One of every three patients who dies in the hospital has sepsis. The life-threatening response to infection is difficult to detect in its earliest stages, and every hour the condition goes untreated increases a patient's mortality risk by 4%.

Currently, the University of Missouri Health System – with five hospitals with 602 beds in total – is using three Cerner technologies in an effort to better identify and treat sepsis: St. John Sepsis Agent/Sepsis Advisor, Pediatric Sepsis Algorithms and the Rapid Response tool.

"The Sepsis Algorithms and Advisor do a fantastic job at identifying and assisting with the treatment of patients who already are septic," explained Benjamin Wax, RN, senior clinical informaticist on the Cerner Applications Team at the Tiger Institute for Health Innovation at the University of Missouri. 

"Cerner's Rapid Response Solution, however, helps to identify subtle signs of patient deterioration, which can be indicative of not only cardiac and respiratory distress, but also of the initial onset of sepsis," he said.

The Rapid Response Solution enables clinicians to intervene earlier, and the earlier that sepsis is identified, and that treatment is provided, the higher the likelihood that there will be a positive outcome.

"When a rapid response team is called on a patient, a team of providers, including experienced physicians, nurses and respiratory therapists, comes to the bedside to immediately assess the patient's condition, with the goal being to treat and prevent the patient from deteriorating further," Wax explained. 

"This has been the key to the University of Missouri's recent success – the implementation of the Rapid Response Solution and its integration into the existing sepsis solutions."

THE PROBLEM

The University of Missouri Hospital is an academic teaching hospital with a large number of resident physicians and interns. Additionally, a significant portion of the nursing staff has less than two to three years of experience.

"Prior to turning to Cerner's Rapid Response Solution, patients at risk of clinical decline due to cardiac/respiratory distress or sepsis were identified through subjective and individual assessment of the patient's current risk," Wax noted. 

"Early signs of clinical deterioration often are very subtle and difficult to recognize, especially for a relatively new and inexperienced staff. The decision-making process used by nursing to determine whether or not to notify the rapid response team was not standardized, nor was the physician response to nursing when a concern about potential deterioration was raised."

This manual assessment and process created an environment in which the services of the rapid response team (known as the Tiger Team at the University of Missouri) often were underutilized or delayed due to the different skill, comfort and knowledge levels of nursing and physician staff. 

Non-ICU code blue activations without prior activation of the rapid response team demonstrated that the utilization rate for the rapid response team at this time was suboptimal.

"Additionally, all of the rapid response team and code blue documentation was completed on paper and scanned into the patient chart by medical records staff well after the event had occurred," Wax said.

"This paper process made it difficult to measure and track the multiple components of the rapid response team response. Without the ability to accurately measure the rapid response team response, it is very difficult to identify what needs to improve."

PROPOSAL

The Cerner Rapid Response solution was proposed as an ideal way to address the university's challenges related to the early recognition of patient deterioration. 

Intended to both supplement and integrate with the existing St. John's Sepsis and Sepsis Advisor solutions, the Rapid Response Solution would use industry-recognized early warning tools such as the National Early Warning Score (NEWS) and the Pediatric Early Warning Score (PEWS) to assist with the identification of patients in clinical distress.

"These scoring systems form the core of the Rapid Response Solution and provide the clinician with an empirical piece of data that can be used to determine a patient's risk for clinical decline based on commonly tracked vital signs," Wax explained. 

"Point values are assigned to abnormal vital signs. The higher the score, the higher the risk for clinical deterioration or mortality. These scores serve as warning signs to prompt earlier intervention and multiple scores can demonstrate trends of potential deterioration over time."

The Rapid Response Solution also would enable the University of Missouri Hospital staff to automate the surveillance of high-risk populations through the use of clinical algorithms based on the NEWS/PEWS and optimize rapid response team utilization with targeted, real-time clinician alerts.

The automated decision support would inform clinicians and care teams and activate the rapid response team to intervene earlier in order to contribute to a reduction of mortality and morbidity. Moreover, it would help to establish a standardized workflow for clinicians to deliver expert care.

"Cerner's Rapid Response solution also would expand our ability to measure both the effectiveness and impact of the rapid response team through reporting," Wax said. "The automated reporting available through the Rapid Response Solution would equip the Clinical Decline Committee, for example, to focus on projects related to improving rapid response practices."

Automated reporting would provide metrics, including rapid response team activation to bedside, length of stay post-rapid response team event, mortality post-rapid response team event and others.

