Many Trusts are tackling sepsis – and for good reason. The fact remains that it’s a killer, and more can be done. Technology is one part of the solution.
Alongside this, education and engagement, workflow design, and supply chain can also contribute to how we tackle the disease. Working well together, these elements can all radically change how we reduce the risk, identify symptoms and treat sepsis faster. Staff need to be aware of common warning signs, and be assisted by clinical decision support, to treat people within that ‘golden hour’ following identification of sepsis.
Having shared some of their progress in our Sepsis Day blog, we recently spoke to staff across Kingston Hospital NHS Foundation Trust about the impact of the new solution on patient care.
Determined to make a difference
The Trust’s deputy medical director, Dr Amira Girgis, highlights that “identifying sepsis early is absolutely essential to improving outcomes for our patients. A tool that can help us spot sepsis early is very welcome and assists us reducing mortality rates. Identifying and treating patients whose condition is rapidly deteriorating, as can happen with sepsis, is really important so that we can treat people effectively and is why we have made this a quality priority for the Trust.”
With this remit in mind, Kingston set out to change the way they tackled sepsis, with staff engagement and education, alongside being one of the first to deploy Cerner’s new Red Flag sepsis alert – aligned to the National Institute of Clinical Excellence (NICE) and UK Sepsis Trust Red Flag sepsis standards.
“Since 2015,” lead specialist nurse for sepsis, Amy Heptonstall, shares, “there has been a huge national drive to improve the care of sepsis patients. We’ve taken action by employing a sepsis nurse full time, auditing the processes we had in place, and providing much more education including running mandatory training sessions. We have also implemented technology to support our clinicians in recognising and taking action to treat potential sepsis.”
Trying to identify and predict sepsis is nothing new, but a process enhanced with technology is supporting the battle now more than ever before. Dr Shabaz Ahmed, ED registrar, notes that “every single patient who comes into A&E is screened by experienced nurses.” But it’s the invisible combination of slight physiological changes that can be missed. “With their vital signs and details being fed and continuously monitored on the EPR [by Cerner’s Red Flag sepsis algorithm], we are supported to recognise patients who potentially have sepsis that otherwise may have been missed.”
Dr Lucy Olsen acknowledges the importance of the EPR and sepsis alerts in her role. “Technology is crucial in the care of our patients because for example, on a weekend I might have fifty patients that I need to be looking after. I can't go around and look at the notes of every single patient every hour to check that they're doing OK. I need to be able to have a quick look on the computer system to see if there is anything flagging up that means I need to worry about a patient, and it's great to be able to do that from one system.”
Although technology is an enabler, coupling with education, support and engagement across the workforce is a key component for success. Pauline Soriano, junior sister on Alexandra Ward, believes that Kingston is very good at prioritising sepsis. She shares that “you can see posters about sepsis displayed prominently in the corridors and on the elevators so are constantly questioning if it’s sepsis that is causing our patient to deteriorate.” Booking staff, especially new starters, onto study days and providing refresher courses about sepsis simulation support the staff’s knowledge and confidence in raising the possibility of sepsis. “The alerts in the EPR trigger the escalation to the doctor to assess or visit the patient. It's excellent”, she concludes.
Berenice Constable, head of nursing for unplanned care, is also keen to call out the importance of educating the workforce. “The staff engagement perspective has hugely impacted on this. It's been a really successful process. Certainly, if we're talking about in ED, the staff down there have really embraced this whole concept and are striving all the time to be ‘sepsis stars’ in their department and that's been really, really impactful for patients too.”
Supporting care team members’ clinical judgement is another powerful benefit, says ED nurse, Celia Hill. As an expert professional, yet relatively junior member of the wider care team, the alerts help empower her to go to a senior clinician and state with confidence that a patient is at risk of sepsis, thanks to visible pre-alerts. “It adds that little bit of weight behind for me to say to the doctor ‘you need to treat this now, please’ - it helps us treat patients at risk of sepsis faster."
Improving care experiences and outcomes
“The Red Flag sepsis alert is absolutely vital in our Trust,” states Amy. “Once an alert is triggered, the appropriate clinician can access the EPR and see if that patient is at moderate or high risk, and assess their patient, immediately.” The solution also has generated a standard report that enables Amy, as sepsis lead, to monitor performance and outcomes on a daily basis - helping the Trust to monitor their fight against the infection.
Staff at Kingston shared some real patient examples of tackling sepsis supported by Cerner’s Red Flag solution:
“I recall one patient who was being treated for a urinary infection and was flagged up by the system as having sepsis. When we reviewed her, it was clear that she was deteriorating and that enabled us to increase our level of care for her. When she did get a higher level of care, more intensive treatment, she improved. If we had missed it, then mortality can be quite high.”
Dr Shabaz Ahmed, ED registrar
“We had a patient who we'd seen on the ward round and who had looked really well. We were actually thinking of discharging her the next day, but later on in the morning, the system flagged that her heart rate was slowly climbing. This was actually the only thing that looked wrong with the patient. She actually looked OK otherwise – she was sitting in a chair and chatting away. The EPR showed that her symptoms were getting worse and triggered our investigations. The next day she had to go back to surgery, and she ended up on ITU. If we hadn't picked up on that, she very well could have died.”
