How to Reduce Hospital-Onset Sepsis

How to Reduce Hospital-Onset Sepsis

At one children’s hospital, a simple electronic trigger reduced onset sepsis cases and mortalities by more than half.
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Sepsis remains a leading cause of pediatric morbidity and mortality, hospitalizing 40,000 children in the U.S. and killing 5,000 annually. The condition is treatable when recognized early, but it can encompass a broad range of underlying causes and present in different ways, making it difficult to identify. Common indicators of sepsis, such as fever and tachycardia, are prevalent in children without sepsis, and vital sign changes may not be reliable markers for sepsis in medically complex patients.

Although these factors make sepsis easy to miss, technology can reduce the risk by creating a shared mental model of potential sepsis, monitoring specific risk factors, and alerting frontline workers. This can be done with an automatic system that reliably screens patients at regular intervals within the electronic health record (EHR).

Yale New Haven Children’s Hospital in New Haven, Connecticut, uses an electronic screening tool to improve sepsis identification and, ultimately, patient outcomes. The hospital implemented an electronic sepsis screening tool based on age-adjusted vital signs as well as clinical markers of perfusion. The tool is integrated with the hospital’s EHR to access a broad range of clinical information to identify rapid changes in the physiologic status of hospitalized children, providing increased opportunities for earlier intervention.

When a patient screens positive for potential sepsis, a best practice alert (BPA) appears in the patient’s chart, which includes sepsis pathways and standardized order sets. The team also uses the EHR software to perform a case-by-case review to reveal missed cases and perform a root cause analysis to adjust the measurements for indicators of sepsis.

Over a two-year period (2017-2019), the rate of hospital-onset severe sepsis at Yale New Haven Children’s Hospital decreased from a baseline rate of 2.05% to 0.38% following the implementation of the screening trigger tool, as well as other initiatives such as an order set, dashboard, sepsis simulation, and education. Mortality related to sepsis decreased from 16% to 5% over two years, and median length of stay decreased from 18 to 11 hospital days.

This single-center experience demonstrates that low-cost technological interventions can successfully reduce the rate of hospital-onset severe sepsis without increasing lengths of stay or intensive care admissions at children’s hospitals.

Challenges to address

The use of an automatic screening tool comes with several challenges. First, there must be buy-in from the frontline teams who will use the electronic interface. The greatest challenge to their acceptance is the electronic trigger, which adds another actionable item to the already high burden of alarms that nursing staff and providers encounter.

To minimize alarm fatigue, it is crucial to regularly evaluate the screening trigger tool and validate the model in pediatrics. Additionally, alarm fatigue could be mitigated by optimizing the specificity and sensitivity of the screening trigger tool before rollout. However, increasing specificity may decrease sensitivity and inadvertently increase the potential for missed cases—this tension must be carefully navigated.

Importantly, it takes time for evidence-based medicine and new practice guidelines to be integrated and adopted into current clinical practice. Research suggests that it can take up to 20 years to incorporate evidence-based medicine into practice. The Surviving Sepsis Guidelines are updated every few years, which means hospitals have to be agile to incorporate the recommendations as the standard of care at all levels of patient care.

While technology cannot replace the physical exam skills and critical thinking of frontline providers, it can serve as an invaluable adjunct to improve early recognition of sepsis. Of course, continued education of frontline providers and staff will be critical to optimize the use of the technology and ultimately improve patient outcomes.

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Written By:
Sarah Kandil, M.D.
Director of Sedation Services and Director of Quality and Safety, Pediatric Intensive Care Unit, Yale New Haven Children’s Hospital
Written By:
Victoria Habet, D.O.
Senior Clinical Fellow in Cardiac Intensive Care, Boston Children's Hospital; Formerly Clinical Fellow in Pediatric Critical Care Medicine, Yale New Haven Children's Hospital

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