Each year in the U.S. sepsis is responsible for more than 1 million hospital admissions costing more than $20 billion and 200,000 deaths.1,2 It’s the most expensive condition treated in U.S. hospitals and has been a target for improvement for many years. With continued rising volumes, worsening outcomes and increasingly higher costs, it’s no surprise that the Centers for Medicare and Medicaid Services (CMS) has prioritized sepsis for improvement.
Effective October 1, 2015, CMS will enforce its new bundle measure for severe sepsis and septic shock as part of the Hospital Inpatient Quality Reporting (Hospital IQR) program. The new bundle is based on two time periods: the first three hours of diagnosis and six hours of diagnosis. The clock starts as soon as presumed or confirmed severe sepsis is documented by diagnosis or criteria are met.
Will the new measure affect sepsis outcomes?
Early identification is key
Who are sepsis patients? Where do they come from? How do we identify them? Across the board, the vast majority of patients with sepsis enter through the emergency department, so are admitted with it. Patients are often admitted with vague symptoms: weakness, fatigue, nausea and vomiting combined with a source of infection that is not readily apparent. The longer it takes to identify a septic patient, the longer the delay before he or she receives antibiotic treatment, thereby increasing the risk of mortality.
The Systemic Inflammatory Response Syndrome (SIRS) criteria, created by the American College of Chest Physicians and the Society of Critical Care Medicine in 1992, was designed to define a clinical response to a non-specific insult of either an infectious or non-infectious origin. The criteria helps identify sepsis patients on admission. Emergency departments should use a sepsis screening tool as part of triage assessment. Ensuring clinicians and providers are educated and equipped to screen and recognize patients for early warning signs of sepsis is the crucial first step.
Evidence-based care saves lives
With a laser focus on identifying and accurately diagnosing septic patients, what’s next?
Appropriate treatment. The new CMS measure aligns with the Surviving Sepsis Campaign guidelines and requires measuring the lactate level, obtaining blood cultures, and administering antibiotics and intravenous fluid bolus within the first three hours of presentation of sepsis.
In addition, there are three requirements to be completed within six hours of presentation:
- Reassessment of the patient’s volume status and tissue perfusion within an hour after initial IV fluid bolus administration;
- Administration of vasopressors for hypotension that does not resolve after initial IV fluid bolus; and
- Repeat lactate measurement if initial lactate is elevated.
Timelines for initiating and ordering diagnostics, administering appropriate treatments and following up are essential to improving outcomes. Every hour of delay in administering antibiotics from hypotension increases the risk of mortality by 7 percent.3
Not everyone likes change, but sometimes it’s essential. Adhering to the sepsis bundles and CMS’ measures using evidence-based care will improve sepsis outcomes. Creating a culture of change and standardization starts at the top. Leadership must create a culture of accountability to adhere to the sepsis protocol.
The best way to know if you are adhering to protocol is to measure it. Data does not lie. In fact, data will reveal your opportunities in complying with best practice. Triage, early resuscitation and ongoing management are all areas where sepsis requires this coordinated care.
Proactive, not reactive
If septic patients are treated successfully and discharged, you’re done, right? Not necessarily. Readmissions of septic patients are increasing. A 2011 study in three states found 26 percent of the severe sepsis survivors returned to the hospital within 30 days. Even worse, nearly half returned within 180 days4. These readmitted patients are commonly associated with increased mortality (6 percent in the study expired) and added cost burdens.
Why are septic patients readmitted? Ongoing follow-up care is often overlooked. It can be as important as the acute treatment. Historical data can shed light on many things including age demographics and discharge location. Working with your community can help improve ongoing support for patients and reduce your readmissions.
Shannon Adler wrote, “The lesson will always repeat itself, unless you see yourself as the problem – not others.” What is your health system doing to prepare for the upcoming release of CMS’ new sepsis measure? What have you been doing to improve sepsis outcomes? Share your successes and struggles below and/or visit Premier’s quality page for more information.
- Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Statistical Brief No. 160 August 2013.National inpatient hospital costs: the most expensive conditions by payer, 2011 [PDF, 142KB].
- World Sepsis Day: Sepsis Fact Sheet. Center for Sepsis Control & Care 2015.
- Kumar A, Roberts D, Wood KE, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589–1596.
- Goodwin A MD, Rice D MD, Simpson K Dr PH, Ford D MD: Frequency, Cost, and Risk Factors of Readmissions Among Severe Sepsis Survivors. Crit Care Med 2015; 43:738 – 746.