Project provides simplified approach to sepsis for rural hospitals

ATLANTA – A Kansas-based program that aims to improve sepsis-related outcomes in rural hospital settings is proving successful and could serve as a model for rural hospitals nationwide.

The program, known as "The Kansas Sepsis Project," was initiated by the Midwest Critical Care Collaborative, and focuses on a simplified approach to sepsis resuscitation for the purpose of reducing sepsis mortality, Dr. Steven Q. Simpson reported at the annual meeting of the American College of Chest Physicians.

Sepsis affects more than 10,000 Kansans each year, and the sepsis-related mortality rate is 30%-50% in most Kansas hospitals, which exceeds the mortality rate associated with acute myocardial infarction, said Dr. Simpson of the University of Kansas Medical Center, Kansas City.

One goal of the sepsis project is to reduce that rate by 10% by the end of 2015.

According to the Midwest Critical Care Collaborative website, a 20% reduction is possible if specific plans for recognition and treatment as outlined by the project are put in place.

The project, which is open to any interested facility including those not based in Kansas, involves baseline surveys, live and online training, ongoing data collection and analysis, formation of performance improvement planning based on those analyses, and – hopefully – changed behavior and reduced sepsis mortality, said Dr. Simpson.

The website states that participants learn to:

• Recognize cardinal features of severe sepsis.

• Initiate rapid, organized care for severe sepsis.

• Evaluate in-house data for recognizing and caring for severe sepsis patients.

• Initiate a performance improvement program, and improve outcomes for patients with severe sepsis.

Participants also have access to useful Web-based tools, such as a severe sepsis screener and a severe sepsis tracker for small hospitals, both of which help to ensure that proper protocols are followed, and that data are tracked.

A severe sepsis protocol for emergency management in small, referring hospitals states that whenever possible, nine steps should be completed within 2 hours for patients with infection, systemic inflammatory response syndrome, and dysfunction of one or more organs. The steps are, if possible:

• Draw blood for serum lactate measurement.

• Draw two sets of blood cultures – before antibiotics are initiated, if possible; however, do not delay antibiotics for the sake of completing this step.

• Start two peripheral intravenous lines (use 18 gauge or larger).

• Initiate broad-spectrum antibiotics as soon as possible.

• Give 2 L of normal saline solution or lactated Ringer’s solution, wide open.

• Draw blood for a complete blood count with a differential, basic chemistry panel if this has not already been done.

• Administer supplemental oxygen to maintain oxygen saturation measured by pulse oximeter above 90%.

• Initiate norepinephrine or dopamine if shock is present. This maintains a mean arterial pressure of 65 mm Hg or greater. Continue intravenous crystalloid at 250 mL/hr.

• Transfer the patient if serum lactate is 4 mmol/L or greater, if systolic blood pressure remains below 90 mm Hg, or if mean arterial pressure is less than 60 mm Hg after 2 L of crystalloid. Place a central venous catheter only if this can be accomplished without delaying transfer.

Following this protocol and using the tools available through the project is leading to dramatic improvements in outcomes. At one hospital, for example, a review of 67 charts from 2009 and 2010 revealed that of 28 cases that met criteria for sepsis, none was identified as such.

Since the hospital entered the project, an additional 61 patients screened positive. Of those, 59 had the severe sepsis tracker completed, 56 had blood cultures drawn prior to administration of broad-spectrum antibiotics, and 57 received broad-spectrum antibiotics within 1 hour of presentation.

Additionally, 22 of the 59 patients for whom the severe sepsis tracker was completed had hypotension, and 18 of those received a 20-mL/kg fluid bolus within 2 hours of diagnosis.

Overall, 54 of the 59 patients who had the severe sepsis tracker completed survived their hospitalization. Only 2 of 35 patients with severe sepsis (5.7%) required transfer to a larger facility because of deterioration in their condition, compared with 7 of 28 patients (25%) in the group from the 2009-2010 preproject chart review.

Numerous states across the United States, especially in the Midwest and Northwest, have rural populations of less than 86 per square mile, similar to Kansas, with 1.330 small facilities serving rural populations located many miles from the nearest referral hospital, and could benefit from this approach to sepsis resuscitation, Dr. Simpson said.

