In this interview with IHI Content Development Manager Jo Ann Endo, IHI faculty member Dr. Sean Townsend, Vice President of Quality and Safety at California Pacific Medical Center (CPMC), discusses efforts to combat sepsis, the number one cause of inpatient death in the United States.
Q: What do you think are the key challenges when it comes to dealing with sepsis?
A: The challenges haven’t gotten much easier over the years. We still have many of the same basic issues which come down to compliance with the Severe Sepsis Bundles and physician compliance when placing central lines. That said, there are some organizations that have really stood out and done a great job over the years and shown us excellent results in reducing sepsis as a result of achieving high levels of compliance with the bundles. Implementation is complicated because there is a Severe Sepsis 3-Hour Resuscitation Bundle and a 6-Hour Septic Shock Bundle—they’re timed—and, secondly, it is an all-or-nothing measure so it requires completing each and every bundle element in order to be successful.
Q: Does it really come down to building a reliable system?
A: Yes, because there are so many moving parts for sepsis. Coordination of care between the emergency department, the ICU, and hospitalists on the medical-surgical floors creates a dynamic in which you really have to be managing multiple areas at once. I think we all know that just controlling the one area we are responsible for takes all of our energy. Straddling multiple locations and coordinating care in each of them can be challenging.
Q: It also sounds as if coordination and communication are important.
A: The coordination of when to make handoffs is critical and efficiency becomes a big part of the equation. Let me give you an example: At California Pacific Medical Center, we implemented a code sepsis strategy simply because we weren’t hitting the level of compliance with the Sepsis Bundles that we wanted for ourselves. The idea is that, at any point of care, if a patient with severe sepsis or septic shock is identified, a code is called to activate a specific team to rescue that patient wherever they are in the hospital—in the ED or on the medical-surgical floor—and take the patient immediately to the ICU. This is essentially modeled after something like a trauma team or a stroke team that we have in hospitals across the country to deal with specific emergencies. Instead of using the usual hospital mechanisms when transitions and handoffs occur, we have a specific team that goes directly to the patient, brings the individual to the appropriate care location, and then begins the right care [i.e., begins implementing the Sepsis Bundles] so we can really have control and coordination.
Q: In the past, most of the focus on sepsis has been in the emergency department, but the IHI Expedition on Treating Sepsis in the Emergency Department and Beyond will be giving participants a chance to identify key opportunities and test changes on the medical-surgical floors. Is this where you see the key opportunities for improvement?
A: A lot of diagnostic work occurs in the emergency department. Staff are attuned to a new patient showing up with a set of conditions and trying to understand why this person has this set of symptoms, what do we need to do for testing, how do we get them to a safe place. A medical-surgical floor, on the other hand, receives patients who have had all of the diagnostic work done—for the most part—and then keeps them in a stable position or delivers therapies that have already been pre-selected to make sure patients are getting better so they can go home. There is a different perspective that each area has.
However, patients on the floor often develop sepsis while they are in the hospital because they are admitted with some problem that predisposes them to developing sepsis. If you came in with pneumonia or a UTI or pyelonephritis or a gall bladder infection, for example, all of those things put someone at risk to have systemic infection and possibly develop sepsis. The infection may stay localized and the patient could just be treated on the medical-surgical floor for the specific condition for which they were admitted. But if the infection progresses, often that progression is not typically detected on medical-surgical floors because—unlike the emergency department, where staff are attuned to rapidly changing conditions—the floor staff expect a certain degree of stability in patients. If we look at patients who present from the emergency department and are diagnosed with sepsis, their mortality rate is lower than patients who present from the floor with a diagnosis of sepsis.
Q: Does some of this build on what we have learned from implementing Rapid Response Teams?
A: Yes, this kind of builds on that notion. The Sepsis Bundles require a sort of “Rapid Response Team plus” strategy. At CPMC, we recommend a screening strategy every shift on the floor that looks at changing conditions and specifically asks, “Does this patient have sepsis?” In that way it is different than a Rapid Response Team, which would not screen for specific conditions. The second thing is that we are fortunate to have a 24-hour intensivist in our CPMC facilities so we have added the intensivist to our code sepsis team. The team is a lot like the Rapid Response Team plus the intensivist, so that person arrives and makes a quick determination of whether they agree this person should be transferred to the ICU.
Q: How do you feel about sepsis being in the mainstream media more in the last few years?
A: I am actually very pleased about it. There are two different things I think are contributing to that. The first is that periodically a case captures the public’s attention and focuses people on how devastating sepsis can be. Recently, there was the death of a child in New York that spawned a lot of work there and because this was such a young person, the public, of course, was stunned. The other factor is that the demographics are working in favor of greater public awareness. As the population ages and this disease becomes more and more of a public health burden, there has been more focus on what we can do to better treat this patient population to prevent progression of sepsis and the associated escalating costs. So, to some extent, public regulatory agencies have started to make sepsis a focus of attention. It has been very gratifying to be doing this work as that has started to occur.
Q: It was recently announced that hospitals in New York will be required to adopt specific sepsis guidelines. What is your opinion in general about legislation requiring specific clinical guidelines for any clinical condition?
A: I think all of us in health care and quality improvement struggle with how much can get done by regulation and how much gets done just through the creativity of frontline teams putting energy into solving problems. Without going into any detail on the New York strategy, it does require a plan of care and screening for patients with sepsis and that is one of the rudimentary aspects of treating patients with this diagnosis. So, I am in favor of basic public health measures that I think are helpful in this case. It may serve as a template for other states to follow.
Q: You’ve been working on the Surviving Sepsis Campaign for a number of years and your advice was invaluable when IHI updated our information on the Severe Sepsis Bundles this year. What keeps you passionate about this issue?
A: It’s been gratifying to watch certain institutions have remarkable success. A paper published recently in the American Journal of Respiratory and Critical Care describes the Intermountain Healthcare experience with sepsis. Intermountain has been a champion and leader in this particular area and they have achieved something that, for a health care system, is truly remarkable: 85 percent compliance with Sepsis Bundles and mortality rates that are less than 10 percent. Knowing those numbers and knowing the quality of work that institution does, I use this as an example of what is possible if we drive providers across the country to get to that level of compliance [with the Sepsis Bundles]. My challenge is to keep people motivated and interested to do that.
