HCA is speeding up detection and treatment of sepsis, no matter where it lurks
Despite advances in modern medicine, sepsis—a life-threatening condition whereby the body responds to infection by injuring its own tissues and organs—continues to be the leading cause of preventable death in U.S. hospitals. More than 1 million Americans are diagnosed each year. But detecting sepsis early can be challenging, experts say, because the symptoms often mimic those of other conditions.
“Diagnosing sepsis very often requires detective work,” says Angie Mitchell, director of nursing services within the clinical operations department at HealthTrust.
The key, she says, is to assess patients as early as possible. If they are presenting with any potentially “septic” symptoms, such as fever, chills, rapid breathing, increased heart rate, rash or disorientation, it’s important to closely monitor their hemodynamic status, begin early antimicrobials, run lab work, and continue to frequently reassess their condition to identify even the most subtle of changes.
Checklists can help, adds Kenneth Sands, M.D., chief epidemiologist and chief patient safety officer at HCA. “Using checklists can ensure that the diagnosis of sepsis is under consideration. Diagnosing sepsis really involves a constellation of findings, and piecing those findings together is an important part of detecting it.”
Although anyone can get sepsis, the risk is higher in people with weakened immune systems, comorbidities, or who are suffering from a severe burn or physical trauma, Sands says. It is estimated that the mortality rate can be 40 percent.
In January 2017, the Surviving Sepsis Campaign published the fourth revision of the Surviving Sepsis Guidelines in both the Critical Care Medicine and Intensive Care Medicine journals. In addition to major recommendations related to antimicrobial stewardship, resuscitation and managing infections, the patient-centered guidelines strongly encourage hospitals and healthcare facilities to implement programs that include screenings in order to detect sepsis earlier and treat it effectively.
Pulling Together a Patient-centered Team
HCA is implementing initiatives to detect sepsis even earlier, treat it more quickly and decrease mortality rates. Through supplier relationships, data analytics, training and education, and dedicated healthcare professionals, HCA is tackling the challenge of sepsis from all angles.
At the center of HCA’s care plan is a sepsis coordinator, a dedicated healthcare provider—typically a nurse—who works in collaboration with the medical staff to provide care to suspected or confirmed septic patients, doing rounds in both the emergency and inpatient units.
Many people are involved in the detection and treatment of sepsis, Sands explains. “Obviously there are emergency physicians, because many patients presenting symptoms of sepsis go to the emergency department (ED). But nurses are important because they monitor patients’ vital signs and administer medication and fluids; infectious disease specialists are essential because they determine the appropriate way to give antimicrobials; pharmacists are needed to make decisions about medication management; laboratory scientists analyze tests and blood cultures; respiratory therapists are necessary for several patients requiring respiratory support; and so on. It’s very much a team effort,” he says.
Administering Antimicrobials to Fight Sepsis
IV antimicrobials should be administered as soon as possible if sepsis is strongly suspected or identified—preferably within one hour. Research shows that each hour delay in the administration of antimicrobials is associated with an increase in mortality, explains Marcus Dortch, former senior director of clinical pharmacy services at HealthTrust. It’s recommended that empiric broad-spectrum therapy be given with one or more antimicrobials to patients presenting with sepsis to cover all likely pathogens—including bacterial, fungal or viral.
“It is believed that the benefits of administering early antimicrobials far outweigh any potential consequences,” says Kenneth Sands, M.D., chief epidemiologist and chief patient safety officer at HCA.
The Surviving Sepsis Guidelines published in Critical Care Medicine and Intensive Care Medicine journals suggest combating delays by using “stat” orders or including a minimal time element on antimicrobial orders. Other suggestions include “sequencing antimicrobial delivery optimally or using simultaneous delivery of key antimicrobials, as well as improving supply chain deficiencies.”
If antimicrobials cannot be compounded and delivered quickly from the pharmacy, Dortch recommends storing ready-to-use or premixed bags in automated dispensing cabinets on unit floors to ensure prompt administration.
“Every dosage needs to be treated as if it is an emergency, and that may mean hand-delivering medication from the pharmacy or preparing the dose on the unit floor,” Dortch says. “The quicker you administer medication, the more likely the patient will successfully respond to treatment.”
If there are market shortages, hospitals may have opportunities to get access to allocated supplies by working with their GPO and wholesalers, Dortch says. However, if there is a critical drug shortage, it’s crucial that only patients in dire need of the medication be the ones to receive it.
Utilizing Technology in the ED
At HCA, physicians and nurses in the ED use an automated system to assess patients, Sands says. When entering a patient’s symptoms and vital signs into the computer, the program prompts the user with questions. The computer program is trained to recognize patterns and predict outcomes based on the information provided by the nurses and physicians.
“The program may ask, ‘Does the patient have a high temperature or an unusually low temperature?’ A certain combination of questions answered ‘yes’ will alert the physician that the patient qualifies for sepsis treatment,” Sands explains.