The need for attention to the problem of sepsis is apparent not only based on the high mortality rates, but also in the outcomes of focus group research showing that only 42% of responding physicians from rural settings consider themselves to be "very knowledgeable" about sepsis diagnosis, treatments, and complications; while the same percentage consider themselves "not too knowledgeable," 4% say they are not at all knowledgeable, and 12% say they aren’t sure how knowledgeable they are, he said.

Similarly, only 2% of respondents said they are extremely knowledgeable about the differences among uncomplicated sepsis, severe sepsis, and septic shock; 27% said they are very knowledgeable; 61% said they are not too knowledgeable; 4% said they are not at all knowledgeable; and 6% said they are unsure how knowledgeable they are.

Few respondents were familiar with the Early Goal-Directed Therapy protocol or the Surviving Sepsis Campaign, and most admitted that the likelihood of missed sepsis diagnoses is high at their institution.

Most (about 85%) agreed that additional training would be extremely beneficial.

Although several challenges and hurdles exist with respect to improving sepsis outcomes in rural settings, including staffing issues, the lack of recognition of the extent of the problem, and the fact that sepsis is not yet a Joint Commission core measure, the results thus far of the Kansas Sepsis Project suggest positive change is within reach, Dr. Simpson said.

For more information about the project, click here.

The Kansas Sepsis Project is supported by the One Breath Foundation in the form of the Third Eli Lilly Distinguished Scholar in Critical Care Medicine Award. Dr. Simpson reported having no relevant financial disclosures.

ATLANTA – A Kansas-based program that aims to improve sepsis-related outcomes in rural hospital settings is proving successful and could serve as a model for rural hospitals nationwide.

The program, known as "The Kansas Sepsis Project," was initiated by the Midwest Critical Care Collaborative, and focuses on a simplified approach to sepsis resuscitation for the purpose of reducing sepsis mortality, Dr. Steven Q. Simpson reported at the annual meeting of the American College of Chest Physicians.

Sepsis affects more than 10,000 Kansans each year, and the sepsis-related mortality rate is 30%-50% in most Kansas hospitals, which exceeds the mortality rate associated with acute myocardial infarction, said Dr. Simpson of the University of Kansas Medical Center, Kansas City.

One goal of the sepsis project is to reduce that rate by 10% by the end of 2015.

According to the Midwest Critical Care Collaborative website, a 20% reduction is possible if specific plans for recognition and treatment as outlined by the project are put in place.

The project, which is open to any interested facility including those not based in Kansas, involves baseline surveys, live and online training, ongoing data collection and analysis, formation of performance improvement planning based on those analyses, and – hopefully – changed behavior and reduced sepsis mortality, said Dr. Simpson.

The website states that participants learn to:

• Recognize cardinal features of severe sepsis.

• Initiate rapid, organized care for severe sepsis.

• Evaluate in-house data for recognizing and caring for severe sepsis patients.

• Initiate a performance improvement program, and improve outcomes for patients with severe sepsis.

Participants also have access to useful Web-based tools, such as a severe sepsis screener and a severe sepsis tracker for small hospitals, both of which help to ensure that proper protocols are followed, and that data are tracked.

A severe sepsis protocol for emergency management in small, referring hospitals states that whenever possible, nine steps should be completed within 2 hours for patients with infection, systemic inflammatory response syndrome, and dysfunction of one or more organs. The steps are, if possible:

• Draw blood for serum lactate measurement.

• Draw two sets of blood cultures – before antibiotics are initiated, if possible; however, do not delay antibiotics for the sake of completing this step.

• Start two peripheral intravenous lines (use 18 gauge or larger).

• Initiate broad-spectrum antibiotics as soon as possible.

• Give 2 L of normal saline solution or lactated Ringer’s solution, wide open.

• Draw blood for a complete blood count with a differential, basic chemistry panel if this has not already been done.

• Administer supplemental oxygen to maintain oxygen saturation measured by pulse oximeter above 90%.

• Initiate norepinephrine or dopamine if shock is present. This maintains a mean arterial pressure of 65 mm Hg or greater. Continue intravenous crystalloid at 250 mL/hr.

• Transfer the patient if serum lactate is 4 mmol/L or greater, if systolic blood pressure remains below 90 mm Hg, or if mean arterial pressure is less than 60 mm Hg after 2 L of crystalloid. Place a central venous catheter only if this can be accomplished without delaying transfer.

