Sepsis bundle reduces hospital mortality from 61% to 24%

ED more quickly diagnoses sepsis

Community hospitals can implement an effective and successful sepsis bundle program despite some initial obstacles, including obtaining buy-in from physicians, a Plano, TX, hospital has shown.

The Medical Center of Plano implemented new sepsis bundles for both diagnosing suspected sepsis and treating severe sepsis in January, 2007, through a collaboration of the hospital's pharmacy department, intensive care unit (ICU), and emergency department (ED).

This effort resulted in the hospital reducing its overall sepsis mortality rate from 61.1% in 2006 to 24% by the end of 2007, say Gita Wasan Patel, RPh, PharmD, BCPS, clinical pharmacy coordinator, and Nicki Roderman, RN, MSN, CCRN, clinical nurse specialist for critical care at The Medical Center. The sepsis program received a 2009 award from the American Society of Health-System Pharmacists (ASHP).

The sepsis bundle also resulted in cost-avoidance, including a savings of about $500,000 from sepsis patients not spending time on ventilators and dialysis machines, as they would have had their disease been diagnosed and treated later as often occurred before the hospital began to use the order sets, Patel says.

"The bundle itself doesn't cost a whole lot of money, but by using it and diagnosing patients up front you can avoid all extraneous costs that go along with treating a sepsis patient," she adds.

Physician adherence to the sepsis diagnostic orders has increased from about 50% after the two years of implementation to 80% now, Roderman says.

The ED's compliance rate for using the diagnostic orders is 100%, and many physicians now follow the order sets' guidelines by memory, she notes.

But it took a while to get most of the hospital's community-based physicians on board, she notes.

"We had to collect a lot of data to show how it was working," Roderman says. "Once we got the medical executive team to recommend the order sets, that's when things changed."

The Medical Center began to focus on improving sepsis outcomes when the Surviving Sepsis Campaign (SSC) was launched five years ago, Patel says.

The SSC originally was an initiative of the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM). The SCCM and ESICM continue to maintain its web site and database. SSC materials can be found at www.survivingsepsis.org.

Here are the steps the hospital took when initiating its sepsis bundle program:

1. For an interdisciplinary sepsis team.

The hospital formed a team that was led by Patel and Roderman. Its other members included the medical director of the hospitalist group, an intensivist, and the medical director of the ED.

"We developed this team to look at the Surviving Sepsis guidelines and to develop an order set," Patel says.

2. Develop a sepsis order set.

One of the problems with the previous sepsis program was that physicians were not diagnosing sepsis in the ED as quickly as ideal, Patel says.

So the team created both a suspected sepsis order set and a diagnosed severe sepsis order set.

"We wanted to efficiently diagnose patients and get them started as quickly as possible on therapy," Roderman explains. "We used guidelines and myriad order set examples that we could find on-line, including material from the Institute for Healthcare Improvement (IHI)."

The order sets are concise with boxes for check marks in front of instructions. To make it simpler for physicians, the appropriate boxes are pre-checked, so all they need to do is sign the order set. Nurses and pharmacists will carry out the instructions.

Here are some sample instructions from the Diagnosed Severe Sepsis Order Set:

• For MAP < 65 mmHg or SBP < 99 mmHg set:

- Norepinephrine (Levophed®) 8 mg in 250 mL D5W at 4 mg per minute — Titrate up or down by 2 mg per minute every 15 minutes to keep SBP > 100 mmHg to maximum of 30 mg per minute.

- Vasopressin 200 unites in 500 mL D5W at 0.6 units per hour — Titrate up or down by 0.2 units per hour every 15 minutes to keep SBP > 100 mmHg to maximum of 2.4 units per hour. Use only if Levophed is more than 20 mg per minute.

- Dopamine 400 mg in 250 mL D5W at 2 mg per kg per minute. Use only if Levophed is more than 20 mg per minute and vasopressin is infusing — Titrate up or down by 2 mg per kg per minute every 15 minutes to keep SBP > 100 mmHg to a maximum of 20 mg per kg per minute. Wean dopamine as possible to keep SBP > 100 mmHg as patient improves.

3. Review and edit order sets.

The sepsis team's order sets were reviewed and edited and then sent to the hospital's special care committee to be reviewed, Patel says.

The sepsis team used order set templates in creating the sheets, but changed these to reflect the institution's specific policies.

For instance, The Medical Center of Plano uses specific antibiotics, and these were put in the order sets, Patel says.

"Our drug choice was determined by our particular antibiogram," she explains. "We do pharmacokinetic/pharmacodynamic dosing of our antibiotics, which means we optimize the mathematical parameters of the drug itself in an effort to maximize efficacy."

For example, in some cases it's wiser to give more frequent smaller doses than less frequent large doses, she adds.

"We use a more aggressive combination than we do for hospital-acquired pneumonia patients," Patel says. "One thing we recently changed was we have added more potent gram-positive agents to the order set."

After receiving input from the special care committee, the order sets were reviewed by the hospital's pharmacy and therapeutics committee. Then they were sent to the medical executive team for final approval, she adds.

4. Educate staff.

The sepsis team held one-hour inservices about the order sets for nursing and emergency department staff. Nurses were educated about how to identify sepsis patients and how to treat them, Roderman says.

The special care committee and medical director helped disseminate information to physicians and others, she says.

They educated staff on an as-needed basis, as well.

"Patients on the oncology floor are more prone to sepsis, so our medical director had conversations with the oncology group and nurses," Roderman says. "All emergency department physicians were inserviced by an educator in the ED."

Whenever a new physician began working with patients in the hospital, the medical director or assistant director would go over the order sets and update the doctor about what the hospital was doing for sepsis patients, she adds.

Also, nurses annually take a competency exam about sepsis.

5. Collect data.

"At first we just looked at everybody who was placed on the orders, and we started seeing a dramatic improvement in mortality rates," Roderman says.

"Then in 2007, I picked up data on patients who were not placed on order sets and looked at them and saw a common theme," she adds.

Physicians who used the sepsis order sets had lower mortality rate among their sepsis patients than those who did not, she explains.

"Then in 2008 we gave reports back to different groups of physicians, including internal medicine and critical care physicians, about what their mortality rates and adherence were on order sets," Roderman says.

Seeing data on the mortality differences helped to convince physicians to use the sepsis bundles.

Slowly over a three-year period, increasing numbers of non-employee hospital physicians began to use the order sets.

Data collection helped with staff buy-in to the sepsis programs. Both physicians and nurses were more motivated to make the changes after learning how much the mortality rate had dropped, Roderman says.

"We posted information in the unit, in the X-ray room, and even in the bathrooms so everyone could see what was going on," she says. "We calculated the mortality rate and let people know how many sepsis patients would have died in the program's first year if we had done nothing."