Sepsis, the body's overwhelming and life-threatening response to an infection, is a costly condition that affects more than 1 million Americans every year and accounts for hundreds of thousands of deaths.
In 2009, sepsis was the sixth most common principal diagnosis for hospitalization in the U.S., accounting for 836,000 stays or 2.1 percent of all hospitalizations, according to the most recent national discharge data reported by the Agency for Healthcare Research and Quality. It was the single most expensive condition treated in hospitals in 2009, and aggregate costs for stays with a principal diagnosis of sepsis totaled nearly $15.4 billion, or 4.3 percent of all hospital costs.
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The prevalence of sepsis in U.S. hospitals has increased at a staggering rate. From 1993 to 2009, sepsis-related hospital stays more than doubled, according to AHRQ. Overall, hospitals saw a 153 percent increase in sepsis diagnoses with an average annual increase of 6 percent and a mortality rate of about 16 percent.
In addition to sepsis' costs and safety implications, the condition is also one for which hospitals face greater scrutiny from insurers. Sepsis is a measure in some value-based reimbursement models, such as the Value-Based Purchasing Program.
Under the fiscal year 2016 Inpatient Prospective Payment System Final Rule, the newly added Severe Sepsis and Septic Shock Early Management Bundle means hospitals providing high-quality care will receive incentive payments, while hospitals performing poorly will take a hit on reimbursement. Furthermore, private insurers will likely follow CMS' lead in looking at sepsis scores in their own value-based care contracts, according to Stacy Pur, vice president of clinical intelligence at VigiLanz Intelligence, a leading provider of software-as-a-system healthcare intelligence and predictive analytics.
The new core measure, in addition to the increasingly deadly and costly challenges sepsis imposes on hospitals, has precipitated an industrywide push to better control the condition.
A New Solution
Retroactively analyzing data and outcomes to inform future strategies fails to efficiently address the growing problem sepsis poses in hospitals. Interventions need to occur at the earliest possible opportunity to achieve optimal outcomes and prevent the most serious complications. A more proactive, preemptive strategy through the use of real-time analytics enables clinicians to treat sepsis at the earliest possible time to produce the best outcomes.
"EMRs are great for providing feedback information, but in order to move to an era of value-based purchasing and managing the population when our eyes are not on patients [in the hospital], we need the surveillance that allows us to identify opportunities to optimize care," David Goldsteen, MD, chairman and CEO of VigiLanz, said at the Becker's Hospital Review 4th Annual CEO/CFO Roundtable in November. "We ought not to miss any events that could be avoided, or miss any opportunities that could have been seized. We can't look back in retrospect to be adding those up. Those missed opportunities are real people."
VigiLanz, which currently provides clinical and business intelligence solutions to nearly 350 hospitals across the U.S., has developed a comprehensive suite of tools that addresses all sides of the current sepsis problem. VigiLanz uses targeted real-time alerting and predictive analytics to identify at-risk populations, and post-discharge population analytics and workflow automation tools to allow clinicians to efficiently identify, treat, improve and document their sepsis interventions.
VigiLanz's enterprise intelligence resources interact with and complement EMRs. The company delivers real-time, actionable insights based on a continually updated data warehouse comprised of EMR data from hospitals across the U.S. Typical EMRs, which tend to simply aggregate and organize medical information, at times allow the client to build their own simple alerts. However, EMR users often have great difficulty dealing with non-standard data or elements from disparate areas. VigiLanz's asynchronous intelligence platform and services interface in real-time with highly robust, exception-based, temporal rules and algorithms to deliver immediate clinical and business intelligence information and insights. The clinical services associated with this platform remove the burden from IT departments by rapidly deploying new alerts within the VigiLanz workflow, as part of any hospital's workflow or in a manner custom to select end-user groups
Early Intervention is Critical
"The purpose of the sepsis shock early management measure is to facilitate the efficient, effective and timely delivery of high-quality sepsis care in support of the Institute of Medicine's aims of quality improvement," says Ms. Pur.
