In 1997, Elizabeth McGlynn wrote, “Measuring quality is no simple task.”1 We are reminded of this seminal Health Affairs article at a very pertinent point—as health care practice progresses, measuring the impact of performance improvement initiatives on clinical care delivery remains integral to monitoring overall effectiveness of quality. Mortality outcomes are a major focus of quality.
Inpatient mortality within the Veterans Health Administration (VHA) was measured as actual number of deaths (unadjusted mortality), and adjusted mortality was calculated using the standardized mortality ratio (SMR). SMR included actual number of deaths during hospitalization or within 1 day of hospital discharge divided by predicted number of deaths using a risk-adjusted formula and was calculated separately for acute level of care (LOC) and the intensive care unit (ICU). Using risk-adjusted SMR, if an observed/expected ratio was > 1.0, there were more inpatient deaths than expected; if < 1.0, fewer inpatient deaths occurred than predicted; and if 1.0, observed number of inpatient deaths was equivalent to expected number of deaths.2
Mortality reduction is a complex area of performance improvement. Health care facilities often focus their efforts on the biggest mortality contributors. According to Dantes and Epstein, sepsis results in about 265,000 deaths annually in the United States.3 Reinhart and colleagues demonstrated that sepsis is a worldwide issue resulting in approximately 30 million cases and 6 million deaths annually.4 Furthermore, Kumar and colleagues have noted that when sepsis progresses to septic shock, survival decreases by almost 8% for each hour delay in sepsis identification and treatment.5
Improvements in sepsis management have been multifaceted. The Surviving Sepsis Campaign guidelines created sepsis treatment bundles to guide early diagnosis/treatment of sepsis.6 In addition to awareness and sepsis care bundles, a plethora of informatics solutions within electronic health record (EHR) systems have demonstrated improved sepsis care.7-16 Various approaches to early diagnosis and management of sepsis have been collectively referred to as an early warning sepsis system (EWSS).
An EWSS typically contains automated decision support tools that are integrated in the EHR and meant to assist health care professionals with clinical workflow decision-making. Automated decision support tools within the EHR have a variety of functions, such as clinical care reminders and alerts.17
Sepsis screening tools function as a form of automated decision support and may be incorporated into the EHR to support the EWSS. Although sepsis screening tools vary, they frequently include a combination of data involving vital signs, laboratory values and/or physical examination findings, such as mental status evaluation.The Modified Early Warning Signs (MEWS) + Sepsis Recognition Score (SRS) is one example of a sepsis screening tool.7,16
At Malcom Randall Veterans Affairs Medical Center (MRVAMC) in Gainesville, Florida, we identified a quality improvement project opportunity to improve sepsis care in the emergency department (ED) and inpatient wards using the VHA EHR system, the Computerized Patient Record System (CPRS), which is supported by the Veterans Information Systems and Technology Architecture (VistA).18 A VistA/CPRS EWSS was developed using Lean Six Sigma DMAIC (define, measure, analyze, improve, and control) methodology.19 During the improve stage, informatics solutions were applied and included a combination of EHR interventions, such as template design, an order set, and clinical reminders. Clinical reminders have a wide variety of use, such as reminders for clinical tasks and as automated decision support within clinical workflows using Boolean logic.
To the best of our knowledge, there has been no published application of an EWSS within VistA/CPRS. In this study, we outline the strategic development of an EWSS in VistA/CPRS that assisted clinical staff with identification and treatment of sepsis; improved documentation of sepsis when present; and associated with improvement in unadjusted and adjusted inpatient mortality.
