Process improvements in the ED increase sepsis bundle compliance, reduce mortality
By improving compliance with the sepsis three-hour bundle, Dartmouth-Hitchcock Medical Center reduced patient mortality by 50% in just 90 days
Effectively treating any infection requires a certain measure of early identification and rapid response. Infections, by their nature, worsen over time, so hospitals with successful care processes that rapidly identify and treat infections often see the most success.
Identifying and appropriately treating a patient with sepsis, however, takes that response to a whole new level. Research shows that early identification and treatment of sepsis significantly reduces mortality. In a 2011 presentation at the Society of Critical Care Medicine 40th Critical Care Congress, researchers showed an 88% increase in mortality in patients who received antibiotics six hours after arrival, compared with those who received antibiotics within two hours.
Furthermore, sepsis has become more prevalent in healthcare over the past decade. According to statistics released by the National Center for Health Statistics in 2011, hospitalization rates for septicemia or sepsis more than doubled from 2000 to 2008. Seventeen percent of hospitalizations related to sepsis ended in death, compared to 2% of all other hospitalizations. In 2011, sepsis was identified as the most expensive condition treated in hospitals.
Despite the severity of the infection, hospitals still struggle with management and prevention, particularly in the ED where patients are often admitted with symptoms that aren't particularly unique, including fever, rapid breathing and heart rate, chills, and disorientation. This makes sepsis difficult to identify in the early stages.
The reason sepsis is still so prevalent and dangerous is not a lack of best practices; the Surviving Sepsis Campaign was created in 2002 and guidelines have been in place for a decade. But sepsis continues to plague healthcare because of an inability to manage the process of applying those best practices consistently and in a timely manner, says Megan Zweig, senior consultant on research and insights at The Advisory Board Company, headquartered in Washington D.C.
"The issue with sepsis isn't that clinicians and physicians don't know how to treat it," she says. "They know how to treat it. The Surviving Sepsis Campaign guidelines have a lot of underlying literature proving that if followed correctly, they reduce mortality, and yet we still see tremendous figures on the number of people that are dying in this country from sepsis."
But some hospitals are finding that focusing on the lean principles of process improvement offer the most effective way to quickly implement sepsis treatment. In December, Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire announced that it has reduced patient mortality by more than 50% by achieving 80% compliance with the three-hour sepsis bundle, and they did it within 90 days.
The hospital achieved these impressive reductions by taking a very "granular look at every step of the process," according to Andreas H. Taenzer, MS, MD, an anesthesiologist at Dartmouth-Hitchcock who led the intervention.
Taenzer says even when they looked around at other high-performing hospitals, their compliance rates with the bundle hovered around 25% to 30%. The trick was to bring together a variety of clinicians from all parts of the hospital to coordinate processes necessary to improve the response time to sepsis patients.
"The three-hour bundle doesn't sound very difficult, but the actual compliance is very low," he says. "The big picture was we know what to do, it just wasn't clear on how to do it."
Corralling all the moving parts
One of the primary reasons that hospitals struggle to adhere with sepsis identification and treatment best practices is because the guidelines involve many different units working in unison. Nurses screen patients in the ED, physicians order tests from the lab, which dictates if and when antibiotics are ordered from the pharmacy.
"I think it's the complexity of the execution and how many people are involved that make it incredibly difficult to translate what we know works into consistent practice," Zweig says.
Starting in January 2014, Taenzer says his team brought in representatives from all sectors of the hospital?ED nurses and physicians, laboratory technicians, and pharmacists?and dissected the entire three-hour bundle from top to bottom.
During each step of the way the multidisciplinary group discussed problems and obstacles that would impact any one of those departments during any stage of the process.
For example, one of the keys to identifying sepsis in an admitting patient is drawing lactate. Dartmouth-Hitchcock found its turnaround time was 60 minutes. After implementing process improvements, that time was reduced to six minutes, Taenzer says.
