The Impact of Early Identification and a Critical Care–Based Sepsis Response Team on Sepsis Outcomes

Sepsis affects 750 000 hospitalized patients in the United States every year, according to the Centers for Disease Control and Prevention.1 In addition, a survey of California hospitals by Kaiser Permanente found that sepsis was a factor in approximately 44% to 55% of hospital deaths between 2010 and 2012.1 From 1997 to 2005, the cost to the US health care system for pneumonia and sepsis grew twice as fast as the overall growth in hospital charges. By 2005 the cost for pneumonia and sepsis totaled $54 billion per year, an increase of approximately 180% from the 1997 cost.2,3Sepsis has been gaining national attention for various reasons. The substantial mortality rate, length of stay, and readmission rate are obvious patient factors contributing to this attention. The heightened awareness also reflects a financial motivation driven by Centers for Medicare & Medicaid Services regulations requiring hospitals to submit data related to sepsis treatment. With the concerning mortality rate and heavy focus on treatment of the septic patient, it is no secret that sepsis management is of top priority in many health care systems.Chambersburg Hospital is a 250-bed community care hospital within the Summit Health System. Sepsis is the most common admission diagnosis at our facility. We admitted 458 patients with severe sepsis and septic shock from October 2014 through September 2015. During that time, our mortality rate was 17.7%, our average length of stay was 7.51 days, and our 30-day all-cause readmission rate was 15.6%. Because of these compelling data and the national push from the Centers for Medicare & Medicaid Services, we decided to develop a team to focus on sepsis care.The newly formed team believed a standardized approach for managing sepsis patients would lead to improved patient outcomes, decreased morbidity and mortality, and decreased length of stay. The team’s goal was to develop tools and strategies to achieve standardized care of sepsis patients throughout our facility.An initial team was formed to develop a plan for implementing the 3-hour bundle in the emergency department. This bundle includes measurement of plasma lactate level, collection of a blood sample for culture before antibiotic treatment, administration of broad-spectrum antibiotics, and administration of intravenous crystalloid fluids at 30 mL/kg to treat hypotension.Several months after the rollout from the 3-hour bundle team, our team used lean methodology to standardize the 6-hour bundle process (vasopressor administration as needed, a focused examination by the health care provider, and measurement of a second plasma lactate level), to develop a process for sepsis detection on the floor, to improve handoff of patients with severe sepsis from the emergency department to the critical care department, and to standardize treatments such as administration of an intravenous fluid bolus of 30 mL/kg.Our multidisciplinary team consisted of critical care and medical-surgical leadership personnel, critical care and medical-surgical staff nurses, a clinical nurse specialist, a pulmonologist, a quality management registered nurse (RN), and a hospitalist physician. The team also used the expertise of personnel from other disciplines, including respiratory therapy, laboratory, pharmacy, and information technology.The team’s initial meeting took place in February 2016, around the same time as the publication of new sepsis definitions and assessment tools (the Sequential Organ Failure Assessment [SOFA] and Quick Sequential Organ Failure Assessment [qSOFA]) in the Journal of the American Medical Association.4 The team decided to adopt the qSOFA and SOFA tools to aid in more timely detection of sepsis in hospitalized patients. The qSOFA tool was built into our documentation system and implemented on 2 pilot units (Figure 1). Two months after our pilot program started we assessed the process, and after minor changes we implemented the qSOFA on 2 additional patient care units. We continued to roll out 2 units at a time until all adult inpatient units, excluding the behavioral health and family birthing units, were using the monitoring tool.A qSOFA score of 2 of more prompts the RN to activate a sepsis alert team (Figure 2). We designed the sepsis alert team to respond and assess patients with elevated qSOFA scores. The sepsis alert team was implemented simultaneously with the qSOFA monitoring tool. This team is composed of a critical care resource/charge nurse, a respiratory therapist, and a laboratory phlebotomist. The critical care RN evaluates the most recent qSOFA score, completes an assessment of the patient, and uses a standardized physician-approved protocol to order laboratory studies that are needed to complete the SOFA score. Once these studies are completed, the responding RN notifies the attending provider of the SOFA score. The physician can then use order sets created by the multidisciplinary team to include the most up-to-date recommendations for sepsis treatment. A provider who diagnoses sepsis can order an intravenous fluid bolus of 30 mL/kg, appropriate broad-spectrum antibiotics, follow-up plasma lactate level, and vasopressors as warranted. The responding critical care RN initiates fluid and antibiotic treatments and facilitates transfer to the appropriate level of care.The team felt that handoff was a key focus for effective continuation of care. We developed a checklist for handoffs between different levels of care (Figure 3). This tool effectively communicates care that has been completed and enables the primary RN to ensure completion of the bundle components.Within the first 5 months of implementation of the sepsis alert process, the critical care team responded to 30 sepsis alerts. Of those 30 patients, 25 received a change in their care; 15 of these had confirmed diagnoses of sepsis. The “false” alerts included conditions such as hypovolemia and respiratory distress, which still benefited from intervention from the critical care team.The mortality rate dropped from 17.7% (October 2014 through September 2015) to 12.9% (October 2015 through September 2016), which equates to 38 lives saved within that year. The mean length of stay at the hospital decreased from 7.51 days to 6.21 days, which represents 1035 days saved. This reduction in length of stay saved our facility approximately $517 500. Finally, the readmission rate decreased from 15.6% to 12.6%. These findings suggest that we have made progress in our efforts with sepsis. This progress could be attributed to the interventions we put in play, increased staff awareness, or a combination of both.Having bedside nurses use a clinically relevant tool can aid in early recognition and identification of sepsis.5 Our process implementation has shown us that a trained critical care nurse available to respond to this early recognition can effectively assess high-risk patients and initiate a preestablished protocol leading to early intervention and improved outcomes.Using the most recent guidelines to develop a standardized protocol that is embedded in the documentation can improve outcomes for this patient population. Our team recognizes that our successful outcomes were the result not only of the process improvements described above but also of the extensive education that we disseminated. We used newsletters, huddle talking points, computer-based learning, videos, and education stations to ensure that everyone had an opportunity to understand the new process. We also conducted a sepsis T-shirt campaign, giving all hospital staff T-shirts to promote sepsis awareness. The extensive educational campaign informed clinical staff that the critical care resource RN was their point of contact for questions related to sepsis.Beyond the challenge of educating all staff, the team was faced with skepticism from some of our providers. The protocol developed was nurse driven but needed to be approved by multiple physician groups before it could be implemented. Some providers expressed concerns related to large volumes of intravenous fluid and screening tools used for all admitted patients. The team enlisted the support of provider champions in different disciplines to help overcome these challenges.Early recognition and treatment of potential sepsis patients can decrease mortality, length of stay, and readmission rates. Assessment of high-risk patients and use of a standardized protocol improves outcomes for these patients.