EXECUTIVE SUMMARY

For the past six years, The Joint Commission’s (TJC) Center for Transforming Healthcare (CTH) has been working with health system partners to identify the root causes for sepsis mortality as well as solutions that will address these problems effectively. In the process, participating organizations have reduced their own sepsis mortality rates by a collective 25%, although some organizations have made even greater strides. The work with CTH will culminate in a Targeted Solutions Tool that will enable all accredited hospitals to take on the issue in their own settings.

  • While most sepsis improvement efforts have focused on severe sepsis and septic shock, CTH leaders decided to aim their project more broadly, focusing on sepsis, severe sepsis, and septic shock, recognizing that many deaths occur among patients with sepsis and severe sepsis.
  • Finding out that 90% of their sepsis cases were present on admission and came into the hospital through the ED, Texas Health Plano developed an early recognition tool and a process for responding to sepsis cases. The approach enabled the hospital to cut its sepsis mortality rate by half.
  • Investigators at Roseville Medical Center in Roseville, CA, identified which groups of sepsis patients could be managed safely outside the ICU, improving resource management while also preserving quality care.

While sharing solutions can offer great benefits, investigators working in concert with The Joint Commission’s (TJC) Center for Transforming Healthcare (CTH) have learned that making headway against sepsis mortality requires individual hospitals to go through a detailed process of self-examination first.

“It is important that organizations drill down to the specific root causes for why sepsis is not recognized and/or why the sepsis bundle elements are not being done in a timely manner. This will help them focus their solutions on those barriers to timely recognition and treatment,” explains Kelly Barnes, project lead for CTH’s multiyear effort aimed at reducing sepsis mortality.

Barnes notes that hospitals can conduct this examination in multiple ways. For example, they can collect data in real time when they identify a patient with sepsis within 24 hours of presenting to the hospital. Typically, this would involve speaking to all the clinicians involved in the patient’s care to determine why specific sepsis bundle elements may not have been completed.

“They can also collect data retrospectively, in which case they would meet with the nurses and physicians and identify a list of common causes or barriers to bundle element compliance or sepsis recognition,” Barnes explains.

It is painstaking work, but the approach has enabled the participating organizations in CTH’s reducing sepsis mortality project to target solutions toward their own root causes, reducing sepsis by nearly 25% in the aggregate. So far, participants have been able to sustain their improvements.

The five hospital systems involved at the start of the project in 2012 include Atlantic Health System (Morristown, NJ), Floyd Medical Center (Rome, GA), Kaiser Permanente (Oakland, CA), Northwell Health at Staten Island University Hospital (New York), and Texas Health Resources (Arlington, TX).

Barnes notes that while the top two identified root causes for lack of bundle element compliance were lack of recognition and staff not following a hospital’s established protocol when a patient was diagnosed with sepsis, the hospital systems collectively uncovered 40 distinct root causes. Each hospital identified its own specific set of root causes to address.

Interestingly, while most sepsis improvement efforts have focused on severe sepsis and septic shock, CTH leaders decided to aim their project more broadly, focusing on sepsis, severe sepsis, and septic shock. Barnes explains this is because project teams determined that when looking at mortality, sepsis is just as important to catch and treat as severe sepsis and septic shock.

“While percentage-wise, septic shock patients have the highest mortality, the organizations on our project had far more sepsis and severe sepsis patients than they had septic shock patients,” she says. “There were more deaths by number for sepsis and severe sepsis patients because the volume of those patients was much higher than the volume of septic shock patients.”

Also, rather than prescribing a particular improvement process for each hospital to follow, each organization developed its own approach for taking on sepsis mortality. “Some organizations developed the project hospital-wide while others started in one area and expanded that across the organization or system over time,” Barnes says. “Our project was designed so that each organization could set the project up however it best fit for them.”

The chosen leadership team for each hospital’s improvement effort also was specific to the organization. “We had sepsis projects led by an organization’s quality improvement team, infection control specialist, ED physicians, and pharmacists,” says Banes. “It does not matter where the project is being led as long as you have the buy-in from leadership and staff involved in treating the sepsis patients.”

Drill Down

Stephen Hadzima, MD, MBA, chief medical officer for Texas Health Plano, notes that he and colleagues there discovered that the biggest opportunity for improvement was around identifying sepsis. “We had patients with sepsis, but we had never tried to figure out where they came from. Did they come out of the operating room, were they on the floors, or did they come through the ED?” Hadzima says. “First, we had to find out where the cases were. Then, we had to create a process.”

When investigators conducted their data analysis, they found that 90% of sepsis cases were present on admission and came through the ED. “We had no systematic approach for identifying [cases] in a timely fashion, much less than delivering a three-hour bundle after that point,” Hadzima says.

Consequently, the hospital focused on how they could identify the sepsis cases most effectively among all patients coming through the ED at the same time. “We developed a tool that was used on every single patient, whether they had chest pain, shortness of breath, or had fallen down and their ankle was swollen,” Hadzima reports. “We screened all patients with the tool essentially for systemic inflammatory response syndrome [SIRS].”

If the screen was positive, it triggered a code sepsis, at which point the patient was taken directly to a room in the back of triage. Then, the hospital completed a sepsis bundle in a timely fashion, Hadzima says.

