Fighting Sepsis Your Way: Using the DECISIOInsight® Clinical Dashboard to Improve Early Sepsis Diagnosis and Surviving Sepsis Campaign (SSC) EGDT Bundle Compliance
Sepsis is a leading cause of death and one of the costliest condition among hospitalized patients in the United States. The Society of Critical Care Medicine & the European Society of Intensive Care Medicine’s Surviving Sepsis Campaign has resulted in greater emphasis on early goal-directed therapy and the initiation of 3-hour and 6-hour sepsis bundles that have been proven to reduce mortality. Yet early identification of sepsis and attempts to institute bundle compliance consistently have been ambiguous, and reports in the scholarly literature about institutional best practices are sparse.
In this white paper, we report the results of a 2017 implementation of DECISIOInsight®, a clinical surveillance data visualization system, at an academic medical center in the United States.
Collaborating with strong clinical partners, we achieved success across four main areas:
1. We improved the health of hospitalized patients by identifying sepsis in its earliest stages and promptly administering antibiotics to reduce its severity, and mortality.
2. We improved patient experience by reducing overall hospital length of stay by 22%.
3. We helped our clinical partners save an estimated $28.2 million dollars per year.
4. We achieved high clinician satisfaction.
Sepsis is a life-threatening complication of infection. It occurs as the body releases a cascade of chemicals into the blood in response to an infectious agent. This process triggers an inflammation response, causing lasting and sometimes irreversible changes, including organ damage and failure.
Left untreated, sepsis can evolve into more serious conditions including severe sepsis and septic shock. More than 1.5 million people develop sepsis each year in the United States. An unfortunate 250,000 Americans die each year from sepsis3.
A third of all patients who die in a U.S. hospital have some form of sepsis – making it a common condition among hospitalized patients. Sepsis is hard to diagnose quickly because the developing signs and symptoms can be attributed to many clinical variables. These include temperature above 101F (38.3C) or below 96.8F (36C), heart rate higher than 90 beats per minute, respiration rate above 20 breaths per minute, decreased urine output, abrupt change in mental status, decreased platelet count, difficulty breathing, reduced ejection fraction, and abdominal pain[2,3].
We know that the early identification of sepsis saves lives4. The Surviving Sepsis Campaign was developed to reduce mortality from sepsis by building awareness, improving diagnosis, and increasing the use of evidence-based treatment guidelines4. The most recent evidence suggests that the rapid implementation of goal-directed therapy reduces morbidity and mortality in patients with sepsis and septic shock.
Decisio Health provides a customized, insight-driven application that uses sophisticated algorithms to identify sepsis in hospitalized patients earlier than clinical staff could otherwise detect it. Decisio Health partners with hospitals to implement visual dashboards that alert key personnel regarding a deteriorating patient who may be septic – thereby affording clinicians the opportunity to intervene earlier and save lives.
This white paper will use the Quadruple Aim objectives to orient the reader to the results of a recent DECISIOInsight® implementation where improvements were achieved in:
- Health of Populations
- Experience of care
- Cost of Care
- Clinician Experience
DECISIOInsight® is a clinical surveillance data visualization system. It is an application that, once configured, collects data effortlessly in real time – surveilling every patient continuously. DECISIOInsight® does this work without any manual data entry on the part of clinicians.
DECISIOInsight® monitors information from disparate information sources like vitals and ancillary monitors, laboratory systems, and medication systems, in addition to the EHR. It compiles information in your hospital’s data center and interprets it right there – in real time.
Decisio Health works with your physicians, nurses, and clinicians to understand and interpret data, while implementing your hospital’s protocols and physiological parameters on a unit by unit basis – respecting the workflows and preferences of the clinicians in your facilities.
DECISIOInsight® proactively presents customized displays to the right person at the right time to decrease both the time to intervention and the variability in care.
→ See Figure 1. DECISIOInsight® Dashboard
The IHI Triple Aim objectives seek to improve the health of population. Decisio Health and its hospital partners have greatly impacted the health and well-being of the patients they serve by continuously monitoring inpatients for subtle changes in their health status.
