Qsource is a nonprofit, healthcare quality improvement and information technology consultancy headquartered in Memphis, Tennessee. Qsource provides a wide range of expert services to assist organizations and providers in improving healthcare quality and delivery with better patient outcomes and cost savings.
A recent Qsource project focused on reducing mortality by using screening tools in a hospital’s electronic medical record system to identify sepsis at an earlier and treatable stage. Within the EMR, the screening tool visually highlights Systemic Inflammatory Response Syndrome (SIRS) criteria at triage. Nurses then initiate physician-designed protocols that deliver sepsis treatment bundles in a timely and consistent way.
The project’s Phase I Go Live occurred in October 2013.
The initial data was encouraging as the first month post go-live sepsis Observed /Expected (O/E) mortality index dropped from 1.67 to 0.71. Unfortunately, this was not sustained.
After several months of refinement and re-education, the hospital again approached the drivers of sepsis mortality and morbidity by focusing on timely triage regardless of admission source; timely assessment by nurse and physician; early and repeat lactate measurement; and good communications among the healthcare team. When a patient was identified as septic, they received aggressive administration of IV fluids, antibiotics, and regular blood cultures.
To reinforce these protocols, care team members received sepsis badge cards to serve as an easy, portable reference. The health system audited daily sepsis reports for order set usage, and developed best practice bundles. The care team received regular feedback, as well as additional training and support as needed.
It is now standard procedure for all patients to receive screening for sepsis at triage in the Emergency Department. Physician order set usage is at greater than 80% and trending upward. All staff receive education on sepsis management, and the health system has implemented a best-practice sepsis pathway for both inpatients and ED patients. The health system has achieved Sepsis bundle protocol compliance (antibiotic, lactate, blood cultures) at greater than 90%.
The sepsis mortality Observed/Expected index decreased from a risk-adjusted index of 1.25 in 2013 (17% mortality) to 0.65 Jan - June 2014 (7% mortality). The most recent data shows a continued downward trend of the O/E index to 0.50 for July, 0.41 for August, 0.32 for September, and 0.38 for October. In total, this led to 22 saved lives over four months as a result of improved processes of early identification and early implementation of evidence based therapies for sepsis. The hospital exceeded their goal of becoming a top decile performer in Premier for sepsis mortality (top decile performers O/E = 0.73).
The Sepsis Project has fulfilled the intent of the Quality Pillar that challenges healthcare to “deliver measurably excellent care that consistently leads to the best patient outcomes”.
In addition to the Quality Pillar, this project has measurably impacted the Financial Pillar of the House of Quality:
- The length of stay (LOS) has decreased for sepsis patients from a risk adjusted index of 0.86 in 2013 to a risk adjusted index of 0.79 (a 1.2 day variation per patient from expected).
- The average cost per case has decreased from $12k in 2013 to $9k (Q1 & Q2 2014)
- Identification of sepsis patients has increased 3 fold from an average of 20 – 30 per month in 2013 to 90 – 100 per month in 2014.
The rise in sepsis mortality after the initial decline led to one of the harder lessons from this project: it takes time for a new process to become hardwired. The goal was not to simply increase awareness of sepsis, but to permanently change the approach to the identification and treatment of sepsis.
Early recognition and timely initiation of appropriate therapy is the key to sepsis survival. Severe sepsis is frequently under-diagnosed at an early stage when it is still potentially reversible. As this example demonstrates, standardization of screening processes and early treatment with evidence-based therapies reduce sepsis related mortality.
Providing physicians and other care providers with sepsis order sets and making these available via electronic physician order entry has increased compliance with recommended therapies. A culture of support and open communications enabled the healthcare team to keep the patient at the center while the care team worked through the challenges of this effort.