All of this work was driven by real-time data at the point of care. Whether for protocol development or outcomes measurement, team members relied on the data they were collecting and analyzing to refine or modify their approach. Informaticists focused on building algorithms that enabled timely review of data, identifying or predicting potential sepsis patients, and recommending appropriate tests and treatment.
They also developed a modeling tool that could demonstrate to clinicians the impact of making changes to the protocol. For example, the tool showed the tradeoff between specificity (i.e. high chance that the patients treated were the right patients, but also high chance that some patients were missed) and sensitivity (i.e. high chance of treating more of the right patients, but also high chance of false positives).
In addition to implementing protocols and constantly responding to new information, Intermountain's success was the result of the following four strategic approaches:
- Support clinical leaders. Our message to the physician leaders was we wanted to help them author a single, standard way for patients to be treated when sepsis was identified. If there were disagreements, it was between expert physicians, not someone looking to cut costs. The adoption was contagious and largely driven by peer-to-peer relationships. Practicing physicians regarded as leaders among their colleagues were involved in the development methodology of the protocols and ultimately "sold it" to their peers.
- Understand that protocols are works in progress. Changes to protocols are needed very frequently—sometimes daily or weekly. We want to understand what data we are gathering now and what we're not. You learn about how to change your information systems to get data the way you need it. We always end up re-emphasizing real-time charting because you need real-time data to drive the protocol—the clinicians need to enter things as they happen.
- Make it easy for clinicians to comply. In our experience, if we're using paper, we've found any given clinical team can remember only about four or five protocols outside of what they are regularly doing for a patient. The more informatics you can build to help them follow these protocols in their daily work, the more likely they are to adhere to them. For example, our information systems have reminders for nurses when necessary information has not been collected. It's also important that everything we collect is collected for a purpose.
- Drill down, even if you look good on the surface. If we look compliant at the composite level, we ask if compliance has translated into better care. If it hasn't, we look to the individual line items that comprise the composite score to identify where we need to improve. The informatics team gives front-line physicians a report showing how they are doing against standards within their region and across the health system. Reporting is also made available to nurses and infectious disease specialists.
When the Intermountain team launched this protocol-based approach to improving sepsis care, the health system's 25% sepsis mortality rate was already below the national average. Four years later, Intermountain has a 9% sepsis mortality rate. As a result, Intermountain saves 85 more lives each year and saves $38 million in annual costs.
Chief information officerIntermountain HealthcareSalt Lake City, Utah