Reducing Inpatient Adult Severe Sepsis and Septic Shock Mortality: A Quality Improvement Project

Purpose:
The objective of this quality improvement project was to reduce adult inpatient sepsis mortality and associated length of stay by implementing standardized processes for early recognition and treatment of severe sepsis and septic shock in the emergency department.

Relevance/Significance:
In the United States sepsis contributes to 570,000 emergency department visits costing $20 billion annually. Patients with severe sepsis or septic shock are known to have higher hospital mortality rates resulting from delayed provider recognition of signs and symptoms of sepsis. As a primary cause of infection related deaths, sepsis continues to be one of the top ten causes of death in the U.S. with 25% to 50% mortality rates and one of the most expensive diseases treated in the U.S.

Strategy and Implementation:
In a non-profit community based hospital three root causes of sepsis mortality were addressed: (a) provider and staff knowledge base, (b) delayed recognition of signs and symptoms of sepsis, and (c) lack of standardized sepsis treatment. The goals were to reduce inpatient sepsis mortality by 25% and length of stay by 10% in a 12 month period; January to December, 2014. A pre and post group quality improvement design was used. Adults >18 years old admitted through the emergency department with a primary or secondary discharge diagnosis of sepsis were included. Interventions included sepsis screening during triage and the use of an electronic sepsis order set with sepsis bundle interventions (i.e. serum lactate, blood cultures drawn prior to antibiotics, broad spectrum antibiotic administration, and fluid resuscitation). Retrospective data was collected; categorical data was analyzed using Fisher's Exact test and two sample independent t-test was used to analyze continuous variables.

Evaluation:
Pre-intervention group (n=223), post-intervention group (n=427). Adult inpatient sepsis mortality decreased from 12% to 8% (OR = 1.51, z = 1.48, p < 0.139; 95% CI [0.87, 2.61]. Length of stay decreased from 6.5 (M = 6.25, SD = 4.76) to 5.23 days (M = 5.23, SD = 4.63); t (648) = 2.32, p =0.021. Sepsis bundle intervention compliance showed a small improvement; 47% to 50%.

Implications for Practice:
Appropriate and timely sepsis screening may improve time to treatment; reducing sepsis mortality and length of stay. Improved adherence to treatment algorithms and sepsis bundles was found to be essential to successfully achieve sepsis core measure requirements and improved patient outcomes.