The academic medical center launched DECISIOInsight® in the surgical ICU beginning in June 2016. It was integrated with their clinical information system and continuously displayed vitals, lab data, and a Foley and Renal Bundles of Care module on a clinical dashboard. This was displayed on a dedicated 42” monitor located at the bedside. One year later, a sepsis screening bundle was added to the clinical dashboard. The dashboard displayed the things it was continuously monitoring, such as heart rate, body temperature, respiration rate, various labs required by the unit, and trending data. The sepsis bundle indicator would turn “red” if the score exceeded a pre-determined threshold. This visual alert signaled a clinician to assess the patient for sepsis and that early intervention may be warranted.
If you are a patient in a hospital bed unknowingly developing sepsis, your best chances for survival are linked to early detection and evidence-based intervention. We know that the earlier sepsis is detected, the earlier a clinician can initiate sepsis care protocols, known as “the sepsis bundle”. Early intervention can prevent sepsis from turning into severe sepsis and then septic shock. Early intervention is what saves lives.
One afternoon right before the winter holidays, a husband and his two teenaged children were visiting his wife who was recovering from a minor, routine surgical procedure in the hospital. They were so happy to see her that they didn’t notice her very mild, labored breathing. Perhaps they thought she was just getting excited listening to the kids talk about all of the plans for the upcoming holiday break. After all, planning a family vacation at the holidays and preparing for family and friends right after surgery would make anyone a little tired! A short while later, the registered nurse entered the room and performed an assessment: Mom was using oxygen by nasal cannula (common in the post-op period), she had a respiration rate of 21 (the normal limit is 20), and a temperature of 100.1 (the normal limit is 98.6). These very small aberrations may have been judged as insignificant to any one nurse at any one particular time, but taken together, they were noted by DECISIOInsight® and triggered a sepsis alert. The nurse drew a lactate lab that was greater than 2 (normal is less than 1), which prompted her to call a “Code Sepsis”. The nurse’s quick action brought a physician to the scene, who diagnosed sepsis and started Early Goal Directed Therapy (EGDT) within an hour of the start of her symptoms. Because of the actions of this high-performing team and the early intervention this patient received, this 45-year Mom stayed on the floor of the hospital, avoided transfer to the ICU, and went home healthy to enjoy the holidays, and many more days, with her growing family.
What’s in a sepsis bundle?
The sepsis bundle is completed within 3 hours for patients presenting with sepsis:
- Measure serum lactate
- Obtain blood cultures
- Administer broad-spectrum antibiotics
- Treat hypotension/elevated lactate with fluids
These things are added to the sepsis resuscitation bundle within 6 hours for patients presenting with severe sepsis or septic shock:
- Maintain mean arterial pressure>65 mmHg with vasopressors
- Achieve a central venous pressure of >8 mmHg
- Achieve central venous oxygen saturation >70%
For ongoing sepsis management within 24 hours:
- Administer lose-dose steroids
- Administer recombinant human activated protein C
- Maintain glucose control lower than limit of normal
- Maintain a median inspiratory plateau pressure <30 cm H20 for mechanical ventilation
The early identification of sepsis has allowed Decisio Health and this particular hospital partner to improve the health of hospitalized patients in three significant ways.
First, the time it took to obtain blood cultures and to administer antibiotics was reduced significantly. We went from a high of 48.9 hours before implementation to a low of 11.6 hours post implementation (p=0.05). We attribute this drop in time to antibiotic treatment to the early warning system developed in partnership between Decisio and the hospital. The combination of the changing color of the sepsis score and the alert workflow signals clinicians to take early action.
Second, the rates of severe sepsis was reduced significantly. We evaluated the incidence of cases of severe sepsis in the hospital pre and post implementation. When sepsis progresses to where signs of organ damage are noted, systolic blood pressure drops below 90 mgHg, and lactate levels are greater than 2 mmol/L, it becomes9 severe sepsis or septic shock (ICD-10 code R65.21).
In a pre-post comparison, we found our rates of severely septic patients (defined as a presumed serious infection requiring at least one vasopressor with a serum lactate level of 2 mmol/L) went from 1.68% pre-implementation to 0.84% post implementation (p=0.08). We attribute this significant drop to the early detection of sepsis and the early use of the sepsis bundles. Compliance with sepsis bundles helps to prevent a patient from progressing to a more severe form of sepsis.
