Strict adherence to sepsis guidelines results in dramatic improvements in morbidity and mortality. Emergency Medicine physicians, internists, hospitalists, intensivists, surgical specialists, nurses, and other providers must be fluent in current standards and ready to act immediately when a patient meets sepsis criteria.
But despite intensive efforts to implement strict protocols and thoroughly educate providers, MDReview’s clients continue to experience problems in fully meeting standards of care. The following discussion may help your hospital recognize the most common pitfalls in treating patients with sepsis and septic shock.
Based on extensive study, sepsis recommendations have undergone continued and rigorous refinement during the past decade. Several sets of guidelines are widely used today, with research pointing to benefits and limitations in each. The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) have adopted Sepsis Core Measures, which are currently in use at over 4,000 TJC-accredited hospitals in the United States. Other hospitals rely on the Surviving Sepsis Campaign guidelines (most recently updated by the Society for Critical Care Medicine in 2016). It is universally accepted that management of sepsis requires very rapid recognition and interventions ,including IV access, blood cultures, lactate measurements, f luid resuscitation, early administration of appropriate antibiotics, and administration of pressors, when needed. Frontline providers at every facility should be able to readily identify the signs of sepsis and follow current guidelines. Based on patterns MDReview has observed in its reviews this year, most failures in sepsis protocol compliance appear to be due to three primary reasons.
The most common shortcoming is under-recognition that a patient’s signs and symptoms may indicate sepsis. MDReview has reviewed many cases in which providers failed to recognize sepsis altogether, or there was a delay in recognition that led to delay in care. Every hour of delay in care is associated with increased morbidity, so prompt recognition is critical for improved outcomes. Ensuring early recognition is a key opportunity for improvement, as whoever first sees the patient–whether a nurse, emergency physician, or other needs to be able to recognize the signs and be empowered to trigger a sepsis alert.
Delay in initiation of the sepsis bundle is the second common failure seen in MDReview’s clients’ cases. It stands to reason that if sepsis is under-recognized or recognized late, treatment will also be delayed. But even when sepsis is quickly identified, avoidable delays in performing the essential steps may still occur for other reasons, usually related to either human performance or process issues. Remediating the causes of such delays represents another opportunity for improvement.
A third common sepsis care challenge concerns compliance with all the elements of the sepsis care bundle. MDReview sees many cases in which much of the care is correct and timely, but one step is missed, delayed, or done in error. Examples include inappropriate antibiotic selection, inadequate fluid resuscitation, failure to reassess serum lactate to look for clinical improvement, or delay in adding pressor agents in patients who do not respond to initial fluid bolus. Current studies clearly demonstrate that better outcomes can be achieved by strict adherence to sepsis bundles. Not sure if your hospital is meeting all sepsis standards?
If you would like to ensure that your facility’s sepsis care meets current standards, external peer review can provide valuable insight into areas of weakness and opportunities for improvement.