NATIONAL HARBOR, MD. – A hospital-wide rapid response protocol decreased the time to antibiotic administration and improved sepsis bundle compliance by creating a team approach to sepsis management.

Creating "Code Sepsis" involved every member of the clinical care team, from nursing assistants to attending physicians, Dr. Catherine Jones said at the annual meeting of the Society of Hospital Medicine. The pilot project has been so successful that it’s being implemented in other units of Wake Forest Baptist Medical Center, Winston-Salem, N.C.

"We’ve started a modified version of it in our surgical intensive care units and, in April, our emergency department rolled out this exact same process. Our goal is to roll it out throughout the organization, including our comprehensive cancer center, because it’s not unusual for patients to show up in clinic with severe sepsis," said Dr. Jones, a patient safety and hospital quality expert at the group.

The incidence of sepsis has been on an upward trajectory since 2000, she said, because of a variety of factors. An aging population and the more frequent use of invasive procedures, chemotherapy, and immunosuppressive drugs probably all contribute to the problem. Patients who develop sepsis are eight times more likely to die during a hospital admission.

The good news is that the international "Surviving Sepsis" campaign, which advocated a resuscitation bundle approach designed for early intervention, does seem to be making a difference in outcomes since it was inaugurated in 2002.

The key element seems to be the earlier timing of antibiotic delivery, with an estimate of one patient saved for every seven bundles implemented, Dr. Jones said.

"The problem is that, on the floor, early recognition of sepsis is difficult. It’s a spectrum of illness from infection to sepsis, severe sepsis, and septic shock, and none of these stages have simple, definable signs, symptoms, lab values, or imaging findings. Many other conditions mimic sepsis and present with the same criteria and organ failure as severe sepsis."

Several years ago, the facility began looking at its overall mortality figures, with a goal of reducing mortality by 15%. Since sepsis is an important driver of mortality, it became a target for intervention. A working group composed of interns, nurses, nursing assistants, pharmacists, and respiratory therapists met for 2 days to create an action plan – and Code Sepsis was born. The name was chosen for two reasons, Dr. Jones said: It connotes both a sense of urgency, and the understanding that there is a set protocol to follow.

The rapid response team is the protocol’s backbone. Consisting of two critical care nurses and a first-call provider, the team goes into action any time a patient meets the criteria for possible sepsis. The nurses activate Code Sepsis by calling emergency communications; they quickly the get blood work done and sent to the lab, and administer any initial treatments. The first call provider evaluates the patient and gives appropriate orders. Respiratory therapists obtain blood gases and manage any airway issues, and a pharmacist expedites the preparation and delivery of antibiotics. An ICU triage nurse locates a bed if the patient needs a transfer to a higher care unit.

The goal is to get broad-spectrum antibiotics flowing within an hour of the code being called. Fluid resuscitation is administered if there’s an elevated lactate level or a mean arterial pressure of less than 65 mmHg.

To make things even smoother, every nursing unit has prepackaged Code Sepsis equipment bundles complete with intravenous supplies and everything necessary to draw blood and send it off for rapid analysis.

The program, launched in March 2012, is now associated with a number of improved treatment parameters, Dr. Jones said. By September 2012, rapid response for potentially unstable patients rose from 30% to 70%. By last March, there were also significant increases in 100% bundle compliance. Antibiotics are now almost always administered in 1 hour or less of a Code Sepsis initiation. The risk-adjusted mortality index has fallen from a high of about 1.8 before the protocol to less than 1.25 – also a significant improvement.

The road to these improvements wasn’t always smooth, Dr. Jones said. The Code Sepsis model required some fine-tuning along the way. And the very valid concern of antibiotic overuse was not an easy obstacle to surmount.

"That was a big barrier. There is a lot of concern in our organization about the early use of antibiotics. To appropriately deliver those within 1 hour requires a leap of faith and the understanding that you may end up giving antibiotics to some who don’t need them, in order to make sure you give them within 1 hour to every patient who does."

Dr. Jones reported having no financial disclosures.

Rapid sepsis response boosts patient outcomes