Best Practices: Crozer-Keystone Hospitals Enact Comprehensive Plans to Care for Severe Sepsis Patients
DCMH and Crozer earned VHA awards for their achievements in improving sepsis care during a VHA conference held at DCMH in June. VHA is a national conglomeration of not-for-profit hospitals dedicated to ethical conduct, quality standards and financial responsibility, improving patient care and efficiency.
Sepsis is the body’s response to an infection, causing an excessive inflammatory response resulting in inadequate tissue perfusion and organ dysfunction and or failure. Sepsis is a serious medical condition that affects 750,000 people each year and has a 30 to 50 percent mortality rate. Early recognition and management following the Surviving Sepsis Campaign guidelines has been shown to reduce severe sepsis mortality. CKHS joined VHA’s ICU RAN (Intensive Care Unit Rapid Adoption Network), a collaborative of 16 hospitals dedicated to decreasing severe sepsis mortality.
DCMH received two VHA awards, one for the development and implementation of a comprehensive sepsis program and another for decreasing sepsis mortality. These awards signify the culmination of a comprehensive multidisciplinary initiative to decrease mortality rates caused by severe sepsis and septic shock. VHA recognized DCMH for their achievements in decreasing mortality rates among patients with severe sepsis and septic shock and improving patient care.
VHA also recognized Crozer-Chester Medical Center with the “VHA Certificate of Excellence for Goal Achievement in Sepsis Mortality Improvement” award. Crozer has improved sepsis standards and decreased its rate of severe sepsis-related mortality.
DCMH, Crozer and Taylor all formed sepsis committees which aimed to develop comprehensive evidence-based sepsis care programs. The committees focused on early recognition of sepsis and rapid treatment interventions. They identified quality measures to monitor performance and assessed the clinical practice to ensure high-quality patient care. They developed sepsis care guidelines, protocols, order sets and procedures and conducted extensive educational programs for physicians and nurses. Springfield adopted the protocols and order set developed by the Crozer team and hosted sepsis educational programs at their site as well.
DCMH team members celebrating their award are, left to right, Judy Falcone, R.N., nurse educator; Jennifer Cummins, RN, Emergency Department staff nurse; Jerri LaRocco, RN, MSN, CNAA-BC, former assistant vice president of Patient Services; Linda Palma, R.N., CEN, CNOR, Evidence-Based Medicine program nurse; Maureen DePrince, RN, stroke coordinator; Andrea Hafer, clinical pharmacist; Patricia LaPorta, RN, clinical nurse educator; Jo-Zetta Shawl, RN, MHA, NEA-BC, assistant vice president of Patient Services; and Flossie Hogan, R.N., ICU nurse.
Linda Palma, R.N., CEN, CNOR, Evidence-Based Medicine program nurse at DCMH, says, “A multidisciplinary team of doctors, nurses, pharmacists, and lab technicians developed our guidelines, protocols and processes after reviewing evidence-based literature. We then introduced our best-practice guidelines by offering an extensive education program to all of our healthcare providers to help deliver the best care possible. We have learned through evidence-based practices that early recognition and management of sepsis can reduce mortality, improve care to these patients and decrease associated costs with length of stay.”
DCMH has decreased severe sepsis mortality by 20.2 percent in this past fiscal year as well as being below national average for three consecutive months. Jackeline Iacovella, M.D., chief of the Section of Infectious Diseases and co-chair of the DCMH Surviving Sepsis Committee, says, “Our combined efforts worked. Delaware County Memorial Hospital is now at the forefront of the management of its patients. Our patients have a better chance to survive a severe sepsis event.
“We want to provide outstanding care to our patients, to our community, to our families and friends. We are proud of the entire Delaware County Memorial Hospital staff, because with their dedication and hard work, many more of our sickest patients are now home with their families,” Iacovella adds.
