There are many good reasons for a quality manager to focus on sepsis data collection and quality improvement (QI), but the most important one is that patients — even those who were recently in optimal health — can die from sepsis if it’s not diagnosed early. Around 750,000 U.S. adults have sepsis each year, and 30% to 35% of them die from the condition.
Middlesex Hospital in Middletown, CT, had 41 patients with a sepsis diagnosis who died in 2013.1
Although the hospital’s sepsis mortality rate was below state and national rates, the hospital’s rapid response review committee decided to initiate a quality improvement initiative to reduce the rate and improve sepsis care, says Terri Savino, MSN, RN, CPHQ, core measure specialist, quality improvement coordinator, and trauma coordinator at Middlesex Hospital. Savino, in October 2015, received the Luc R. Pelletier Healthcare Quality Award by the National Association for Healthcare Quality (NAHQ) for her project to implement evidence-based sepsis guidelines for early identification and treatment of sepsis.
“We had three cases that we classified as serious safety events, relative to a delay in recognition and treatment of sepsis,” Savino says. “We thought there was an opportunity to improve our care.”
The QI project resulted in a 20% reduction of severe sepsis mortality, with the rate falling from 5.6% to 4.5% within one year. There were an estimated 25 lives saved during the first year after implementation and sepsis length of stay decreased 5% in one year.1
“We had a national speaker from New York come into grand rounds,” Savino says. “He recommended that we measure not just sepsis mortality, but all hospital mortality, and that we look at the number of sepsis diagnoses, and we did.”
When the sepsis committee reviewed the length of stay related to sepsis diagnoses, the committee saw that there was a 5% decrease in sepsis length of stay because of the improvements.
Making such a change requires stakeholder involvement, especially executive leadership sponsorship, she notes.
“We had our vice president of patient safety and quality with us at the meetings, and he fully supported it,” Savino says.
The first step involved creating an Interprofessional Sepsis Task Force that met weekly from September 2013, through February 2014. The task force included physicians and representatives from laboratory and pharmacy.
“First we looked at the literature,” Savino says.
The task force also reviewed data involving patient outcomes and safety. “Everything comes down to the patient,” Savino says.
But collecting data is only the beginning.
“If you collect all this data and don’t do anything with it, you won’t see improvements,” Savino says. “We give this data back monthly and quarterly to managers and staff.”
The task force recommended the hospital make these three major changes:
1. Use Surviving Sepsis Guidelines. The International Guidelines for Management of Severe Sepsis and Septic Shock, updated several years ago, include details about screening for sepsis, treatment, supportive therapy, pediatric considerations, references, and future directions.
“We hadn’t updated our clinical pathway, so we wanted to make sure our pathway was updated, and we did that in December 2013,” Savino notes.
2. Hospital-wide sepsis education. The task force recommended educating nurses, physicians, and others on the signs and symptoms of sepsis and what needs to be done within three hours and within six hours, Savino says.
3. Early warning system for sepsis. The hospital’s electronic medical record (EMR) can be used to gather patient data continuously and provide an early warning system alert for sick patients at risk of sepsis. The nurse or emergency department physician receives an alert when the system finds the following risk factors:
- three signs of systemic inflammatory response syndrome (SIRS), or
- two signs of SIRS and one sign of organ dysfunction (sepsis).
“The early warning system rolled out in February 2014,” Savino says.
Within a few months of the hospital implementing the changes, data showed improvement. In the most recent report for October 2015, the hospital had gone 20 months with zero serious safety events (SSE) related to diagnosis and treatment of sepsis. The last SSE was in February 2014, and there were the three SSEs in 2013.
“The other interesting data that came out of this, and which we were not expecting, was that we actually saw a reduction in our patients who were transferred to a higher level of care,” Savino says.
Including all patients — not just those with sepsis — transferred to a higher level of care, the percentage declined from 43.9% to 29.3% over a 12-month period, Savino says.
“Just by implementing all of our improvements, including the early warning system, we identify sicker patients faster,” she explains. “It’s not just sepsis, but it’s alerting us to all sick patients.”
Savino discovered this correlation when collecting data for the rapid response team. “Monthly, we look at the number of patients transferred to a higher level of care, and as I was reporting that data, a lightbulb went off,” she says. “I checked the data and saw that the transfers had decreased since we implemented the early warning system.”
The sepsis education required staff buy-in, and the committee used sepsis case studies to help engage staff.
“We told a story of sepsis,” Savino says. “It can sometimes be challenging; I try to get the front line staff involved because they are the ones out there caring for patients, and they’re the ones who can recognize changes.”
It helps to have nurse educators and staff nurses on the team educating staff. “They can add details and answer questions,” Savino notes.
One nationally known story involves the case of a 12-year-old New York boy named Rory, who developed sepsis after a cut from a fall in the gym, she says.
Savino highlights the importance of hospitals focusing QI efforts on sepsis with Rory’s tragic story: Within a few days of his fall, Rory had a fever, vomiting, weakness, and leg pain, which were misdiagnosed as stomach flu and pain from his fall. He was discharged from the emergency department, only to become sicker at home. By the time he returned to the New York hospital, it was too late as the infection had overwhelmed his body, killing him.
In another story, a patient who was seen in the ED after a drug overdose vomited, aspirated, and developed a lung infection. ED doctors and nurses were focused on treating the patient’s overdose and missed the earliest signs of sepsis, Savino says.
Once the sepsis changes were implemented, QI efforts focused on measuring success and making continuous improvements, as needed.
The hospital began to focus on a three-hour bundle in which medical staff would have to make sure that a list of actions were taken within three hours of the patient’s sepsis diagnosis.
As an incentive, nurses and staff who follow the three-hour bundle consistently receive a sepsis star, followed by a congratulatory email.
“Everyone wants to be on that list now,” Savino notes.
As of Jan. 1, 2016, the hospital will reward employees who follow the new sepsis core measures by the Centers for Medicare & Medicaid Services (CMS). These include a six-hour bundle that is a little more challenging, she says.
Also, the hospital is continuing with sepsis education for new staff and with reminders, including a Surviving Sepsis Campaign badge holder, for existing staff.
- Savino T, Connelly M, Cosentino D. Using technology to improve sepsis care. Poster published in 2015 by Middlesex Hospital, Middletown, CT.
- Terri Savino, MSN, RN, CPHQ, Core Measure Specialist, Quality Improvement Coordinator, Middlesex Hospital, Middletown, CT. Telephone: (860) 358-3026. Email: firstname.lastname@example.org.