→ See Figure 2. Incidence of Severely Septic Patients
Third, Decisio Health is grateful for the opportunity to put DECISIOInsight® to use because, in its short time in operation in the ICU, it is already saving lives. A 2017 pre-post analysis revealed a significant reduction in mortality among ICU patients with sepsis. Prior to implementation, mortality was 27.9% and post implementation it dropped to 16% (p=0.05).
→ See Figure 3. Mortality Rate Among Patients with Sepsis
EXPERIENCE OF CARE
For patients, being in the ICU can be a frightening experience. Even people who enter the ICU without feeling particularly ill report feeling extremely tired and weak. Those who chronicle the experience of being cared for in the ICU describe how quickly muscle wastage and neuropathies occur – rendering even the most basic activities of daily living difficult to perform. People in the ICU may be unable to eat by themselves, brush their teeth, or even communicate with their family and friends. This can be extremely frustrating for previously healthy, high-functioning people. It can lead to sense of isolation with nothing more to do than “watch and stare” at the things going on around them. This, in turn, can lead to depression.
The most effective thing we can do is to prevent ICU admissions in the first place. When admissions do occur, we should strive to make them as short as possible. In this way, we return hospitalized patients and their families to environments where they can have more control in their day to day care. We can return them to environments where they can enjoy a better experience of care.
A retrospective analysis revealed a 22% reduction in total hospital length of stay (LOS) and a 25% reduction in ICU LOS after the implementation of DECISIOInsight®.
→ See Table 1. Changes in LOS
We believe that we can improve a patient’s experience of care as we show them the multitude of ways we are investing in technology that is helping to keep them safe and healthy. DECISIOInsight® is one such technology that silently monitors hospital patients and alerts the care providers early for signs of decompensation due to sepsis and other causes, as well as helps clinicians to be visually aware of their patient care guidelines to promote a high reliability care facility. This directly translates to patient safety. DECISIOInsight® also engages the patients and their families in their care journey and creates an transparent environment for effective and meaningful communication between the care providers and the patient and their families. This experience also helps alleviate the anxiety, the uncertainty, the helplessness surrounding the families in the critical care environment and that helps the care providers as well.
COST OF CARE
There is an old adage in health care quality improvement circles that “improving quality saves money.” If you think this is an idea that has gone out of fashion, think again; countless government initiatives, programs, and regulations are based upon this premise. If you go to work every day and use an EHR, you are operating under the assumption that EHRs improve patient safety, operational efficiencies, and the lower the costs of care. You, or the organization you work for, has likely benefited from an EHR Incentive Program check for the meaningful use of that EHR at some point over the last five years. The idea is a simple one: do it right the first time, and you will be rewarded with lower costs.
At some point in the 1990s, we grew to accept that about 30% of our health care system costs were based upon waste and inefficiencies. The figure came from a now infamous editorial in the New England Journal of Medicine that the author himself promoted as an estimate based on the “reasoned judgment of respected experts” – while simultaneously calling for more studies to properly evaluate the cost of poor quality care11. We can debate whether or not the actual figure holds, but since it was proposed, we have a heightened sense of the costs of care. It is now common to measure not only the clinical outcome of interventions but also utilization and cost outcomes.
To this end, we worked with our clinical partners to identify the cost savings associated with decreased utilization. In this case, a decrease in ICU length of stay (LOS) in the overall hospital LOS for patients with sepsis, was measured before and after the implementation of DECISIOInsight®.
To calculate this savings, we subtracted the pre and post LOS to create a difference in LOS factor. That difference factor was multiplied by the number of patients seen with sepsis during the post-implementation period by the number of days in the period to create a per day savings rate for patients hospitalized with sepsis. The per day savings rate can then be forecasted on an annual basis.
