Identifying severe sepsis when it happens
Critical Care team develops alert in electronic medical record
Pediatric Intensivist Samir Shah, MD, thinks about severe sepsis like Wayne Gretzky thinks about hockey.
Gretzky once said, “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.”
The critical care intensivist has dedicated the last 14 years searching for the best way to determine the moment severe sepsis happens in a patient.
“Literature has clearly shown that every hour that is lost in not managing a patient with severe sepsis appropriately is associated with increasing mortality. Every hour that goes by without goal-directed therapy increases the possibility of involving other organ systems,” Shah said.
The quicker the treatment, the better the outcome
Shah and a multi-disciplinary team at Le Bonheur Children’s Hospital have developed an algorithm that continuously screens hospital electronic medical records for signs of sepsis. When triggers line up, the system sends a computerized sepsis alert to the bedside nurse and a text alert to the resident and a medical response team nurse. Together, after confirming the diagnosis, they implement the necessary treatment.
When used with adolescent patients in testing this year, the screening tool helped identify true positive patients earlier without any false negatives. The tool is now used regularly with adolescent patients, and overall severe sepsis mortality for Le Bonheur is at an all-time low.
Preventing septic shock
“Severe sepsis is the last step before the slippery slope down to septic shock, which has a very high incidence of mortality and morbidity. We want to capture and recognize severe sepsis earlier, manage it and prevent the slide into the abyss of septic shock,” said Shah, interim division chief, for Pediatric Critical Care Medicine at Le Bonheur and the University of Tennessee Health Science Center.
Along that slippery slope, it’s hard to identify markers that a patient is progressing from sepsis to severe sepsis to septic shock.
“Unfortunately, there is no absolute clinical or laboratory test that can pinpoint the occurrence of severe sepsis,” Shah said. “Since it’s a combination of a group of clinical signs and symptoms and laboratory tests, it becomes difficult for people to identify severe sepsis earlier because there is a significant variation in an individual’s level of experience, education and training. They may not be able to identify these patients with severe sepsis earlier. The eyes cannot see what the mind does not know.”
A screening tool
Shah became interested in predicting the moment severe sepsis begins in a patient while working at Children’s Hospital of Winnipeg and University of Manitoba in Canada in the early 2000s. The hospital, working in partnership with the Canadian Collaborative, developed a paper tool for identifying severe sepsis. The tool, along with a six-point management bundle, was used by Medical Response Team (MRT) nurses. While the tool demonstrated a decrease in mortality, it was used after an MRT was called. Shah saw there was still an opportunity for earlier detection.
He joined Le Bonheur and the University of Tennessee Health Science Center in 2008 and saw the same opportunity in Memphis. Around the same time, the hospital was implementing a new electronic medical record (EMR). Adult facilities have implemented such screening tools in an EMR, but there was no validated pediatric screening algorithm when the Memphis team began. The range of ages and physiological variables in pediatrics presents a unique challenge. The eASSIST project (electronic Application of a Pediatric Severe Sepsis EMR-Integrated Screening Tool) was launched after detailed analysis and the creation of an offline retrospective database to simulate an EMR-integrated screening tool. The tool was tested, and multiple PDSA (Perform, Do, Study, Act) cycles were conducted until the existing electronic tool was designed for real time implementation.
Le Bonheur’s parent system, Methodist Le Bonheur Healthcare, implemented a severe sepsis EMR alert in 2008 for one of the adult hospitals. This knowledge prepared the information systems team for the challenges of working with a pediatric population.
“The adult population uses the same criteria and thresholds across a larger age group. With pediatrics, the criteria, vary between age groups,” said Brian Williams, manager of information systems. “Each age group will look at different criteria and any similar criteria will have different thresholds. Knowing this, there needed to be additional suppression criteria applied for the pediatric population. All of these variances required more clinical analysis to get the right mix so as to reduce the number of alerts which were not true positives showing severe sepsis.”
The Le Bonheur team worked for 18 months developing and refining the eASSIST tool. First, the electronic tool was used with a retrospective database of patient medical records. This work was published in the June 2014 issue of Frontiers in Pediatrics. In offline testing, the team found the sensitivity and specificity was good, but they were concerned about the three and a half-hour lag time from the occurrence of severe sepsis to identification. For better outcomes, patients need to immediately receive goal-directed therapy, including oxygen, starting venus access, giving adequate IV fluid boluses and appropriate antibiotics.
“The ability to immediately respond to documentation taking place within the EMR allows for the right people being made aware of the possibility of severe sepsis much faster. With a paper process, the ‘dots’ may not be connected as quickly, and when they are connected, making the right people aware of the situation may take time as well,” Williams said.
eASSIST runs constantly, scanning medical records of admitted patients and those seeking care in the Emergency Department and urgent care clinics. Once sepsis and acute organ dysfunction happen together, a text alert is sent to an iPhone, which is carried by MRT nurses who have been trained in the management of severe sepsis. The alert includes the patient’s room number and the key terms that caused the patient to be identified.
Charge nurses and nurse practitioners examine the patient, determine if severe sepsis there is evidence of, consult with the physician and begin the treatment bundle.
Critical Care Nurse Practitioner Anna Olivia Jordan, CPNP-AC, says eASSIST helps nurses critically think in regards to their patients.
“The nurses have the triggers that have been collected per the sepsis tool. The nurses must use this data and analyze it. Once analyzed they must make a clinical judgment based on the patient’s assessment and declare if this patient needs further attention such as a fluid bolus, oxygen administration or a higher level of care. The bedside RN must be the person to recognize that the patient needs these interventions and advocate to obtain them.”
"The goal was to develop a tool that could recognize severe sepsis rather than some of the mimics of severe sepsis,” said Shah.
The tool has 100 percent sensitivity, 97 percent specificity and a positive predictive value of 58 percent. Shah says that while the tool is not perfect, it has made a significant difference for patients. Le Bonheur has seen a decrease in mortality for patients with severe sepsis.
Currently, the team is using the third iteration of the eASSIST tool with adolescent patients. It is continually reviewing and making changes to make a more robust tool, so it catches all severe sepsis and eliminates false positives. The eASSIST team’s work has had a ripple effect in the hospital. The Emergency Medicine team is working on a tool as well.