Charting a new course in sepsis management

 

A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.

This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.

Every year, more than 1.5 million Americans develop sepsis – arising from the body’s overwhelming and self-destructive response to infection – and roughly 250,000 die from it. According to the Centers for Disease Control and Prevention, about one in three hospital deaths can be at least partially linked to sepsis.

Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.

The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.

Patients on the wards, though, usually begin with a nonsepsis diagnosis, which can produce an anchoring bias. Furthermore, Dr. Odden said, the data needed to identify sepsis may arrive asynchronously, increasingly the difficulty of pulling it all together for a timely diagnosis. As Dr. Horton points out, the trigger for transferring a decompensating sepsis patient from the wards to the ICU is murkier as well. “We don’t know what is too sick for the floor,” he said. “A lot of it is kind of a gestalt.”

Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.¹ “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
 

Dueling definitions

Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.

A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.² The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.

For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”

CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.

Hospitalist Lisa Shieh, MD, PhD, medical director of quality in the department of medicine at Stanford (Calif.) University Medical Center, said Sepsis-3 was never meant to be a screening tool. It can, however, help doctors identify patients at higher risk. Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the University of Pennsylvania, Philadelphia, said many providers agree that, at least theoretically, changes in a patient’s qSOFA score can predict bad outcomes better than SIRS criteria.

Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.

Another big issue is that sepsis screening still is based on early recognition, Dr. Shieh said. “The problem with Sepsis-3 is that it is later in the continuum of sepsis.” As such, she recommends sticking with the CMS definition for now. “It catches sepsis earlier, which is the whole strategy for improving sepsis mortality,” she said.
 

 

Reshaping sepsis pathways

So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.

At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.

As part of a QI effort led by an interdepartmental task force, the hospital first updated its inpatient and ED sepsis pathways to incorporate the Surviving Sepsis Campaign’s 2012 guidelines. “We continued to tweak our pathways, so they’ve now embedded other infection pathways into the sepsis pathway to make sure that we’re not missing anybody,” Ms. Savino said. The hospital also launched an early recognition and treatment educational effort targeting all health care staff and rolled out a new electronic early-warning system in February 2014.

In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.

Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.³ Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.

Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.

The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.

To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
 

Winning interdisciplinary buy-in

To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”

 

Dr. Horton and collaborator Kencee K. Graves, MD, an academic hospitalist at the University of Utah, Salt Lake City, agreed that “face time” was the best way to get buy-in throughout their hospital during their own QI initiative. “We spent a lot of time sitting and listening to concerns and feedback from providers,” Dr. Graves said. “We would then integrate some of their feedback into the process, so people they knew they were heard.” Securing the buy-in of nursing staff was another huge key to their success in improving the quality of sepsis care and reducing costs.⁴ “Honestly, they were the secret sauce of the whole project,” Dr. Horton said. Changing the culture in the hospital helped immensely but required considerable time and patience to build both trust and acceptance within different units.

Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.

No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.

Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
 

References

1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.

2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.

3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.

4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.

 

A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.

This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.

Every year, more than 1.5 million Americans develop sepsis – arising from the body’s overwhelming and self-destructive response to infection – and roughly 250,000 die from it. According to the Centers for Disease Control and Prevention, about one in three hospital deaths can be at least partially linked to sepsis.

Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.

The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.

Patients on the wards, though, usually begin with a nonsepsis diagnosis, which can produce an anchoring bias. Furthermore, Dr. Odden said, the data needed to identify sepsis may arrive asynchronously, increasingly the difficulty of pulling it all together for a timely diagnosis. As Dr. Horton points out, the trigger for transferring a decompensating sepsis patient from the wards to the ICU is murkier as well. “We don’t know what is too sick for the floor,” he said. “A lot of it is kind of a gestalt.”

Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.¹ “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
 

Dueling definitions

Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.

A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.² The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.

For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”

CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.

Hospitalist Lisa Shieh, MD, PhD, medical director of quality in the department of medicine at Stanford (Calif.) University Medical Center, said Sepsis-3 was never meant to be a screening tool. It can, however, help doctors identify patients at higher risk. Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the University of Pennsylvania, Philadelphia, said many providers agree that, at least theoretically, changes in a patient’s qSOFA score can predict bad outcomes better than SIRS criteria.

Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.

Another big issue is that sepsis screening still is based on early recognition, Dr. Shieh said. “The problem with Sepsis-3 is that it is later in the continuum of sepsis.” As such, she recommends sticking with the CMS definition for now. “It catches sepsis earlier, which is the whole strategy for improving sepsis mortality,” she said.
 

