surviving Sepsis Campaign’ from the Society of Critical Care Medicine. The CMS change in 2015 gave us an additional impetus to really focus on improving care for septic patients.”
When Huntley started as the sepsis coordinator at UCH, she was essentially a one-woman band, attempting to make improvements across two areas of the hospital: the emergency department and all inpatient units. However, she soon realized her efforts would go further if she was able to form an interprofessional group. In the summer of 2016, Dr. Pierce joined the sepsis steering committee and he and Huntley established two goals: 1) to produce data on every aspect of sepsis care and 2) to increase the engagement of all clinicians working on sepsis care across the organization.
Although UCH receives regular reports on their sepsis care from CMS, Dr. Pierce explained that there was insufficient data to create meaningful change.
“It usually takes 2–3 months after submitting our data before we receive reports from CMS, and often the reports don’t include all the information we’d like,” he said. “Most people who are delivering care for patients with sepsis want to know pretty quickly how things went if one of their patients developed the condition.”
Dr. Pierce, Huntley and a large coalition of invested colleagues have worked hard to create data sets for clinicians so they could see exactly how care was delivered for each patient. In the ED, a much more detailed sepsis management report has been in use for three months and often the team is now able to provide feedback in just a matter of days. A similar report for the inpatient group is being finalized.
The team’s second objective was to create groups of local clinical leaders and help them examine how sepsis care happens, propose ways to make care happen more efficiently and study how ideas about care either do or do not improve clinical outcomes.
“Often, a lot of data reported to CMS ultimately becomes attached to some sort of judgment of care, which may end up feeling like personal criticism,” Dr. Pierce said. “A big part of what we’ve tried to do is engage clinicians so they can look at data regularly and discuss how they—as a team—can improve the system to make it easier to provide the right care.”
This approach is having promising results. In the ED, the sepsis mortality rate is down to 7% from a baseline of 9% and patients with sepsis often now receive antibiotics within two hours. The team is hopeful the inpatient group will see similar results with time.
“In each group, this initiative is bringing people together to collaborate on how best to deliver care, enabling them to debrief after the care has been provided and then helping them use data about the care process to drive future improvements,” Dr. Pierce said.
A key factor behind this success is the sepsis alert in Epic. Providers can trigger the alert when a patient exhibits two or more changes in vital signs and there is suspicion of an infection. Once triggered, clinicians follow a set procedure to confirm whether sepsis is present. The alert has been live for nearly a year but has undergone several improvements in recent months. Health care teams are now calling 2–5 sepsis alerts each week.
Over the next 6–12 months, Huntley and Dr. Pierce aim to refine the sepsis alert further and to achieve measurable and sustained improvements in key steps of care, such as how quickly patients with sepsis receive antibiotics and fluids.
“Every time we speak with people about sepsis, we hear they want more data, more information,” Dr. Pierce said. “The sorts of information we are creating allow us to have a different kind of conversation, which in turns helps us to achieve better and more reliable care.”
For Huntley, it’s vital that the team continues these conversations with every clinician involved in sepsis care.
“We’re working hard to improve this process and with each step I’m more excited about the future,” she said. “At UCH, our sepsis mortality rate already compares favorably to the national average, but we won’t stop until we’re the best.”
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