Clinical Review

Early Recognition: The Rate-Limiting Step to Quality Care for Severe Sepsis Patients in the Emergency Department

Journal of Clinical Outcomes Management. 2015 May;22(5)

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While attractive conceptually, large-scale implementation of this movement is unlikely to occur outside of tertiary care academic medical centers. In the many EDs across the US without ED intensivists, and confronted with limited clinician resources, flexible physician and nursing staffing models will be necessary to ensure that care provisions are in accord with established guidelines. Potential solutions to provide the resources to meet the needs of these high-intensity patients include critical care consultation and a strategy traditionally applied to the ICU, telemedicine [58]. Last, given the relationship between hospital volume and mortality in severe sepsis [59,60], timely transfer to a high-volume center for specific cases may be appropriate, although the optimal timing, case selection, and impact of transfer on outcomes warrant further examination.

Clinical Decision Support Strategies

To complement the identification and risk-stratification available by screening and scoring systems, clinical decision support systems are novel tools to improve outcomes in the era of electronic medical records (EMR). Specific to sepsis care delivery, performance improvement initiatives including audit-and-feedback practice can increase severe sepsis guideline adherence, and even modest improvements in adherence appear to lead to sustained improvements that contributed to a 25% relative risk reduction in the observed mortality rate [61,62]. Clinical decision support tools can be used to link early recognition to optimal care processes, such as the Surviving Sepsis Campaign resuscitation and management bundles. The use of prompts as strategies to ensure that bundles of care are ordered and carried out is an important aspect to operationalize during the design phase [63].

Significant preparation is required to effectively carry out the clinical decision support design strategy. For example, to ensure timely antibiotic dispensing, a number of process steps will be required, including prompt notification to a central pharmacist or preferably, an ED pharmacist with access to a local pharmacy pre-stocked with commonly used antibiotics [64]. In addition, the use of an institution-specific antibiogram within the physician computer-order entry sepsis order set, that includes site-specific recommendations (eg, pulmonary, gastrointestinal source) and susceptibility patterns, is an essential aspect of optimal sepsis processes of care. Last, the antibiogram will need to be frequently updated to include season-specific (eg, oseltamivir administration for high-risk cases during influenza season) recommendations to ensure that providers are prompted with the most up-to-date clinical information.

Audit and Feedback and Continuous Performance Improvement

The multimodal approach required to translate knowledge (eg, guidelines) into sepsis care implemented at the bedside is an iterative process. An ED armed with a robust track-and-trigger system and an effective efferent arm, including sophisticated clinical decision support strategies, will require frequent auditing in the plan-do-study-act model of quality improvement to yield clinical effectiveness [61,62,65]. Auditing, paired with feedback to frontline providers, is essential to refine and improve the complex process required to provide expert care to the septic patient [29,65]. Sustained success in optimizing sepsis care delivery is the goal, yet significant work is required to determine the best strategies to achieve this endpoint.

Conclusion

Severe sepsis affects millions of individuals each year in the United States. Delays in recognition result in increased morbidity and mortality, at a tremendous cost to the patient and society. By designing strategies to identify sepsis in a timely, efficient, and effective manner, and by implementing ED structures and processes to increase adherence with sepsis-based guidelines, improved patient-centered outcomes can be realized.