Crozer team members at the VHA event included, left to right, Teresa Pisani, R.N., 1West nurse; Lucinda Scheuren, clinical pharmacist; Christine Young, coordinator of Infection Control at Crozer; Clare Povey, R.N., Shock Trauma Unit nurse; Caroline Haggerty, CKHS Evidence-Based Medicine program coordinator at Crozer; Eileen Gonzalez, R.N., Shock Trauma Unit nurse; Nancy Eisenhuth, R.N., nurse manager of the Shock Trauma Unit and Step Down Unit; Krista Burnell, R.N., nurse manager of 2 South; Angel McCullough, R.N., MBA, NEA-BC, nurse manager of the Medical Intensive Care Unit and the Cardiovascular Intensive Care Unit.
Crozer’s sepsis team developed its protocols and order set aimed at standardizing care focused on assessment and rapid treatment of sepsis in patients presenting to the Emergency Department as well as patients already in the hospital. Early recognition prompts early intervention, a hallmark of the international Surviving Sepsis Campaign. The committee created a nurse-driven protocol to facilitate early diagnosis. Crozer has decreased severe sepsis mortality by 3 percent over this past fiscal year ending in June and is 20 percent below last year in this first two months of the new fiscal year. Following Crozer’s lead, Springfield - with a much smaller patient volume - experienced an 8 percent decrease in severe sepsis mortality over the past fiscal year.
Gary Wendell, M.D., medical director of the Medical Intensive Care Unit and co-chair of the sepsis team at Crozer-Chester Medical Center, and Caroline Haggerty, CKHS Evidence-Based Medicine program coordinator and co-chair of the Crozer team, lead the sepsis initiative. Recognizing that the bedside nurse is the key to saving lives, the team created a nurse-driven protocol to facilitate early diagnosis. “Early recognition prompts early intervention, and the bedside nurse plays a critical role in both,” Haggerty says.
“Nurses are in the best position to recognize signs of sepsis because they see the patients all day every day,” notes Stephen Nelson, M.D., an Infectious Disease physician and member of the Sepsis Team at Crozer. “The protocol allows the nurse to take action without a physician order and begin running tests that provide clues to a sepsis diagnosis. Based on test results, the nurse may alert an intensivist who will intervene much earlier than in the past, before the sepsis cascade picks up steam. We are very hopeful that nurses will help us continue to reduce mortality related to sepsis just as they did in the past with C. difficile.”
Among those providing leadership on Taylor’s team are, left to right, Rosemary Connelly, RN, nurse director of Critical Care, and Pat Eckenrode, RN, nurse director of the Emergency Department.
Like DCMH and Crozer, Taylor’s multidisciplinary team has improved care efficiency and outcomes. Taylor has decreased severe sepsis mortality by 22 percent over this past fiscal year through their team efforts.
“Taylor’s Emergency Department initiated the use of CVP lines and hemodynamic monitoring in the department to guide fluid resuscitation,” says Pat Eckenrode, R.N., nurse director of the Emergency Department at Taylor and co-chair of Taylor’s sepsis committee along with Rosemary Connelly, R.N., nurse director of Critical Care. “Once we diagnose severe sepsis and begin treatment we want that patient in the ICU environment as soon as possible. Time to ICU directly impacts survivability. Through a team effort, we have already decreased the time it takes from assigning a patient a bed to transferring them to the ICU to 2.5 hours. We are continuing to work on further process improvements to attain our one-hour goal.”
Because of the commitment of the caregivers involved, Taylor was able to achieve significant results in a short time.
“We went live in February or March of this year, and by the end of the fiscal year we were able to reach our goal for the entire year in terms of reducing mortality for severe sepsis patients,” says Gregory Cuculino, M.D., chairman of the Department of Emergency Medicine and president of the Medical Staff at Taylor. “It has been an outstanding team effort.”
Crozer-Keystone representatives from all of the hospitals participated in a series of meetings with the East Coast regional office ICU network of VHA. The hospitals joined the program to learn new strategies for improving care and decreasing sepsis-related mortality.
