Patient care: "Believe in the Lactate"
July 11, 2012
By Chris Snyder
This article originally appeared in the July 2012 edition of DOTmed Business News
Many people would be surprised to learn that sepsis is the tenth leading cause of death in the United States – even topping heart disease. Many may not even know what it is — an infection that reaches the bloodstream. Severe sepsis is a systemic blood infection that can cause a patient’s death within 24 hours if not properly treated. Sometimes patients arrive at the hospital with the infection; sometimes they acquire it during their stay. Regardless, action must be swift and targeted in order to save a life.
One day, I was galvanized into action when a patient died of sepsis in our Emergency Department (ED). From that day, Peninsula Regional Medical Center (PRMC) made the early detection and treatment of the infection a formal quality initiative. As a result, PRMC decided to join the Institute for Healthcare Improvement’s (IHI) project of improving treatment by participating in the global Surviving Sepsis Campaign.
We established a multidisciplinary Severe Sepsis team and engaged our health IT department in the project. Team members analyzed our sepsis treatment and found that antibiotics, blood cultures, volume resuscitation or central lines sometimes were not applied in the optimum accelerated timeline. Patients that “looked well” might be placed on medical units instead of receiving intensive care. We presented our data as well as the evidence from IHI to the ICU and ED directors. With the evidence in hand, they joined the effort.
Using our health IT tools, we developed a single process for addressing sepsis. The process leveraged our health IT solutions for computerized physician order entry, clinical documentation, bedside medication administration, laboratory, pharmacy and alerts. Using IHI’s Guidelines for the Surviving Sepsis Campaign, we implemented decision support for any lactate value equal to or greater than 4.0. We established the protocol as a “CODE SEPSIS” in the ED.
When a patient’s lab result shows an elevated lactate value, the system sends an alert to the team. The alert advises that the patient has an elevated value, which requires immediate treatment with broad-spectrum antibiotics. The team can log into the hospital’s physician portal from wherever they are and concurrently review the patient’s treatment. We can assess whether antibiotics have been given and when they were started-- a critical piece of data for fighting sepsis. We can also review the physician’s notes.
Once alerted, we monitor the case to ensure evaluation and treatment is prompt. For ICU patients, we can review the acuity score of how sick they are — which helps us determine whether to intervene in the patient’s treatment. If we don’t see action taken, one of the team members proceeds to the ICU or ED with complete knowledge of the patient’s status and what steps have been missed. You only have to do that once to change behavior. We advise clinicians to “believe in the lactate,” not the patient’s appearance.
The alerts for elevated lactate values have enabled us to accelerate treatment. We’ve achieved a sustained 74-minute faster start to antibiotic administration. From October 2009 to December 2011, our hospital has saved 130 patients suffering from severe sepsis. We’ve also reduced ventilator days and length of stay in the ICU. By addressing sepsis now, we are prepared for the future negative impact on reimbursement for hospital-acquired conditions by Medicare and some health plans.
Through this project, we learned that clinicians will change their behavior if they are involved in the problem-solving process. Just provide them with simple, clinically appropriate tools, show them their data, and demonstrate how the protocol has made their care more effective and safer. Using this standard protocol has enabled us to reduce care variation and improve outcomes.
Our care team remains excited about our progress in this area, and we look forward to achieving even greater improvements in the sepsis care that we offer to the PRMC community.
About the author:
Chris Snyder, D.O., currently serves as the chief medical information officer (CMIO) and as a hospitalist at Peninsula Regional Medical Center (PRMC). Over the last decade, he has worked in utilization and performance improvement at PRMC. He specializes in clinical data mining and physician engagement using evidence-based educational and communication tools. PRMC is ranked by the independent health care ratings organization, HealthGrades in the top 5 percent of hospitals nationwide for quality.
This article originally appeared in the July 2012 edition of DOTmed Business News
Many people would be surprised to learn that sepsis is the tenth leading cause of death in the United States – even topping heart disease. Many may not even know what it is — an infection that reaches the bloodstream. Severe sepsis is a systemic blood infection that can cause a patient’s death within 24 hours if not properly treated. Sometimes patients arrive at the hospital with the infection; sometimes they acquire it during their stay. Regardless, action must be swift and targeted in order to save a life.
One day, I was galvanized into action when a patient died of sepsis in our Emergency Department (ED). From that day, Peninsula Regional Medical Center (PRMC) made the early detection and treatment of the infection a formal quality initiative. As a result, PRMC decided to join the Institute for Healthcare Improvement’s (IHI) project of improving treatment by participating in the global Surviving Sepsis Campaign.
We established a multidisciplinary Severe Sepsis team and engaged our health IT department in the project. Team members analyzed our sepsis treatment and found that antibiotics, blood cultures, volume resuscitation or central lines sometimes were not applied in the optimum accelerated timeline. Patients that “looked well” might be placed on medical units instead of receiving intensive care. We presented our data as well as the evidence from IHI to the ICU and ED directors. With the evidence in hand, they joined the effort.
Using our health IT tools, we developed a single process for addressing sepsis. The process leveraged our health IT solutions for computerized physician order entry, clinical documentation, bedside medication administration, laboratory, pharmacy and alerts. Using IHI’s Guidelines for the Surviving Sepsis Campaign, we implemented decision support for any lactate value equal to or greater than 4.0. We established the protocol as a “CODE SEPSIS” in the ED.
When a patient’s lab result shows an elevated lactate value, the system sends an alert to the team. The alert advises that the patient has an elevated value, which requires immediate treatment with broad-spectrum antibiotics. The team can log into the hospital’s physician portal from wherever they are and concurrently review the patient’s treatment. We can assess whether antibiotics have been given and when they were started-- a critical piece of data for fighting sepsis. We can also review the physician’s notes.
Once alerted, we monitor the case to ensure evaluation and treatment is prompt. For ICU patients, we can review the acuity score of how sick they are — which helps us determine whether to intervene in the patient’s treatment. If we don’t see action taken, one of the team members proceeds to the ICU or ED with complete knowledge of the patient’s status and what steps have been missed. You only have to do that once to change behavior. We advise clinicians to “believe in the lactate,” not the patient’s appearance.
The alerts for elevated lactate values have enabled us to accelerate treatment. We’ve achieved a sustained 74-minute faster start to antibiotic administration. From October 2009 to December 2011, our hospital has saved 130 patients suffering from severe sepsis. We’ve also reduced ventilator days and length of stay in the ICU. By addressing sepsis now, we are prepared for the future negative impact on reimbursement for hospital-acquired conditions by Medicare and some health plans.
Through this project, we learned that clinicians will change their behavior if they are involved in the problem-solving process. Just provide them with simple, clinically appropriate tools, show them their data, and demonstrate how the protocol has made their care more effective and safer. Using this standard protocol has enabled us to reduce care variation and improve outcomes.
Our care team remains excited about our progress in this area, and we look forward to achieving even greater improvements in the sepsis care that we offer to the PRMC community.
About the author:
Chris Snyder, D.O., currently serves as the chief medical information officer (CMIO) and as a hospitalist at Peninsula Regional Medical Center (PRMC). Over the last decade, he has worked in utilization and performance improvement at PRMC. He specializes in clinical data mining and physician engagement using evidence-based educational and communication tools. PRMC is ranked by the independent health care ratings organization, HealthGrades in the top 5 percent of hospitals nationwide for quality.