Ascension, Baylor Scott & White tackle sepsis systematically

Leaders at Ascension noticed that nearly 10% of patients in their hospitals who were diagnosed with sepsis died, five times the average mortality for all inpatients.

They decided to prioritize the goal of improving sepsis outcomes at all their hospitals during fiscal year 2019. That's no easy task in a company with 151 hospitals in 21 states and the District of Columbia.

Meanwhile, Baylor Scott & White was similarly targeting sepsis as part of a drive to reduce length of stay in its intensive care units in 20 hospitals.

Both efforts required careful attention to developing support and leadership at each hospital, and not bigfooting local clinicians and staff.

Sepsis is the body's inflammatory response to an infection that can cause blood pressure to plummet and organs to shut down. There's no certain way to diagnose it, and the condition requires rapid treatment involving antibiotics, fluids and blood-pressure support drugs. Hospital staff often spot it too late.

Ascension deployed a four-part strategy for standardizing clinical processes and outcomes across its facilities. That's based on its previous successful campaigns to reduce central line infections, cut unnecessary antibiotic use and standardize medication use.

Dr. Mohamad Fakih, Ascension's senior medical director who leads clinical quality initiatives for the chain, and his team worked to build physician and staff support at each hospital through a multimedia communications campaign to illustrate why improving sepsis treatment matters to patients. They based it on the story of one patient who died from the condition.

They also identified a local physician champion in each of Ascension's 12 markets, along with an improvement team at each hospital.

Ascension developed a standard order set for sepsis on its electronic health record platform, so clinicians had all the elements they needed for early identification and management of the condition.

"If I'm a chef and I don't have all the ingredients in one place, I may be forgetting something," Fakih said. "This makes it way easier for providers to do the right thing."

The company established a sepsis outcome dashboard, updated every month, so people can see how they're performing.

Both front-line staff and Ascension clinical and operations leaders at the local level are held accountable for improved processes and outcomes.

If Fakih and his national team see a hospital struggling to improve its sepsis numbers, they may fly out to help them. While they recognize that Ascension hospitals in urban and rural markets differ greatly in size, expertise and resources, "there are things that are non-negotiable," he said. "There are best practices should be the same everywhere."

Ascension said that from last July to this past March, its comprehensive package of sepsis treatment changes saved 177 lives, reduced mortality by 6.5%, and saved $9.3 million.

The campaign had the spin-off benefit of reducing hospital-acquired infections from invasive devices, surgical procedures and other sources, Fakih said.

Ascension's work on improving clinical process reliability in sepsis and other areas has saved about $120 million so far this year by reducing unnecessary care costs, said Dr. David Pryor, Ascension's executive vice president and chief clinical officer.

Pryor cited the sepsis campaign as an example of how a hospital company can become a "learning system" that establishes processes to spread improvements from one part of the organization to another.

At Baylor Scott & White, leaders saw that intensive care unit patients accounted for a disproportionate share of their hospitals' operational costs in acute care. With 505 ICU beds, they decided about four years ago to focus on improving efficiency in those units at 20 of their hospitals.

Twice a month, BSW's system acute care council, including hospitalists and emergency medicine leaders, meet to work on improving communication, continuity of care and safe handoffs. They developed evidence-based care "bundles" for sepsis patients, with an emphasis on starting patients on fluids and antibiotics in a timely manner, said Dr. Edgar Jimenez, BSW's system vice president for critical care, who leads the improvement effort.

From February 2018 to February 2019, the length of stay in BSW's intensive care units decreased by 20% while the mortality rate dropped by 30%, Jimenez said. Some ICUs have seen average stays shrink by as much as two days.

Different hospitals are at different stages in the improvement process, he said. The ICU physicians at some hospitals have a cohesive group culture, while those at other hospitals have practiced with little group interaction.

Because BSW relies heavily on independent rather than employed physicians, BSW's contracts with physician groups serving ICU patients now include requirements to follow the care-bundle protocols as well as tighter performance measures.

"We are insisting that whether you are employed or independent, you will engage in efforts to apply evidence to the patients you serve to produce beneficial outcomes," said Jim Hinton, CEO of Baylor Scott & White.