Case study: Automating sepsis alerts at Harborview Medical Center
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September 1, 2018
Using a simple EMR alert, the hospital reduced sepsis fatalities by 41%
Sepsis is the body’s extreme response to an infection. The condition is life-threatening, common, and on the rise. In 2014 alone, there were 1.7 million sepsis hospitalizations and 270,000 sepsis deaths in the U.S. And in 2017, it was reported that even though sepsis is only present in 6% of hospitalizations, it accounts for 15% of in-hospital deaths.
Sepsis mortality rates increase quickly when the condition is left untreated, even for just a few hours. However, there isn’t a simple test for sepsis. Instead, providers have to watch for patterns and symptoms that could indicate sepsis. As a result, it’s common to have misdiagnoses or delays in diagnosis.
Sepsis is also the most fatal complication for burn victims, accounting for 50%–60% of burn injury deaths. That last issue is a particular concern for places like Harborview Medical Center in Seattle. The 413-bed facility is the only designated Level I trauma and burn center in Washington state and is the regional trauma and burn referral center for Alaska, Montana, and Idaho. It has around 17,000 admissions, 259,000 clinic visits, and 59,000 emergency department visits annually.
Rosemary Grant, BSN, RN, CPHQ, is the sepsis coordinator at Harborview. She says her facility chose to focus on sepsis detection because the condition is “prevalent, expensive, and deadly.”
“When we looked at data from our hospital and others, we saw that patients who develop sepsis in the hospital have a much higher mortality than patients who arrive in the emergency department with sepsis,” Grant says. “So we knew we needed to focus on faster identification of sepsis in our inpatient population.”
In 2011, the Harborview team decided to fight sepsis by changing the way they detected it. Working in-house, they developed an automated flagging system for their electronic health record (EHR).
When a patient is admitted to Harborview, the patient’s vitals are plugged into the EHR several times each day. The system searches for patterns, trends, and symptoms that might indicate sepsis. If found, a red box appears around the patient’s name, and the nurse is assigned a task in the EHR to screen the patient for infection.
The nurse then assesses the patient for non-sepsis causes for the readings. If the nurse decides the readings could indicate sepsis, then the physician is alerted. The system is designed so it won’t sound more than every 12 hours, she says, meaning nurses won’t get more than one alert per patient per shift.
“I think the most important component of our system is that it incorporates the bedside nurses’ clinical judgment,” says Grant. “The alert is just a computer algorithm, and if it paged the provider every time, they would become tired of it very quickly. Instead, it asks the nurse who is spending his/her shift with a patient whether infection is suspected based on abnormal vitals and the patient’s overall clinical picture. It’s only if and when the nurse suspects infection that the provider is notified.”
Since the system’s inception, Harborview has seen remarkable results. Sepsis mortality has gone down 41% from 2011 to 2017, and over 95% of alerts are addressed by a nurse within two hours. There’s also been an increased awareness of the condition and its risks, Grant adds.
Currently, Harborview’s system uses systemic inflammatory response syndrome (SIRS) criteria to determine if a patient has sepsis. SIRS is defined as a combination of the following symptoms:
- Temperature less than 36°C (96.8°F) or greater than 38°C (100.4°F)
- Heart rate greater than 90 beats per minute
- Respiratory rate of more than 20 breaths per minute or an arterial carbon dioxide tension (PaCO2) of less than 32 mmHg
- Abnormal white blood cell count (either greater than 12,000/µL or less than 4,000/µL, or greater than 10% immature band forms)
Harborview’s system also looks for:
- Systolic blood pressure less than 90 mmHg
- Lactate level greater than or equal to 2 mmol/L
Grant does note that there are slightly different criteria for burn patients, pediatric patients, and burned pediatric patients.
While sepsis and SIRS are closely linked, sepsis isn’t the only possible cause for SIRS or SIRS symptoms. A patient could register on the SIRS scale if he or she has been more active, is in pain, has a bad cold, etc. That’s why a nurse has to make the final call.
“If a patient has two or more of these criteria, the bedside nurse is asked if he/she is concerned for infection,” she says. “If the nurse says yes, the provider is automatically paged to come to the bedside. If the nurse says no, he/she is asked to explain why the patient has abnormal vitals if it’s not infection.”
Building the system
The original build for the alert system took 12 months of work, says Grant. That included designing it, getting feedback and buy-in, building it in the EHR, and implementation. Then, in September 2016, Harborview held a weeklong rapid process improvement workshop (RPIW) to further refine the system based on provider feedback.
Approximately 15 team members were in attendance for the RPIW: attending physicians, resident physicians, bedside nurses, APRNs/PAs, a data analyst, a quality improvement specialist, and IT support. Afterward, the system was updated, with a continuing back and forth between the RPIW team on what changes to keep or drop.
“Since the implementation of those changes in February 2017, we have seen further decreases in mortality for hospital-acquired sepsis as well as increased three-hour [sepsis] bundle compliance,” she says.