When the sepsis project began, three-hour sepsis bundle compliance was somewhere in the 20% range. “After creating and implementing the screening tool and the process to get the patient to the appropriate level of care, three-hour bundle success ... went up to around 70% to 75%,” he says. “In the end, our sepsis mortality dropped by about 50%.”

While the approach has undergone continual refinements, the same basic process is still in place today. “In the ED, the code sepsis is called when [the screening tool] triggers at least two SIRS indicators in triage,” he says. “It is called by the triage nurse in the ED using our paging device.”

In response, an emergency physician, the charge nurse in the ED, and a bedside nurse will act. Staff from the lab and pharmacy will report to where the sepsis bundle will commence. “Then, we have a systematic approach in the room, making sure the physician is getting the basic history and confirming that, yes, there is a suspicion of sepsis,” Hadzima says.

This group takes blood cultures and starts fluids. Antibiotics are administered in a timely fashion, although Hadzima acknowledges that the approach is resource-intensive. “We call a code sepsis in the ED between three and five times a day, or roughly 100 to 150 times a month.”

Spread Best Practices

Thomas J. Russell, MD, sepsis clinical lead for Kaiser’s Northern California region and an emergency physician at Roseville Medical Center in Roseville, CA, was representing his hospital when CTH’s sepsis program was first launched. At the time, based on the strength of Kaiser Permanente’s extensive internal data, the hospital had implemented many improvements regarding the early recognition of sepsis that some other hospitals in the collaborative were working on.

“We recognized that we had a very solid approach for our septic shock patients, but we determined that with [patients] who had severe sepsis, our approach was much less organized. Yet, this population had a great number of deaths at our hospital,” Russell recalls. “We focused on putting in a treatment bundle based on some internal data we had used to derive the correct fluid amount.”

Throughout the improvement effort, investigators took pains to ensure they were not causing harm and that they were seeing benefits from the treatment bundle. “Most of our patients were getting some fluids even before we implemented [the new] bundle. Overall, our mortality went from 8.8% to 7.9%,” Russell reports.

Investigators also focused on a second piece in their sepsis work, this time concerning a growing trend of up-transferring patients in the hospital. “[Certain patients] would be admitted to med/surg or telemetry, and they would go to the ICU within 48 hours,” Russell says.

While studying the data, investigators sought to determine which sepsis patients could be managed outside the ICU safely, and they identified two such groups, Russell explains. The first group included septic shock patients with initial lactic acid readings higher than 4 mmol/L. Investigators found that if lactic acid levels decreased below 3 mmol/L or by 50%, then it was safe for these patients to placed somewhere other than the ICU. The second group that could move safely out of the ICU included patients who were no longer hypotensive and were not on vasopressors.

“With this information, we got together with our critical care folks and came up with an admission guideline that not only turned out to decrease ICU admissions, but in the long run it also decreased ICU days as well,” Russell says. “We don’t have the numbers yet to say this decreased mortality because the numbers are too small, but we would expect mortality to go down in that population as well.”

One tradeoff to implementation of the admission guideline was that length of stay in the ED increased by about one hour, but that was a tradeoff the hospital was willing to make, Russell notes.

Now that he is overseeing sepsis improvements across 21 facilities, Russell looks for processes that are going well at one and tries to apply those processes at others. However, he stresses that not every solution is a fit for all facilities. “A small facility that doesn’t have pulmonary critical care fellows cannot do the same sorts of solutions that a large facility that has a pulmonary critical care fellow in house 24/7 can do,” he warns.

Leverage Data

Ultimately, all the work partnering hospitals are conducting with CTH is aimed at producing a Targeted Solutions Tool, an online application that all accredited organizations can use to guide their hospitals or health systems through a sepsis project, Barnes explains.

“The organization will set up a project in the tool and enter data on sepsis recognition and bundle element compliance timing,” she says. “The tool will then analyze [the hospital’s] data for [administrators] and show them where in the process they are having issues with recognition and/or bundle element compliance.”

The tool will provide hospitals with a roadmap of sorts, including proven solutions that other organizations have used to solve the same issues. “The tool will also track [a hospital’s] mortality over time to compare baseline rates with improve rates,” Barnes adds. The Targeted Solutions Tool for sepsis mortality is expected to be available free of charge for TJC-accredited hospitals in 2019.

Hospitals interested in beginning the hard work of tackling their sepsis mortality rates in an effective way need to focus on collecting and analyzing their own data first, Barnes advises. “So many organizations request best practices from us. They want to know what other organizations are doing to combat sepsis, and then they want to take their tools and just implement them in their own organizations,” she says.

However, Barnes stresses the importance of understanding where in the process a hospital is struggling with recognition and bundle compliance. “For example, if an organization does not get its lactate results within three hours, is it because they ordered the lactates late, they drew the lactates late, or the results from the pharmacy were late?” she offers. “Only if you understand where things are going wrong can you target specific solutions that will address your biggest problems.”

SOURCES

  • Kelly Barnes, Project Lead, Reducing Sepsis Mortality, Joint Commission Center for Transforming Healthcare, Oakbrook Terrace, IL. Email: kbarnes@jointcommission.org.
  • Stephen Hadzima, MD, MBA, Chief Medical Officer, Texas Health Plano, Plano, TX. Email: stephenhadzima@texashealth.org.
  • Thomas J. Russell, MD, Sepsis Clinical Lead, Kaiser Permanente Northern California; Emergency Physician, Roseville Medical Center, Roseville, CA. Email: thomas.j.russell@kp.org.