Although sepsis kills more than 200,000 Americans annually, it has gone largely unnoticed among the general public. In fact, 60 percent of American adults were not familiar with sepsis in 2010, according to a poll commissioned by the Feinstein Institute for Medical Research in Manhasset, NY, which convened an international symposium on the topic that same year. The news media attention generated by the tragic death of a young New York boy recently has succeeded in shining the spotlight on a disease that is the cause of 25 percent of US hospital deaths.
As one of the nation’s 20 largest healthcare providers with 15 hospitals in the New York metropolitan area, the North Shore-LIJ Health System mounted an aggressive sepsis prevention and early identification initiative that has reduced our sepsis mortality rate by 35 percent since 2008. We did it by approaching the problem from several angles. North Shore-LIJ is now a strategic partner with the Institute for Healthcare Improvement (IHI), pursuing additional efforts to reduce sepsis mortality by 50 percent over the next five years.
By way of background, it’s important to understand that there are three types of sepsis:
• Sepsis (infection + systemic inflammatory response (SIRS)
• Severe Sepsis (Sepsis + organ dysfunction from sepsis)
• Septic Shock (sepsis + fluid resistant hypotension and / or tissue hypoxia (low oxygen) manifested by an elevated serum lactate)
We have taken the approach of targeting all three stages of sepsis. We have also targeted the clinical process at several key steps. First, we seek to achieve early recognition of patients who may have sepsis in any form. The current focus has been on our emergency departments and having highly reliable processes in place to identify possible symptoms of sepsis.
We have developed triage criteria to screen patients who are septic (those who have gone into septic shock) or have severe sepsis. Specifically, we look for patients who have an infection + any two of the following: elevated body temperature, lower-than-normal temperature, a heart rate of 120 or greater, a respiratory rate of 24 or greater, blood pressure less than 90 or unexplained altered mental status. These patients are immediately moved to a bed and seen by a physician, the same approach we would take for patients who have suffered an acute stroke or heart attack.
To screen patients for sepsis (infection + SIRS criteria), we look for two or more of the following: elevated temperature, lower-than-normal temperature, a heart rate greater than 90, a respiratory rate greater than 20, altered mental status or elevated white blood cell count. Those who are diagnosed with sepsis are given a serum lactate test, in addition to any blood tests being run for any reason, in order to to determine if they have severe sepsis. Together, these two processes are decreasing the time it takes to identify patients at risk.
Once recognized as sepsis, treatment urgency is our next focus. Treatment guidelines established by the Surviving Sepsis Campaign – an initiative of the European Society of Intensive Care Medicine, the International Sepsis Forum (ISF) and the Society of Critical Care Medicine — call for patients to receive antibiotics within 180 minutes of when a septic patient presents at an Emergency Department. North Shore-LIJ has taken a more aggressive stance, with a goal of administering antibiotics to septic patients within 60 minutes, 180 minutes for all sepsis and 60 minutes from when lab tests come back indicating that the sepsis case meets severe sepsis criteria, which includes a variety of organ function assessments.
The Surviving Sepsis Campaign also calls for septic patients to receive intravenous fluids. North Shore-LIJ is seeking to do the same for all severe sepsis cases and is also encouraging fluids for patients with sepsis only – although the data is not definitive as to whether aggressive fluids benefit sepsis patients, our consensus is that they do in most cases.
We are working closely with IHI on developing highly reliable processes to expedite the treatment of patients with all forms of patients. All of North Shore-LIJ’s Emergency Departments (ED) have been testing and reengineering processes to:
• decrease “door to doctor time” in the ED
• identify and remove impediments to the administration of early antibiotics;
track and modify processes to get lactate test results back to the physicians within 90 minutes of the patient presenting
• start fluids quickly with appropriate volumes given
We have implemented a modified early warning score (MEWS), or the pediatric equivalent (PEWS), in all of our medical/ surgical units. This is not specific for sepsis, but we’re beginning to use this trigger in any patient with an infection to drive a sepsis evaluation. We are seeking the same early, appropriate antibiotics and fluids as we are seeking to accomplish in the EDs.
To further improve our processes, we also recently joined with The Joint Commission Center for Transforming Healthcare in a sepsis collaborative at Staten Island University Hospital to share and learn from others around the country.