A strategic systemwide initiative reduced patient mortality by more than 60%
Sepsis is a life-threatening condition defined as a systemic inflammatory response to infection. Without early recognition and prompt treatment, a patient with sepsis will decline and proceed through the sepsis continuum. This includes deterioration to severe sepsis (organ dysfunction) and septic shock (hypotension refractory to fluid resuscitation). Without appropriate treatment, death often follows.
Sepsis affects nearly 1 million people in the United States each year; 25% to 50% of them die.1 Severe sepsis strikes about 750,000 U.S. patients each year and kills an estimated 200,000 worldwide.2,3In 2008, Northwell Health President and CEO Michael J. Dowling prioritized the prevention of sepsis as a systemwide initiative across the Northwell’s 11 hospitals. Senior clinical leaders convened an interprofessional group of clinicians from the emergency department (ED) and intensive care units to form the Northwell Health Sepsis Task force. The panel was charged with reducing the health system’s mortality rate by 50% in 5 years. The task force’s efforts exceeded that goal.
The Sepsis Task Force
The initial primary focus was the ED, since most patients with sepsis present there. Work groups were comprised of clinicians and operations staff from across all hospital EDs. Each hospital had its own sepsis task force and team to manage unique challenges and distinct resources, as well as different patient populations.
The task force encouraged front-line teams to adapt best practices to their own hospitals, allowing them to identify local best processes. To keep sepsis care a priority, Northwell Health hosted a biweekly collaborative conference call encouraging staff throughout the system to discuss their progress and challenges. This collaboration allowed the teams to learn from colleague successes and failures.
An early task force decision was to shift focus from patients who were at highest risk of death to patients who were at earlier stages of sepsis. For that group, clinicians interrupted the progression of deterioration prior to major patient injury. As a result, in 2010, the group developed triage criteria to screen ED patients for sepsis and redesigned processes to accelerate the following:
- early administration of antibiotics to septic patients
- returning serum lactate test results to physicians, who could identify severe sepsis
- starting empiric fluids quickly and appropriately.
ED-specific metrics with uniform definitions were established and used by all 11 hospitals at Northwell Health.
Two major outcomes of the task force’s ED triage focus were the development of the “Code Sepsis” and the development of triage criteria for probable severe sepsis, nicknamed “Super SIRS” (Systemic Inflammatory Response Syndrome).
The Code Sepsis, similar to a cardiac code, immediately brought varied, designated members of the healthcare team to the bedside of the patient with identified severe sepsis/septic shock. The team worked in concert to complete the elements of the 3-hour bundle in an expeditious manner. The use of Code Sepsis also accelerated the transfer of the septic patient to the next appropriate level of care when indicated. The Code Sepsis was adapted in all EDs according to site-specific workflow design and staffing patterns.
The development of Super SIRS criteria included: hypothermia or hyperthermia as defined in SIRS criteria; modifying the SIRS heart rate criteria to ≥ 120 beats per minute and respiratory rate criteria to ≥ 24; and including unexplained altered mental status or hypotension. White blood cell results were not included because they are not available at triage.
The implementation of “Super SIRS” allowed Northwell Health clinicians to identify ED patients who were likely to have severe sepsis before the confirmation of organ dysfunction by laboratory reports and to accelerate aggressive treatment.
To assure data accuracy and reliability, Northwell Health instituted many initiatives. The task force designed sepsis algorithms, order sets and screening tools, which it disseminated to all EDs. This process reduced practice variation and improved sharing of evidence-based practices. In addition, each hospital was assigned a data abstractor who was educated in the use of the web-based collection tool developed by the task force, providing greater reliability in data collection. To support accuracy in data collection and to capture the demographics, clinical data elements, process and outcome measures for severe sepsis and septic shock and evaluate adherence, a uniform and standardized database was administered by the Krasnoff Quality Management Institute, a division of Northwell Health.4
The Northwell Health Improvement Science (IS) team was another important component of this interprofessional task force. Utilizing a structured approach for process improvement, the IS team partnered with the site sepsis teams to develop definitions, metrics and strategies to identify barriers and develop education, resulting in high reliability and sustainable improvement. These strategies resulted in high-fidelity execution of the resuscitation bundle in patients identified with sepsis/severe sepsis/septic shock in the ED. Later, the work was expanded to include medical/surgical teams. This approach led to a universal sepsis algorithm and improved adherence to the 3-hour bundle elements: blood cultures before antibiotic administration, lactate levels, timely aggressive antibiotic administration and empiric fluid bolus administration.
Need for Staff Education
Sepsis is one of the most common contributors to mortality at Northwell Health. With early recognition as key to successful patient outcomes, the role for nursing was understood as essential to initiation of treatment utilizing the sepsis bundles. Identification of the signs and symptoms within the first hour is pivotal to mortality reduction. Each hour of delay is associated with a 7.6% increased risk of death.5 Although the systemwide initiation of educational programs intended to reach all clinicians with comprehensive information, the need for a targeted education program for nurses was identified.
