By Dorothy Brooks
Administrators at Tampa (FL) General Hospital (TGH) tried for years to improve care for sepsis patients. When COVID-19 finally receded, leaders decided to kick their efforts into high gear. Because it is one of the leading causes of death among hospitalized patients,1 sepsis makes an excellent target for quality improvement, according to Peggy Duggan, MD, chief medical officer at TGH. “What really happens in sepsis is organ injury from undermanagement. When you treat people quickly, you can preserve their organs and preserve their lives,” she says.
Giving clinicians a head start on detection and treatment required a whole-hospital approach that fully leverages technology, but also provides the expertise and resources needed to respond faster. After just a few months of full implementation, program administrators are making gains. Not only have they shortened the average length of stay for patients with sepsis by nearly one day, they also have lowered mortality rates from 6% to 4% among patients who die within two days of coming to the hospital. When early recognition and treatment is the goal, the ED plays a critical role in ensuring patients with sepsis are set up for success.
Duggan says TGH started by building a tool that worked well at notifying clinicians early of patients at risk for sepsis. “If you develop a tool that is going to alert, it needs to be precise. Over-alerts lead people to ignore the tool,” Duggan says. “We really worked toward making the tool work well enough so that the teams would respond well to it.”
Then, there was spirited debate within the hospital about how to apply the tool. “We wanted every patient who is admitted to Tampa General Hospital to have the benefit of early identification and treatment. We worked with our teams to think about what would be the most appropriate group of clinicians to be monitoring and managing this work,” Duggan says.
While many hospitals have created rapid response teams for sepsis, Duggan notes these teams typically are called into action when a nurse or physician suspects they are seeing a patient with sepsis. However, through the TGH process, a specially trained nursing team responds to deterioration detected from vital signs and lab results entered into a patient’s electronic medical record (EMR). In the TGH analytics-driven command center, staff monitor these data around the clock.
“As a result of this process, the sepsis response often occurs before the bedside clinician even picks up on the risk. The sepsis nurses are going proactively to the bedside, identifying the patient, and starting treatment as early as possible,” Duggan shares.
Although sepsis can be diagnosed on any unit, roughly 80% of these patients present to the ED.2 Emergency clinicians are skilled at identifying many cases, but the TGH analytic-driven approach has helped staff detect subtle clues earlier, explains Jason Wilson, MD, MA, CPHQ, CPE, FACEP, associate medical director of the TGH ED.
“If a patient walks in the door, is tachycardic, has low blood pressure, looks sick, and has a fever, that is not a hard case to diagnose with sepsis. But for another patient who comes in with a little bit of a cough or a sore throat, and then maybe they are younger or healthier — [sepsis] is not as high of a suspicion,” Wilson explains.
When an emergency clinician immediately a sepsis patient, he or she will enter an order that flags the person with a sepsis alert, which notifies the sepsis response team. “That will allow all the coordinated care steps to happen as the patient moves about the hospital, from the ED to the ICU or wherever the patient is going,” Wilson says.
For a case the emergency clinician has not identified, staff monitoring the EMR data will communicate with the emergency provider about signs of potential sepsis. They will discuss each case, deciding how to proceed.
Since there are so many sepsis cases diagnosed in the ED, there generally is a sepsis nurse stationed in the department. This person can step in right away to coordinate with other care providers. They ensure all the needed resources are in place, and evidence-based care steps are completed within the recommended time frames.
“We like to call out an overhead alert for sepsis in the ED, just to bring some recognition to it in case the nurse needs other resources,” Wilson shares. If a sepsis nurse is not on the unit, the response team can send a nurse.
For sepsis, the ED’s role extends beyond identifying cases and initiating treatment. Clinicians also must determine where to send these patients for continued care. “If [a patient] is septic because he or she has an infected gallbladder, admitting them to the ICU will not do them much good. I need to get a surgeon down to come take the patient to the operating room,” Wilson observes. “If the patient needs to have a ... central line put in to monitor their blood pressure, that is something I need to do as an emergency medicine physician to help the treatment course continue.”
Bacterial infections are common sepsis culprits,1 but there are other potential causes that may require surgical procedures or other interventions that can be performed best on specific units. “Once we get past some of those guideline-driven steps that will help us figure out where the patient should go next, we can start working on admitting the patient,” Wilson says.
It is critical for emergency staff to hit the first three hours of the sepsis bundle, a core measure from the Centers for Medicare & Medicaid Services that includes several steps, each of which is backed by evidence suggesting following such steps will improve care.3 “Our goal in the ED is to identify time zero; meet the requirements of the first bundle at three hours; and then have a good, coordinated handoff to make sure people are going to meet the [requirements] at hour six,” Wilson reports.
The TGH process helps clinicians ensure they are completing all required steps in the bundle on time and documenting such achievements. “That was a struggle sometimes for us to make sure we had every piece documented,” Wilson adds.
A sepsis response team member often moves with the patient through the process, regardless of where he or she is undergoing treatment or to which service the patient will be admitted following treatment in the ED. “We’re starting to see a bend in the curve — a fall in our mortality index with sepsis patients,” Wilson says.
Since the new process became fully operational in August 2022, Duggan observes the process, along with the faster treatment it has facilitated, has prevented more than 100 early deaths from sepsis. Further, she reiterates it is not just the sophisticated tools TGH has put in place to pick up on the early signs of sepsis risk, but also the infrastructure the hospital assembled around the tool. “[A] sepsis oversight committee is going to [help us] keep working and keep evolving,” Duggan says. “Once you start taking your foot off the gas, people start to change focus.”
The sepsis oversight committee consists of several top administrators, including Duggan, the chief operating officer, the chief clinical officer, and the vice president for finance. The committee also includes nurse and physician leaders from the ED, two hospitalists, a process improvement team, and the nurse leader for rapid response. The group meets two or three times a month.
Putting this type of comprehensive program in place requires commitment from the frontlines, but there has to be real leadership from the hospital’s upper ranks to produce success. Duggan says TGH’s president and CEO was the one who issued the challenge and committed the necessary resources to achieve the program’s goals. “It speaks volumes for teams to have the current hospital president be in with them,” Duggan adds. “It’s a big deal.”
REFERENCES
1. Centers for Disease Control and Prevention. What is sepsis? Page last reviewed Aug. 9, 2022.
2. Rhee C, Dantes R, Epstein L, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA 2017;318:1241-1249.
3. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Crit Care Med 2021;49:e1063-e1143.
At Tampa General Hospital, staff have shortened the average length of stay for patients with sepsis and lowered mortality rates. When early recognition and treatment is the goal, the ED plays a critical role in ensuring patients with sepsis are set up for success.
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