SummaryThe University of California, San Francisco’s Integrated Nurse Leadership Program ran a 22-month collaborative involving nine hospitals that focused on reducing deaths from sepsis. Although implementation specifics varied across hospitals, participants generally adopted four common approaches, including sepsis screening of all patients, a fast-track workup to confirm the diagnosis, initiatives to promote adherence to protocols that call for prompt initiation of appropriate treatment, and ongoing monitoring. Participating hospitals reduced mortality among sepsis patients during the study period by 44 percent. One-year, poststudy mortality decreased by 54.5 percent and was sustained 2 years poststudy at 49.8 percent. The initiative has generated a positive return on investment.Moderate: The evidence consists of pre- and post-implementation comparisons of sepsis mortality rates in participating hospitals and an estimate of the return on investment generated by the program.
Developing OrganizationsUniversity of California, San Francisco
The nine San Francisco Bay area hospitals participating in the collaborative included Alameda County Medical Center, Contra Costa County Medical Center, El Camino Hospital, Kaiser Fremont, Kaiser Hayward, St. Rose Hospital, San Francisco General Hospital, San Mateo Medical Center, and Sequoia Hospital.
Date First Implemented2008
Problem AddressedSepsis, a range of conditions resulting from the body's systemic response to infection,1 occurs frequently in hospitalized patients, almost always leading to longer inpatient stays and frequently resulting in death. Prompt diagnosis and treatment greatly increases the chance of survival, but many hospitals fail to identify and treat sepsis in a timely manner.
- A common, often fatal condition: Severe sepsis occurs in approximately 750,000 patients each year in the United States, with 28 to 50 percent of these patients dying as a result.2,3
- Failure to diagnose and treat in a timely manner: The timely administration of antibiotics can significantly improve outcomes among those with sepsis.4,5 Yet many hospitals fail to identify and treat these patients in a timely manner. For example, even though expert guidelines disseminated by the Surviving Sepsis Campaign call for the administration of antibiotics within 1 hour of suspected bacterial infection, the average time to first infusion of antibiotics exceeds 3 hours. Other treatment problems that contribute to poor sepsis patient outcomes include use of narrow-spectrum (affecting a limited number of organism types) rather than broad-spectrum (affecting a wide variety of organisms) antibiotics and lack of treatment protocols and standardized processes to support early initiation of goal-directed therapy, which emphasizes close monitoring and management of physiological parameters such as blood pressure, central venous pressure, and tissue oxygenation.6
Description of the Innovative ActivityThe University of California, San Francisco’s Integrated Nurse Leadership Program ran a 22-month collaborative involving nine hospitals that focused on reducing deaths from sepsis. Participating hospitals adopted four common strategies, including sepsis screening of all patients, a fast-track workup to confirm the diagnosis, strategies to promote adherence to protocols that call for prompt initiation of appropriate antibiotics and other needed treatment, and ongoing monitoring. Although the implementation of these general strategies varied across hospitals, common elements included the following:
- Sepsis screening of all patients: All newly admitted patients are screened for sepsis on admission and then again at the start of every shift. In the emergency department (ED), nurses use a screening form incorporated into the triage intake process to assess newly admitted patients for signs of sepsis. The form lists an expanded set of vital signs and patient history elements that might indicate sepsis, including a possible history of infection, low or elevated white blood cell count, low blood pressure, elevated temperature, shortness of breath, and signs of organ dysfunction (such as a decreased level of consciousness). Nurses on all medical/surgical units and intensive care units (ICUs) use a similar approach to screen every newly admitted patient and perform repeat screening on all patients at the start of each shift.
- Fast-track diagnostic testing: Patients who have at least two signs listed above and a suspected or confirmed infection receive a serum lactate test because elevated levels of lactic acid suggest sepsis. To expedite diagnosis, most participating hospitals allow nurses to order this test (although in some hospitals physicians must do so). To speed up the testing process, some hospitals perform lactate testing in the ED, while others have arranged for priority testing and/or designation of serum lactate as a “critical lab value” (meaning that a lab technician telephones a unit nurse to report results). In addition to the serum lactate test, the ordering clinician also requests a complete blood count, blood cultures, and rapid evaluation by a physician (if the ordering clinician is a nurse).
