CEO SUMMARY: When Intermountain Healthcare began a quality improvement program to address sepsis, its sepsis mortality rate was 20.2%, among the lowest in the nation. By 2007, all 15 of its hospitals had deployed this program. A breakthrough came in recent years, when a phlebotomist was added to the team and contributed new insights into how to diagnose “tweener” patients early, meaning those who have yet to show all the symptoms of sepsis. Intermountain’s sepsis mortality rates fell to under 9%.
EIGHTEEN MONTHS into its nationally-recognized quality improvement program for managing severe sepsis and septic shock in the emergency department and ICU, the team at Intermountain Healthcare in Salt Lake City had hit a wall. But after adding a phlebotomist to the team, a wave of impressive gains was realized.
“That phlebotomist and the suggestions he offered to our team made such a difference that the initiative showed improvements in compliance with the program’s protocols almost immediately,” stated Todd Allen, MD, who started with the original program at Intermountain in 2004.
Saving hundreds of Lives
“The other significant benefit was that, soon thereafter, sepsis mortality rates started to drop as well,” added Allen, who is the Program Chair of the Emergency Department Development Team within Intermountain’s Intensive Medicine Clinical Program.
When the program commenced, Intermountain’s sepsis mortality rate was 20.2%, which was among the lowest in the recognized quality improvement nation. But Allen believed Intermountain could do better. The numbers tell the story. As a result of the sepsis-management protocols Allen and his team instituted, Intermountain has cut the mortality rate in half. Today that rate is less than 9% and Intermountain’s program saves more than 100 lives annually, according to Hospitals & Health Networks magazine.
Pathologists and lab professionals can use the lessons learned and experience gained at Intermountain Healthcare to inform similar efforts to improve the diagnosis and management of sepsis at their own hospitals throughout the nation.
What will be particularly inspiring to hospital laboratory administrators is how, after including a phlebotomist and his frontline expertise on the team, the sepsis management program could achieve further, ongoing improvements in reducing mortality from sepsis and septic shock that have saved hundreds of lives.
The challenge presented by sepsis is huge. The mortality rate in most hospitals is 25% to 50% of patients with severe sepsis, and the condition kills 220,000 patients annually, H&HN reported. As of January 1, the federal Centers for Medicare & Medicaid Services put new rules in place for the treatment of patients with sepsis and septic shock, called SEP-1.
“When I started the work of improving our diagnostic and treatment reliability on patients with sepsis and septic shock, I didn’t fully appreciate the importance of how blood tests were collected and processed,” Allen said in an interview with THE DARK REPORT. “My approach to labs was simplistic: I thought I would order a lab test and get a number back.
“I didn’t think carefully about all the steps of ordering a lab test, collecting the specimen, sending the order to the lab, and incorporating those results back into the process of care,” he noted. “I didn’t see that each was a critical step in our process-improvement effort.
“Consequently, when the team was organized, it did not include a member of the lab staff, and, in particular, phlebotomy was left off of our team,” continued Allen. “For that reason, despite lots of effort in the first 18 months of the program, we made almost zero progress. By excluding that key part of the process—phlebotomy—it seems like I doomed myself from the beginning.
adding a phlebotomist
“During those 18 months when we weren’t seeing much progress on our sepsis management goals, we tried many different kinds of improvements,” recalled Allen. “First we worked harder, then we worked smarter. Then we got more educated and then looked for an IT solution. Then we went back to get more education. Then we hoped and prayed. But nothing seemed to click until we finally added a phlebotomist to the program.”
More months might have passed if the phlebotomist, Ryan Black, hadn’t asked to work with Allen. “Ryan Black was preparing to go to medical school and wanted to add some activities to his application in order to show that he did more than just work as a phlebotomist,” Allen said. “He wanted to help in any way he could and so I suggested he join the sepsis project.
“As I recall, I said something like, ‘I don’t think you’ll have much to add,’ ” Allen explained. “‘But come along, you’ll learn something, and I’m happy to certify that you participated on this team.’
“So he did and he was polite and professional and tried not to interrupt,” noted Allen. “But then, at one point, he said, ‘I think we’re missing an important piece in the process of identifying patients with potential sepsis and getting an earlier start on their diagnostics and treatment. Here’s my idea. What do you think about it?’
“As a phlebotomist working on the clinical team, he had a sense—through his experience with our patients—of when people are potentially septic or not,” Allen said. “He saw that we were very good at identifying those patients who definitely have sepsis and excluding those who definitely do not have sepsis. The signs of sepsis are sometimes obvious, such as fever, low blood pressure, clear infection, and tachycardia.
“But he also saw that we had a difficult time with patients you might call ‘tweeners.’ By that, I mean patients who may not have developed a fever yet, maybe their complaint isn’t the productive cough or painful urination,” stated Allen. “These patients may have weakness, dizziness, malaise, nausea—all of which can be early nonspecific signs and symptoms of sepsis.
“In a busy emergency department, I’m often in a hurry,” he continued. “So I take a brief history, do a focused exam, and I may not pick up all the clues that are there. But Ryan noticed that all of these patients were at least ill enough to require some diagnostics and so we ordered lab tests on almost all of them. That meant he would get involved to do the blood draw.
“Ryan then observed that most of these who turned out to be septic were intravascularly depleted and it was tough to find a good vein to access,” he explained. “So in order to find that good vein, he had to get really close to the patients and spend some time with them, touching, warming, and looking carefully at the skin. Sometimes it took him three minutes or so to find the vein. Ryan started to notice subtle changes in capillary refill and skin warmth that, in his experience, correlated with sepsis.
reading Signs, Symptoms
“Then Ryan told me this: ‘As a result of the thousands of patients from whom I’ve drawn blood, I think I can tell when patients are sick by the touch, by their skin turgidity, by the cap refill rate. These are all signs of a potentially more serious illness,’” noted Allen.
