Christiana slashes sepsis mortality rate
Christiana slashes sepsis mortality rate
Performance earns system the Codman Award
In a campaign that earned it the prestigious Ernest Amory Codman Award from The Joint Commission, Christiana Care Health Services of Wilmington, DE, reduced the mortality rate for patients with severe sepsis from 61.7% to 30.2% by addressing three major areas of sepsis care: identification of patients with sepsis, resuscitation strategies, and ICU management.
This 49.4% decrease in mortality rates was accompanied by a 34% decrease in average length of stay; a 188.2% increase in the proportion of patients discharged to home; and increases in patients receiving antibiotic therapy within the first hour before or after issuance of a Sepsis Alert and decreased average time from emergency department triage to first antibiotic administration.
Christiana's "Sepsis Alert" program, grounded in the concept of collaboration between all health team members, used as one of its primary tools a Sepsis Alert packet, which included:
- a care management guideline;
- a treatment algorithm;
- an ED treatment order set;
- kits with single-dose vials of antibiotics;
- multidisciplinary education about sepsis and the importance of prompt, aggressive management.
Among the key strategies were:
- early and appropriate antibiotic administration;
- rapid fluid resuscitation;
- early central venous catheter placement;
- vasopressor administration;
- venous oxygen saturation measurement and analysis;
- assessment for activated protein C administration.
The program is described in detail in an article in the April 2008 issue of The Joint Commission Journal on Quality and Safety.1
Campaign is trigger point
"For years I had been concerned about the inconsistent resuscitation of patients with shock," recalls Marc T. Zubrow, MD, FACP, FCCP, FCCM, director of critical medicine for the Christiana system and medical director of e-care and lead author of the article.
Shock patients, he explains, fall into several categories. "Trauma patients have protocols, cardiac patients go to the catheterization lab, but in sepsis and other types of shock, it was very difficult to organize physicians into systematic treatment," he notes.
This all changed in 2004 when the nationwide Surviving Sepsis Campaign (http://www.survivingsepsis.org) was launched, says Zubrow. "We started talking about [the campaign] and sepsis resuscitation and everyone was onboard," he recalls. "We brought our concept to senior management and by February 2005 they told us to go ahead."
Although Christiana adopted the Surviving Sepsis guidelines, "What we did uniquely is that we made it institution-wide," says Zubrow. "In most other places they just did it in the ED, which is a smaller area with a defined doctor and nurse population. We have two hospitals and 1,100 beds."
Spreading the message
In order to accomplish system-wide change, Zubrow explains, "we had to develop a way to get the protocol to the floor patients and different nursing vectors; it was a huge organizational challenge."
To do this, Zubrow brought all the key "players" to the table: intensivists from medicine and surgery; critical care nursing; ED physicians and nurses; the pharmacy department; and respiratory therapy.
"There was also a subset of people, because we have rapid response teams, and they became our vectors to administer the treatment outside the ED," Zubrow notes.
The nurses were "not only on board, but enthusiastic," says Zubrow, while not surprisingly, the physicians presented the greatest challenge. "You have to be careful of taking away the doctor's ability to individualize his patient treatment," Zubrow explains.
Whenever a physician expressed reluctance, Zubrow would meet with them one-on-one and ask what he could do to convince them to fully participate in the program.
"We also conducted a huge PR effort, with videos, talks to all the different [stakeholder] groups, and going on the rounds of every department to bring them up to speed on the problem and why we had to make those changes," says Zubrow. "Once they were on board and could see good results, there was no problem because everyone loves to be a winner. We now have so much momentum that there is institutional buy-in everywhere; it's spectacular, and very gratifying."
Tips for quality managers
His experiences with this initiative have provided some valuable lessons for quality managers, says Zubrow. "No. 1, you have to engage all the players and make sure they understand why you are doing this," he says. "Then, recognize that nobody believes in not doing their best, so you have to give them the tools to succeed — education, simplification of the treatment process, and so on."
To motivate your physicians, he says, you must show them, for example, that if they follow the protocol for every patient, that those patients will get their antibiotics faster and receive better care. "Trauma people talk about the 'golden hour' of trauma," Zubrow notes. "I talk to them about the golden hour of shock — you have one hour to be a hero."
In addition, he advises, "you need to do lots of education and you need to do it repetitively. We found that if you do not regularly put out a new bulletin or poster then the program starts fading from radar screens."
Finally, Zubrow recommends, "Track your data to make sure the times are going where they need to go."
[For more information, contact:
Marc Zubrow, MD, FACP, FCCP, FCCM, Medical Director of eCare, Director of Critical Care Medicine, Christiana Care Health System, Wilmington, DE. Phone: (302) 623-0616.
For additional inquiries about Surviving Sepsis, e-mail: [email protected].]
Reference
- Zubrow MT, Sweeney TA, Fulda GJ, Seckel MA, Ellicott AC, Mahoney DD, Fasano-Piectrazak PM, and Farraj MB. Improving Care of the Sepsis Patient. Jt Comm J Qual Patient Saf April 2008; Vol. 34 No. 4: 187-192.
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