"This paper process made it difficult to measure and track the multiple components of the rapid response team response. Without the ability to accurately measure the rapid response team response, it is very difficult to identify what needs to improve."

Benjamin Wax, RN, Tiger Institute for Health Innovation at the University of Missouri

"Also included with this solution was a rapid response team dashboard and a population-based MPage view that would be embedded directly into PowerChart," Wax noted. 

"This dashboard would assist the rapid response team, the house manager and STAT nurses with the monitoring and care of patients, and would give them the ability to stratify patients based on clinical severity. Furthermore, this dashboard would provide us with the ability to identify clinical decline based on objective criteria and optimize the experience levels of staff caring for them."

MARKETPLACE

There are many vendors with electronic health records systems on the health IT market, including Allscripts, athenahealth, Cerner, DrChrono, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.

MEETING THE CHALLENGE

The rollout of Cerner's Rapid Response Solution at the University of Missouri Health System was completed over several phases spanning nearly three years.

For the first two years, starting in August 2017, the NEWS algorithm ran silently in the background without sending alerts. Staff spent this time working with the project's physician champion, Catherine Jones, MD, and two Cerner consultants, Chris Fitzgibbon and Erin Hoemann, fine-tuning and customizing the NEWS algorithm to ensure that it was as accurate as possible.

In March 2018, at the request of Jones, staff made the NEWS scores visible to the internal medicine providers, who used them to both assist in determining the proper level of care for patients upon admission as well as for prioritizing their daily rounding.

"We took the alerting component of the Rapid Response Solution live in March 2019 at the University Hospital, our adult facility," Wax recalled. "A NEWS score was calculated automatically on each patient every time the nursing staff documented a patient's vital signs. While a full set of vitals was necessary for the initial score to be calculated, a fresh score would be generated every time an individual parameter was modified going forward."

Based on data accumulated during the prior two years, taking into account the average score of patients on a given unit, the scores that would typically warrant rapid response team intervention or result in a transfer to an intensive care unit, we stratified the scores into four categories (Low, Moderate, High and Very High).

"Once these NEWS thresholds had been identified, we were able to design a preemptive NEWS-Driven Nursing Protocol that provided the nursing staff with a set of tools and a standardized approach for responding to patients in clinical decline," Wax explained. 

"Notification of the rapid response team would occur automatically based on the NEWS scores or when a provider was unable to be at the patient's bedside within 15 minutes of being notified by the nursing staff."

The NEWS-Driven Nursing Protocol also included a set of labs and diagnostics that the nursing staff had the ability to order prior to the arrival of the rapid response team that are intended to help the clinicians identify the cause of the clinical decline. 

Along with the NEWS-Driven Nursing Protocol, a Sepsis Differential Diagnosis Quick Guide was developed to assist the rapid response team with ruling out sepsis when evaluating patients with elevated NEWS scores.

"The NEWS alerts received by the nursing staff replaced the SIRS alerts that the clinical staff had been receiving, integrating seamlessly into the existing sepsis solution," Wax said. "When a patient's vital signs trigger the NEWS alert to fire, two things happen. First, the unit's charge nurse/nursing supervisor is notified through the Ascom phones that they carry that either a High or Very High alert has been triggered in their unit."

The charge nurses/nursing supervisors typically are the unit's more experienced staff and are able to serve as a resource for the other nurses in the unit. The patient's primary nurse also receives a Discern pop-up alert within PowerChart, providing them with the vitals that triggered the alert to fire.

"From the alert itself, nursing is able to document another set of vitals to confirm that the alert is accurate," Wax said. "They also are able to access a PowerForm directly from the alert that allows them to document the actions they have taken, order any appropriate labs/diagnostics from the NEWS-Driven Nursing Protocol, and contact the rapid response team."

While physicians do not receive these same Discern pop-up alerts for elevated NEWS scores, they do receive a less intrusive SmartZone notification within the patient's chart signaling that their NEWS is either High or Very High. Providers also will see the same kind of SmartZone notification in a patient's chart when a rapid response team has been called on the patient.

By clicking on these alerts, the provider will automatically be taken to the results flowsheets within the patient's chart where they can see the vitals that triggered the alert, the actions documented by the nursing staff, and any interventions taken by the rapid response team.

"In the spring and summer of 2020, we began work on the next phase of the Rapid Response project, the rollout of Cerner's Pediatric Sepsis Algorithm/Alert and the PEWS scores at the University of Missouri's Women's and Children's Hospital," Wax said. 

