Improving outcomes for sepsis in rural Kansas
Rural health care providers are often looking for ways to improve the care they give patients, and one of the latest efforts toward quality improvement is the Kansas Sepsis Project.
Sepsis occurs when a severe infection gets into a person's bloodstream and causes inflammation throughout the body. This severe reaction to a seemingly simple infection is the result of the body's immune system essentially kicking into overdrive, setting off a series of uncontrolled changes in blood pressure, heart rate, breathing and white blood cell count. Severe forms of sepsis can cause shock or organ dysfunction, potentially leading to death.
In Kansas, there are an estimated 10,000 to 20,000 cases of severe sepsis and septic shock every year, with mortality rates as high as 50 percent. That's higher than for heart attack or stroke, which have mortality rates of 9.6 percent and 9.3 percent, respectively.
The good news is the numbers for sepsis can be decreased dramatically by recognizing the symptoms and implementing a few early treatment procedures at the bedside. Known as "early goal-directed therapy," these procedures include the rapid provision of large amounts of intravenous fluids and antibiotics to help restore tissue oxygenation. While early goal-directed therapy was introduced in 2001 by Emanuel Rivers, M.D., MPH., the criteria for recognizing severe sepsis was developed by Roger Bone, M.D., during his tenure as assistant professor at the University of Kansas Medical Center.
One component of the Kansas Sepsis Project is a continuing education program offered through the KU Medical Center Office of Continuing Education and Professional Development. Steven Simpson, M.D., course director, and Lucas Pitts, M.D., associate course director, both of KU Medical Center's Department of Pulmonary and Critical Care Medicine, are working with providers around the state to increase recognition and rapid treatment of sepsis in order to improve outcomes and reduce mortality rates.
The program involves analyzing records of patients hospitalized with an infection in the past six months, then using a web-based screening and tracking tool to identify where diagnosis and treatment differed from recommended practices. An action plan is then developed to change the practice, using an interdisciplinary team, to diagnose and treat severe sepsis and septic shock according to established recommendations. Participants are then asked to compare their results six months after starting the program with the previous results to identify additional areas of needed improvement.
Participants of the program earn continuing education credit while learning to recognize the cardinal features and initiate rapid care for severe sepsis. "Our whole goal is not just to educate, but to actually see a decrease in mortality from severe sepsis," explained project manager Elizabeth Wenske, Ph.D., of the KU Medical Center Office of Continuing Education and Professional Development.
The program is targeting critical access hospitals — hospitals with 25 or fewer beds that transfer patients with more critical needs to larger network hospitals — so a higher quality of care is delivered before the patient requires transfer, possibly avoiding a transfer altogether.
"The hospitals that participate are able to improve their recognition and the things they do for severe sepsis, and improve the survival from severe sepsis, actually at financial savings to the hospital," Simpson said. "Because they treat aggressively, early, and according to the protocols that we give, we think it allows the critical access hospitals to keep more patients at home in their small hospital and still have better outcomes."
The University of Kansas Hospital has already seen sepsis mortality rates drop from 49.1 percent to 22.6 percent with a program using the same principles as the Kansas Sepsis Project. "We already know that we're reducing medical costs by $18 million a year just at the University of Kansas Hospital," Simpson said.
The program is not complicated, Pitts said, it just requires more awareness and a different thought process. "Sepsis is not more complicated to recognize, it just requires more education. But the important thing to note is that protocols do exist for severe sepsis and they have been simplified down to nearly the point of myocardial infarction."
Smaller hospitals are already seeing results with the program.
"It's pretty easy to participate," said Stephanie Bjornstad, risk management director for Rooks County Health Center, a critical access hospital in Plainville, Kan. "We didn't think we really had that many septic patients, but when we started reviewing the data and all the search criteria that KU Medical Center has out, we found out we did, we just weren't recognizing it.
"Now we have standing orders in place. If a patient comes into the emergency room and meets the criteria, the expectation is that we will administer the antibiotics and have one, if not two, liters of fluid in within an hour. If we're hitting them at the door and treating them the way they should be treated, then their survival rate is better and their recovery rate is faster. To make that happen, you have to have a lot of teamwork."
Jen Brull, M.D., a family physician at Rooks County Health Center, added that the medical staff jumped at the chance to improve patient care at the facility. "The program is fantastic. We definitely learned a lot about the recognition and treatment of sepsis. Some of the work needs to be done locally because there is no 'cookie cutter' approach to sepsis order sets since each facility is unique, but we really like the product we came up with."
Bjornstad also said there were a few surprising changes as well, citing a significant increase in the amount of certain pharmaceuticals used, changes needed in coding and billing due to the use of two IVs — rather than one — to run antibiotics simultaneously, and a shift of duties for a member of the infection control department to key in the data to track results as part of the program. "It's been work, and a lot of teaching, and then realizing that it's an emergent condition," she said. "But it's not rocket science, it just takes a little education and organization, and being aware and watching for it. I just think everybody should be doing it, and I think everybody that does it would be doing a service to their patients and their community."
In 2013, Simpson and the Kansas Sepsis Project received the inaugural Community Partnership Award from KU's Institute for Community Engagement. This award recognizes a community partner and KU Medical Center faculty team for excellence in community engagement, as demonstrated by a project that addresses a critical health issue in the community.