Heart & Lung 43 (2014) 546e549

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Heart & Lung journal homepage: www.heartandlung.org

Care of Patients in Acute and Critical Care Settings

The impact of an electronic medical record surveillance program on outcomes for patients with sepsis Laura McRee, DNP, ACNP-BC, RNFA a, b, *, Joanne L. Thanavaro, DNP, ANP-BC, GNP-BC, AGACNP-BC, DCC, FAANP b, Karen Moore, DNP, APRN, ANP-BC b, Melissa Goldsmith, PhD, RN a, Alice Pasvogel, PhD, RN a a b

University of Arizona, Tucson, AZ, USA St. Louis University School of Nursing, St. Louis, MO, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 3 February 2014 Received in revised form 12 May 2014 Accepted 13 May 2014 Available online 21 June 2014

Objectives: To evaluate the effects of this EMR surveillance on sepsis, severe sepsis or septic shock outcomes in patients admitted to a medical telemetry unit, including length of hospital stay, patient discharge and mortality. Methods: A retrospective review of pre- and post-implementation of a pilot electronic medical record (EMR) sepsis surveillance. Results: Implementing EMR sepsis surveillance significantly improved home discharge (49.0% versus 25.3%, p < .05) and reduced hospital mortality (1.0% versus 9.3%, p < .05). Although there was no difference in the length of hospital stay for the whole group, patients in the surveillance group who triggered an alert on the EMR surveillance had a decreased length of hospital stay compared to those without an alert (7.2  4.2 versus 11.6  9.4 days, p < .05). Conclusion: These results offer promising evidence that the use of an EMR sepsis surveillance alert could decrease the ravishing effects of sepsis, severe sepsis and septic shock by early identification and treatment. Ó 2014 Elsevier Inc. All rights reserved.

Keywords: Sepsis Electronic medical record Sepsis campaign Sepsis surveillance Mortality

Introduction Sepsis presents as a systemic inflammatory response of infection caused by bacterial, viral or fungal invasion in the body. Sepsis is associated with a high incidence of morbidity and mortality, which may be improved with appropriate strategies for monitoring, timely recognition and early targeted intervention.1 The incidence of sepsis continues to increase, occurring in approximately 2% of all hospitalizations and even higher in all intensive care unit (ICU) patients (6e30%).2 Three stages of sepsis have been described which includes: sepsis, severe sepsis and septic shock. Sepsis includes: signs and symptoms of infection (SSI), elevated white blood count, fever and a suspected infection. Severe sepsis includes: SSI, infection and signs of tissue hypoperfusion and organ dysfunction. Septic shock includes: SSI, infection, organ dysfunction and circulatory collapse despite fluid resuscitation and vasoactive agents to support blood pressure.1

* Corresponding author. 1305 North Martin St., Tucson, AZ 85721, USA. Tel.: þ1 520 332 3695. E-mail address: [email protected] (L. McRee). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2014.05.009

Approximately 750,000 cases of severe sepsis from an infectious process are diagnosed in the United States each year.3,4 The Institutes of Health reported mortality rates of 30e50% associated with severe sepsis. Azevedo and associates characterize septic shock as the most severe form of shock associated with refractory hypotension and mortality rates reported to be as high as 50e60%.5 It remains one of the main causes of mortality in ICU. Once signs of sepsis and severe sepsis are identified, research has supported that early intervention decreases mortality.6 In an attempt to reduce the devastation and mortality of severe sepsis and septic shock, the Surviving Sepsis Campaign (SSC) was organized by professionals from international, multi-organizational, multidisciplinary groups and they concluded that early goal directed therapy was imperative in treating sepsis in order to prevent mortality related to severe sepsis and septic shock.7 The SSC and the Institute of Healthcare Improvement developed guidelines, often referred to as sepsis bundles that aim to build awareness of sepsis, improve diagnosis, increase the use of appropriate treatment, educate health care professionals, improve postICU care, develop guidelines for care and facilitate data collection for the purposes of audit and feedback.8 The sepsis bundles are specific regarding time intervals of sepsis identification and

