Rapid-response process reduces mortality, facilitates speedy treatment for patients with sepsis
Approach brings added resources to bear on suspected sepsis cases
Sepsis is a leading cause of mortality in hospitals, but it is challenging to address because while studies suggest that speedy treatment can improve outcomes, all the tests and evaluations that are required to pin down the diagnosis take time to complete.
Given these tricky circumstances, it is no wonder that hospitals struggle to stay on top of this condition, particularly in the hectic environment of the ED where staff-to-patient ratios can make it even more challenging to identify sepsis at an early stage.
However, with appropriate buy-in from staff and commitment from higher-ups, administrators at Wake Forest Baptist Medical Center in Winston-Salem, NC, have shown that it is possible to improve both outcomes and performance related to sepsis care. By employing a rapid-response protocol and an institution-wide education effort related to sepsis, the hospital has been able to reduce its risk-adjusted mortality index from 1.8 to less than 1.25 in just one year.
Further, in the ED specifically, where a modified version of the protocol has only been in place since April 1 of this year, time-to-treatment for sepsis patients has drastically improved. "Prior to implementing the protocol, about 20% to 25% of patients who turned out to have sepsis got antibiotics within the first hour," explains Howard Blumstein, MD, director of the ED, which sees about 110,000 patients per year. "After we implemented the protocol, 85% received antibiotics within the first hour. And that is just for the ED in the month of April." (Also see: "Mandatory education module, department champions facilitate adoption of new process for sepsis care," p. 92)
Get stakeholders involved
Catherine Messick Jones, MD, MS, associate chief medical officer, medical services, at the level 1 trauma facility, explains that hospital leaders decided to focus on sepsis as part of an organizational goal to reduce mortality by 15%. "That was set at a high level, so if you think about the things that people die of within a hospital, sepsis is pretty high on that list," she says. "Also, sepsis was something where it seemed as though there was in the literature a set of evidence-based guidelines that would allow us to really make a difference."
Jones acknowledges that it took some time for hospital leaders to find the right path toward improvement. "In the beginning, we did the traditional things that hospitals and health care systems do. We had meetings, we talked about it, and we made policies," she says. "We showed people their data and we implored them to do better."
However, it became pretty clear that just providing people with knowledge would not be enough to move the needle on improvement, so administrators organized what is known in the lean literature as a Kaizen event, where they brought a very large and diverse group of stakeholders within the organization together to share their perspectives and identify what steps they could take to improve sepsis care.
The group included everyone from nursing assistants and emergency physicians to medical directors and pharmacists, explains Jones. And from the outset, the goal was to figure out how to recognize patients with sepsis quickly and administer antibiotics to them within one hour.
"Setting the time goal helped to influence our thinking," notes Jones. "For example, we made a decision to deviate from evidence-based practices because we knew that in our organization, lactic acids are read by our lab on the main chemistry line. That means that certainly if you order a serum lactic acid in a routine fashion, you will not get it back in the hour, let alone have time to administer your antibiotics."
Administrators knew that up on the floors in the hospital they could quickly conduct whole blood lactate tests in their blood gas lab, so they decided to use whole blood lactates instead of serum lactic acids when assessing patients for sepsis. And when the ED implemented the approach, administrators there opted for point-of-care tests in order to get results quickly in that environment.
Establish early indicators
Also, instead of taking steps to teach every nurse in the hospital how to screen for sepsis using the SIRS (Systemic Inflammatory Response Syndrome) criteria when taking vital signs, the group opted to train about 15 rapid-response nurses. This enabled the hospital to get a rapid-response system up and running quickly rather than waiting weeks or months for all the nurses to get trained, explains Jones.
In addition, the improvement team decided to take full advantage of the modified early warning score — or the aggregated weighted vital signs scoring system, which was already embedded in the hospital’s electronic medical record (EMR). This score, which can be automatically tabulated by the EMR with the push of a button, can provide a first indication that a patient might have sepsis, so the group elected to use this process as an initial step in its rapid-response system.
"We have a policy that stipulates in the first 24 hours we check vital signs and do the early warning score every four hours. That is our routine vital signs policy [for inpatients]," says Jones.
In the ED, the vital signs and early warning score are tabulated at triage when the nurse is first evaluating a patient. After that point, it is up to the nursing staff to recognize any deterioration in vital signs, explains Blumstein. "All of these patients are on monitors, and the nurses are responsible for checking those vital signs and seeing if they are becoming unstable," he says.
The early warning score is also tabulated on any ED patients who are being admitted to the hospital. "That is a second chance to assess whether the patient is getting better or worse, and to check on whether the plan of care we have worked out for the patient is appropriate," says Jones. "Sometimes, we catch something at this point, so getting that second early warning score determination before a patient actually gets into a bed helps us to make sure that we have done all we need to do in the ED, and the patient is going to the right location of care."
