Sepsis Treatment: Target Five Key Areas to Improve Sepsis Outcomes
- Sepsis kills 258,000 Americans each year.
- Sepsis contributes to as much as 50 percent of in-hospital deaths.
- The mortality rate for patients diagnosed and hospitalized with severe sepsis or septic shock is 25 percent—more than eight times higher than the mortality rate for any other diagnosis.
- Patients with sepsis have an average length of stay (LOS) that is 75 percent longer than those hospitalized for other conditions.
- Patients who survive sepsis hospitalizations are more likely to have long-term cognitive and physical function impairments.
- Sepsis poses a huge economic burden to the U.S. healthcare system, accounting for more than 20 billion dollars in annual costs.
Despite these sobering sepsis facts and the industry’s ongoing efforts to improve outcomes for septic patients (mortality, LOS, readmissions, cost per case, etc.), outcomes for this population are getting worse. Although health systems juggle myriad demands and priorities—reporting requirements, population health management, etc.—improving sepsis outcomes should rank at the top of their lists.
So, what can these organizations do to drastically improve outcomes for their septic patients? This article highlights five key areas health systems should focus on to improve sepsis outcomes, from early recognition in the ED to patient stratification. This article also offers a helpful consensus definition of sepsis and useful resources to prepare systems for their sepsis improvement work, whether they’re beginning or midstride.
Start Here: Consensus Definitions of Sepsis and Septic Shock
The industry’s definitions of sepsis and septic shock continue to evolve, so it’s important to start with an awareness of the most recent consensus definitions, which were updated in 2016:
- Sepsis: a life-threatening organ dysfunction caused by a dysregulated host response to infection.
- Septic shock: a subset of sepsis in the underlying circulatory and cellular/metabolic abnormalities profound enough to substantially increase mortality.
Helpful Resources: Surviving Sepsis Guidelines and Sepsis Alliance
Just as sepsis definitions evolve, so do its treatments. According to the Surviving Sepsis Campaign (SSC) “the optimum treatment of severe sepsis and septic shock is a dynamic, evolving process requiring further programmatic clinical research to optimize these evidence-based medicine recommendations.” Health systems must continually monitor research and guidelines from the organizations leading the battle against sepsis:
Surviving Sepsis Campaign (SSC)
The battle against sepsis isn’t a new one: the SSC was launched in 2002 to reduce the mortality rate of severe sepsis and septic shock using evidence-based guidelines and performance improvement initiatives. The most recent SSC recommendations, released in 2013, were created in bundles:
- Early identification and treatment of the severe sepsis or septic shock patient.
- Blood cultures before antibiotic therapy.
- Administration of broad-spectrum antimicrobials within one hour of severe sepsis or septic shock recognition.
- Initial fluid resuscitation in sepsis induced hypotension/hypovolemia at 30 ml/kg of crystalloids.
The Sepsis Alliance
The Sepsis Alliance, founded in 20017, is the largest sepsis advocacy organization in the U.S. To support its mission—to save lives and reduce suffering by raising awareness of sepsis as a medical emergency—the Alliance produces educational materials (e.g., sepsis information guides, infographics, and videos) and hosts events (e.g., free webinars) to help healthcare professionals and the public learn more about sepsis.
The following sepsis resources are also informative and helpful:
- Agency for Healthcare Research and Quality: Septicemia Innovations Exchange
- The American Hospital Association, Health Research & Educational Trust, Health Education Network: Severe Sepsis & Septic Shock Change Package
- Institute for Healthcare Improvement (IHI): Severe Sepsis Bundles
Distilling the industry’s continuously changing clinical and quality improvement knowledge is time consuming; this article does some of the legwork by summarizing five key areas every health system should focus on while working to improve sepsis outcomes.
Sepsis Treatment: Focus on Five Key Areas to Improve Sepsis Outcomes
Having identified sepsis as a promising area for quality improvement (because of its impact on people, health systems, and the entire industry), Health Catalyst has worked with more than a dozen health systems to improve outcomes for septic patients. There are five areas health systems should prioritize to improve sepsis outcomes, which are based on the success of Health Catalyst’s outcomes-driven collaborations and the SSC’s recommendation that healthcare organizations implement process improvements:
#1: Early Recognition in the ED
The ED represents the best opportunity for early recognition because, nationally, 80 to 85 percent of sepsis cases present in the ED. However, despite the overwhelming evidence demonstrating the importance of early recognition, many health systems do not have standardized early recognition processes.
Identifying sepsis demands a high degree of awareness, vigilance, and knowledge. Although challenging, early recognition is possible. A standardized approach to ED care can speed recognition and improve care. There are several possible interventions:
- Develop and implement a standardized sepsis screening tool for all patients, which can be as sophisticated as an algorithm firing from an EMR, or as simple as a checklist.
- Create and implement electronic automated sepsis identification and alerts.
- Involve multidisciplinary staff in defining barriers, protocols, and workflows.
- Create visual cues to identify patients who screen positive for sepsis.
- Combine ED and critical care order sets.
- Create and implement focused communication, training, and reviews: pocket, cards, posters, audit, and feedback.
This focus area can reduce average time from ED arrival to recognition of sepsis and initiation of sepsis treatment.