However, he adds that physicians must still use clinical judgment. “The program simply ensures that we are addressing the possibility of sepsis, and it helps identify vital sign elements that might lead to a diagnosis,” he says.
Once a patient is identified as having sepsis, treatment must start immediately. For every hour that treatment is delayed, the risk of mortality is increased by 8 percent. Broad-spectrum antimicrobials (see sidebar below) and fluids are given intravenously to ensure they get into the patient’s bloodstream quickly and efficiently.
Fluid resuscitation is a central component of sepsis management—the body needs extra fluids to keep blood pressure from dropping too low and causing the patient to go into shock. Intravenous fluids allow medical staff to monitor how much fluid is being administered and control which type of fluid the patient receives.
The HCA clinical services group is introducing a new device for EDs. The noninvasive ClearSight system monitors hemodynamic factors, giving clinicians immediate insight into a patient’s condition, explains Lyndsey Wagner, the team’s project manager. Developed by Edwards Lifesciences (HealthTrust Contract No. 2143) the system is comprised of the ClearSight finger cuff and the EV1000 clinical platform. The finger cuff monitors hemodynamic factors such as stroke volume, stroke volume variation, cardiac output, systemic vascular resistance and continuous blood pressure. It then transmits that information to the EV1000 platform. Clinicians can choose which facts they want to monitor on the platform, and also set up alarms or targets for hemodynamic optimization.
“Using the system helps clinicians monitor how much fluid the patient needs and determine when to give the patient more,” Wagner adds.
ClearSight was first introduced in November 2016 as a pilot program at Brandon Regional Hospital and Blake Medical Center, in HCA’s West Florida division. Data from the pilot program revealed a greater than 50 percent decrease in mortality, says Bob Foster, assistant vice president of emergency services at HCA.
Leveraging Clinical Data and the Laboratory
Although no single test yet exists that accurately diagnoses sepsis, the laboratory plays an active role in early detection. Lab scientists help identify a number of biomarkers that can determine whether a patient has sepsis or another type of systemic inflammation, explains Belinda Vanatta, former director of laboratory services at HealthTrust.
Elevated levels of biomarkers like lactate and procalcitonin—a peptide precursor of the hormone calcitonin—are strong indicators of sepsis, Vanatta says. But these aren’t the only tests that should be ordered. Often, a C-reactive protein test, blood cultures, complete blood count tests and cerebrospinal fluid analyses are used to detect or rule out sepsis, according to the American Association of Clinical Chemistry. When analyzed along with hemodynamic factors, the ability to detect sepsis is greatly improved.
Though sepsis can’t always be prevented, there are some measures that people can take to avoid it. Promoting better knowledge about sepsis among the general population can help people get treatment earlier, suggests Kenneth Sands, M.D., chief epidemiologist and chief patient safety officer at HCA. The Centers for Disease Control and Prevention
recommends healthcare providers share these three tips with their patients:1. Get vaccinated against the flu, pneumonia and any other infections that could lead to sepsis.2. Prevent infections that can lead to sepsis by cleaning scrapes and wounds, and practicing good hygiene (e.g., handwashing).3. Remember that time matters. If you have a severe infection, watch for signs of sepsis—shivering, fever, extreme pain or discomfort, clammy or sweaty palms, confusion or disorientation, shortness of breath, rapid breathing and a high heart rate—and if they appear get yourself to the nearest emergency department.
HCA’s Clinical Excellence Facility Interface Team (ceFIT) is using these lab tests to build an algorithm for early detection of sepsis. Working alongside a team of data scientists with the Clinical Services Group Data Science Team, the ceFIT team has developed SPOT (Sepsis Prevention and Optimization of Therapy), a program that analyzes every inpatient’s temperature, pulse rate, respiratory rate and white blood counts, as well as lactate levels, antibiotic use and blood cultures, explains Adam Mindick, senior consultant for the ceFIT team.
The program monitors the lab results and vital signs of all inpatients every 15 minutes, adds Anna Harb, the director of the ceFIT team. If the SPOT program detects that a patient potentially has sepsis, an alert is sent to the facility’s sepsis coordinator. That can help the bedside caregiver complete a sepsis screening more quickly.
Though the team is still fine-tuning the algorithm, recent data has shown that SPOT can detect sepsis approximately 12 hours prior to a nurse documenting a positive sepsis screen, Mindick explains. The goal is to detect sepsis even faster, and when that happens, the team will work to expand the program.
Keeping the Goal in Mind
Sepsis continues to be one of the most dangerous—and expensive—conditions that a hospital treats, and part of preventing it has to do with patient education. (See sidebar above.)
“It’s important that we educate patients, especially those with underlying conditions, about how to lessen their chances of developing sepsis,” Sands says. “If patients have catheters in place, ensure they know how to care for them. If they recently had surgery, make sure they understand postoperative care instructions.”
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