Award-winning program slashes sepsis mortalities
Award-winning program slashes sepsis mortalities
LOS drops, antibiotic administration rates up
In a campaign that earned it the prestigious Ernest Amory Codman Award from The Joint Commission, Christiana Care Health Services of Wilmington, DE, reduced the mortality rate for patients with severe sepsis from 61.7% to 30.2%.
While the initiative was a systemwide program, about 85% of the patients were treated in the ED. The program also achieved a 34% decrease in average length of stay (LOS), a 188.2% increase in the proportion of patients discharged to home, increases in patients receiving antibiotic therapy within the first hour before or after issuance of a sepsis alert, and decreased average time from triage to first antibiotic administration.
One of the primary tools of the Sepsis Alert program was the sepsis alert packet, which included:
- a care management guideline;
- a treatment algorithm;
- an ED treatment order set (see sample);
- kits with single-dose vials of antibiotics;
- multidisciplinary education about sepsis and the importance of prompt, aggressive management.
The guidelines were based on the international "Surviving Sepsis" program, notes Marc T. Zubrow, MD, director of critical care medicine and medical director of electronic care (eCare) for the Christiana system. The Surviving Sepsis Campaign, an initiative of the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine, has been developed to improve the management, diagnosis, and treatment of sepsis.
"I was sitting in a lecture and heard about Surviving Sepsis and realized that was exactly what we needed to do," recalls Zubrow, who himself had been campaigning for a more systematic approach to treating sepsis. Management quickly approved part-time administrative assistants, plus the printing of posters and information sheets. "We were off to the races," he says. Zubrow says the program cost less than $10,000.
Key elements lacking
What was lacking in the existing system was a well-defined process, Zubrow says. "First and most important was the identification of the patient population," he notes.
This process involved educating nurses and physicians to recognize the main SIRS (Systemic Inflammatory Response Syndrome) criteria, which involve the following factors: respiratory rate, heart rate, white blood cell count, and temperature. "If they meet two or more of the criteria, they should be looked at very seriously and in a time-dependent fashion," says Zubrow.
Emergency medicine professionals often talk about the "golden hour" for treating heart attacks and strokes, but that term has been less well defined for sepsis, he says. "Now we have strict criteria and hard objectives," Zubrow explains.
In addition to reinforcing the message that care was time-dependent, the program also standardized care. "Prior to this systematic approach, patient care was dependent on the individual physician," Zubrow notes. "One doctor might have put a patient on antibiotics and said, 'Call me in the morning,' where if he had been more aggressive on the front end, the patient might not have gotten as sick as they did."
This standardized care also resulted in streamlined care, he says. "We told everyone that this was the right way to do it," Zubrow notes. "Once we had success, the numbers were so overwhelming [in terms of reducing the mortality rate], it became a very positive thing."
Tom Sweeney, MD, FACEP, vice chair of emergency medicine, says one of the keys to getting physicians and nurses on board "was making the connection for them that this was just another logical step in our central work of identifying sick people and resuscitating them."
That message, and an overview of the program, was presented in departmental meetings, the residency training program, educational conferences, via e-mail, and on posters that sketched out the early goal-directed therapy. "Once we began implementing the protocol, we gave individual follow-up through our performance improvement program," says Sweeney. "We let people know if they had done a good job and, if not, we let them know how it could have been done better."
For the first three years of the program, the system provided a full-time person from the performance improvement department to the Sepsis Alert Committee to review charts. The committee, which oversaw and coordinated the various aspects of the initiative, included director of critical care medicine/ECare; directors of medical and surgical critical care units; vice chair of emergency medicine; nurses from the medical intensive care unit and ED; residents from emergency medicine, internal medicine, and surgery; the performance improvement coordinator; a hospital data analysis expert; and a pharmacy representative.
"Now, we only do a 10% case review, but the program is mature enough, we really don't need any more than that," says Sweeney.
The program unfolded "in gradual fashion," Sweeney explains. "First, we needed to make the central line and measurement of central venous pressure common practice. Once we had that down, we could put more emphasis on measurement of venous oxygen saturation." This emphasis, he notes, required close coordination with the nursing staff.
"We had to put a lot of emphasis on identification of sepsis patients from the standpoint of sending lactates on patients who had SIRS," he says. "We went from not measuring lactates at all to doing it commonly." When chart reviews showed that not all providers were doing that, "we had to go back to them and stress the importance of lactate levels," Sweeney says.
Emphasis also was placed on early antibiotics and making sure cultures were done before antibiotics were given. "That dovetailed nicely with our efforts to get antibiotics quickly to pneumonia patients, so we got a double bang for our buck," Sweeney says.
For more information on the Surviving Sepsis program, go to: www.survivingsepsis.org.In a campaign that earned it the prestigious Ernest Amory Codman Award from The Joint Commission, Christiana Care Health Services of Wilmington, DE, reduced the mortality rate for patients with severe sepsis from 61.7% to 30.2%.
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