- Timely treatment based on evidence-based protocols and order sets: Patients diagnosed with sepsis receive treatment according to evidence-based guidelines (promulgated by the Surviving Sepsis Campaign and the Institute for Healthcare Improvement or IHI) that call for timely, goal-directed therapy. (More information can be found in the Tools and Other Resources section.) These guidelines call for antibiotic administration within 1 hour of diagnosis, placement of a central line, and administration of intravenous fluids, vasopressor agents, and other needed therapies. Participating hospitals took several steps to ensure adherence to these protocols, as outlined below:
- Developing or updating order sets, protocols: Participants developed or updated treatment order sets and protocols to help clinicians follow the guidelines, making it easy for them to choose appropriate antibiotics, initiate other treatments, and track the patient's progress versus established therapeutic goals for systolic blood pressure, mean arterial pressure, central venous pressure, and venous oxygen saturation.
- Other strategies to expedite care: Participating hospitals have adopted various strategies to expedite sepsis treatment, including paging a hospitalist whenever a patient screens positive for sepsis, stocking antibiotics on the floors, arranging for the immediate transfer of severe sepsis patients from the ED to the ICU, arranging for a prompt critical care consult, developing a sepsis response team, and/or expanding the scope of practice of existing rapid response teams to include sepsis.
- Ongoing nurse monitoring: Unit-based nurses monitor all patients diagnosed with sepsis at least once per shift, using the expanded set of vital signs.
Context of the InnovationThe University of California, San Francisco’s Integrated Nurse Leadership Program promotes nurse-led interventions to improve the quality of care. Following a successful initiative that reduced medication errors in eight San Francisco area hospitals, the Integrated Nurse Leadership Program received additional funding to focus on sepsis mortality. The 9 hospitals participating in the program collectively have approximately 2,500 beds and handle 400,000 ED visits and 70,000 inpatient admissions annually. More information about the Integrated Nurse Leadership Program and how it has been used to create and spread innovations can be found in the related Expert Perspective piece.
ResultsThe nine hospitals participating in the initiative reduced overall sepsis mortality by 44 percent during the study period. One-year, poststudy mortality rates declined even further—by 54.5 percent—and were sustained 2-years poststudy at 49.8 percent. The initiative also generated a positive return on investment (ROI).
Moderate: The evidence consists of pre- and post-implementation comparisons of sepsis mortality rates in participating hospitals and an estimate of the return on investment generated by the program.
- Decline in sepsis mortality: The nine participating hospitals had an average sepsis mortality rate of 27.7 percent during the 6-month period before implementation. Two years later (December 2010), the average sepsis mortality rate declined by 44 percent. Average sepsis mortality rates continued to improve, declining by 54.5 percent one-year poststudy. Information provided in July 2013 indicates that two-years poststudy, the average sepsis mortality rate sustained improvement and is still 49.8 percent lower than the baseline mortality rate. All participating hospitals achieved significant improvements, with some of the most impressive declines as follows: San Mateo Medical Center (from 40 to 21 percent), San Francisco General Hospital (from 42.4 to 22.7 percent), Contra Costa Hospital (from 19 to 12.8 percent), El Camino Hospital (from 36.5 to 9.1 percent), and Sequoia Hospital (from 18.5 to 10 percent).
- Positive ROI: An analysis conducted by the Integrated Nurse Leadership Program indicated that the sepsis initiative generated a 56-percent ROI. This estimate is based on a $2.5 million investment, the percentage decrease in mortality (based on the coded data reported by each hospital), and an estimated cost savings per case avoided. To derive this figure, the Integrated Nurse Leadership Program analysis used a case mix index for each hospital and applied it by year to adjust cost based on patient severity scores. To determine the cost savings associated with sepsis, the analysis used an industry-accepted base cost of $22,100 (as estimated by the Institute of Medicine's Medication Safety study) and escalated the cost by 1 percent each year to account for gradual, expected cost increases.
Planning and Development ProcessSelected steps included the following:
- Recruiting hospital participants: Integrated Nurse Leadership Program leaders contacted nurse leaders and chief medical officers at the hospitals that participated in the medication error initiative, and all expressed interest in this initiative as well. In addition, several representatives from other area hospitals contacted the Integrated Nurse Leadership Program to express interest.
- Developing sepsis-reduction goals: Integrated Nurse Leadership Program leaders and participants met during three half-day sessions to define a set of goals related to sepsis reduction based on those set forth by the Surviving Sepsis Campaign guidelines and the IHI sepsis resuscitation and management bundles. The group also defined performance indicators to be tracked.
- Holding training sessions: Relevant staff from participating hospitals attended seven 1-day training sessions over an 18-month period. Sessions focused on developing skills related to the Integrated Nurse Leadership Program model of quality improvement and on promoting peer-to-peer learning and the sharing of best practices for reducing sepsis mortality.
