Quality and Patient Safety Annual Report 2017 Quality & Safety Annual Report 2017 | Page 7

UAB’S WAR ON SEPSIS “We recognized that sepsis was a leading cause of death in our organization and that we needed a different approach to how we treated it,” says William Stigler, MD, assistant chief medical officer and sepsis physician champion. “With the implementation of the CODE Sepsis process and recruitment of a sepsis coordinator, we are now positioned to greatly improve our response to potentially septic patients through an evidence-based, standardized process across care settings.” “Not unlike other organizations, our leaders knew we needed to address sepsis-related care if we were to attain the outcomes expected of us by our patients and the community,” says Anisa Xhaja, manager of Quality Improvement. “There have been many efforts and pilots over the years to improve sepsis care (sepsis alert, early warning score, unit pilots), with varying and limited success. We needed a hospital-wide, concerted effort and a systematic approach. By declaring a ‘War on Sepsis’, our UAB Care clinical effectiveness team was able to catalyze improvement efforts centered on recognizing and treating sepsis, culminating with a series of meetings with key stakeholders, in which we defined the ‘UAB way’ to respond and treat suspected and actual sepsis.” Since implementing the new processes, CODE Sepsis has been initiated on over 500 patients in the hospital, and over 2,000 sepsis alerts or orders have been issued for patients in the UAB Hospital and UAB Hospital-Highlands emergency departments. The Sepsis PowerPlan, which includes standardized orders for treating new or worsening sepsis based on the Surviving Sepsis Campaign guidelines, has been initiated over 2,000 times on almost 1,700 unique patients. UAB Care, the clinical effectiveness program at UAB Medicine, held four Sepsis Summits in July 2016 to design and implement a robust CODE Sepsis process throughout UAB Medicine. These summits were attended by an interprofessional group of physicians, nurses, pharmacists, respiratory personnel, and information technology leaders, as well as frontline staff, to address variation in care in the management of septic patients. The new CODE Sepsis process includes an innovative screening tool, early response, and a treatment process to deliver rapid and standardized care to patients with new or worsening sepsis, while increasing the sense of urgency. The new process went live on Oct. 6, 2016, at UAB Hospital’s main campus and at UAB Hospital-Highlands across all care areas (emergency departments, acute care, and intensive care). In addition, a sepsis coordinator position was established in November 2016 to support the initiative’s momentum and provide continuous, focused education for nursing and providers. Sepsis continues to be the leading cause of death in hospitals in the United States and the most expensive condition billed to Medicare. The experiences within UAB Medicine have been no different than those of the country at large. With an observed-to-expected (O:E) sepsis-related mortality index well above 1.0, reaching as high as 1.77 in July 2015, and increased expenditures associated with treating the condition, UAB Hospital leadership declared “War on Sepsis” and set an institutional goal in FY2017 to reduce sepsis mortality to below 1.0. The CODE Sepsis process has resulted in improved outcomes for patients experiencing sepsis during their hospitalization. This is reflected in UAB Hospital’s sepsis O:E mortality index decreasing to 0.92 in Aug. 2017 – the lowest in the history of UAB and below our institutional goal of 1.0. This decrease in sepsis-related mortality equates to 67 lives being saved in 11 months following implementation of CODE Sepsis. Additionally, downward trends in length of stay (LOS) and variable cost-per-case have been observed, reflecting sepsis- related care provided within the hospital that is both clinically effective and operationally efficient. “We’ve seen a tremendous response to the CODE Sepsis process across the hospital,” says Mary Grace Cox, RN, sepsis coordinator. “Our care teams have risen to the occasion and really embraced these new processes to most effectively treat patients who become septic during their hospitalization. Having now reached our goal to achieve a mortality index below 1.0 for three months, our leaders and staff are only further motivated to sustain the CODE Sepsis process as the ‘UAB way’ to care for these patients.” www.uabmedicine.org 5