Sepsis presents a distinct challenge to all nurses in terms of awareness, critical thinking, patient assessment and rapid intervention. Severe sepsis is defined as sepsis with acute organ dysfunction or tissue hypoperfusion secondary to infection.6,7 Sepsis is a syndrome that represents a life-threatening immune response.6,7Recognition of sepsis can be complicated since its manifestation may be masked by other conditions.
Our team identified the Surviving Sepsis Campaign treatment guidelines,7 referred to as the sepsis bundles, as guiding principles for the educational program.
Taming Sepsis Education Program
The Taming Sepsis Education Program for Nurses (TSEP) was developed in 2011 as a response to the need for comprehensive systemwide nursing education. The program was supported by funds from the U.S. Bureau of Health Professions Division of Nursing. The TSEP, implemented in 2012, was originally developed to engage nurses in critical care units and EDs with early recognition and effective treatment of sepsis, severe sepsis and septic shock. The TSEP employs a multimodal blended learning model of education. The methodology employs didactic education with web-based curricula and simulations for practice.
Program Content
The TSEP provides the clinical knowledge and communication skills necessary to care for critically ill patients. The TSEP consists of five online modules, including an introduction highlighting the importance of sepsis; a bundles review; TeamSTEPPS review; and a cultural awareness/health literacy module.8 The final module is the brief course on the signs, symptoms and stages of sepsis, and case studies. This peer-reviewed continuing education offering was developed at the Center for Learning and Innovation, the corporate university of Northwell Health. The TSEP was authored by nurse leaders who were members of the sepsis task force and reviewed by physician experts before dissemination.
Learners then participate in two high-fidelity simulation scenarios debriefed by simulation specialists. The simulation and debriefing activities are an assessment of the core principles taught in the modules. The simulation exercise gives learners an opportunity to apply the knowledge gained in a controlled environment, enhancing knowledge retention.9-11 Research using simulation as an evaluative tool found improved performance in sepsis management.12
The TSEP can be modified to meet the needs of additional clinical specialties. It was adapted for physician use, and four physician-specific programs are available.
Initiative Outcomes
A review of the data identified a sustained downturn in mortality rate: a 62% reduction over the course of 5.5 years, from 31% in 2009 to 12% in October 2015. The reduction in sepsis mortality has come without an expensive infrastructure, but with significant time and effort investment from the entire enterprise. A nurse administrator in the Department of Clinical Transformation dedicates 40% of her time to support the sepsis initiative, and an industrial engineer spends 20% of her time helping hospital teams identify and remove barriers to adherence to the sepsis care protocols.
The TSEP began in 2012, and by 2015 more than 6,500 nurses and 380 physicians had completed the educational modules. With other sepsis initiatives, the TSEP was part of a greater collaborative strategic effort by Northwell Health to reduce mortality.
The program has been recognized for its effectiveness. In 2014, Northwell Health received the John M. Eisenberg Patient Safety and Quality Award from the Joint Commission and the National Quality Forum for reducing sepsis mortality. Also that year, the TSEP received the Innovation in Education Award from the International Association for Continuing Education and Training. In 2015, the TSEP was designated First Place Winner in Program Innovation Abstracts at the 15th International Meeting on Simulation in Healthcare.
Over the past 7 years, Northwell Health has worked to improve sepsis outcomes by working on the elements of the 3-hour sepsis bundle under the guidance of the task force. Using a corporate strategy supported by senior leaders at facility, Northwell Health has achieved a current sepsis mortality rate of 12% and set a goal of single-digit mortality. As providers of frontline care, nurses must be well-versed in early recognition and rapid treatment of sepsis.
References
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2. Dellinger RP, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Inten Care Med. 2013;39(2):165-228.
3. Skrupky LP, et al. Advances in the management of sepsis and the understanding of key immunologic defects. Anesthesiology. 2011;115(6):1349-1362.
4. Doerfler ME, et al. Methods for reducing sepsis mortality in emergency departments and inpatient units. Jt Comm J Qual Patient Saf. 2015;41(1):205-211.
5. Kumar A, et al. The duration of hypotension before the initiation of antibiotic treatment is a critical determinant of survival in a murine model of Escherichia coli septic shock: association with serum lactate and inflammatory cytokine levels. J Infect Dis. 2006;193(2):251-258.
6. Edwards JD. Management of septic shock. BMJ. 1993;306(6893):1661-1664.
7. Diamond LC, et al. Do hospitals measure up to the national culturally and linguistically appropriate services standards? Med Care. 2010;48(12):1080-1087.
8. Messias DK. What nurses need to know about the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in health care. SC Nurse. 2003;10(3):23-24.
9. Lasater K. High-fidelity simulation and the development of clinical judgment: students’ experiences. J Nurs Educ. 2007;46(6):269-276.
10. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007;2(2):115-125.
11. Lewis R, et al. Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence. Open Nurs J. 2012;6:82-89.
12. Ottestad E, et al. Evaluating the management of septic shock using patient simulation. Crit Care Med. 2007;35(3):769-775.
