Improving Unadjusted and Adjusted Mortality With an Early Warning Sepsis System in the Emergency Department and Inpatient Wards
Background: Mortality reduction has been a major focus of improvement for health care systems. Although several studies have noted improved sepsis-related mortality with the use of electronic health record (EHR) systems, there are no known published early warning sepsis systems using the Veterans Health Administration (VHA) EHR system.
Methods: The Malcom Randall Veterans Affairs Medical Center (MRVAMC), a large academic 1a VHA facility within the North Florida/South Georgia Veterans Health System (NF/SGVHS), was identified as having opportunities for improvement related to inpatient mortality outcomes. Sepsis was discovered as the primary contributor to inpatient mortality for MRVAMC’s acute level of care (LOC). Education along with implementation of an early warning sepsis system (EWSS) was subsequently integrated in the VHA EHR known as the Veterans Information Systems and Technology Architecture/Computerized Patient Record System (VistA/CPRS) at NF/SGVHS, which applied a combination of informatics solutions within a Lean Six Sigma quality improvement framework.
Results: At MRVAMC, there was an observed decrease in the number of inpatient deaths for the acute LOC from a high of 48 in fiscal year (FY) 2017, quarter 3 to a low of 27 in FY 2019, quarter 4. This resulted in as large of an improvement as a 44% reduction in unadjusted mortality with education and implementation of an EWSS from FYs 2017 to 2019. Additionally, the MRVAMC acute LOC risk-adjusted mortality (standardized mortality ratio) improved from > 1.0 to < 1.0, demonstrating fewer inpatient mortalities than predicted from FYs 2017 to 2019.
Conclusions: Education along with the possible implementation of an EWSS within the VHA EHR was associated with improvement in unadjusted and adjusted inpatient mortality at MRVAMC. This may be an effective approach for patients with sepsis.
Limitations
This program has limitations. The EWSS was studied at a single VHA facility. Veteran demographics and local epidemiology may limit conclusion of outcomes to an individual VHA facility located in a specific geographical region. Additional research is necessary to demonstrate reproducibility and determine whether applicable to other VHA facilities and community care settings.
SMR is a risk-adjusted formula developed by the VHA Inpatient Evaluation Center, which included numerous factors such as diagnosis, comorbid conditions, age, marital status, procedures, source of admission, specific laboratory values, medical or surgical diagnosis-related group, ICU stays, immunosuppressive status, and a COVID-19 positive indicator (added after this study). Further research is needed to evaluate sepsis-related outcomes using the EWSS during the COVID-19 pandemic.
EWSS in the literature have demonstrated various approaches to early identification and treatment of sepsis and have used different sepsis screening tools.22 Evidence suggests that the MEWS + SRS sepsis screening tool may result in false-positive screenings.23-27 Additional research into the specificity of this sepsis screening tool is needed. Ward nursing staff were encouraged to initiate automatic sepsis alerts when MEWS + SRS was ≥ 5; however, this still depended on human factors. Because sepsis alerts are software-specific and others were incompatible with the VHA EHR, it was necessary to design our own EWSS.
Despite improvement with MRVAMC acute LOC unadjusted and adjusted mortality with our EWSS, we did not identify any actual improvement in earlier antibiotic administration times once sepsis was recognized. While accurate documentation regarding degree of sepsis improved, a MRVAMC clinical documentation improvement program was expanded in FY 2018. Therefore, it is difficult to demonstrate causation related to improved sepsis documentation with template changes alone. While sepsis alerts on the inpatient wards were variable since EWSS implementation, nonspecific ERT alerts increased. It is unclear whether some sepsis alerts were called as nonspecific ERT alerts, making it impossible to know the true number of sepsis alerts.
MRVAMC experienced an increase in nurse turnover during FY 2018 and as a teaching hospital had frequent rotating residents and fellows new to processes/protocols. These factors may have contributed to variations in unadjusted mortality. Also the decrease in inpatient mortality and improvement in SMR on acute LOC could have been the result of factors other than the EWSS and the effect of education alone may have been at least as good as that of the EWSS intervention.
Conclusions
Education along with the possible implementation of an EWSS at NF/SGVHS was associated with a decrease in the number of inpatient deaths on MRVAMC’s acute LOC wards from as high as 48 in FY 2017, quarter 3 to as low as 27 in FY 2019, quarter 4 resulting in as large of an improvement as a 44% reduction in unadjusted mortality from FY 2017 to FY 2019. In addition, MRVAMC’s acute LOC SMR improved from > 1.0 to < 1.0, demonstrating fewer inpatient mortalities than predicted from FY 2017 to FY 2019.
This multifaceted interventional strategy may be effectively applied at other VHA health care facilities that use the same EHR system. Next steps may include determining the specificity of MEWS + SRS as a sepsis screening tool; studying outcomes of MRVAMC’s EWSS during the COVID-19 era; and conducting a multicentered study on this EWSS across multiple VHA facilities.
