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Establishing a High Reliability Sepsis Infrastructure: A Shared Sepsis Language
Authors: Summer Gupta, RN & Russell Kerbel, MD from UCLA Health

In a recent webinar, in honor of Patient Safety Awareness Week, the authors Dr. Russell Kerbel and Summer Gupta of this article provided insight and practical tools to help an organization move the needle on important sepsis related measures. In this article, the authors discuss the changes in sepsis definitions over time and how having a shared terminology can lead to the establishment of high reliability in the care of patients with sepsis.

Sepsis is associated with 1.7 million adult hospitalizations and 270,000 deaths in the United States each year1 . These cases account for almost $24 billion in annual costs2 . In an effort to decrease sepsis-related morbidity, mortality and cost, some health care organizations have adopted principles of high reliability organizations (HRO). HROs have four key elements:

  • Standardizing processes
  • Transparent data
  • Individual and team accountability
  • A common culture for systemic change3

A core principle of organizational culture includes the utilization of a shared terminology. Presently, there are various definitions of sepsis, providing an additional challenge to process for quality and clinical documentation improvement teams.

Although the term Septicemia was first introduced in classic times, the past 30 years have provided numerous iterations of sepsis-continuum definitions. The most familiar are the 1992 American College of Chest Physicians / Society of Critical Care Medicine (ACCP/SCCM) consensus statement definitions of systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock4 . These were updated in 2001 in what is now referred to as “Sepsis 2.0.” These definitions were adopted by both the Surviving Sepsis Campaign (2003, 2008 and 2012), as well as the Centers for Medicare and Medicaid services for ICD-9 and ICD-10 coding5 . These Sepsis 2.0 definitions became both the backbone for the SEP-1 Core Measure as well as various observed-to-expected mortality models6

However, these are not the only sepsis definitions that currently exist, and in 2016, the Society of Critical Care Medicine and European Society of Critical Care introduced new definitions referring to them as “Sepsis 3.0.”7 This change shifted the definitions by re-identifying severe sepsis as “sepsis.” Additionally, Systemic Inflammatory Response Syndrome (SIRS) criteria were eliminated, and scoring systems such as the sequential organ failure assessment (SOFA) and quick SOFA (qSOFA) scores were introduced.

Complicating matters, various other professional organizations, such as the Infectious Disease Society of America (IDSA) did not recognize these redefined measures8 . While some argue that “Sepsis 3.0” more accurately describes a patient’s immune dysregulation, others state that the definitions may miss patients’ clinical decompensating. Recently, one national insurance carrier informed hospitals they would no longer recognize “Sepsis 2.0” definitions, instead opting for “Sepsis 3.0” definitions9 . This move has caused confusion among clinicians, documentation staff, coders and quality improvement teams throughout various health systems.

To further complicate matters, the Centers for Disease Control (CDC) recently introduced a third set of definitions for sepsis known as adult sepsis events10 . These differ slightly from both “Sepsis 2.0” and “Sepsis 3.0” definitions. The CDC also introduced the electronic SOFA (eSOFA) score to identify these patients. It will be an exciting and challenging endeavor for health systems, researchers, clinicians and sepsis quality improvement leaders to integrate these new definitions and tools into practice.

In summary, patient safety leaders must be aware of the current sepsis literature and definitions and not solely focus on the SEP-1 definitions and bundles. It is essential for sepsis quality improvement team leaders to stay up-to-date with the Surviving Sepsis Campaign, guidelines from various professional societies, leading medical journals, and even sepsis researchers on social media. As a sepsis process improvement leader, one must be thoughtful prior to approaching clinicians for incorrectly documenting or implementing bundles. That individual may, in fact, believe they are using correct terminology or enacting the appropriate elements of care. Thus, leaders and front-line staff of high reliability health care organizations must use a shared sepsis language to advance process improvement and enact system change.

Resources and References

  1. Rhee C, Dantes R, Epstein L, et al., Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. Jama, 2017. 318(13): p. 1241-1249
  2. Torio C (AHRQ), Moore B (Truven Health Analytics). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013. HCUP Statistical Brief #204. May 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.pdf
  3. Ikkersheim DE, Berg M How reliable is your hospital? A qualitative framework for analyzing reliability levels
    BMJ Quality & Safety 2011;20:785-790.
  4. Definitions for Sepsis and Organ Failure and Guidelines for the Use of Innovative Therapies in Sepsis
    Bone, Roger C. et al. CHEST , Volume 101 , Issue 6 , 1644 – 1655
  5. http://www.survivingsepsis.org/Guidelines/Pages/default.aspx
  6. https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228774725171
  7. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287
  8. IDSA Sepsis Task Force; Infectious Diseases Society of America (IDSA) POSITION STATEMENT: Why IDSA Did Not Endorse the Surviving Sepsis Campaign Guidelines, Clinical Infectious Diseases, Volume 66, Issue 10, 2 May 2018, Pages 1631–1635, https://doi.org/10.1093/cid/cix997
  9. https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2018/network-bulletin/October-Interactive-Network-Bulletin-2018.pdf
  10. https://www.cdc.gov/sepsis/pdfs/Sepsis-Surveillance-Toolkit-Mar-018_508.pdf