Following this protocol and using the tools available through the project is leading to dramatic improvements in outcomes. At one hospital, for example, a review of 67 charts from 2009 and 2010 revealed that of 28 cases that met criteria for sepsis, none was identified as such.

Since the hospital entered the project, an additional 61 patients screened positive. Of those, 59 had the severe sepsis tracker completed, 56 had blood cultures drawn prior to administration of broad-spectrum antibiotics, and 57 received broad-spectrum antibiotics within 1 hour of presentation.

Additionally, 22 of the 59 patients for whom the severe sepsis tracker was completed had hypotension, and 18 of those received a 20-mL/kg fluid bolus within 2 hours of diagnosis.

Overall, 54 of the 59 patients who had the severe sepsis tracker completed survived their hospitalization. Only 2 of 35 patients with severe sepsis (5.7%) required transfer to a larger facility because of deterioration in their condition, compared with 7 of 28 patients (25%) in the group from the 2009-2010 preproject chart review.

Numerous states across the United States, especially in the Midwest and Northwest, have rural populations of less than 86 per square mile, similar to Kansas, with 1.330 small facilities serving rural populations located many miles from the nearest referral hospital, and could benefit from this approach to sepsis resuscitation, Dr. Simpson said.

The need for attention to the problem of sepsis is apparent not only based on the high mortality rates, but also in the outcomes of focus group research showing that only 42% of responding physicians from rural settings consider themselves to be "very knowledgeable" about sepsis diagnosis, treatments, and complications; while the same percentage consider themselves "not too knowledgeable," 4% say they are not at all knowledgeable, and 12% say they aren’t sure how knowledgeable they are, he said.

Similarly, only 2% of respondents said they are extremely knowledgeable about the differences among uncomplicated sepsis, severe sepsis, and septic shock; 27% said they are very knowledgeable; 61% said they are not too knowledgeable; 4% said they are not at all knowledgeable; and 6% said they are unsure how knowledgeable they are.

Few respondents were familiar with the Early Goal-Directed Therapy protocol or the Surviving Sepsis Campaign, and most admitted that the likelihood of missed sepsis diagnoses is high at their institution.

Most (about 85%) agreed that additional training would be extremely beneficial.

Although several challenges and hurdles exist with respect to improving sepsis outcomes in rural settings, including staffing issues, the lack of recognition of the extent of the problem, and the fact that sepsis is not yet a Joint Commission core measure, the results thus far of the Kansas Sepsis Project suggest positive change is within reach, Dr. Simpson said.

For more information about the project, click here.

The Kansas Sepsis Project is supported by the One Breath Foundation in the form of the Third Eli Lilly Distinguished Scholar in Critical Care Medicine Award. Dr. Simpson reported having no relevant financial disclosures.

ATLANTA – A Kansas-based program that aims to improve sepsis-related outcomes in rural hospital settings is proving successful and could serve as a model for rural hospitals nationwide.

The program, known as "The Kansas Sepsis Project," was initiated by the Midwest Critical Care Collaborative, and focuses on a simplified approach to sepsis resuscitation for the purpose of reducing sepsis mortality, Dr. Steven Q. Simpson reported at the annual meeting of the American College of Chest Physicians.

Sepsis affects more than 10,000 Kansans each year, and the sepsis-related mortality rate is 30%-50% in most Kansas hospitals, which exceeds the mortality rate associated with acute myocardial infarction, said Dr. Simpson of the University of Kansas Medical Center, Kansas City.

One goal of the sepsis project is to reduce that rate by 10% by the end of 2015.

According to the Midwest Critical Care Collaborative website, a 20% reduction is possible if specific plans for recognition and treatment as outlined by the project are put in place.

The project, which is open to any interested facility including those not based in Kansas, involves baseline surveys, live and online training, ongoing data collection and analysis, formation of performance improvement planning based on those analyses, and – hopefully – changed behavior and reduced sepsis mortality, said Dr. Simpson.

The website states that participants learn to:

• Recognize cardinal features of severe sepsis.

• Initiate rapid, organized care for severe sepsis.

• Evaluate in-house data for recognizing and caring for severe sepsis patients.