#2: Three-Hour Sepsis Bundle Compliance
Despite their awareness of three-hour sepsis bundle guidelines and their ability to improve outcomes, health systems often struggle to comply with this bundle.
The following three-hour sepsis bundle intervention guidelines—specifically, broad-spectrum antibiotics—have been repeatedly shown to improve sepsis outcomes, and are supported and widely accepted by the medical community:
- Centralize/organize equipment to support rapid and appropriate care (e.g., a sepsis trolley).
- Implement a standardized protocol that includes reminders.
- Create prompts near antibiotic storage.
- Define a sepsis threshold (a “Time Zero” or other) and provide visual cues (e.g., clock with targets highlighted, colored blanket on patient bed) for the timing of interventions based off it.
- Create antimicrobial guides/algorithms.
- Store the first antibiotic dose in an automated dispensing system.
- Implement a “Code Sepsis” to fast-track tests and treatments; identify specially trained rapid‑response nurses assigned to process.
- Develop and implement focused education, training, job aids, and audit-feedback.
- Implement clinical decision support.
#3: Six-Hour Sepsis Bundle Compliance
Tasks associated with the six-hour bundle must be carried out while the patient remains in the ED, is in the process of being admitted, or has already arrived in the intensive care unit. Care of the patient who is critically ill with septic shock is complex, time sensitive, and resource intensive, and requires health systems to be focused and coordinated.
The six-hour sepsis bundle includes interventions for patients who are at greatest risk of death from septic shock:
- Include vasopressors and lactate re-measurement on standardized ED and ICU collaborative protocols and order sets.
- Implement an early goal-directed therapy checklist.
- Train ED and ICU staff in appropriate vasopressor dosing.
- Provide visual cues that identify bundle elements in a time-based process (e.g., clock with targets highlighted).
- Adopt a Shock Index (heart rate divided by systolic BP) to identify patients who would benefit from vasopressor therapy.
- Initiate lactate reflex testing.
- Improve documentation tools to capture ongoing physiologic monitoring.
Six-hour sepsis bundle compliance has numerous clinical and financial benefits, including reducing hospital mortality rate, decreasing LOS, and decreasing variable cost per case.
#4: In-House Recognition of Sepsis
It’s often difficult to recognize patients who become septic in ICUs, but it is even more challenging to recognize sepsis in patients on a floor ward. Early sepsis recognition in already-hospitalized patients can reduce progression to septic shock and mortality, but provides additional challenges—This group of patients already has complex medical or surgical conditions that can confuse or delay a diagnosis of sepsis.
Initiating interventions like those listed below can begin to help identify and intervene on this complicated population of patients.
- Implement a q12 hour manual nurse sepsis screening surveillance tool.
- Automate screening tools that utilize EHR data may potentially decrease diagnostic delays, improve documentation, and improve inpatient sepsis treatment by initiating sepsis care bundles.
- Tweak rapid response team criteria to be more sensitive in identifying septic patients.
- Consider use of biomarkers for diagnosis of sepsis.
- Develop weekly sepsis huddle teams to review identification and care of hospitalized patients who become septic.
- Identify nurse champions to monitor screening compliance.
#5: Sepsis Readmissions: Prioritize risk stratification.
Up to one-third of patients discharged after sepsis treatment are readmitted within 30 days. In fact, sepsis is the most common cause of readmissions among CMS-tracked medical conditions. Patients readmitted after sepsis are more likely to die or require hospice care, regardless of the severity of their original sepsis diagnosis. Costs associated with sepsis readmissions exceed $1.1 billion.
In addition to interventions like boosting post-discharge care (e.g., better care management to treat recurrent or other infection), health systems need to prioritize risk stratification for patients likely to return for readmissions. For example, one health system’s model assigns a risk score that indicates patients most likely to return for readmission; once these patients are identified, the system pairs them with care managers committed to keeping them on the right track.
The interventions listed below can also help reduce sepsis readmissions:
- Develop transition of care practices for sepsis patients being discharged that includes a follow-up appointment within seven days, follow-up phone calls, care giver education, etc.
- Create protocols for patients identified to be at high risk of readmission, and implement appropriate actions.
Healthcare Must Work Together to Improve Sepsis Outcomes
The severe clinical, financial, operational, and patient experience consequences of sepsis make it an industrywide priority. Improving sepsis outcomes is a group effort, from hospital teams working together to implement sepsis care best practices to the entire industry working together to share what works and what doesn’t. Every healthcare organization should actively participate in industry-wide collaboration to improve sepsis outcomes.
By focusing on the five key areas outlined in this article, health systems will improve early detection, action, and intervention for septic patients; health systems will reduce the economic burden sepsis continues to have on the industry; and, most importantly, health systems will save more lives within their communities.
Would you like to learn more about this topic? Here are some articles we suggest:
- Saving Lives with Best Practices and Improvements in Sepsis Care
- How to Significantly Reduce Sepsis Mortality
- Lowering Sepsis Mortality and Length of Stay: One Hospital System’s Story
- How to Improve Sepsis Diagnosis and Outcomes through Innovative Healthcare Analytics
- In Pursuit of the Patient Stratification Gold Standard: Getting There with Healthcare Analytics