Hospital's sepsis program initiative boosts safety
An initiative aimed at standardizing interventions related to the rapid diagnosis and treatment of severe sepsis has significantly improved patient safety at Barnes-Jewish Hospital in St. Louis.
The multidisciplinary team, led by pharmacy staff, recently received the 2007 American Society of Health-System Pharmacists (ASHP) Award for Excellence in Medication-Use Safety. The award recognizes on a national level pharmacy professionals who have assumed a leadership role in promoting safety in the medication-use process.
The award signaled success not only in improving safety, but also in showing that patient safety leaders can come from all departments, says Scott Micek, PharmD, clinical pharmacist for critical care at the hospital and the pharmacist who led the Barnes-Jewish multidisciplinary team in its medication safety initiatives.
"This award demonstrates that research can be translated into clinical practice on a local level through teamwork, organization, and standardization of care, all key components to improving quality of care, safety, and patient outcomes," he says.
Sending signal to community
The team's work was significant not just for the measurable improvements in patient safety, but for the signal it sent to the rest of the hospital community, says Roslyn Corcoran, RN, BSN, manager of patient safety/risk management at Barnes-Jewish Hospital. "Infection control is at the height of public awareness, so as risk managers, it is imperative that we create a culture of patient safety and transparency for our employees and patients," Corcoran says. "This results in better understanding and compliance, which is the right thing to do for patients."
Sepsis is a serious condition in which infection has spread into the bloodstream, Micek explains. When bacteria or other infectious organisms spread throughout the body and overwhelm the immune system, the infection can be life threatening. Patients with sepsis need immediate medical attention.
The Barnes-Jewish Hospital team instituted and standardized interventions related to the rapid diagnosis and treatment of severe sepsis in patients in the Barnes-Jewish Hospital emergency department. About 1,200 patients diagnosed with severe sepsis are seen at Barnes-Jewish each year, Micek says. The team wanted to incorporate the best clinical research into daily practice at the hospital, Micek says, focusing on the patients who present to the emergency department with a complication that could lead to sepsis. Using clinical literature and benchmarks available in the literature, the team created a process that helps staff identify patients at risk and then make sure they received the appropriate treatment in a standardized fashion.
"It was essentially a quality improvement program," he says. "We wanted to optimize care by using those clinical benchmarks."
A key change was in the nursing triage, Micek says. ED nursing staff and physicians were trained in how to recognize the signs of sepsis and how to put the patient on the proper path for treatment, he says. "In that sense, it is no different from how nurses screen for other symptoms and put the patient in the proper pathway for stroke treatment, for instance," he says. "We introduced the sepsis pathway and had patients steered toward that treatment course. Patients were more rapidly identified, and physicians were more aware of the risk." (Editor's note: Sepsis pathways are included in their published research. See references on p. 35.)
Standardized order set helps
The team also developed a standardized order set for managing septic shock. Once the ED staff identified patients at risk, the standardized order set allowed each patient to receive care driven by best practices, Micek explains.
Prior to the system being introduced in early 2006, there was no standardization for treating these patients, Micek says. The sepsis team, which included members from the pharmacy department along with nurses and physicians, had to devote considerable effort up front to obtaining buy-in from the ED staff, he says. Having nurse and physician members who could talk to their colleagues about the need for standardization was a big plus, Micek says.
"The education process included group meetings and one-on-one training with individual staff members over a period of months, but it was worth it to get that buy-in from the people who are the key players in actually implementing this program," he says. "It helped that we weren't introducing completely new therapies. Rather, we were standardizing the way we did these things."
Implementing the program, from conception to full use in the ED, took about a year. Micek says. "My advice for other hospitals would be to focus on simple, easy-to-use treatment pathways with triggers that move the patient forward through the process according to best practices," he says. "The other important lesson is that you will get much farther with a multidisciplinary team that can introduce this kind of idea to their colleagues, rather than having it handed down from another department."
New protocol yields better outcomes
The standardized hospital order set for the management of septic shock in the emergency department at Barnes-Jewish Hospital in St. Louis, yielded measurable improvements in patient safety. Scott Micek, PharmD, clinical pharmacist for critical care at the hospital and the pharmacist who led the Barnes-Jewish team, suggests the team's published report on the clinical criteria could be useful for pharmacy staff or multidisciplinary teams seeking similar improvements.1
The team studied a total of 120 patients with septic shock. Sixty patients (50%) were managed before the implementation of the standardized hospital order set for septic shock, constituting the "before group, and 60 (50%) were evaluated after the implementation of the order set, making up the "after group."
Patients in the after group:
- received statistically more intravenous fluids while in the emergency department (3,789 + 1,730 mL vs. 2,825 + 1,624 mL);
- were more likely to receive intravenous fluids of more than 20 mL/kg body weight before vasopressor administration (88.3% vs. 58.3%);
- were more likely to be treated with an appropriate initial antimicrobial regimen (86.7% vs. 71.7%) compared with patients in the before group.
- were less likely to require vasopressor administration at the time of transfer to the intensive care unit (71.7% vs. 100%);
- had a shorter hospital length of stay (8.9 + 7.2 days vs. 12.1 + 9.2 days);
- had a lower risk for 28-day mortality (30% vs. 48.3%).
The authors concluded that the implementation of a standardized order set for the management of septic shock in the emergency department was associated with statistically more rigorous fluid resuscitation of patients, greater administration of appropriate initial antibiotic treatment, and a lower 28-day mortality. "These data suggest that the use of standardized order sets for the management of septic shock should be routinely employed," they wrote.
Micek also directs risk managers to the research showing the economic benefits of the program.2 In this analysis, Micek and his colleagues compared patients treated before the protocol with those cared for after the protocol was implemented. They studied 120 patients, evenly divided between those treated before the new protocol and those treated with it. There were more survivors following the protocol's adoption (70% vs. 51.7%). Median total costs were significantly lower with use of the protocol ($16,103 per patient vs. $21,985). The length of stay also was on average five days less among the post-intervention population.
The researchers concluded that the protocol resulted not only in improved mortality but also in substantial savings for institutions and third party payers. "Broader implementation of sepsis treatment protocols represents a potential means for enhancing resource use while containing costs," the authors wrote.
References
1. Micek ST, Roubinian N, Heuring T, et al. Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med 2006; 34:2,707-2,713.
2. Shorr A, Micek S, Jackson Jr. W, et al. Economic implications of an evidence-based sepsis protocol: Can we improve outcomes and lower costs. Crit Care Med 2007; 35:1,257-1,262.
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