Quality Improvement in Sepsis Recognition & Treatment

By: Joseph Di Genova

Loma Linda University Medical Center’s Response

• Creation of a new initiative due to poor compliance with the sepsis bundle and because CMS has made severe sepsis recognition and treatment a core measure.–Came into effect October 1, 2015–Part of 2016 regulatory surveys

LLUMC’s Rates/Statistics

Nationally: Overall mortality 10.8%Loma Linda Health:

13.3%

Nationally ALOS : 10.37Loma Linda Health:

17.1

Nationally: Nursing task are performed within 3 hours from entry.Loma Linda Health

Statistics:Percent with 2 blood

cultures before antibiotics: 32% (6 of 19)

Door to Antibiotic hung: Average: 6 hrs 46 mins

Door to Lactic Acid Order: Average: 4 hrs 7 mins

At least 2L of IVF administered : 26% (5 of 19)

Current LLUMC Sepsis Protocol

Identifying Severe Sepsis via Electronic Surveillance

• “The software identified 477 patients, compared with 18 by adjudication” and was “more sensitive but less specific than care team or administrative data.”

• “The system can be a useful tool when implemented appropriately but lacks specificity, largely because of its reliance on discreet data fields.”

• The study determined the ability of a software system to extract data from the EMR to identify patients with severe sepsis throughout the hospital.

Reduction in Time to First Action as a Result of Electronic Alerts for Early Sepsis Recognition

• Use of computerized medical records to create an electronic alerting system with the potential to identify high-risk patients and initiate interventions sooner; this creation of this alerting system with real-time data decreased the time it took to begin sepsis workup and treatment on patients with possible sepsis.

• “The implementation of sepsis alerts decreased time to first sepsis-related intervention, suggesting that the alerts significantly improved timely sepsis recognition as a whole. The alerts improved the timeliness of some, but not all, individual sepsis-related interventions.”

• An identified negative to use of the electronic alert is what is sometimes called “alert fatigue.” Basically, the alert fires so often (including on patients who are found not septic) leading to possible “action by a provider to ‘clear’ the alert without actually being followed through.”

Care of Patients in Acute and Critical Care Settings: The impact of an electronic medical record surveillance

program on outcomes for patients with sepsis• A study was performed to “evaluate the effects of this EMR

surveillance on sepsis, severe sepsis or septic shock outcomes in patients admitted to a medical telemetry unit, including length of hospital stay, patient discharge and mortality.”

• Implementation of EMR sepsis surveillance considerably improved home discharge and reduced hospital mortality.– “Shows promising evidence that the use of an EMR sepsis

surveillance alert could decrease the ravishing effects of sepsis, severe sepsis and septic shock by early identification and treatment.”

Utilizing the EMR• Best Practice Advisory (BPA) Alert Pop-Up on Epic charting system

• Early identification and intervention in sepsis patients can be aided through utilizing the Epic charting system alerts.

• Epic- based interventions developed to ensure the identification and ‐early treatment of septic patients.

• The alert will helps to:– provide early goal directed therapy within the 1st hour– complete the evidence- based Sepsis Resuscitation Bundle within 6 hours‐

• On all adult Acute Care units, a red BPA (Best Practice Advisory) fires when a patient meets all 4 criteria for Systemic Inflammatory Response Syndrome (SIRS)

• Temp <= 36 or >=38.3 (in past 24 hours)• HR > 90 (most recent)• Respiratory rate > 20 (most recent) or PaCO2<32 (most recent in last

24 hours)• WBC > 12k or < 4k or Bands > 10% (most recent in last 24 hours)

The RN Sepsis BPA-Sample

RN Action-Sepsis/Severe SepsisSteps:1. Acknowledge BPA2. Page MD with “FYI: Sepsis Alert” message and patient information3. Three default orders:

a. Lactate Q3 x 2b. Blood Culture once x 1 (Aerobic and Anaeorbic)c. 4.5 gram Zosyn IV (given first over 15-30 min) +1 gram Vanco IV,

given second over 60-90 min. (Pen Allergy: Aztreonam 2 gram IV + Amikacin 15 mg/kg IV) if the patient has not received antibiotics in the past 24 hours

4. Two additional orders available, for order if they have not been ordered in the past 24 hours:a. CMPb. CBC

MD Action-Severe Sepsis

• Physicians are expected to evaluate patients identified as having severe sepsis within 60 minutes of receiving page alert.

• ICU: – If no response, notify attending.

• Non-ICU:– Activate RRT

Summary

• Problem– Delayed sepsis recognition/treatment in other hospitals

• Solutions/Compliance– Utilize EMR system (BPA alert) & standard protocol to

provide prompt recognition/treatment• Improving Outcomes– Adequately train staff and enforce/audit usage and patient

outcomes• Maintaining Progress– Continually review & study implementation of BPA alert– Seek ways to critique/improve recognition of potentially

septic patients (algorithm used by EMR system)

References

Carolyn Davidson, RN, MSN – LLUMC EducatorAreas of specialty: Adult Medical and Surgical Education, Housewide In-servicingKaren Lawson, RN, MSN-LLUMC EducatorUnit: Surgical Neuro-Trauma ICU Clinical

ReferencesIdentifying Severe Sepsis via Electronic Surveillance.

(2015). American Journal of Medical Quality, 30(6), 559-565 7p. doi:10.1177/1062860614541291

Kurczewski, L., Sweet, M., McKnight, R., & Halbritter, K. (2015). Reduction in Time to First Action as a Result of Electronic Alerts for Early Sepsis Recognition. Critical Care Nursing Quarterly, 38(2), 182. doi:10.1097/CNQ.0000000000000060

McRee L, Thanavaro J, Moore K, Goldsmith M, Pasvogel A. Care of Patients in Acute and Critical Care Settings: The impact of an electronic medical record surveillance program on outcomes for patients with sepsis. Heart & Lung - The Journal Of Acute And Critical Care [serial online]. November 1, 2014;43:546-549. Available from: ScienceDirect, Ipswich, MA. Accessed November 20, 2015.