On a shift last month, Elliott Larson, RN, a nurse on the Medicine Specialties Unit at University of Colorado Hospital, was caring for a recently admitted patient when he noticed changes that worried him.
Larson saw the patient’s responsiveness deteriorate. She complained of new pain and was restless and agitated. He also noticed red skin on her calves. The warning signs ultimately led to a diagnosis of sepsis, a systemic inflammatory response to infection that can lead to death if not treated quickly. It kills 258,000 people a year in the United States alone, according to the Centers for Disease Control and Prevention (CDC).
The patient was transferred to the Medical Surgical Progressive Care Unit and later to the Medical Intensive Care Unit. She eventually recovered and was discharged from the hospital.
If Larson sees a patient with similar symptoms today, he has an additional tool at his disposal to expedite care: an “Early Warning System” (EWS) new to UCH that helps providers make potentially lifesaving catches. Entering a patient’s vital signs and other information into flow sheets in the Epic electronic health record (EHR) produces a score that reflects the risk of sepsis.
If the score is high enough, a “best practice advisory” appears, alerting the nurse to order a lactate and CBC (complete blood count) test to help to confirm or rule out sepsis. If tests and blood cultures show the patient is septic, providers order fluids and antibiotics.
The EWS helps nurses to confirm their clinical observations and suspicions about a patient’s deteriorating condition, Larson said. Nurses can independently order the lactate and CBC test rather than calling a provider for it, another time saver.
“It puts a number on my otherwise subjective concerns so we can get to the next step and let the physicians get the ball rolling,” he said.
Singling out sepsis
The EWS, which launched at UCH as a pilot in the Medicine Specialties Unit in December, is part of a broad effort by UCHealth to identify patients at risk of sepsis as early as possible and administer treatment quickly to those who have it. The hospital has convened a steering committee that includes representatives from the Emergency Department, the medical/surgical and intensive care units, Pharmacy, and Clinical Excellence and Patient Safety to combat the condition, which affects patients at UCH far more often than stroke or heart attack.
“We have a core group that has set out to own sepsis,” said Nicole Huntley, RN, CNS, sepsis coordinator for UCH, who co-chairs the steering committee with Chief Quality Officer Jeff Glasheen, MD.
The primary goal of the EWS, which went into place three months ago at UCHealth Northern Colorado, is to save patients. There are a million cases a year in the United States, according to the CDC, and hospital mortality rates for severe sepsis range from 18 to 50 percent. But hospitals can save lives with quick recognition and action, said Chris McStay, MD, chief of clinical operations for the ED at UCH. He, along with Clinical Nurse Specialist Robin Scott, RN, CNS, has helped to emphasize the importance of sepsis suspicion to emergency providers. Epic also fires best practice advisories in the ED when patients meet certain criteria, McStay said.
“If we give septic patients fluids and administer antibiotics right away, we can fix a fair amount of the cases, and we can keep a good chunk of them out of the intensive care units,” said McStay, adding that a septic patient appears in the ED most every day. “The whole goal of an early warning system is to treat the condition aggressively.”
At UCHealth Northern Colorado, a diagnosis of severe sepsis triggers a “sepsis alert,” which puts pharmacists and the labs on notice that lab tests and antibiotics might be needed stat, said Elise McKnight, RN, sepsis coordinator for Medical Center of the Rockies (MCR) and Poudre Valley Hospital (PVH).
Still, the signs of sepsis can be subtle, McStay said. For example, both hypothermia and fever can be a clue to sepsis.
“Everyone is challenged to recognize it,” he said. “Sepsis is easy to miss unless we are thinking about it all the time.”
Raising the stakes
The Centers for Medicare and Medicaid Services (CMS) upped the ante for targeting sepsis by making evidence-based standards of care for the condition a core measure in October 2015. Complying with the requirements will affect hospitals’ Medicare reimbursement. That makes documenting measures like timely ordering of lactate tests in the EHR essential, Huntley said.
“We are working as a group to educate providers to make sure they know what CMS requires for documentation,” she said. The EWS creates a workflow in Epic that allows providers to document a complete medical note with the appropriate CMS measures, such as measuring lactate levels within three hours for patients with symptoms of severe sepsis, Huntley added.
Of course, the EWS will only be useful if providers use it consistently. The Medicine Specialties Unit was the logical choice to pilot the system because it sees the largest population of septic patients among UCH’s med-surg floors, said Nurse Manager Marcee Paul, RN.
“It’s one of the top 10 diagnoses we see on the unit,” she said.
The unit has always followed criteria for calling the hospital’s Medical Emergency Team (MET) when a patient becomes severely unstable, she said, but the new system helps to sharpen decision making.
“Now, rather than call the MET, our nurses are empowered to do something themselves by following the protocol in the EWS,” Zak said.
The response is similar at UCHealth Northern Colorado, McKnight said. A survey of nurses on pilot units at MCR and PVH showed that a majority find the EWS helpful in making clinical determinations about their patients and prioritizing all critically ill patients, not only those who are septic.
“They believe the tool has empowered them in their ability to talk to providers, and has been helpful in trending patients to see their improvement,” McKnight said.
The stream of data from the EWS is valuable, whether or not patients have sepsis, Danielle Justice, RN, charge nurse on the Medicine Specialties Unit, agreed.
“It gives us another tool to maintain the safety of our patients and determine how sick or unstable they are,” she said. “We can crunch the numbers and look at baselines and trends.” The acuity information, in turn, helps Justice make patient assignments that balance nurses’ workloads.
At UCH, the EWS officially launched Dec. 5 on the Medicine Specialties Unit, after a period of preparation that included input from physicians, Paul said. There were some initial concerns. For example, the unit has a large number of hepatology patients, she noted. Providers wanted to make sure that the system didn’t fire best practice advisories for patients with encephalopathy related to chronic liver disease, which can produce symptoms similar to sepsis.
“That would have created an extra workload,” Paul said. Test-run results, however, showed that the EWS did not produce a large number of advisories for those patients.
The roll-out of the EWS began in the south pod of the Medicine Specialties Unit, with Clinical Nurse Educator Madelin Adames, RN, helping to support nurses as they learned the tool. Larson was in that group and followed up two weeks of training by teaching nurses in the central and north pods of the 36-bed unit how to enter the risk-assessment data in the EHR and in what order. He also emphasized the importance of keeping a close eye on patients at risk for sepsis.
Nurses have done a good job of entering the data, he said. “Sometimes the beginning of the shift gets hectic,” he said, “and we have to get our scores caught up later in the day. We’re also getting used to having something else to do in our workflow.”
The experience is similar at MCR and PVH, said McKnight, noting that providers must take several steps in Epic to get the EWS score. “That can be hard on a busy day,” she said. Making improvements to the functionality will be important going forward, as the goal is to file the risk score one hour after taking a patient’s vital signs, she added.
These and other challenges are real, but the early returns on acceptance of the system at UCH are encouraging. Huntley pulled data one month after the EWS launch for 200 patients screened for sepsis. The compliance rate for entering scores was 95 percent, although a fair number had gaps that made them invalid, she said. But the screenings identified about 40 patients at moderate risk of sepsis, and a dozen patients at high risk for the condition. Of those 12, sepsis was ruled out for eight, but diagnosed in four. As of early January, one of those has been discharged, Huntley said.
The EWS and the campaign to raise system awareness “has become a point of conversation” on the unit, Paul concluded.
“We’ve always been good about acting quickly to help patients,” she said. “We’re now taking that to another level.”