 

Reshaping sepsis pathways

So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.

At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.

As part of a QI effort led by an interdepartmental task force, the hospital first updated its inpatient and ED sepsis pathways to incorporate the Surviving Sepsis Campaign’s 2012 guidelines. “We continued to tweak our pathways, so they’ve now embedded other infection pathways into the sepsis pathway to make sure that we’re not missing anybody,” Ms. Savino said. The hospital also launched an early recognition and treatment educational effort targeting all health care staff and rolled out a new electronic early-warning system in February 2014.

In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.

Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.³ Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.

Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.

The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.

To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
 

Winning interdisciplinary buy-in

To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”

 

Dr. Horton and collaborator Kencee K. Graves, MD, an academic hospitalist at the University of Utah, Salt Lake City, agreed that “face time” was the best way to get buy-in throughout their hospital during their own QI initiative. “We spent a lot of time sitting and listening to concerns and feedback from providers,” Dr. Graves said. “We would then integrate some of their feedback into the process, so people they knew they were heard.” Securing the buy-in of nursing staff was another huge key to their success in improving the quality of sepsis care and reducing costs.⁴ “Honestly, they were the secret sauce of the whole project,” Dr. Horton said. Changing the culture in the hospital helped immensely but required considerable time and patience to build both trust and acceptance within different units.

Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.

No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.

Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
 

References

1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.

2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.

3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.

4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.

 

A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.

This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.

Every year, more than 1.5 million Americans develop sepsis – arising from the body’s overwhelming and self-destructive response to infection – and roughly 250,000 die from it. According to the Centers for Disease Control and Prevention, about one in three hospital deaths can be at least partially linked to sepsis.

Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.

The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.

Patients on the wards, though, usually begin with a nonsepsis diagnosis, which can produce an anchoring bias. Furthermore, Dr. Odden said, the data needed to identify sepsis may arrive asynchronously, increasingly the difficulty of pulling it all together for a timely diagnosis. As Dr. Horton points out, the trigger for transferring a decompensating sepsis patient from the wards to the ICU is murkier as well. “We don’t know what is too sick for the floor,” he said. “A lot of it is kind of a gestalt.”

Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.¹ “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
 

Dueling definitions

Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.

A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.² The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.

For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”

CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.

Hospitalist Lisa Shieh, MD, PhD, medical director of quality in the department of medicine at Stanford (Calif.) University Medical Center, said Sepsis-3 was never meant to be a screening tool. It can, however, help doctors identify patients at higher risk. Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the University of Pennsylvania, Philadelphia, said many providers agree that, at least theoretically, changes in a patient’s qSOFA score can predict bad outcomes better than SIRS criteria.

Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.

Another big issue is that sepsis screening still is based on early recognition, Dr. Shieh said. “The problem with Sepsis-3 is that it is later in the continuum of sepsis.” As such, she recommends sticking with the CMS definition for now. “It catches sepsis earlier, which is the whole strategy for improving sepsis mortality,” she said.
 

 

Reshaping sepsis pathways

So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.

At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.

As part of a QI effort led by an interdepartmental task force, the hospital first updated its inpatient and ED sepsis pathways to incorporate the Surviving Sepsis Campaign’s 2012 guidelines. “We continued to tweak our pathways, so they’ve now embedded other infection pathways into the sepsis pathway to make sure that we’re not missing anybody,” Ms. Savino said. The hospital also launched an early recognition and treatment educational effort targeting all health care staff and rolled out a new electronic early-warning system in February 2014.

In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.

Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.³ Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.

Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.

The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.

To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
 

Winning interdisciplinary buy-in

To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”

 

Dr. Horton and collaborator Kencee K. Graves, MD, an academic hospitalist at the University of Utah, Salt Lake City, agreed that “face time” was the best way to get buy-in throughout their hospital during their own QI initiative. “We spent a lot of time sitting and listening to concerns and feedback from providers,” Dr. Graves said. “We would then integrate some of their feedback into the process, so people they knew they were heard.” Securing the buy-in of nursing staff was another huge key to their success in improving the quality of sepsis care and reducing costs.⁴ “Honestly, they were the secret sauce of the whole project,” Dr. Horton said. Changing the culture in the hospital helped immensely but required considerable time and patience to build both trust and acceptance within different units.

Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.

No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.

Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
 

References

1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.

2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.

3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.

4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.