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recommended treatments. The bundle is a set of evidence-based treatments that is structured with specific assessments and interventions to improve patient care and outcomes.9,10 For patients with severe sepsis or septic shock, elements of the sepsis resuscitation bundle improve outcomes when they are implemented within the first 6 h of identifying the diagnoses.9 Funk and associates reported that a patient who is septic may initially present with only subtle symptoms and be admitted to a medical unit for less intensive observation.11 A continuous systematic monitoring program is required to triage a patient to a higher level of care or immediate intervention once symptoms begin to comprise the patient’s hemodynamic status. Continuous monitoring is needed to prevent the ravishing complications associated with severe sepsis or septic shock. The critical factor in improving sepsis outcomes is early identification and treatment. The detrimental contribution of the delayed sepsis identification and lack of trained staff in ICU to mortality has been demonstrated.12 Based on the literature early goal directed therapy is key to reduction of the devastating mortality rate.13e15 Education with respect to recognition and decision making in identifying and treating patients with sepsis in a timely manner is imperative. Nguyen et al studied a cohort of medical students at various levels providing simulated scenarios, workshops and lectures on septic shock.13 Following two weeks of intensive simulated training, a significant improvement in how the students managed patients in septic shock was reported. Puskarich and associates reported a significantly decreased mortality from severe sepsis/septic shock after one year of implementing a program which provided early identification and goal directed treatment for severe sepsis and septic shock.16 The Electronic Medical Record (EMR) may be used to alert the clinician when patients are demonstrating signs of sepsis progressing to a more severe stage. The use of technology such as the EMR and critical alert systems are in the beginning phases of development although a high specificity EMR alert of severe sepsis (80.1%) has been reported.17 The success of reducing mortality from septic shock is complex. This will be achieved not only through EMR alert systems but through training of medical and nursing staff.14 When sepsis surveillance and treatment programs are implemented, significant improvement in outcomes associated with sepsis/septic shock has been demonstrated. The use of EMR is able to provide immediate communication and alerts to the health care team. The purpose of this study was to evaluate the effects implementing EMR sepsis surveillance on length of hospital stay, hospital discharge and mortality. Methods Design A retrospective chart review of patients diagnosed with sepsis, severe sepsis and septic shock, based on the International classification of diseases diagnostic coding ninth revision (ICD-9) codes of 995.91 sepsis, 995.2 severe sepsis and 785.52 septic shock. Approval for the retrospective records review was obtained from the Institutional Review Board of the participating institutions. Sample Medical records of patients admitted to an adult medical telemetry unit with the diagnoses of sepsis, severe sepsis and septic shock were reviewed. The following information was extracted from the medical record: age, gender, co-morbidities, length of stay, and discharge outcome (home, intermediary care and death). Data

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were transcribed on to data collection forms; they were entered twice into two separate Statistical Package for the Social Sciences (SPSS) files and compared to identify inconsistencies. They were checked against the data collection forms for entry errors and data cleaning was accomplished using measures of frequency to check for missing entries. The sample was divided into two groups based on the time of EMR sepsis surveillance implementation: six months prior to implementation and six months after implementation of EMR sepsis surveillance. Prior to implementing the EMR sepsis surveillance, the intensive care unit was the only unit which had a sepsis protocol. There was no sepsis treatment protocol for patients admitted directly to the adult telemetry unit. Patients were treated based upon the decisions of the attending physician including obtaining blood cultures and lactic acid serum levels, intravenous fluid resuscitation, empiric antibiotic administration, antipyretics and vasopressors if needed. The following protocol was employed for EMR sepsis surveillance for patients admitted directly to the telemetry unit. The presence of two of the following criteria of systemic inflammatory response of infection including: fever >38.0  C or hypothermia 90 beats/minute, tachypnea >20 breaths/ minute, leukocytosis >12/L or leukopenia 90 (70.5  16.5)

30 to >90 (69.9  14.1).

48 (64.0%) 27 (36.0%)

57 (59.4%) 39 (40.6%)

27 (36.0%) 22 (29.3%) 26 (34.7%) 5.53  2.5 8.5  6

39 (40.6%) 36 (37.5%) 21 (21.9%) 5.09  2.4 8.7  6

68 (90.7%) 7 (9.3%)

95 (99.0%) 1 (1.0%)

19 (25.3%) 49 (65.3%) 7 (9.3%)

