Sepsis Bundle Helps Improve Patient Outcomes Across Hospital System
By Matt Phillion
In the U.S. sepsis accounts for 35% of all hospital deaths. Over 1.7 million patients are diagnosed with sepsis and 270,000 die from it annually. Only heart disease, cancer, and preventable injuries occur more frequently in the annual death toll.
Surviving sepsis requires early detection and treatment. To improve how their organization treats and reacts to sepsis, Sentara’s Clinical Performance Review Team developed a systemwide push to implement the Surviving Sepsis Campaign’s intervention bundle. This bundle provides a standardized protocol for treatment of severe sepsis and septic shock in hospital. Since it was first implemented in 2022, Sentara’s mortality rates for sepsis have fallen by 36.7%.
“As an industry, we’ve seen a significant shift to paying more attention to sepsis. Recent papers have found that approximately 70% of hospitals have a sepsis team, have a leader, and give that leader time to focus on sepsis, as Sentara does,” says Dr. Doug Browder, emergency department medical director for Sentara Leigh Hospital and the physician champion for Sentara’s systemwide mortality reduction effort. “As an industry, we’re headed in the right direction as it is one of the leading causes of mortality in most hospitals. This increased focus is where we need to go.”
The bundle works through providing recommended steps to be carried out within the first hours of sepsis recognition—treating sepsis depends on speed of that reaction, Browder notes.
To recognize sepsis, clinicians, particularly in the ED or acute care space, must be on constant alert for symptoms like fever, infection, and mental decline.
To aid in recognizing and triaging by frontline physicians and nurses, each of Sentara’s 12 hospitals named a sepsis site coordinator champion. These coordinators aid physicians at each hospital by developing and promoting tools for quick entry of labs, administration of antibiotics and life-saving fluids, and more. They also collaborate with the nursing staff and physicians to coach continuous improvements.
“Hopefully leveraging some of our existing technology, including the EHR, can make this job easier for clinicians and nurses,” says Browder.
The initial push to implement the bundle came from recognizing that sepsis was an area the system could improve overall, he explains.
“Within our system, we have very high goals, and we want to be within the top quartile of everything we do,” Browder says. “We recognized that compared to state and national cohorts back in 2019 or 2020 we weren’t performing where we wanted to be.”
The system has a well thought out, planned process improvement structure, which is used to reevaluate key clinical goals and metrics and decide which ones to focus their energy on. In 2021, they recognized sepsis as an area for improvement and assembled key leaders, including nursing, the chief medical officer, a process improvement engineer, data analytics, and clinical leaders to take charge of the initiative. Browder, as the medical director for the system’s busiest ED, had operational experience working on this in real time.
“These key leaders from broad specialties and nursing worked through our ideas and reached out to site staff that were doing well in this area and from that ideation we conducted a value and needs analysis to create a master solution index to identify the things we need to do better on,” says Browder.
The team sees standardizing taking care of these patients and leveraging order sets through their EHR were key to improving sepsis care.
“We needed to find a better way of collating our data around sepsis performance in a timely fashion. We identified a need for a site-specific leader or coordinator, but also tailor it to each individual site,” says Browder. “A key element we identified early was that we need to treat sepsis as an emergency. In cases like myocardial infarction or stroke, we did a great job, so treating this as an emergency and helping clinicians document it in the EHR were key improvements.”
As they developed and implemented these changes, one surprise that arose was that it was going to require a fair amount of cultural buy-in and support, explains Browder.
“We need to work hard with staff to make sure they support that buy-in element. It was a completely different approach to taking care of these patients,” he says. “We also became aware of the importance of a leader at each site, not only for analyzing data but also looking for ways to improve and interact with staff one-on-one to help with that cultural support.”
They also came to see how important focusing on patient-oriented outcomes was to help clinicians really get behind the program and buy in to it.
“That patient-oriented outcome for us was showing we were improving through mortality rates,” says Browder. “With any clinical and process improvement project you initiate, you may be asking them to do more work or change the way they do the work, The staff may feel this is making them work harder or document more. It’s very important that we work with our staff and if we’re asking to improve care, we want their advice and support and to give them the tools to take better care of their patients.”
EHR, order sets, and more
The most effective tool the team implemented to help improve sepsis treatment processes was a functional, easy-to-use order set that can be rapidly entered and would promote the standard of care for patients.
“This also allowed you to individualize that care if you have other issues,” says Browder. “Spending a lot of time getting that order set right was key to buy in. We have an over 70% order set use for it and when we started, order set use was in the 10% to 20% range. Once we got this right, we found that is actually reduced the workload on the clinicians.”
The second tool that helped care improve was the additional of an electronic form that allowed nurses to track ongoing bundle care.
“They don’t have to double-document things on paper, and we’ve developed smart text elements that pull in elements of care and document steps they might not have been getting credit for doing before,” says Browder.
One of the challenges for sepsis bundle compliance is fluid administration, which must be individualized and targeted to the individual patient, Browder explains. This also needs to meet CMS requirements.
“Documenting the reasons you’re giving a volume or type of fluid can be difficult,” says Browder. “We created a smart test that gets that information into the EHR and shows all the work they’re putting into patient care but also meets CMS requirements.”
Adoption and escalation of the bundle occurred withing months on the ED and present-on-admission side, but was slower on the inpatient side, Browder notes.
“Present on admission is a bit of a different animal than hospital-acquired sepsis,” he says. “It requires a different approach. We tried to apply the same order set and tools from ED cases to inpatient cases, and realized we needed it to be different and spent a lot of time working with inpatient leaders to continuously improve the approach and tailor it to their needs.”
It was a matter of recognizing this subset of patients have different care needs and different presentation, and then further individualizing the tools to meet the needs of the care team.
Identifying champions
Finding the right leader makes a big difference with implementation as well, Browder explains.
“You need someone who has a process improvement background, such as a nurse, in that role. The key to these teams is they have to be passionate about the work they’re doing,” he says. “You can’t just assign someone the job. One thing we’ve done a really good job with is finding site coordinators who are really passionate. They know [sepsis] is a big cause of morbidity and mortality and they don’t just want to do a great job to meet metric, but they want to ensure excellent clinical outcomes all of these patients. They also want to make it easier for staff to do this.”
The team constantly seeks out feedback, asking what can be done to improve the tools, if they are helping, what could be done to improve the order set and documentation and reevaluate every year.
“I do think it’s something that will take continuous improvement to maintain,” says Browder. “We have a second process improvement team around disease-specific mortality and we’re going to correlate that work with our sepsis bundle compliance so we can further drill down on what we can do to improve mortality rates particularly on the inpatient and critical care side. We also want to improve readmissions for this population.”
Their ongoing improvement in sepsis care also involves the community.
“I feel very passionate that we need to continue to educate our community about how to recognize sepsis,” says Browder. “The key to decreasing mortality is more than just providing treatment, it’s identifying these patients earlier. The earlier we get to the patient, the better the chances they have of a good outcome.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.