"Due to the overlap of the Sepsis and Rapid Response Solutions, we worked on the pediatric sepsis algorithms and PEWS algorithms concurrently, going live with both solutions at the same time in September 2020."

While the pediatric versions function similarly to their adult counterparts, the algorithms that calculate the scores and fire the alerts are significantly more complex and are stratified by patient age, he added.

RESULTS

The University of Missouri Health System has seen some exceptional results, particularly around the volume of rapid response team calls on general floors, code blue calls on general floors, and overall mortality index (O:E).

"Initially our rapid response team calls were lower than we would anticipate for a facility our size with code blue calls being higher than we would prefer, averaging around eight a month on general floors," said Mason Crawford, RN, performance improvement coordinator at MU Health Care. 

"By implementing standardized NEWS responses on the general floors including automatic calling of rapid response teams with Very High (11-20) scores, we have seen the rapid response team and code blue volumes change drastically.

"Rapid response team calls on general floors were initially 3.46/1000 PD," he continued. "But after implementation of the NEWS algorithm for frontline nursing staff, we have seen that number climb to as high as 7.3/1000 PD. Our initial goal of a 25% increase (4.3/1000 PD) was overshot significantly. This cannot be attributed completely to the standardization of automatic calls from frontline staff since there aren't that many Very High alerts occurring."

But the fact that NEWS at even a Moderate (5-7) or High (7-10) brings closer attention to the patient early results in earlier intervention including rapid response team calls in what would have previously been a code blue call.

"Code blues have seen an inverse effect," Crawford noted. "Moving from an average of eight calls per month on general floors to only 1-2. We saw 1.17/1000 PD initially and have now exceeded our goal of a 25% reduction (0.88/1000 PD) to 0.33/1000 PD. With regard to sepsis in particular, we have increased proactive sepsis-related rapid response calls 63% while decreasing the code blue calls 40%.

"Along with this, we have seen considerable movement in the overall 'Mortality Observed: Expected,'" he continued. "Initially, the baseline was 0.92 with a goal of the top quartile when compared to other Vizient Academic Medical Centers (0.8). However, we have been able to achieve a sustained mortality rate near 0.60 for several months."

Staff were able to reduce the sepsis mortality index by 22% and avoided an estimated 12 sepsis-related deaths within the first nine months of the solution going live. This cannot be solely attributed to NEWS, but it is a major factor. By using NEWS as the initial warning for clinical decline, frontline staff have been able to get the right attention, to the right patient, at the right time.

"This is resulting in better patient outcomes and anecdotally increased staff satisfaction with the care they are able to provide," Crawford said. "Patients that used to be coded are now only requiring the rapid response team and are able to stay in floor beds more often. We have seen reduced patient transfers from general floors to ICU. Initially there were 14.65/1000 PD, but we have seen that number drop to 12.1/1000 PD."

Patients are not requiring higher levels of care and are being treated in place effectively because staff are able to identify clinical decline early enough to intervene. It has allowed staff to become proactive rather than reactive and that is helping ensure the highest quality of care, he added.

ADVICE FOR OTHERS

"Our experience with the sepsis and rapid response solutions has taught us a number of things," Wax noted. "As demonstrated by our experience, these solutions have significant overlap. While the NEWS scores are intended to identify clinical decline from any number of medical conditions, they excel at recognizing the early onset of sepsis."

It was for this reason that the University of Missouri Health System rolled out the pediatric sepsis and PEWS alerting concurrently at the pediatric facility.

"We would strongly recommend that any facility pursuing a sepsis identification/alerting system also invest in a rapid response solution at the same time," Wax advised. "While it is important to know which patients are septic, early recognition and intervention are absolutely critical and are the key to a successful and comprehensive solution.

"We also found it tremendously beneficial to use the rapid response solution and the structure and standardization it provides to assist in the development of a nursing protocol and sepsis differential diagnosis tool," he continued. 

"Our nursing staff has been empowered to address the time critical nature of sepsis proactively. The subtle signs of clinical decline are brought to their attention earlier now, and they have been given the tools, support and autonomy they need to provide their patients with the optimal care."

The nursing protocol is an essential component of success, he added, and said he would recommend that other organizations do the same.

"We found that it was beneficial to roll out the rapid response solution with the NEWS scores and alerts in phases," he advised. "By having the algorithms run initially in silent mode, we were able to work with clinicians to make the NEWS and PEWS as accurate as we could. This helped to ensure that the clinicians trusted the scores and were familiar with how they were generated before we went live with the alerting. While the phased approach is not always feasible, we found it to be very beneficial."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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