• Initiate a performance improvement program, and improve outcomes for patients with severe sepsis.

Participants also have access to useful Web-based tools, such as a severe sepsis screener and a severe sepsis tracker for small hospitals, both of which help to ensure that proper protocols are followed, and that data are tracked.

A severe sepsis protocol for emergency management in small, referring hospitals states that whenever possible, nine steps should be completed within 2 hours for patients with infection, systemic inflammatory response syndrome, and dysfunction of one or more organs. The steps are, if possible:

• Draw blood for serum lactate measurement.

• Draw two sets of blood cultures – before antibiotics are initiated, if possible; however, do not delay antibiotics for the sake of completing this step.

• Start two peripheral intravenous lines (use 18 gauge or larger).

• Initiate broad-spectrum antibiotics as soon as possible.

• Give 2 L of normal saline solution or lactated Ringer’s solution, wide open.

• Draw blood for a complete blood count with a differential, basic chemistry panel if this has not already been done.

• Administer supplemental oxygen to maintain oxygen saturation measured by pulse oximeter above 90%.

• Initiate norepinephrine or dopamine if shock is present. This maintains a mean arterial pressure of 65 mm Hg or greater. Continue intravenous crystalloid at 250 mL/hr.

• Transfer the patient if serum lactate is 4 mmol/L or greater, if systolic blood pressure remains below 90 mm Hg, or if mean arterial pressure is less than 60 mm Hg after 2 L of crystalloid. Place a central venous catheter only if this can be accomplished without delaying transfer.

Following this protocol and using the tools available through the project is leading to dramatic improvements in outcomes. At one hospital, for example, a review of 67 charts from 2009 and 2010 revealed that of 28 cases that met criteria for sepsis, none was identified as such.

Since the hospital entered the project, an additional 61 patients screened positive. Of those, 59 had the severe sepsis tracker completed, 56 had blood cultures drawn prior to administration of broad-spectrum antibiotics, and 57 received broad-spectrum antibiotics within 1 hour of presentation.

Additionally, 22 of the 59 patients for whom the severe sepsis tracker was completed had hypotension, and 18 of those received a 20-mL/kg fluid bolus within 2 hours of diagnosis.

Overall, 54 of the 59 patients who had the severe sepsis tracker completed survived their hospitalization. Only 2 of 35 patients with severe sepsis (5.7%) required transfer to a larger facility because of deterioration in their condition, compared with 7 of 28 patients (25%) in the group from the 2009-2010 preproject chart review.

Numerous states across the United States, especially in the Midwest and Northwest, have rural populations of less than 86 per square mile, similar to Kansas, with 1.330 small facilities serving rural populations located many miles from the nearest referral hospital, and could benefit from this approach to sepsis resuscitation, Dr. Simpson said.

The need for attention to the problem of sepsis is apparent not only based on the high mortality rates, but also in the outcomes of focus group research showing that only 42% of responding physicians from rural settings consider themselves to be "very knowledgeable" about sepsis diagnosis, treatments, and complications; while the same percentage consider themselves "not too knowledgeable," 4% say they are not at all knowledgeable, and 12% say they aren’t sure how knowledgeable they are, he said.

Similarly, only 2% of respondents said they are extremely knowledgeable about the differences among uncomplicated sepsis, severe sepsis, and septic shock; 27% said they are very knowledgeable; 61% said they are not too knowledgeable; 4% said they are not at all knowledgeable; and 6% said they are unsure how knowledgeable they are.

Few respondents were familiar with the Early Goal-Directed Therapy protocol or the Surviving Sepsis Campaign, and most admitted that the likelihood of missed sepsis diagnoses is high at their institution.

Most (about 85%) agreed that additional training would be extremely beneficial.

Although several challenges and hurdles exist with respect to improving sepsis outcomes in rural settings, including staffing issues, the lack of recognition of the extent of the problem, and the fact that sepsis is not yet a Joint Commission core measure, the results thus far of the Kansas Sepsis Project suggest positive change is within reach, Dr. Simpson said.

For more information about the project, click here.

The Kansas Sepsis Project is supported by the One Breath Foundation in the form of the Third Eli Lilly Distinguished Scholar in Critical Care Medicine Award. Dr. Simpson reported having no relevant financial disclosures.