Six health care organizations sign on to participate in project aimed at curbing sepsis mortality
Hospitals and EDs across the country continue to struggle with how to most effectively identify and treat patients who present with sepsis or develop the condition sometime after they have been admitted. The Joint Commission (JC) reports that sepsis is the leading cause of death in hospitalized patients, and it is also the most expensive condition to treat, costing hospitals upwards of $17 billion annually.
For all of these reasons, the JC's Center on Transforming Healthcare has decided to tackle sepsis mortality head-on for its eighth project. It has assembled a team of six health system participants to both identify barriers to effective care and devise solutions to improve patient outcomes. (See "Project team for participants for reducing sepsis mortality," below) The ultimate goal of the project is a targeted solutions tool that will be shared with the JC's 19,000 member institutions.
Project Team Participants for Reducing Sepsis Mortality Project
|
The task is a tall order, but also just the type of challenge that the Center for Transforming Healthcare — a separate entity from The Joint Commission's accreditation arm — was set up to take on, according to Donise Musheno, RN, MS, center project lead at the Center for Transforming Healthcare. "Every year 750,000 Americans are diagnosed with sepsis and 220,000 of these people die, so the mortality rate is 30%," she explains. "When we looked at the statistics around this issue, we certainly saw a burning platform."
Early detection is challenging
Sepsis, or the body's own life-threatening, inflammatory response to an infection, can result from pneumonia, a urinary tract infection, a surgical site infection, or any other infection site, says Musheno. "The signs and symptoms of sepsis are really the signs and symptoms of an infection until it gets to the very late stages, so it is challenging to detect."
Thomas Russell, MD, assistant chief, Department of Emergency Medicine, Roseville Medical Center, Roseville, CA, agrees, noting that simply identifying that there is a risk is the most difficult aspect. "Several of the tools that have been talked about overlap with disease entities other than sepsis. For example, specific criteria can be positive in a pregnant woman, an asthmatic, and many people who have no infection at all, so identifying the sepsis patient is difficult," he says. "While there are vital sign triggers, historical triggers, and laboratory tests that can be done, no one piece of it is diagnostic. It actually takes accumulating multiple pieces to put the disease in context so that it can be identified."
Once a case of sepsis is confirmed, the complexity continues as the patient needs to be risk-stratified to determine the proper course of treatment. "Sepsis actually represents a continuum of illness," observes Russell. Clinicians must decide when to be aggressive and when to take a more conservative approach, he says. "Risk-stratifying into that spectrum is something that really has not been well discussed in the medical community."
However, it is an area that Kaiser Permanente has investigated extensively, so the organization is bringing that knowledge base to the table as a participant in The Joint Commission's sepsis project. "We have quite a robust division of research, and it has enabled us to look at well over 20,000 cases, and to use those cases to risk-stratify sepsis patients," explains Russell. "So we have some clues on which patients we can be more aggressive with and which ones we can be more conservative with."
Key skill lacking in many EDs
What's missing at this point, especially in ED settings, is a systematic approach for identifying and treating the sepsis patient, explains Boris Khodorkovsky, MD, FACEP, assistant director, Emergency Medicine Department, Staten Island University Hospital in Staten Island, NY, which is part of the North Shore Long Island Jewish Health System. "When people are doing different things, you don't really create a unified front," he explains. "By decreasing variations you can create a better effect, and you can also decrease the wait. Unfortunately, there is still a lot of time wasted on doing things that are completely unnecessary, so if we create a tool, establish goals, and reduce sepsis mortality, then we will have succeeded in creating a benefit and eliminating the waste."
However, while experts agree that a systematic approach is important, many EDs lack an important skill set that is integral to a systematic approach for treating the sickest sepsis patients — and that is the placing of central lines, says Russell. "Over the last decade or so, many ED physicians moved away from placing central lines. We had other options and other ways of doing things that had traditionally been done by using central lines, so the skills have been lost by many ED physicians," he explains.
Musheno, who worked as an ED nurse before coming to The Joint Commission, agrees, noting that central line access is a barrier for many EDs when they first start looking at a sepsis initiative. "Some organizations have residents or interns who can provide central line support, but other organizations often have to rely on critical care teams to come to the ED to place central lines," she explains. "That, of course, leaves the ICU not covered for a period of time, so it all about resources and time."
Bringing this skill back, and enhancing it with the use of ultrasound so that placing a central line is no longer a blind procedure, has been a significant challenge for emergency medicine, says Russell. While placing a central line is an invasive procedure that has been associated with infections, Russell points out that with proper technique and diligence, central line infections can be dramatically reduced. "In our 21-hospital system in northern California, our central line infection rate is well below national averages, and it is simply because we are very aggressive at removing central lines when they are no longer needed," he says.
Another area that needs more attention is the identification and treatment of sepsis in children. "The screening tools we use for adults have virtually no validity in children. We have to have a whole new screening system for children which is, frankly, somewhat in development," says Russell. "This is one of the big challenges in sepsis care, and it is one of the reasons why Kaiser Permanente is participating in The Joint Commission sepsis project — to look at tools for screening for sepsis in children."
Working with the six participating health care organizations, the Center for Transforming Healthcare will leverage its own Robust Process Improvement (RPI) methods to identify problems and develop solutions to reduce sepsis mortality. The RPI approach borrows heavily from the Lean Six Sigma and other change management methodologies to develop data-driven solutions. Musheno emphasizes that the project has an aggressive timeline for results. The goal is to make a web-based, targeted solutions tool available to all member organizations by the end of 2013. "This is important," stresses Musheno. "We need to move on this and make sure it gets out there."
Sources
- Boris Khodorkovsky, MD, FACEP, Assistant Director, Emergency Medicine Department, Staten Island University Hospital, Staten Island, NY. E-mail: [email protected].
- Donise Musheno, RN, MS, Center Project Lead, The Joint Commission Center for Transforming Healthcare, Oakbrook Terrace, IL. E-mail: [email protected].
- Thomas Russell, MD, assistant chief, Department of Emergency Medicine, Roseville Medical Center, Roseville, CA. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content