"That sounds like something simple to do, but we brought everyone in a room for at least 20 hours total time, and just walked through the ED, [looking at] what is the patient flow? Where does one need to go to get the antibiotics? Where are they stored? Who replenishes them when they are being used? What are the optimal dosages? How can we simplify all that?" he says.
The team also adjusted the process to empower nurses to better identify potential sepsis patients that arrived in the ED. From there, it installed an accelerated pathway that would start the process of notifying the physician, drawing labs, ordering IVs, and alerting the rest of the ED staff that this was a high-priority case.
Timing is imperative in treating sepsis patients, but Taenzer says that nearly every delay they encountered with the three-hour bundle was process-oriented. The process improvements allowed clinicians to quickly identify sepsis patients and then get them started on antibiotics as soon as possible.
Zweig says the early detection of sepsis in the ED relies heavily on a fluid process.
"I think education can be helpful, but I think it's about having a hardwired and defined process for who should be doing that screening, and during the screening, what they should be looking for," she says. "Depending on what they are looking for, if they see potential signs of sepsis, who should they tell and what are the follow-up steps?"
Setting an aggressive goal
Dartmouth-Hitchcock president and CEO James N. Weinstein, MD, set an aggressive goal of hitting 80% compliance within 90 days. Initially, Taenzer admits he thought the goal was "a little lofty or ambitious," but it ultimately drove the team toward high standards of improvement.
"It's something that has to be learned from leaders in healthcare, that sometimes you have to set the goal as high as he did and go for it," Taenzer says.
The hospital was able to achieve such a rapid improvement for two reasons, Taenzer adds. First, they reached out to 16 other member hospitals in the High Value Healthcare Collaborative (HVHC).
North Shore-Long Island Jewish Hospital offered a sepsis identification tool and Intermountain Healthcare provided some suggestions for implementation improvements.
Second, Dartmouth-Hitchcock utilized professionals from its Value Institute, an initiative created in 2012 that utilizes "Lean Six Sigma" methodology to improve healthcare processes. Sam Shields, MBA, a performance improvement expert with the Value Institute, was imperative to the success of the intervention in the ED, and then later in transitioning to the ICU, Taenzer says.
"His background is chemical engineering," he says. "The same methodology that they use there to keep production safe and efficient can be used in healthcare. That was a key component to getting this done right."
Start in the ED
Statistics show that the identification of sepsis patients begins in the ED, which is why many healthcare organizations start by adjusting ED procedures and then move to other units, like the ICU.
According to The Advisory Board's Crimson program, which tracks data analytics from more than 1,000 hospitals, there is an 80-20 split that identifies where sepsis patients are coming into the hospital.
"When I'm talking to an organization who wants to improve sepsis outcomes, one of my first recommendations is you need to look at the ED because you're going to catch 80% [of] your patients based on this data set if you're more deliberate about screening for sepsis in ED triage," Zweig says.
She also notes that most hospitals have had success when screening tools or checklists are made available to ED nurses, who can use them to catch symptoms that may have otherwise gone unnoticed.
From there, the process can be tweaked to fit into other units. Dartmouth-Hitchcock has implemented a process in the ICU and rolled out an inpatient detection tool for the early identification of sepsis. Now clinicians are required to take an annual sepsis class, just as they would for CPR.
The hospital is also making efforts to attack sepsis at a community level, Taenzer says. Because patients are often transferred to Dartmouth-Hitchcock from surrounding areas, a delay in sepsis treatment can negatively impact those patients. Research shows that for each hour that the patient goes without antibiotics, the risk of mortality increases 8%.
Unlike other time-sensitive illnesses like stroke or heart attack, where small hospitals don't have the means to perform complicated interventions, sepsis prevention merely relies on administering fluids and antibiotics.
"Because that three-hour bundle is relatively easy to do, we really want the community hospitals to start that bundle and get it going and then send us the patient," Taenzer says.