→ See Table 2. Cost Savings
This is a conservative estimate, based on a few key factors: (i) the cost per day was taken from a standard national report and is much lower, based on conversations with our clinical partner, than their current average, (ii) savings from a reduction in ICU bed days, which are costlier than non-ICU days, have not been included in the calculation, and (iii) this assumes roughly the same case mix or number of patients with sepsis, throughout the calendar year (this observation occurred Jun-Nov).
Finally, we present cost savings based upon LOS data because it is striking and convincing. It is important to consider that there are other, meaningful ways in which a tool like DECISIOInsight® helps to reduce the cost of care that are harder to quantify but which can add up to tremendous savings. These include things like:
- Efficiencies gained from workflow standardization and automation
- Reduction of inpatient acuity with early identification and treatment of sepsis which thereby reduces staff/patient ratios and ICU time
- Avoidance of financial penalties associated with global APR-DRG billing
- Avoidance of financial penalties associated with readmissions
- Improved ability to report data to pay for performance or other optional quality reporting initiatives which may in turn improve revenue
- Improved publically reported quality rankings which improves public perception about the desirability of being cared for in your facility
We believe we have demonstrated that the old adage is true, improving quality does save money.
Physicians Thomas Bodenheimer and Christine Sinsky have proposed that in order to meet the IHI Triple Aim goals of improved population health while simultaneously improving the patient’s experience of care and reducing costs, a fourth aim may be required. Attending to the work life of clinicians and the staff providing the nation’s healthcare is crucial. In essence, we must care for the people who care for us.
At Decisio Health, we think this makes perfect sense. It’s why we have designed a visualization system that collects data passively and does not require clinicians to do extra documentation of any kind in order to generate a sepsis score. We create interfaces with the information systems we need to make the algorithms run undetected in the background. Here are some of the other ways we demonstrate care and respect for the clinicians we work with:
- We bring the tools to our clinical partners and let them decide how to implement them. We do not tell them which sepsis bundle to use or what should be in it. Our clinical partners can use existing order sets or go through their existing governance councils to update whatever they wish, but we do not push anything on them.
- Our clinical partners decide how the sepsis alerts should look and feel. We adapt to their needs. They can look the same in every unit within the organization or can be designed to meet the needs and preferences of different departments.
- We adapt to the changing workflow requirements of clinical departments and program the software accordingly. Where should the sepsis alert go? To the bedside nurse? To the physician? To the chief resident? We can customize alerts based on our partner’s preferences.
- We understand that dashboard reporting can make a big difference in the quality of care you are able to provide. We are available to help and make real-time changes as needed.
We’re here to support your clinicians so they can do what it takes to keep your patients happy and healthy, as these stories demonstrate.
Decisio Health supports their clinical partners with a 24/7 help line that is available to make immediate changes to the configuration of dashboards that clinicians rely on to provide care. One evening in the ICU the nursing director called because data known as the “ABGs” (Arterial Blood Gases – lab results that ICU staff rely on tell them how well a patient’s lungs are moving oxygen into cells and carbon dioxide out of the body) were not displaying on the dashboard. The Decisio team was able to immediately investigate the situation and let the nurse know that although this data is coming through for other patients, there wasn’t an order for it in the EHR for this patient. As soon as the order was placed and blood was drawn, the results pushed through and displayed on the dashboard. Problem solved! Bedside nurses? Happy!
The DECISIOInsight® dashboard can be configured in any number of ways to meet the needs and preferences of its hospital partners. In one ICU, it was configured by design so that when a patient was being supported by mechanical ventilation, the visual on the dashboard defaulted to a view of the waveform (the visual image, or PPV graph) that measures the respiratory cycle. When that image was on the screen other information, such as lab values, were hidden from view. One day, the nurse caring for a patient on a vent had several family members in the room who were all carefully monitoring the dashboard alongside her. It turns out they were all doctors and they wanted to know why the liver function labs were no longer being displayed! She explained that the patient’s liver function, along with many other indices, were still being monitored, dynamically, real-time, in the background, but it just wasn’t on the screen. Before the nurse went off shift, she called Decisio and explained the family’s concerns. Overnight, Decisio re-configured the dashboard. The next day when the family came back to visit, they were thrilled to see all of the data that they wanted. Everyone in the ICU was surprised at the speed with which this happened. Problem solved! Physicians? Happy!