The IOM has advised the early recognition and intervention of sepsis can reverse its inflammatory response. Treatment follows a time-based schedule, as the severity and mortality rate of the condition increases with every hour of delayed intervention.
CMS' composite process of care guidelines include a protocol for tests and treatments at the three-hour and six-hour mark after a sepsis diagnosis: Three interventions included in the guidelines (measuring lactate, obtaining blood cultures and administering broad spectrum antibiotics) should occur within the first three hours of presentation of severe sepsis, while subsequent interventions (fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion and repeating lactate measurement) should occur within six hours of presentation of septic shock.
Adhering to these timelines is critical for leveling the severity of septic shock and ultimately saving patients' lives, as well as reducing costs.
In addition to following the prescribed timetable for administering septic interventions, it is also important to address the various measures outlined by the Severe Sepsis and Septic Shock Early Management Bundle. When all aspects of a bundled or composite measure are performed collectively, it makes each of those elements more impactful than if they were performed separately, according to Ms. Pur. However, the challenge for hospitals is ensuring 100 percent compliance with the measure, because not following every indicated bundle element for each patient with septic shock constitutes an error.
"If one measure is not performed, the bundle fails," says Ms. Pur. "If there is not 100 percent compliance, there is zero compliance."
Identifying Patients at Risk for Sepsis — Right Away
Early intervention is critical for treating sepsis, but this is not easy; clinicians are challenged to identify the condition against the backdrop of the patient's existing infectious illness and comorbidities. Often, by the time sepsis is identified, it's too late to treat.
What if clinicians could identify which patients were at risk for sepsis before they even walked through the hospital doors? With predictive analytics, deriving such insight is possible. While real-time analytics enhance clinicians' ability to detect sepsis at the earliest stage possible, predictive analytics help clinicians anticipate which patients are at the greatest risk of developing the disease before they get it, according to Ms. Pur.
VigiLanz is constantly running thousands of real-time evidence-based rules to create a seamless, asynchronous umbrella over each organization to assure not only early identification of sepsis patients, but also additional alerting when key components of sepsis intervention have not been met, or have changed. A classic example is confirming not only that a broad spectrum antibiotic has been ordered, but also assuring that the right antibiotic has been selected.
Today's sepsis challenges include a component of mandated reporting using concurrent review of the severe sepsis core measure. Automation is an integral component of streamlined concurrent review workflows. VigiLanz incorporates a high degree of automation not only around required elements for reporting, but also related to collecting data for special populations, intervention opportunities and analytical elements such as morbidity. "Automating the collection of sepsis-related data as much as possible eliminates the amount of [manual] abstraction needed," says Ms. Pur.
Fighting Sepsis Requires Cultural Buy-In
It is important to note that not all hospitals are alike, so when considering a new approach for combating sepsis, both hospitals and their third-party partners must keep culture, clinical workflow and business operations in mind.
Cultural buy-in is a critical predictor of the success of any new initiative, as is physician trust. When taking an analytical approach to fight sepsis, clinical deficiencies may be exposed, but such areas of weakness present opportunities for learning. Enemies to cultural buy in include over-alerting and data gaps.
"Because VigiLanz is able to leverage many disparate elements of the patient's electronic chart and work easily with data gaps and non-standardization issues, we are able to customize performance improvement efforts to the specific needs of individual hospital systems across the continuum of care," says Ms. Pur.
Conclusion
The fact alone that the number of people dying of sepsis in hospitals is rising is indication enough that the U.S. healthcare system is in great need of change regarding sepsis diagnosis and intervention. Furthermore, hospitals' financial health is on the line if they are unable to manage the problem effectively. With the new CMS bundle tying sepsis treatment to reimbursement, this financial impetus is even greater.
As technology evolves and clinicians' and operations managers' capacity for using data insights proactively — instead of retrospectively — increases, hospitals can be empowered to take control and gain an edge in the fight against sepsis. With targeted real-time alerting, workflow automation and predictive analytics, clinicians can fulfill the IOM's guidelines for early and timely intervention as effectively as possible.