Facilitate rapid diagnoses
When a bedside nurse sees a high early warning score, she is directed to call a rapid-response nurse, whether she thinks the patient has an infection or not, notes Jones. "We know high early warning scores are associated with bad outcomes from any clinical condition," she says. "So the nurse will put in a call to our emergency communications center, which will activate a page to the rapid-response nurses who will come and evaluate the patient. They will screen and document SIRS criteria and evaluate the patient for a possible infection."
In cases in which the rapid-response nurses believe a patient may have sepsis, they will call the hospital’s communications center to issue a Code Sepsis page, a prompt that will go to a variety of key departments in the hospital that provide support services for sepsis patients, explains Jones. For example, the blood gas lab will receive word that it can expect orders for a whole blood lactate level on a patient that will need to be prioritized and processed before their routine samples, and the pharmacy will receive word that they should be anticipating orders for antibiotics.
"The pharmacists who get these pages are typically in the central pharmacy, and they know the clock is ticking," observes Jones. "So, if a Code Sepsis is paged and they don’t receive an antibiotic order, they will call the rapid-response nurse to find out what is going on, or whether there is anything the pharmacist can do to help."
To eliminate delays, the hospital has put policies in place so that if a physician has identified the source of sepsis on a particular patient, pharmacists can actually enter the orders for antibiotics themselves, using recommendations from the hospital’s antibiotic stewardship group, adds Jones.
Respiratory therapy will also receive a page because therapists from this group may need to assist in drawing blood gasses or in providing mechanical ventilation in cases in which potential sepsis patients have pneumonia. In addition, the intensive care unit will receive a heads up that a sepsis patient may soon require an ICU bed.
In the ED, creation of the Code Sepsis fit right in with the culture, explains Blumstein, noting that there are already codes for stroke and heart attack. "Nurses have a set of criteria in which they can call a Code Sepsis — even without consulting a physician, and physicians have the freedom to call a Code Sepsis whenever they believe a patient may have sepsis, and they are encouraged to do so broadly," he says. "There is no penalty and no downside to calling a Code Sepsis, even if a patient turns out not to have sepsis."
To the contrary, Blumstein points out that a Code Sepsis brings added resources to bear on a suspected sepsis case, and it enables testing and treatment to occur much more quickly than in the past. "We get a second nurse, so the patient’s bedside nurse and the second nurse can bang out all the nursing tasks that need to be done fairly quickly," he says. "It also brings us X-ray techs to shoot a portable chest X-ray; it gets us a quick bedside urinalysis; the pharmacist comes out to help us with antibiotic choice and administration; and it gets us a respiratory therapist who comes right to the bedside to get a point-of-care testing lactate."
Getting sepsis identified at an early stage, and then having a process for completing all the tests necessary to confirm the diagnosis quickly are the key reasons why the ED has been able to chart swift improvements in sepsis care, explains Blumstein. Such changes are hardly insignificant when you consider that the ED sees about 50 patients per month who have sepsis, he adds.
Blumstein clarifies that the Code Sepsis protocol is designed to be implemented in cases of severe sepsis or septic shock, not the milder form of sepsis. Patients suspected of having less severe sepsis will still likely be treated with antibiotics, but time-to-treatment is not as critical a factor as in the more severe cases, he says.
One of the things that prompted hospital administrators to reach out to the ED to implement the Code Sepsis protocol was the discovery that some patients who had been admitted to the hospital through the ED ended up triggering a Code Sepsis once they were on the inpatient floors. "They had been started on antibiotics, but not in the time frame that we try to administer them on the floors," explains Jones. "That gave us the idea that if we started this process when patients arrive in the ED, then we would be ahead of the game."
Jones acknowledges that the ED faces unique challenges because there are typically no laboratory data to rely on at this stage, but she observes that the upper floors sometimes struggle with having so much data that clinicians have trouble picking out sepsis from all the other things that could be going on.
In fact, now administrators are looking at starting the early warning process in the clinics that feed into the hospital because many patients with sepsis initially arrive in a clinic setting. "We have the tools, so we could potentially recognize this when a patient arrives at a clinic and has their vital signs checked," says Jones. "This is a never-ending job because the more you work on this, the more you see what you can do, but I think we have made a good start."
• Howard Blumstein, MD, Director, Emergency Department, Wake Forest Baptist Medical Center, Winston-Salem, NC. E-mail: email@example.com.
• Catherine Messick Jones, MD, MS, Associate Chief Medical Officer, Medical Services, Wake Forest Baptist Medical Center, Winston-Salem, NC. E-mail: firstname.lastname@example.org.