47 (49.0%) 48 (50.0%) 1 (1.0%)

process in which early recognition and consistent application of evidence-based practices are implemented. The severe sepsis bundles are a progression of assessment and treatments when implemented together, achieve improved outcomes than when implemented individually.9 Implementing the EMR sepsis surveillance in this study significantly improved sepsis treatment outcomes which lead to more patients returning home and decreased mortality. In addition fewer had to be transitionally discharged to other health care facilities. These findings are similar to other studies that demonstrate early identification and goal directed treatment for severe sepsis and septic shock significantly decreased mortality.7,9,16 Although the EMR sepsis surveillance did not improve length of hospital stay for the whole group; those patients who triggered an alert had a significantly shorter length of hospital stay. The overall results of this study provide evidences that an interdisciplinary team communicating with the use of the EMR sepsis alert to identify and manage patients with sepsis is an effective approach to clinical practice decisions. Patients in the pre-implementation group had less severe sepsis and more septic shock. These findings imply two possibilities. First, patients in the pre-implementation group were sicker at the onset of the admission which naturally is expected to lead to poor outcomes regardless of the time or types of treatment. On the other hand it is possible that the EMR surveillance identified patients with severe sepsis earlier and the treatment was initiated promptly to avoid further clinical deterioration from severe sepsis to septic shock as it was intended to. This would substantiate other studies that early goal directed therapy improves sepsis outcomes.7,9 The current retrospective analysis lacks information to differentiate between these two possibilities and future prospective study will help clarifying this dilemma. Clinical significance and limitations This study provides evidence that early identification and treatment of sepsis, severe sepsis and septic shock decreases mortality and length of stay. An interdisciplinary team in conjunction with the use of the EMR sepsis alert is an effective approach to improve sepsis treatment outcomes. The limitations of this study are that it was a retrospective chart review study that lacked detail on admitting diagnosis severity. The study was implemented and conducted in only one hospital and the guidelines for following a timed course of treatment based on the IHI guidelines was not offered except in the Intensive Care Unit in which a sepsis bundle order set is established. There was only one chart reviewer which is a limitation to this study in regards to establishing inter-rater reliability of the data collected. Recommendations Future research should include other important factors such as types of organisms causing the sepsis, lactic acid levels, antibiotics used and prodromal symptoms and list. The initial diagnosis severity should be clearly documented. Evaluating EMR sepsis surveillance in multiple care sites and a study in which the EMR sepsis surveillance is introduced first in the emergency department are needed because the emergency department is an important initial point of care for patients with sepsis and identifying these patients early at their presentation is imperative to improve patient outcomes. Conclusions The goal of implementing EMR sepsis surveillance is to promote early sepsis identification and to promptly initiate goal

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directed therapy as recommended by the SSC and the Institute of Healthcare Improvement. Implementing EMR sepsis surveillance significant improves patient outcomes including length of hospital stay, home discharge and mortality. These results offer promising implications to how the use of an EMR sepsis surveillance alert contributes to decreasing the ravishing effects of all types of sepsis.

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8. Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36(1):296e327. 9. Stoneking L, Denninghoff K, DeLuca L, Keim S, Munger B. Sepsis bundles and compliance with clinical guidelines. J Intensive Care Med. 2011;26: 172e182. 10. Rivers E, Ahrens T. Improving outcomes for severe sepsis and septic shock: tools for early identification of at risk patients and treatment protocol implementation. Crit Care Clin. 2008;23:1e47. 11. Funk D, Sebat F, Kumar A. A systems approach to the early recognition and rapid administration of best practice therapy in sepsis and septic shock. Curr Opin Crit Care. 2009;15:301e307. 12. Salluh J, Bozza P, Bozza F. Surviving sepsis campaign: a critical reappraisal. Shock. 2008;3:70e72. 13. Nguyen H, Underwood L, Ginkel C, et al. An educational course including medical simulation for early goal directed therapy and the severe sepsis resuscitation bundle: an evaluation for medical student training. Resuscitation. 2008;80:674e679. 14. Compilation J. Sepsis bundles: time for a nursing initiative? British Association of Critical Care Nurses. Nurs Crit Care. 2009;14:161e165. 15. Ferrer R, Artigas A, Suarez D, et al. Effectiveness of treatments for severe sepsis. Am J Respir Care Med. 2009;180:861e866. 16. Puskarich M, Marchick M, Kline J, Steuerwald M, Jones A. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care. 2009;13:167e173. 17. Gerald J, Alsip J, Hicks J, Waldrum M, Dunlap N. Using the EMR to perform continuous real-time surveillance to identify hospitalized patients at risk for sepsis. Chest; 2011:426. 18. Campion, M. Hospital charges surge for treating severe sepsis, but reasons unclear. Anesthesiology News. 36:7.

The impact of an electronic medical record surveillance program on outcomes for patients with sepsis.

To evaluate the effects of this EMR surveillance on sepsis, severe sepsis or septic shock outcomes in patients admitted to a medical telemetry unit, i...
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