Reducing Sepsis Mortality and LOS with Improved Recognition and Treatment Protocols

In the U.S., over 1.5 million people are treated for sepsis annually. One in four people with sepsis die, making improving early identification and providing patients with timely treatment a top priority. Hospitals and health systems continue to look to improve outcomes for patients with sepsis.

Allina Health, a not-for-profit healthcare system of 12 hospitals and 90 clinics, all serving patients throughout Minnesota and western Wisconsin, previously implemented a rapid process improvement project using a three-part bundle focused on the early identification of sepsis. However, sepsis mortality rates remained higher than desired. After turning to an analytics platform to replace its burdensome manual review process, Allina Health was able to identify opportunities for improvement and develop evidence-based processes for sepsis identification and treatment.

IDENTIFICATION AND TREATMENT—KEY TO REDUCING SEPSIS MORTALITY

In the U.S., over 1.5 million people are treated for sepsis annually, and one in four of the patients die.¹为了更好地了解和降低可预防的败血症死亡率，医疗保险和医疗补助服务中心(CMS)确定了公开报告的措施，包括基于证据的3小时和6小时的败血症护理套餐，确定了特定治疗的时间，并对确诊为败血症的患者进行评估。²

Historically, the gold standard for diagnosing sepsis was systemic inflammation response syndrome (SIRS). In 2016, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine published a new clinical definition of sepsis based upon organ dysfunction, with the recommendation to use a sequential organ failure (SOFA) score as an index.³

医院败血症改善工作的核心依赖于使用捆绑包，这是一套精选的元素，旨在简化有效管理严重败血症患者所需的复杂护理过程。Implementing bundle elements reduces variation in care, allowing improvement teams to create a reliable system that reduces sepsis mortality.⁴

Allina Health, a not-for-profit healthcare system, is dedicated to the prevention and treatment of illness and enhancing the greater health of individuals, families, and communities throughout Minnesota and western Wisconsin. Allina Health cares for patients from birth to end-of-life through its over 90 clinics, 12 hospitals with over 109,000 inpatient admissions, and 336,000 emergency department visits annually. The health system focused on improving sepsis outcomes as an opportunity to provide better care to its patients.

IMPROVEMENT EFFORTS LIMITED BY LACK OF PERFORMANCE DATA

随着败血症成为一个全国性的健康话题，阿利纳卫生实施了一个快速流程改进项目，使用由三部分组成的捆绑包，重点关注败血症的早期识别，但死亡率仍然高于预期。

Upon further investigation, Allina Health identified that key components of sepsis care varied widely across the system, including:

• Clinician awareness of assessment and interventions required for sepsis core measures.
• Multiple, often conflicting, procedures to activate a sepsis alert (an early warning notification within the EMR indicating the patient meets criteria for sepsis).
• Fourteen different sepsis order sets.

The electronic screening tool and alert system in the EMR Allina used were not effective, as they were not located within the clinicians’ workflow. Alerts were triggered when documented patient findings met the inclusion criteria for sepsis care, yet nursing documentation for sepsis was located in a different portion of the EMR, delaying timely sepsis identification and implementation of evidence-based care.

Allina Health lacked meaningful performance data that could be used to evaluate performance. Because documentation of sepsis was not standardized, it was difficult to obtain meaningful data that could be used to guide improvement efforts. To understand performance, Allina Health had to conduct burdensome manual case review, delaying feedback about performance. Even after performing manual case review, the health system was largely unable to give its providers the data they wanted, as it was unable to share provider-specific bundle compliance and could not tie the use of bundle elements to patient outcomes.

To improve its sepsis outcomes, Allina Health needed to better understand its performance and improve the consistency of care provided to patients with sepsis.

DATA UNLOCKS PATH TO IMPROVING SEPSIS MORTALITY

To exceed its previous sepsis performance and improve the outcomes for its patients with sepsis, Allina Health elevated the status of the improvement efforts to an ongoing program, convening an improvement team, whose members include physician leadership, nursing leadership, quality specialists, and analysts.

为了提高护理的一致性，Allina Health开发并验证了标准败血症订单集，并在EMR中构建订单集。Allina Health developed seven sepsis bundle elements that closely mirror the CMS core measures, incorporating decision support tools within the EMR to support timely delivery of the bundle elements, including:

• Obtaining initial lactate within three hours of time zero, defined as the triage time for patients presenting to the emergency department (ED).
• Ensuring blood cultures drawn within three hours of time zero and before antibiotics are started.
• Administering appropriate antibiotics within three hours of time zero and after blood cultures are drawn.
• 对符合感染性休克标准(持续性低血压或乳酸水平大于或等于4mmol /L)的患者在6小时内以30ml/kg的速度静脉输液。
• Obtaining a repeat lactate within six hours of initial evaluation.
• 给脓毒性休克病人适当的血管加压剂。
• Completing and documenting patient reassessment after intravenous fluid administration for patients with septic shock.

