When the Institute for Healthcare Improvement began working on critical care two decades ago, sepsis management was not on its hit list. But over time, the sepsis toll on patients became clear and IHI spent several years focused on reducing sepsis mortality.
“We are very excited to see that this topic has taken hold and it has become a widespread concern and another opportunity to reduce unnecessary deaths,” says Andrea Kabcenell, R.N., an IHI vice president.
Why is the new sepsis bundle core measure, which is debuting this year, controversial?
Kabcenell: A lot of people who haven’t had experience with the sepsis resuscitation bundle fear it is not safe science yet and it’s out of reach. So, having a core measure about it feels like a push too soon.
Creating a core measure is a strong way to [get hospitals to focus on sepsis mortality], but it’s an effective way to do it. When something becomes a core measure, it gets attention. But there may be unexpected consequences along the way as people struggle to get up to speed.
Sepsis management used to be considered an intensive care unit problem, but now there is a wide range of approaches to improving sepsis care. What do you advise?
Kabcenell: The quickest way to reduce sepsis mortality is to start in the emergency department and focus on early diagnosis and adherence to the sepsis bundle as an all-or-none bundle, not just one or two elements of it. That’s been productive for almost everyone because if you can catch people with sepsis early in their ED stay and before they are sent to a unit, they have a good start. The discipline to get that diagnosis right and, under those circumstances, have the confidence to get the communication right and load up on fluids when needed serves well when you move to other parts of the hospital.
There are reasons people want to start in the ICU — there’s a team there and it’s easier to control the work, and often emergency departments are so beleaguered that people don’t want to start there with a new initiative. But ultimately, if they want to reduce mortality in the organization, the biggest bang for the buck is in the ED.
Hospitals typically have sepsis mortality rates between 20 and 50 percent. What should leaders set as the target?
Kabcenell: They should not start with the idea, ‘Oh, well, we’re already at 20 percent, so we don’t have to worry.’ That’s not the right attitude. The right attitude is that, unless you have an unusually low mortality rate — like 10 percent or lower — you can make big gains wherever you are. In fact, you'll probably cut the rate in half over a couple of years.
Start by looking at compliance rates to make sure the individual elements of the sepsis resuscitation bundle are improving and compliance is approaching 100 percent. Then look for high compliance with the entire bundle. Then you’ll start to see the sepsis mortality move.
What makes sepsis management so challenging?
Kabcenell: Getting sepsis mortality down in most hospitals requires a lot of cross-boundary communication. When a patient who has sepsis leaves the ED and goes to the unit, coordination is really tough, and the ability to take care of those patients across boundaries challenges everyone. There is lots of tension because treatment sometimes also involves loading people with fluids — something that seems unsafe to many clinicians.
“All of that cross-boundary work requires leaders to be very supportive and insistent on good clinical communication, very good handoffs, taking the time to get this right and maybe put some more trivial things aside to address a bigger need. So, it takes leadership and empathy with the people who are working hard on change.”