If your facility is considering setting up its own automated sepsis flagging program (and it should), Grant says that holding an RPIW or similar event with stakeholders is the way to go.
“So much was accomplished having the right people in the room, especially the bedside nurses who will use the system every day,” she says. “They were also able to go back to their units and talk to their colleagues about suggested changes before they were made, and we were able to further refine and improve the system based on that feedback.”
One of the benefits of gathering stakeholders together was convincing them of the system’s merit. Grant says at the start, there was some pushback from providers who thought their patients were “somehow different than other patients in the hospital.”
“We worked using a ‘pilot’ model where we asked if [the stakeholder] could just try [the system] for three months and see,” she says. “It usually worked out that they realized the benefit of the system.”
The pilot model also allowed Harborview to gather patient safety data as well as metrics that also impact administrators, such as length of stay (LOS). By demonstrating shorter LOS for patients diagnosed with sepsis more quickly and treated efficiently, they were able to get the needed leadership support for the program.
There is still room for the system to improve; for instance, vital signs currently have to be typed in manually. Time is a major factor in treating sepsis, with each hour of delay in administering antibiotics resulting in a 7.6% decrease in survival on average. Having vital signs automatically updated in the EHR would make it easier and faster for caregivers to notice worrisome changes in a patient’s condition.
“I think it would be great to not have to manually enter the vital signs, and there are some groups working on that, although we haven’t explored much at Harborview—yet!” says Grant. “I think this would be helpful for a lot of reasons. But the system is still very successful even with the sometimes delayed entry of vitals.”
Get Ahead of Sepsis
Earlier this year The Centers for Disease Control and Prevention (CDC) launched an anti-sepsis campaign to bring attention to the condition. Called “Get Ahead of Sepsis,” the program was launched last August as an educational initiative to protect Americans from the devastating effects of sepsis, including emphasizing the importance of early recognition and rapid treatment, as well as the importance of preventing infections that could lead to sepsis.
The program calls on healthcare professionals to educate patients, prevent infections, suspect and identify sepsis early, and start sepsis treatment fast. In addition, this work urges patients and their families to prevent infections, be alert to the symptoms of sepsis, and seek immediate medical care if sepsis is suspected or if an infection is not improving or is getting worse.
“Detecting sepsis early and starting immediate treatment is often the difference between life and death. It starts with preventing the infections that lead to sepsis,” said CDC Director Brenda Fitzgerald, MD, in a CDC statement. “We created Get Ahead of Sepsis to give people the resources they need to help stop this medical emergency in its tracks.”
How states are fighting sepsis
Here are some examples of what states are doing to battle sepsis:
Gabby's Law – Illinois Senate Bill 2403 (SB 2403)
This law was named in honor of a 5-year-old girl who developed an infection from an undetected tick bite that led to sepsis. It requires hospitals to:
• Implement an evidence-based process for quickly recognizing and treating adults and children with sepsis
• Train staff to identify and treat patients with possible sepsis
• Collect sepsis data to improve the quality of care and provide it to the state (e.g., the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program)
(New York) Rory’s Regulations – NYCRR Title 10 Sections 405.2, 405.4, and 405.7
This law was named in honor of a 12-year-old boy who died when he developed an infection that led to sepsis after falling and cutting himself in a school gym. It requires hospitals to:
• Implement an evidence-based process, which should include suitable training, resources, and equipment for healthcare providers, for quickly recognizing and treating sepsis in adults and children.
• Collect sepsis data to improve the quality of care and provide this data to the state annually.
• Implement a Parents’ Bill of Rights to ensure that parents and primary care providers receive vital information about children’s care. Some components include:
Allowing parents or guardians to stay with pediatric patients at all times
Reviewing medical tests with the patient or the patient’s parent or guardian before discharging a child patient
Reducing Sepsis Mortality in Ohio – Ohio Hospital Association’s Sepsis Initiative
This two-year sepsis prevention and early recognition program, funded from CMS’ Leading Edge Advanced Practice Topics (LEAPT), focuses on reducing sepsis mortality in Ohio by 30%. The program encourages hospitals to:
• Conduct a survey to identify gaps in sepsis knowledge and treatment
• Identify, track, and report sepsis data
• Provide healthcare provider training for sepsis prevention and early recognition
“Think Katie First” – Wisconsin Hospital Association’s Partners for Patients Initiative
This initiative was named in honor of Katie McQuestion, a 26-year-old healthcare worker who died from sepsis after being hospitalized with flu-like symptoms. It brings Wisconsin hospitals together to:
Reduce sepsis mortality through early detection and rapid treatment of sepsis
Share sepsis prevention and early recognition best practices
Collaboration efforts have led to a 16% decrease in mortality-associated sepsis since 2013.
Below is a non-comprehensive list of our previous BOAQ articles and blog posts on the dangers of sepsis as well as treatment solutions: