Sepsis is the most common cause of death in U.S. hospitals. Nationally, mortality rates for sepsis cases entering the hospital through the emergency department range from 20 percent to more than 50 percent. With that stark reality in mind, my colleagues and I from Intermountain Healthcare's Intensive Medicine Clinical Program developed and deployed an evidence-based protocol for the aggressive detection and treatment of sepsis, starting in the ED and continuing into the intensive care unit.
The process that my colleagues, including Terry Clemmer, M.D., Nancy Nelson, R.N., M.S., Wayne Watson, M.S.N., R.N., and others created initially required 11 — and, after revision, seven — clinical elements during the first 24 hours of treatment. It has succeeded in dramatically decreasing sepsis-related mortality at Intermountain hospitals and offers a replicable model for reducing the impact of this all-too-common killer.
Reducing Deaths Even Further
When we began this work, Intermountain Healthcare already had one of the best sepsis mortality rates in the nation: 20.2 percent. But that rate was still unacceptably high to many of us. We knew that better was possible. Five years later, Intermountain has defined a new standard of best care: Our mortality rate for septic patients entering the ED has fallen to less than 9 percent. That means more than 100 lives saved each year.
Critical to this reduction was the rigorous implementation of a bundle of 11 elements: Four typically are implemented in the ED, four in the ICU, and three can be applied in either setting. The bundle addresses the following elements: (in the ED) serum lactate, blood cultures, broad-spectrum antibiotics and fluid resuscitation; (in either setting) vasopressors, CvO2 measurement, and inotropes and/or blood transfusion; (in the ICU) steroids, glucose control, rAPC use in eligible patients and a lung protective ventilator strategy.
In 2011, we reduced the bundle to seven elements: two of the original 11 (glucose control and rAPC) were eliminated to reflect new medical evidence; two others (vasopressors and inotropes and/or blood transfusion) were dropped for reporting purposes but not in practice.
This treatment process was designed between 2004 and 2005 in response to a goal adopted by Intermountain Healthcare's board of trustees. Implementation began in 2006 and spread by 2007 to all 15 Intermountain Healthcare hospitals that have both EDs and ICUs. Vigorous monitoring, feedback for learning and compliance continued.
Rigorous implementation was not without its challenges. In a multihospital system, it's difficult, for instance, to establish a consistent screening process — identifying all cases similarly and as early as possible — in all EDs, given different staffing structures and community missions. It also takes significant effort to ensure consistent communications within hospitals, regions and departmental fields of discipline, and among staff members — with everyone singing from the same song sheet. Regular face-to-face meetings, conference calls and WebEx Web conferencing were essential.
Intermountain Healthcare uses its Intensive Medicine Clinical Program structure to design and implement its clinical processes and protocols. The Clinical Programs have been in operation since the mid-1990s, but this work required new avenues and methods of communication, cooperation, measurement and reporting.
By 2010, bundle compliance had reached 80 percent. And that 80 percent compliance measured 100 percent implementation of the required elements. If even only one of the then-11 elements was not implemented, it was recorded as a failure unless the patient was not deemed eligible for that particular element.
In association with our 80 percent bundle compliance, Intermountain's mortality rate for patients with severe sepsis or septic shock who were admitted through the emergency department decreased to 8.3 percent. It was a remarkable achievement, but we still recognize that a 20 percent margin for compliance improvement remains. Just as before, "better" may still be possible, and we are embarking on our next improvement project for patients with sepsis.
Saving Lives and Reducing Costs
As a result of the 80 percent compliance, Intermountain achieved the following care and cost improvements from a study cohort of 4,329 patients from 2004 to 2010:
- The rate of survival increased from 20.2 percent mortality to less than 9 percent.
- The average length of hospital stay was reduced by 20 hours.
- The average cost per patient declined by nearly $3,000.
This is a great example of better care at a lower cost, and it's eminently replicable. A more detailed description can be found in a journal article that I co-authored, "Multicenter Implementation of a Severe Sepsis and Septic Shock Treatment Bundle" in the July 1, 2013, issue of the American Journal of Respiratory and Critical Care Medicine.
The bundle for the early identification and treatment of sepsis has proven to be effective, and, if Intermountain Healthcare's hospitals can save 100 lives per year by implementing this protocol, many thousands of lives could be saved nationally each year — all while reducing health care costs.
Todd L. Allen, M.D., is a specialist in emergency medicine at Intermountain Healthcare, a nonprofit health care provider based in Salt Lake City.