Often overlooked and more difficult to identify than many other life-threatening conditions, sepsis causes one-third to one-half of all deaths in U.S. hospitals, according to a 2014 JAMA study. “The data suggest this is maybe the most unmet need in public health right now,” says James M. O’Brien, MD, system vice president for quality and patient safety at OhioHealth in Columbus. “We have a condition that’s very common and we don’t have terribly high adherence to what is best practice.”
Giving focused attention to sepsis, which results from infection, can lower its devastating impact, experts say. In addition to being potentially fatal, it is a leading cause of unplanned hospital readmissions, as shown in a 2017 JAMA article, and billions of dollars in health care costs, according to the Centers for Disease Control and Prevention (CDC).
Academic medicine is finding ways to lower sepsis mortality by speeding up sepsis recognition and treatment. Some teaching hospitals and health care systems have recently instituted coordinated sepsis action plans with alerts from electronic health records (EHRs).
International clinical guidelines for sepsis assessment and treatment with antibiotics and fluids, along with evidence-based recommendations, have been updated three times, the latest in 2017. The CDC launched a campaign for health care providers to improve prevention, diagnosis, and treatment. At least four states have sepsis initiatives or legislation to reduce the condition’s toll.
“The data suggest this is maybe the most unmet need in public health right now. We have a condition that’s very common and we don’t have terribly high adherence to what is best practice.”
James M. O’Brien, MD
Such plans are vital, as sepsis continues to be a significant and deadly problem. “We know a lot of things that need to be done and some of them are not very complicated,” says Jonathan Sevransky, MD, professor of medicine at Emory University School of Medicine in Atlanta and coauthor of the international sepsis guidelines. “But actually getting people to identify the patients and successfully treating them early takes concerted effort, even if you know what to do.”
Developing best practices
From 70–86% of sepsis patients enter the hospital with the condition identified in the emergency department; others develop it or have it recognized after admission. There is no single diagnostic test for sepsis and symptoms can be similar to other conditions. When identification and appropriate treatment happen within a three-hour window, patient survival improves.
At the University of Colorado Hospital in Aurora, a team working to improve sepsis care noted that it took an average of five hours to provide antibiotics after sepsis was recognized in admitted patients. “We know for every hour you wait beyond the realization that it’s probably sepsis, mortality climbs significantly,” says Read G. Pierce, MD, an assistant professor of medicine at the University of Colorado School of Medicine and associate director of the Institute for Healthcare Quality, Safety, and Efficiency at University of Colorado Health.
Pierce and Nicole Huntley, RN, the hospital’s sepsis coordinator, cochaired a committee that found delays were caused by complexity in the hospital care process. Physicians and other team members would arrive separately to conduct tasks such as symptom assessment, blood draws, lab test orders, and other care steps. In addition, although the EHR system had alerts for deteriorating conditions in patients, there was no warning solely for sepsis, Pierce notes.
After meeting with frontline clinicians and hospital staff, the committee developed a new sepsis diagnosis and treatment checklist, which they turned into a sepsis-specific alert system in the EHR. They also created a team care approach, to bring the patient’s nurse and a sepsis team (resource nurse, physician, and pharmacist) to the bedside together.
A nine-month pilot of the new system in four hospital units cut time to treatment from five hours to 73 minutes, and sepsis mortality dropped 15%. The approach went hospital-wide in September 2017. The sepsis alert system is now being standardized across the entire University of Colorado health system.
“We know for every hour you wait beyond the realization that it’s probably sepsis, mortality climbs significantly.”
Read G. Pierce, MD
University of Colorado Health
Emory University Hospital has taken a similar approach, using an electronic trigger system, engaging the patient’s physician and a bedside team of sepsis specialists, including a phlebotomist to make timely blood draws. Because various departments were using different sepsis protocols, Sevransky says, planners saw the need for health care providers to work together better and to follow a standardized order set in most cases.
Emory uses a three-hour bundle of tests and treatments that developed from the international sepsis guidelines and have been proven effective. “The purpose of the bundle is to make sure that the clinician thinks hard about delivering each particular item to the patient. The overwhelming majority of patients will need those and should get them,” Sevransky explains.
The 11 OhioHealth hospitals range from Riverside Methodist Hospital in Columbus, a large teaching institution, to small rural hospitals. “You can’t take a cookie-cutter approach to fixing problems with sepsis in each of those places,” says O’Brien. The system established consistent sepsis care standards but individual campuses evaluated their own problems to find ways to improve.
The program began in mid-2015, when sepsis mortality at Riverside was 25.2% and 24% system-wide. Just over two years later, sepsis mortality was 21.2% at Riverside and 17.8% system-wide.
“We estimate we’ve saved about 248 lives,” notes O’Brien, who also is an adviser to an Ohio Hospital Association sepsis initiative. “Any improvement is Ohioans alive tomorrow who would have died in the past.”
Bringing learners into sepsis care
Residents and fellows, often the frontline physicians for patients, are being trained to better identify the signs of sepsis and monitor conditions. Fellows have joined sepsis project teams at hospitals and some have written abstracts about their work.
Graduate medical education (GME) learners are included along with nurses and medical directors when the University of Colorado gives instruction in the new sepsis approach. To improve outcomes, training has to reach “the many hundreds of residents and fellows who are rotating in our hospitals every month,” says Pierce.
OhioHealth hospitals engage residents through patient simulations showing actions that quicken sepsis recognition and treatment. O’Brien believes medical students should also learn more about sepsis.
“In medical school, I had an hour of education about sepsis and I had an hour of education about Creutzfeldt-Jakob disease [“mad cow” disease], which I’ll probably never see,” he says. “There absolutely needs to be a greater balance in early medical school training about things they’re actually going to see in practice and in the hospital.”