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Value Grand Rounds - November 2016

Value Grand Rounds - November 2016

There are one million hospital admissions for sepsis annually in the United States, and sepsis accounts for 20 percent of Intensive Care Unit (ICU) admits and 50 percent of ICU deaths. Sepsis causes more deaths than heart attacks, and more deaths than breast and prostate cancers combined. “Sepsis is brutal,” said Gerard Kiernan, MD, FAAFP, FHM, at the start of his November 8, Value Grand Rounds presentation entitled, “Sepsis Bundle Process Improvement for Cheshire Medical Center/Dartmouth-Hitchcock Keene (CMC/D-HK) ED [Emergency Department].”

Sepsis rates were also very high at CMC/D-HK in southwestern New Hampshire, which has 169 licensed beds and 125 providers. Over the past two years, they recorded a septic shock mortality rate of 44 percent, a severe sepsis mortality rate of 20 percent and an overall sepsis mortality rate of 14 percent. To help improve performance, Kiernan, a hospitalist and quality lead for Cheshire’s Section of Hospital Medicine, enrolled in a Dartmouth-Hitchcock (D-H) Value Institute Greenbelt program in the fall of 2015. He noted that the Greenbelt project would also help Cheshire prepare for the upcoming Centers for Medicare and Medicaid (CMS) Core Measure for sepsis (SEP-1) initiative. As of October 2015, all hospitals began reporting sepsis performance to the CMS, and beginning in October 2016, hospital payment is now linked to sepsis performance.

“Doing well on the core measure requires that you have all of the components working; the 3-hour bundle, the 6-hour bundle. It all needs to work,” Kiernan said.

Their project goals were to achieve reliable delivery of sepsis care by:

  • Improving performance of the ED sepsis screen
  • Improving ED provider and nurse recognition and documentation of sepsis
  • Lowering the time to initial lactate measurement and antibiotic administration
  • Performing reliable blood cultures prior to antibiotic administration
  • Properly stratifying patients for subsequent interventions

CMC/DHK started the pilot project in May of 2016 and fully implemented it by the end of June. Some of their findings included:

  • The wrong antibiotics were often hung initially, when a broad spectrum antibiotic would have been more effective
  • Sepsis screening remains a challenge, due to a focus on fever
  • A point of care lactate device with a one-minute turnaround time dramatically cut the delays they had previously experienced waiting for lactate orders and results
  • Weekly feedback on process and outcome measures have been very effective

“What saves people’s lives?” Kiernan asked. “Probably antibiotics and fluids more than anything else. We’re doing pretty well on blood cultures, but it’s still a challenge.”

In a comparison of patients admitted with severe sepsis from October through December 2015 versus patients admitted from June to September 2016, the data was as follows:

  • October to December 2015: 36 sepsis cases, seven deaths, 19 percent mortality
  • June to September 2016: 59 sepsis cases, six deaths (including one comfort care only patient), 10 percent mortality

“We can extrapolate that there are 15-20 people a year who make it out of Cheshire who in the past may not have survived,” Kiernan said.

Among the other “wins” he cited were improved nursing and provider engagement, improved care delivery, “order from chaos” and core measure improvement and visibility. “The back and forth can be a little tense,” Kiernan said, “but it’s a matter of remembering to be hard on problems and soft on people.”

Kiernan, who has been a hospitalist for seven years after transitioning from family medicine, added, “During this project I felt like I was a doctor for a hospital. I’d love to see us spend 15 percent of our time on projects like this. We’ve got to keep improving. The Value Institute has really opened my eyes to some methodology and ways to improve what we do.”