Decisio Health produces a visual surveillance system that is designed to provide bedside decision support to clinicians. This system can be used for a wide variety of clinical tracking purposes. This white paper discussed its use during a recent implementation in an academic medical setting designed to identify the incidence of sepsis, a common infection among hospitalized patients in the United States, and to facilitate rapid treatment.
HEALTH OF POPULATIONS
We demonstrated that use of DECISIOInsight® was significantly positively associated with decreased time to antibiotic administration (p=0.05) as well as the incidence of severe sepsis (p=0.08). Even with less than a year’s worth of data, we observed a significant reduction in mortality from sepsis (p=0.05).
EXPERIENCE OF CARE
As measured by length of stay (LOS), which is a stressful time for patients, we noted a significant reduction (p=0.03, p=0.05) in both overall hospital LOS (22% reduction) and ICU LOS (25%).
COST OF CARE
Our clinical partners calculated an initial cost savings equal to $28.2 million per annum, largely due to a reduction in length of stay.
We’re proud to report that our clinical partners are using DECISIOInsight®, which is helping them to adhere to the Surviving Sepsis guidelines and to improve the quality of care they provide. This is being done on their terms, according to their own needs and preferences.
1. Rivers E, Nguyen B, Havstad S et al. (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377
2. Mayo Clinic. (2018). Sepsis. Available at: https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214
3. CDC. (2017). Making Health Care Safer: Think Sepsis. Time Matters. Available at: https://www.cdc.gov/sepsis/datareports/index.html
4. Society of Critical Care Medicine. (n.d.) History: Surviving Sepsis Campaign. Available at: http://www.survivingsepsis.org/About-SSC/Pages/History.aspx
5. Song, J.E., Kim, M. H., Jeong, W.J., Oh, D.h., Kim, Y. C., Kim, E. J., Joeng, S.J., Ku, N.S., Kim, J.M. & Choi, J.Y. (2016). Mortality Risk Factors for Patients with Septic Shock after Implementation of the Surviving Sepsis Campaign Bundles. Infection and Chemotherapy, 48(3), 199-208. doi: 10.3947/ic.2016.48.3.199 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5048001/
6. Leisman, D., Zemmel D’Amore, J., Gribben, J., Ward, M.F., Masick, K., Bianculli, A., Bradburn, K., D’Angelo, J., & Doerfler, M. (2017). Early sepsis bundle compliance for non-hypotensive patients with intermediate versus severe hyperlactemia. American Journal of Emergency Medicine, 35, 811-818.
7. Society of Critical Care Medicine. (n.d.) 3-Hour Bundle. Available at: http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-Three-Hour-SSC.pdf
8. Khan, P. & Divatia, J.V. (2010). Severe sepsis bundles. Indian Journal of Critical Care Medicine, 14(1), 8-123. doi: 10.4103/0972-5229.63028 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888324/
9. Lee, S.M. & An, W.S. (2016). New clinical criteria for septic shock: serum lactate level as new emerging vital sign. Journal of Thoracic Disease, 8(7), 1388-1390. doi: 10.21037/jtd.2016.05.55
10. University of Oxford. (2014). HealthTalk Online: Intensive care patient experiences. Available at: http://www.healthtalk.org/peoples-experiences/intensive-care/intensive-care-patients-experiences/emotional-experiences-icu
11. Diamond, F. (2011, May 1). ‘High Quality Saves Money’, Or so the Story Goes. Managed Care. Available at: https://www.managedcaremag.com/archives/2011/5/%E2%80%98high-quality-saves-money%E2%80%99-or-so-story-goes
12. Bodenheimer, T. & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine, 12, 573-576. doi: 10.1370/afm.1713
© Decisio Health, Inc. 2018
Colorafi, K., Jang, B., & Quinones, E. (2018). Fighting Sepsis Your Way: Using the DECISIOInsight® Clinical Dashboard to Improve Early Sepsis Diagnosis and Surviving Sepsis Campaign (SSC) EGDT Bundle Compliance. Houston, TX: Decisio Health. Available from www.decisiohealth.com
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