Bringing everybody on board
Wake Forest Baptist Health put sepsis on the front burner when analysis of benchmarking data showed that its sepsis mortality index was significantly higher than those of its comparative institutions.
Its sepsis initiative worked. Within two years, the average amount of time to start antibiotics for a septic patient on an inpatient floor fell from 396 minutes to 53 minutes, and total compliance with a four-element bundle of care for sepsis patients went from 13 to 71 percent.
The result: Wake Forest Baptist’s sepsis mortality index dropped below that at benchmark health systems, and has remained there for nearly three years.
The keys to success, says Ryan LeFebvre, performance improvement adviser, were executive leadership support and multidisciplinary collaboration. “When it’s something that the folks at the top really believe in, and they’re willing to put themselves out there as advocates, it’s going to happen,” he says.
Historically, diagnosing and treating sepsis had not been urgent concerns. The medical center’s protocol was to use the four-element bundle developed by the Surviving Sepsis Campaign, but “there was a whole lot of ‘let’s wait and see,’ before labeling a patient as potentially septic,” LeFebvre says.
As part of the approach, an hour-long educational session, featuring patient stories and a review of protocols, was mandatory for everyone from physicians to receptionists. “It wasn’t a silo of physicians and a silo of nurses,” he says. “It was true multidisciplinary education with everybody receiving the same message.”
For the first six months of the initiative, Cathy Messick-Jones, M.D., the physician champion for sepsis care at that time, tracked the response to every Code Sepsis incident. If any element of the sepsis bundle was not completed within the appropriate time frame, she used a phone call or email message to find out why.
“Dr. Jones would actually reach out to physicians individually and say, ‘What happened here? Why weren’t we compliant?’” LeFebvre says. “Having that level of executive support was huge. It made people feel like this was an important thing to do.”
What every health care executive should know about sepsis:
• Accurately tracking compliance with sepsis care protocols is challenging, even for organizations that are sophisticated and experienced in the use of data. Investing in a clinical nurse specialist who makes sure those data are complete and accurate is worthwhile, says Todd Allen, M.D., an emergency physician at Intermountain Healthcare.“It makes a world of difference in having the clinicians trust the data and be willing to make actionable choices based on what the data are revealing,” he says.
• High-quality care pays for itself. Preventing a patient from moving from severe sepsis to septic shock saves about $3,000 per case — and dramatically improves the likelihood the patient will survive. “Added up over time, that’s an easy return on investment,” Allen says. “That relationship plays itself out again and again in these quality improvement initiatives.”
• The primary outcome measure is the mortality rate for patients with severe sepsis — but an effective sepsis control program may make the rate increase initially. “If I have fewer people get severe sepsis because they didn’t progress to that stage, my sepsis mortality rate — the number of deaths per the number of people who have the condition — may go up because the denominator is smaller,” says Martin Doerfler, M.D., senior vice president of clinical strategy and development at North Shore-LIJ Health System.
• While Intermountain Health has a sepsis mortality rate of just 9 percent, that may be an unrealistic benchmark for many health systems in the short term. A better goal may be to cut the sepsis mortality rate by 50 percent within two years, which is something many organizations have done.
• Eliminating sepsis is not realistic. “For patients with advanced lung cancer or leukemia or other things that we cannot treat, part of the process that results in those individuals dying is sepsis,” Doerfler says. “But, by appropriate treatment, we can minimize the organ injury that causes suffering unrelated to their main problem.”