- Providing onsite consultation: Integrated Nurse Leadership Program leaders visited participating hospitals to observe their sepsis reduction strategies and provide onsite consultation to staff and clinicians.
Resources Used and Skills Needed
- Staffing: No additional hiring was required to implement the program; existing Integrated Nurse Leadership Program staff oversaw the program, and hospital-based nurses participated as part of their regular duties. However, these hospitals had to pay other nurses to cover units during the time that participating nurses attended the aforementioned training sessions.
- Costs: The Integrated Nurse Leadership Program spent approximately $2 million to fund training sessions and support data-collection efforts at the individual hospitals. Participating hospitals covered the costs of the extra staffing required to allow nurses to attend training.
Funding SourcesGordon and Betty Moore Foundation
The University of California, San Francisco’s Integrated Nurse Leadership Program is funded by a $6 million grant from the Gordon and Betty Moore Foundation.
Tools and Other ResourcesThe Surviving Sepsis Campaign (a collaborative initiative of the European Society of Intensive Care Medicine, International Sepsis Forum, and Society of Critical Care Medicine) has produced guidelines on the management of severe sepsis and septic shock, available at: http://www.guideline.gov/content.aspx?id=43904&search=surviving+sepsis.
The IHI sepsis resuscitation and management bundles can be accessed at: http://www.ihi.org/knowledge/Pages/Changes/ImplementtheSepsisManagementBundle.aspx.
Getting Started with This Innovation
- Choose elements based on evidence: Core program elements should be based on well-established evidence, thus making it easier for participating hospitals to win acceptance of these components within their organizations.
- Define common metrics: Participating hospitals should all track the same performance metrics, thus allowing for cross-institution comparisons.
- Ensure appropriate infrastructure: This infrastructure must include detailed training to support frontline clinicians in executing quality improvement initiatives, an executive group or steering committee (made up of representatives from across the hospital) to support and oversee the work, and unit-based teams to develop and test changes.
- Allow flexibility: Once components of sepsis care and outcomes measures are agreed upon, make it clear that individual sites remain free to implement those components based on their own culture, workflows, and other organization-specific considerations.
Sustaining This Innovation
- Communicate constantly: Constant communication of key messages related to the initiative helps to reinforce its importance and maintain support among leaders, managers, and frontline staff.
- Train new staff: Incorporate information about the program into new employee and medical resident orientation and training sessions.
- Standardize and automate care processes: Standardizing and automating care through forms, protocols, and order sets help reduce variations in care, even when staff turnover occurs.
- Review and share performance data: Continually track data that demonstrate the program's impact and display these data on the units so that frontline staff remain engaged and committed to incorporating the processes into their everyday work.
- Hold regular meetings: Regular meetings (ideally two per month) of the steering committee and unit-based teams help to ensure that new processes are continually analyzed and adjusted as necessary.
Contact the InnovatorJulie Kliger, MPA, BSN, RN
Director, Integrated Nurse Leadership Program, University of California, San Francisco
Founder and Principal, The Altos Group LLC
13100 Skyline Boulevard
Oakland, CA 94619
Innovator DisclosuresMs. Kliger reported that she has received consulting fees from multiple organizations, as well as grants and other support services through the University of California, San Francisco. Ms. Kliger also has a pending contract with a health information technology company to help develop sepsis-related technologies. Information on funders is available in the Funding Sources section.
References/Related ArticlesColliver V. Sepsis: Bay Area hospitals sharply cut death rates. SF Gate/San Francisco Chronicle. April 20, 2011. Available at: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/04/20/MNEM1J3QM1.DTL.
Darves B. Stopping sepsis. Today’s Hospitalist. 2001; October: 22-25.
Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303-10. [PubMed]
3 Colliver V. Sepsis: Bay Area hospitals sharply cut death rates. SF Gate/San Francisco Chronicle. April 20, 2011. Available at: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/04/20/MNEM1J3QM1.DTL.
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36(1):296-327. [PubMed]
Nobre V, Sarasin FP, Pugin J. Prompt antibiotic administration and goal-directed hemodynamic support in patients with severe sepsis and septic shock. Curr Opin Crit Care. 2007;13(5):586-91. [PubMed]
Claessens YE, Dhainaut JF. Diagnosis and treatment of severe sepsis. Crit Care. 2007;11(Suppl 5):S2. [PubMed]
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Original publication: August 01, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.