Having established the systemwide standard of care for patients with sepsis, Allina Health developed a robust communication and implementation plan, informing providers and nursing staff of the seven sepsis bundle elements, including inclusion criteria, and the recommended treatment interventions. At-the-elbow support and coaching was also offered to clinicians providing care to patients with sepsis.

为了进一步支持改进工作，阿利纳卫生确定需要额外的临床医生专业知识，创建了一个正式的败血症项目协调员角色。败血症项目协调员是注册护士(RN)，具有临床专业知识和绩效改善技能。败血症项目协调员监控性能，并在护理点促进过程改进工作，同时确保协议与当前最佳实践保持一致。

To gain insight into sepsis performance that could be used to drive improvement, Allina Health leveraged the Health Catalyst^®数据操作系统(DOS™)平台，实现败血症改善应用程序。世界杯厄瓜多尔vs塞内加尔波胆预测分析应用程序是为急诊、重症监护和住院病房的临床医生、医疗主任、操作主任和临床项目指导团队设计的。The analytics application provides near real-time actionable data to help improve early recognition of sepsis, early intervention for severe sepsis, and early therapy for septic shock to reduce mortality, morbidity, and cost (see Figure 1).

With the new insight provided by the analytics application, Allina Health conducted a deep dive into its data, discovering that more than 85 percent of its patients with sepsis arrived through the ED, leading to additional, focused educational efforts for ED clinicians including:

• 对医生进行教育，告知他们识别器官功能障碍所需的核心测量资格，根据器官功能障碍诊断脓毒症休克，以及目前基于证据的脓毒症干预措施。
• 护理教育的重点在于分诊时败血症的早期识别，以及与医生沟通的关键发现，以促进早期败血症干预。

A systemwide standard sepsis alert was built within the EMR driving interventions in alignment with ED workflow and documentation, including:

• 纳入标准基于SIRS标准和临床结果。
• 指导护理人员应与医生沟通的信息。
• Protocol-based nursing interventions to initiate early treatment.

通过使用分析应用程序，Allina Health能够近乎实时地监控性能，包括患者数量、视力、死亡率、LOS和单个患者、医生、护士和单位级别的成本。通过点对点对话、部门会议和标准信函，每月提供败血症改善性能的正式反馈，从而能够提供关于捆绑使用如何影响患者结果的有意义的信息。

RESULTS

By applying this comprehensive, data-driven approach for early identification and reduced variation in sepsis care, Allina Health’s multi-year improvement journey has realized substantial improvements in the outcomes for patients with sepsis, including:

• 18.6 percent relative reduction in mortality rate and 10.9 percent relative reduction in hospital LOS for all patients with sepsis.
• 30.3 percent relative reduction in mortality rate and 18.4 percent relative reduction in hospital LOS for patients with severe sepsis and septic shock.
• $1.1 million in annual cost savings, the result of efficiencies and substantial reductions in hospital LOS for patients with severe sepsis or septic shock.

阿利纳卫生实现了这些显著的改善，同时被诊断为败血症的患者数量增加了30%以上，这反映出在及时识别败血症方面有所改善。

“Sepsis is evolving, and change is difficult. Physicians value data that demonstrates how changes in their workflow impact patient care. For example, showing physicians that the use of the sepsis order set decreases variability and improves outcomes has increased use of the sepsis order set. Providing relevant data and individual provider feedback are the tools we rely on to educate and engage physicians to change behaviors.”

– Sandy J. Fritzlar, MD
Emergency Medicine Physician
Medical Director of the Allina Sepsis Program

WHAT’S NEXT

Allina continues to monitor performance and provide feedback as part of the ongoing sepsis improvement program, engaging its clinicians in meaningful dialogue to sustain and further improve upon patient outcomes, as well as further refine processes as new evidence is available.

参考文献

1. Centers for Disease Control and Prevention. (2017).Making health care safer.
2. Motzkus, C. A., & Lilly, C. M. (n.d.).Accountability for sepsis treatement – The SEP-1 core measure.American College of CHEST Physicians.
3. Fujishima, S. (2016). Organ dysfunction as a new standard for defining sepsis.Inflammation and Regeneration, 36, 24. Retrieved fromhttps://www.ncbi.nlm. nih.gov/pmc/articles/PMC5725936/
4. Society of Critical Care Medicine. (2015).Surviving sepsis campaign bundles.