More than a million Americans are stricken with sepsis each year, with about 15-30% of those cases resulting in death, according to the National Institute of General Medical Sciences.
Because of this, awareness of sepsis cases has been on the rise in healthcare circles and has been the focal point of a number of efforts nationwide to apply, informatics, data analytics and process improvement to the problem.
To tackle this critical issue in its emergency department, Tampa General Hospital (TGH) applied a method that not only addressed the problem immediately but put in place a process that, through continual evaluation, will quickly address the issue in the future.
Dr. Peter Chang, Chief Medical Informatics Officer at TGH, spoke about the hospital’s use of clinical process management in March at the annual HIMSS conference in Las Vegas.
Dr. Chang also is an assistant professor of hospital medicine at USF Health’s Morsani College of Medicine at the University of South Florida.
The Sepsis Process
TGH applied clinical process management to the problem of sepsis, which occurs when the body tries to battle an infection by flooding it with chemicals. This excess of chemicals winds up causing inflammation throughout the body. According to the Centers for Disease Control and Prevention, the condition “is life-threatening, and without timely treatment, sepsis can rapidly cause tissue damage, organ failure, and death.”
Sepsis also had a tremendous impact on two crucial metrics for TGH, length of stay and costs per patient.
TGH’s challenge was to develop repeatable and scalable models to address difficult clinical initiatives and improve patient outcomes.
With a goal of early diagnosis and treatment of sepsis in the emergency department, Chang and his teams implemented a plan that included electronic health record-generated alerts and treatment advice as well as a process for review of clinicians’ response time and treatment decisions.
The approach was divided into three parts.
Standardize the following areas:
- Early identification of sepsis
- Clinical processes for potentially septic patients in the emergency department
- Setting a time mark for when treatment begins, which is when a provider enters a sepsis alert into the system
- Clinician response
Leverage CPI software to measure:
- Clinician to patient interactions
- Clinical decision-making
- Adoption level of order set, a standardized set of actions to be taken with sepsis patients.
- What are the response times?
- How many providers are accepting alerts?
- Who needs coaching?
Findings and Solutions
The evaluations found mixed results. Chang and his team created a best practice advisory (BPA) for nurses and another for doctors. Both were triggered by signals from the patient’s body that it might be susceptible to sepsis.
The nurses’ BPA, however, proved to be too inclusive. One nurse received 583 alerts but reported only three patients as possible sepsis cases.
The BPA used by providers, however, proved more accurate. Out of 288 alerts, action was taken 282 times.
The most important measure though, was the 18% decrease in sepsis deaths during the year from January 2017 to January 2018.
Two secondary items the team addressed performed even better.
Chang’s team sought to reduce orders of Dilaudid, a powerful pain medication. The Drug Enforcement Agency, Chang said, clamped down on the amount of the drug hospitals could receive in response to the opioid crisis. Their efforts reduced TGH’s Dilaudid orders by 20%.
Even more successful were the team’s attempts to reduce occurrences of clostridium difficile, or C. diff, a nasty infection that can occur when a patient is treated with a heavy dose of antibiotics. The antibiotics destroy all the body’s bacteria, good and bad, and, according to Chang, the bad grows back more quickly, leaving the patient with fever, stomach pain and diarrhea. Chang and his team were able to reduce occurrences of C. diff by 50%.
Clinical process improvement is about continuous evaluation, meaning if TGH sticks to protocol, they should not only keep these gains secure but improve them as well.
“We’ve built things for C. diff and they’re working,” Chang said. “We’re doing things for sepsis. All we have to do is make sure the pedal remains pinned to the metal and we’re seeing sustained improvement.”
One of Chang’s most important conclusions from these studies is that the best way to achieve success for any healthcare institution is standardization.
“Every other industry is standardized,” Chang said. “Medicine is always the last to adopt that train of thought.”
For healthcare facilities to succeed, Chang said, “we have to stay as top-notch as we can, and we have to be able to decrease costs. One of the only ways you can really do that is through standardization.”