The following is a guest article by Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse, Health Learning, Research & Practice, Wolters Kluwer.
Sepsis affects 1.5 million people in the U.S. annually, and it is a leading cause of morbidity and mortality, attributing over $20 billion in annual hospital fees. As hospitals and health systems focus on this deadly and preventable condition during Sepsis Awareness Month, it’s important to reflect on the state of the industry and how the nation is performing following increased regulatory attention in recent years.
Sepsis in not a new diagnosis. In fact, the third definition of sepsis and septic shock was published in 2016. As an industry challenge, the complexities of getting out in front of sepsis and reducing its impact have plagued healthcare organizations for years. Too often clinicians fail to recognize the severity of an infection and that the patient actually has sepsis. The failure to recognize and diagnose sepsis can lead to a deadly outcome.
The key to sepsis survival is early detection and intervention, and research has demonstrated that decreasing variability of care positively impacts patient outcomes. Recognizing that the sepsis challenge requires a multi-pronged, multi-disciplinary approach that draws on the latest industry evidence, the Centers for Medicare and Medicaid Services (CMS) instituted a program in 2015 to put standardized protocols to the test through a sepsis treatment bundle. These standards of practice have been implemented and supported nationally to improve the outlook, and hospitals are wise to prioritize implementation of the protocols as sepsis performance scores are now published on the publicly-available Hospital Compare website.
SEP-1: Sepsis quality measure to decrease variability of care
CMS instituted the SEP-1 quality measure to standardize and promote best practice treatment of sepsis in hospitals as part of the Hospital Inpatient Quality Reporting Program (IQRP). The latest update to the measure came in 2018 when the Surviving Sepsis Campaign’s (SSC’s) released the International Guidelines for Management of Sepsis and Septic Shock 2016 and focuses on immediate resuscitation and management of the condition.
The SEP-1 program measures include a 3- and 6-hour treatment and resuscitation bundle for patients that incorporates:
- Fluid resuscitation
- Antibiotic administration
- Blood cultures
- Lactate measurement
- Use of vasopressors for hypotension unresponsive to volume resuscitation
- Bedside evaluation of the patient’s response to treatment
U.S. Performance with SEP-1: A Closer Look
A cross-sectional study of U.S. hospitals participating in the CMS Quality Reporting Program was conducted in 2019. Of the 3,283 acute care hospitals eligible for the analysis, only 2,851 (86.8%) reported SEP-1 performance data. What they discovered is the reporting process was not as efficient as it could be and bundle compliance was generally low with a mean score of 48.9%, SD 19.4%. In addition, smaller, for-profit, nonteaching, hospitals with intermediate-sized ICU’s performed better than larger, non-profit, teaching hospitals.
In July 2018, SEP-1 measures were made publicly available through Hospital Compare, and the first full-year of data for 2017 was published in October. The data revealed a slightly better score with the national average reaching 55% compliance with sepsis bundles.
While compliance with SEP-1 remains lower than what the industry would hope, the reality is that sepsis bundles work. The state of New York implemented required reporting of compliance rates with sepsis bundles across all hospitals, and as a result, mortality rates for sepsis show a marked decline.
Where can we make improvements?
There is an opportunity to improve the performance on the SEP-1 quality measures, but first, hospitals will need to implement better reporting processes for the SEP-1 measures. Education on the importance of early recognition and management and then implementation of the sepsis bundle standards could also improve the performance on the sepsis quality measures; however, this hypothesis would need to be validated through further research. In the case of education, clinicians need access to the most up-to-date digital professional development resources to garner a deeper understanding of sepsis, the latest standards and practice application.
In addition, the use of a tool to identify a patient who is at risk for mortality can be helpful. One example is the Quick Sepsis Related Organ Failure Assessment (qSOFA) tool which uses a three-point system to identify a patient at risk for increased mortality. One point is given for each of the following: low blood pressure (systolic BP ≤100 mmHg); elevated respiratory rate (≥ 22 breaths per minute); or altered mental status (glascow coma scale score < 15). If the patient has a score greater than or equal to 2, the patient may be at risk for death.
Nurses need to be educated to use this system and be made aware of alerts that point to these variables. Recently the qSOFA tool has been shown to be less accurate in patients with multiple comorbidities. Further research still needs to be done to discover the best screening tool for identifying patients who are at risk of dying from sepsis.
Clinical decision support tools at point of care also provide automated updating of new evidence as it relates to sepsis bundles. These tools, in turn, foster confidence that nurses have that right information when needed.
The bottom line is, sepsis remains a leading cause of inpatient mortality and healthcare organizations and healthcare professionals have an opportunity to improve patient care by implementing the sepsis bundle to decrease care variability and improve patient outcomes.
About Anne Dabrow Woods
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN is the Chief Nurse of the Health Learning, Research and Practice business unit at Wolters Kluwer. She is also a critical care nurse practitioner for Penn Medicine, Chester County Hospital, and she is adjunct faculty for Drexel University in the College of Nursing and Health Professions.