Wendell says, “The meetings were very helpful, both in terms of bringing in speakers on topics and to interact with other people going through the same problems we were - seeing how they were taking care of the problems, and sharing our ideas. That was great stuff.”
CKHS SEPSIS BUNDLE
The first 6 hours of care
If the nurse suspects an infection, assessment should be done for two or more of the following:
- Temp ≥ 38C (110.4F) or ≤ 36.0C (96.8F)
- Heart rate ≥ 90
- Resp rate ≥ 20 or PaCO2 ≤ 2 mmHg
- WBC ≥ 12K, ≤ 4K or ≥ 10% bands
If two or more of the assessment measures are present, the nurse obtains STAT lab work per their sepsis protocol. With this information in hand, the team begins their rapid resuscitation with the goal to complete the six elements of the Resuscitation Bundle within 6 hours. The elements include:
- Serum lactate level with initial work-up.
- Blood cultures before administering antibiotics.
- Antibiotics within 3 hours of ED arrival or 1 hour of suspected diagnosis in-house.
- Fluid resuscitation of 20 ml/Kg of NSS for hypotension or serum lactate level ≥ 4mmol/L
- Vasopressors (norepinephrine or dopamine) for persistent hypotension to maintain MAP ≥65.
- Achieve and maintain CVP ≥8 within 6 hours for hypotension despite fluid resuscitation or lactate ≥4 mmol/L
CKHS SEPSIS COMMITTEE MEMBERS
Delaware County Memorial Hospital
Jackeline Iacovella, M.D., Co-chair
Tim Prestel, M.D., Co-chair
Rob Albrecht, D.O.
MaryAgnes Boyle, RN
Sharon Davies, BS MT(ASCP)
Maureen DePrince, RN
Lorraine Erieg, RN
Judy Falcone, RN BSN
Jim Fee, MHA, RT
Andrea Hafer, PharmD
Caroline Haggerty, RN
Patricia LaPorta, BSN, RN , MS, CCRN, BC
Jerri LaRocco, RN, MSN, NEA-BC
Kathy Manuel, RN
Susan McAneny, MT(ASCP)
David McCloskey, M.D.
Mary Moser-Grimes, RN
Peaches Procaccio, RN
Linda Palma, RN CEN, CNOR
Bonnie Rabinowitch, M.D.
John Reilly, D.O.
Kathleen Schwalm, RN
Michael Slavin, M.D.
Pauline Videtto, RN, BSHA
Eileen Young, MSN, RN
Crozer-Chester Medical Center
Caroline Haggerty, RN, Co-Chair
Gary Wendell, M.D., Co-chair
Krista Burnell, RN
Nancy Eisenhuth, MSN, CCRN
Beth Fuller, RN, MS, CCRN, CEN, CFRN, EMT
Eileen Gonzalez, RN, BSN, CCRN
Ali Hurwitz, M.D.
Annemarie Kennedy, RN, BSN, BA
Angel McCullough, RN, MBA, NEA-BC, CCRN
Stephen Nelson, M.D.
Bruce Nisbet, M.D.
Teresa Pisani, RN
Clare Povey, RN
Lucinda Scheuren, PharmD
Christine Young, MT, MBA, CIC
Eileen Young, MSN, RN
Rose Connelly, RN, BSN, Co-Chair
Patricia Eckenrode, RN, SANE, Co-Chair
Nicki Alessi, RN
Kathy Archacki, RN
Diane Beatty, RN, MSN, MBA, OCN
Gregory Cuculino, M.D.
Lisa Eckenrode, RN, BS, MBA
Caroline Haggerty, RN
Alisha Hartunian, RN, BSN
Stanley Josue, M.D.
Lisa King, RN
Christine Mendez, RN
Karen Simonetti, RN, BSN, CCRN
Eileen Young, MSN