“Ryan was worried that, whenever he noticed these signs, my orders did not always reflect that same level of concern,” noted Allen. “If my orders didn’t include a blood culture or a lactate test, it meant I was not thinking about the possibility of sepsis in these patients. Ryan could tell when his suspicions did not match mine!
“He asked if I were willing to expand the test-ordering permissions and governance to allow him to start the approved sepsis diagnostic pathway as long as I gave my confirmation later,” he explained. “A physician must sign off at some point. He saw that I was busy and he did not want to wait to start the diagnostic process if he suspected sepsis. We agreed that we would start a trial of initiating the sepsis diagnostic bundle independent of my approval.
“That’s when I had my ‘aha moment’ about phlebotomy,” declared Allen. “I had almost completely ignored that part of the process and the expertise of the phlebotomist, both as a member of the core team and at the bedside. So, I took his suggestion and implemented it as soon as possible, and it made all the difference in our sepsis management program.
“We instituted a standing directive that he (or his trained phlebotomy colleagues) could initiate lactate and blood culture tests as long as the treating physicians approved them later,” added Allen. “The quid pro quo was a promise that I wouldn’t get mad at him if he was wrong. Essentially, he would bail me out and I would keep him safe. After all, he was looking out for me and our patients.
“That one change gave us the extra intelligence we needed on those tweener patients,” he said. “Thereafter, we began to see improvements in compliance with all steps in our sepsis bundle.“Improved compliance with the bundle means that: 1) we drew the blood culture test before antibiotics were administered and, 2) that the serum lactate test was done for patients with potential early sepsis and septic shock,” observed Allen. “After Ryan got involved, we saw those numbers improve almost immediately. And they continued to improve whenever we made adjustments to the bundle.
“This phlebotomist helped us break through our self-imposed glass ceiling in terms of bundle compliance,” emphasized Allen. “Once we got that compliance moving up toward 80% in all 22 hospitals, then our mortality rate from sepsis started to drop as well.
appointed Lead phlebotomist
“Looking back on it, I saw that Ryan had a special combination of skills and knowledge and that’s why we made him our lead phlebotomist,” he added. “We now recognize that most well-trained and experienced phlebotomists can do what he did.
“Let me add that the phlebotomists I’ve met and worked with at Intermountain are a special bunch,” he enthused. “They have a special skill set and if you treat them as healthcare professionals and allow them to use their skills maximally, then you’ll get good results. The same is true of nurses or patient care technicians. If you give people the opportunity to excel, they will.”
In addition to serving as a team mem-ber who could order preliminary diagnostic tests, Black served as a liaison to the clinical lab, a factor that led Allen to work more closely with pathologists. “Once I got smarter about lab testing, I reached out to our laboratory leaders, the pathologists, to make sure they knew what I was trying to do. It was important, for example, to ensure blood cultures were drawn before antibiotics are given and the pathologists helped us achieve the lab test result turnaround time our sepsis team needed.
“Improving TAT was just a matter of helping them identify the specimens we care about most and having them make those specimens a priority,” recalled Allen. “Everyone in the clinical lab was very willing to help us.
“Today, the 22 hospitals in the Intermountain system use our sepsis protocol,” he continued. “Because we have such a variety of facilities, each hospital and each emergency department had to somewhat customize how sepsis patients’ laboratory tests flowed from those departments to our regional labs or to the local laboratories. But from central lab leadership on down and throughout the system, every lab and every person seemed fully invested. All that helped us figure out how to be more timely and accurate with these tests.”
Contact Todd Allen, MD, at 435-792-1950.
Reducing Mortality from Sepsis is Multi-Year Effort By Improvement Team at Intermountain Healthcare
IN 2004, A CLINICAL TEAM at Intermountain Healthcare in Salt Lake City began developing an evidence-based protocol for the aggressive detection and treatment of sepsis. The goal was to start in the ED, then expand use of the protocol into the intensive care units.
Nationally, it is recognized that mortality rates for sepsis cases that enter the hospital through the emergency department can vary from 20% to 50%. In 2004, Intermountain Healthcare was recording one of the lowest sepsis rates in the nation, at 20.2%.
Under the direction of team leader Todd Allen, MD, Program Chair of the Emergency Department Development Team within Intermountain’s Intensive Medicine Clinical Program, an initial bundle of 11 elements was developed. In a story published by Hospitals & Health Networks, Allen explained that “four typically are implemented in the ED, four in the ICU, and three can be applied in either setting. The bundle addresses the following elements: (in the ED) serum lactate, blood cultures, broad-spectrum antibiotics and fluid resuscitation; (in either setting) vasopressors, CvO2 measurement, and inotropes and/or blood transfusion; (in the ICU) steroids, glucose control, rAPC use in eligible patients and a lung protective ventilator strategy.” These elements were reduced to seven in 2011 to reflect changes in clinical practice.
Implementation began in 2006 and by 2007, all 15 IHC hospitals were using the protocol in their emergency departments and ICUs. Allen reported that, by 2010, compliance with the sepsis protocol bundle had reached 80%—meaning that, 80% of the time, 100% of the appropriate bundle elements were followed by the clinical team.
Allen wrote that: “As a result of the 80% compliance, Intermountain achieved the fol- lowing care and cost improvements from a study cohort of 4,329 patients from 2004 to 2010:
- The rate of survival increased from 20.2% mortality to under 9%.
- The average length of hospital stay was reduced by 20 hours.
- The average cost per patient declined by nearly $3,000.”
Because of this quality improvement program, Intermountain has reduced the sepsis mortality rate to under 9%. It saves the lives of more than 100 patients annually because of better compliance with guidelines.