SUMMARY:

• There is a need to increase effective management of sepsis patients.

• Currently, evidence demonstrates the lack of fully implementing sepsis care bundles in clinical settings.

• Lack of crucial knowledge and communication are key barriers to optimizing sepsis care.

REVIEW:

• The development of sepsis is linked to both short and long term consequences with poorer health outcomes.

• Athough 3 and 6 hour bundle elements are recommended, evidence demonstrates the lack of fully implementing these recommendations at clinical sites.

• CMS SEP-1 guidelines are only fully implemented at 62% of hospitals within the CMS database.

• Before we can improve effective management of sepsis patients, we need to understand the barriers to achieving optimum care.

Early Sepsis Recognition

• Gaps in knowledge regarding sepsis criteria and relevant clinical signs.

  • Most prevalent in the outpatient arena (EMS and Primary Care) and emergency department junior staff.

• Early sepsis detection by providers within various disciplines. Contributing factors include:

  • Complexity of the disease

• • High patient acuity and volume

• • Time limited staff

• • Assessments by less qualified junior staff

• • Clinicians unaware of current guidelines

• • Lack of consistent adherence to current guidelines

• Electronic Warning Systems

• • Do not provide clinically relevant specificity

• • Perceived low precision in critically ill patients with high false positive alerts

• • Lack of algorithm transparency

• • Alerts should move from predefined threshold values to clinical condition assessments

• • Machine learning algorithms may prove more beneficial AI tools show promise in intensive care units (ICU) and emergency departments (ED) patients.

• • How the team uses the alert is more important than the alert itself

• Referral to Hospital

• • Guidelines are based on hospital patients and may be too narrow in the ambulatory setting

• • Uncertainty by primary care providers, EMS, etc in the referral decision

Timely Treatment

• Prioritization of Sepsis

  • EMS teams have sepsis as a lower priority as compared to the top 7 initiatives (i.e. cardiac arrest, MI, stroke, etc).

• Barriers

• • Uncertain fluid needs and volume, especially outside the ICU

• • Existing protocol complexity – not very intuitive

• • Large amount of clinical documentation required

• • Complexity and variability of sepsis disease presentation

• • Time pressures, workload, staff shortages

• • Delayed results (labs, drug orders)

•  Implementation

• • Antibiotic stewardship – barriers to timely antibiotic treatment

• • Transitions of care – ED-Floor-ICU

• • Lack of Communication

Aftercare of Sepsis Survivors

• Long Term Sequelae from Sepsis

• • Disability

• • Weakness

• • Cognitive function

• In patient to Out Patient Continuity

• • Long time interval for care after discharge

• • Care coordination between inpatient to outpatient lacking

• • Family Involvement needed

• Primary Care

• • Primary Care plays a key role in aftercare

• • • Additional information is needed on the hospital stay

• • Limited access to supportive care

• • • Care management

• • • Patient Education

CONCLUSIONS:

• Programs which provide education and standard communication between all providers have the greatest potential for optimal outcomes.

• The complex disease state of sepsis contributes to adequate completion of the care pathway.

• Resources devoted to outpatient education on sepsis should expand from the inpatient sepsis education model.

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Erkan Hassan is the Co-Founder & Chief Clinical Officer of Sepsis Program Optimization where he designs & oversees the implementation of solutions to optimize sepsis programs.

To discuss your organization’s Barriers of Effective Sepsis Care, contact Erkan by phone (844) 4SEPSIS (844-473-7747), email (erkan@spo.icu), or video chat.