Dr Lucy Olsen
“I remember an elderly patient that was in a side room in Alex Ward. I was the nurse in charge. The EPR flagged up to me immediately that her NEWS2 scores were elevated. The ward team didn't know yet because they were with another patient. I was able to have a look at her observations really quickly, alert the doctors immediately, and then proceed to give the patient fluids and put her on oxygen straight away. Once the doctor had come in, we'd already implemented immediate actions to counteract the low blood pressure and low oxygen, after which we continued with screening. We did the Sepsis Six bundle, but she did become really unwell. The outreach team were there, and the senior doctors and consultant had been alerted and had come to review this priority patient. She did need to go to ITU, however if we hadn't been alerted at the very beginning and taken those early actions, she could have deteriorated very quickly - particularly due to her age. It helped us detect her risk early, catch the signals in time, and improve her outcome.”
Pauline Soriano, junior sister
Recognising the value
Seeing the sickest patients daily, Shabaz is uniquely positioned to comment on the importance of the Red Flag sepsis alert. “From a patient point of view, they've come here to be treated and expect world-class treatment, and that is what we can deliver. As long as we don't delay starting treatment for sepsis, the patients have a very good outcome.”
Berenice notes that “visibility of sepsis enables our response to be much better. With this system in place, we have the evidence that we need to demonstrate how we work at Kingston. It's a standard solution across the hospital so it's consistent. This provides a lot of confidence that we are all working in the same way for patients.
“We’ve seen a huge improvement in the Trust’s performance in terms of getting antibiotics into patients at the earliest possible point, definitely improved outcomes, and contributing to our outstanding CQC rating.”
Amira agrees, “because people are seeing the sepsis alerts on a regular basis now, they are absolutely talking about sepsis and are absolutely clued up and looking for sepsis and treating it early.”
As lead sepsis nurse, it’s obviously close to Amy’s heart, and seeing the fruits of their efforts is rewarding. “The impact of the Red Flag on patient care has been invaluable. We've had an improvement in our screening for sepsis, so obviously it improves the recognition of those patients potentially with sepsis and this means we have improved the treatment of patients with sepsis as well. Since 2015, when we first started our national Commissioning for Quality and Innovation (CQUIN) audit, we have increased screening from 52% to over 90%1 and antibiotic administration in 1 hour has gone from about 49% up to over 90% as well.”2
The Trust have also seen a 17%, or 1.5-day, average reduction in length of stay among ICU sepsis patients.3
Implementation of the Red Flag Sepsis solution has enabled the Trust to meet their CQUIN standards for the first time. “It's a massive improvement from an audit side of things,” Amy continues, “but what really matters is that we're delivering the best care that we can for our patients, and the improvement is continuing. I think engagement with all the healthcare professionals, is really key because it empowers them to escalate the patients that have a pop-up that says, ‘could it be sepsis?’ It makes them think about sepsis. We talk about it more.”
Shaun Kidd, EPR manager, calls out that the solution “helped us to achieve our sepsis CQUIN targets and provides a stronger audit trail.” It also saves time, “instead of Amy having to trawl through sets of paper notes, she, and others, can just look onto the system, which is a lot quicker. There is more concise information around timings and what action is being taken.”
“It’s all part of a bigger picture,” says Shaun. With HIMSS Stage 6 under the Trust’s belt, “our digital roadmap has been quite vast; we’re proud that we can prove the concepts that we say we're delivering, allowing us to move on to bigger and better things.”
Amy sums up the project succinctly: “the care that we're delivering for patients has improved enormously, and we’re supported in our fight against sepsis.”
1 ‘% of patients who met the criteria for sepsis screening and were screened for sepsis’ measured from 1 January to 31 December 2019 and compared to a 12 month period from 1 April 2015 to 31 March 2016. Measures taken at Kingston Hospital’s emergency department using Cerner Millennium. Screening increased from 52% of patients during baseline period, and increase to 91% with Cerner’s red flag sepsis alert.
2 ‘% of patients who present with severe sepsis, Red Flag Sepsis or septic shock and were administered intravenous antibiotics within 1 hour’ measured from 1 January to 31 December 2019 and compared to a 12 month period from 1 April 2015 to 31 March 2016. Measures taken at Kingston Hospital’s inpatients and emergency department using Cerner Millennium. Timely administration of antibiotics increased from 49% of patients during baseline period, and increase to 91% with Cerner’s red flag sepsis alert.
3 ‘ICU Average LOS for patients with a sepsis diagnosis’ measured from 1 January to 30 June 2019 and compared to a month period nine month period from 1 April 2017 – 31 December 2017. Measures taken at Kingston Hospital’s ICU department using Cerner Millennium. Average length of stay for patients in ICU with a diagnosis of sepsis reduced from 8.6 days during baseline period, to 7.1 days using Cerner’s red flag sepsis solution, an average reduction of 1.5 days (17%).
4 ‘Admissions to ICU with Sepsis related to Sepsis’ measured from 1 January to 30 June 2019 and compared to a nine month period from 1 April 2017 – 31 December 2017. 40 out of 518 patients (7.7%) were admitted to ICU during baseline period, compared to 25 out of 364 patients (6.9%) using Cerner’s red flag sepsis solution – an average reduction of 10%.
Differences in data claims between filmed interviews and written metrics are due to an extended period of data collection which completed after filming.
Kingston calculated their own improvement data. Cerner has not validated the accuracy of these claims.