How to Attack Sepsis, the Most Expensive Hospital Condition

Lessons from Reading Health: test clinical hypotheses, make few process changes, highlight patient quality over hospital costs, and switch to risk-based payment contracts.

Sepsis, the dangerous immune response to infection that overwhelms bodily organs, is the most expensive condition treated in U.S. hospitals, costing more than $20 billion per year to treat, according to the Agency for Healthcare Research and Quality. Many hospitals and health systems have responded with coordinated treatment approaches.

At Reading Health System in West Reading, PA, senior leaders recently created clinical effectiveness teams designed to find strategies for improving the care of patients with sepsis, along with renal failure, chronic obstructive pulmonary disease, heart failure and shock, gastrointestinal hemorrhaging, and for patients having bowel surgery.

Each of the six teams consists of a physician lead, a nursing lead, a quality expert who functions as the facilitator, and five to seven subject matter experts, such as an infectious disease specialist, a cardiologist, or a bedside nurse.

Steep rise in sepsis garners attention

Gregory Sorensen, MD, Reading Health's senior vice president and chief medical officer, says the skyrocketing rates of sepsis motivated the health system to make it a key area of emphasis.

Hospitals in the state are required to report all inpatient information to the Pennsylvania Health Care Cost Containment Council, an independent state agency formed to address rapidly growing healthcare costs. The aggregated data has shown a sharp increase in sepsis in recent years.

"What we discovered over the past five years through this data is there has been a 74% increase in sepsis in patients. One reason is because we are better able to diagnose it. The other factor may be that there are, in fact, higher numbers of patients with comorbid diseases for sepsis," Sorensen says.

"With those two things in mind, we think the higher number of patients with sepsis is an important piece to focus on. Our goal for the sepsis team is to achieve reductions in mortality, morbidity, length of stay, and cost of care."

Building new clinical protocols

For about the last eight months, Reading Health has been focused on identifying ways to drive early identification and treatment of sepsis. One of the sepsis team's core strategies is to establish hypotheses, institute clinical changes to test them, and monitor their impact on patient care.

One hypothesis was that the earliest possible diagnosis of sepsis risk for patients coming into the emergency department would lower severity, Sorensen says.

"We modified early-warning systems that look at the risk factors and identify patients who may be high sepsis risk candidates. Then, we order additional diagnostic tests and intervene earlier with fluids, blood cultures, and antibiotics. We measure from the time they enter the ED to the initial diagnosis to interventions with fluid therapy and antibiotics," he says.

"That degree of rigor has helped us focus on potential hypotheses that are statistically relevant, and we are not wasting our time on those that don't have the potential to impact outcomes. We've seen some very important reductions in our morbidity, mortality, and length of stay numbers as a result."

So far, Reading Health has experienced a 17% reduction in length of stay, a 40% reduction in mortality, and a 13% reduction in costs for its sepsis patients, Sorensen reports.

Because of these new clinical protocols, patients are also now being admitted from the emergency department to the right level of inpatient care more often, which is another way of delivering better, more cost-effective care, he adds.

"We are looking at determining if a patient should be admitted to the intensive care unit first rather than going to a floor, getting sicker, and needing to be moved to intensive care. If we get it right to begin with, we won't have to move as many patients," Sorensen says, noting that since the inception of the sepsis team, the percentage of patients that need to be moved to a higher level of care has dropped from 7% to below 4%.

Small changes add up to big success

Robert Jones, DO, Reading Health's medical director for performance improvement and clinical integration, says that to achieve success when redesigning processes, it's important to make incremental changes so that clinicians are not overwhelmed and are more likely to support the new methodologies.

"When making process changes, you don't create tasks that are incredibly difficult to do and require a lot more work. You look for small changes that have a large impact," he says.

"We are identifying things that look to have statistical significance, and the team will work to identify what is the best way to execute those so they make the most sense. Then our leaders are going out on the floor and making sure everyone is engaged in the process. They are also looking at how successful it is or isn't and seeing how to improve upon it."

Highlighting quality over finance

Another critical component of attaining long-term success for these kinds of efforts is to emphasize the impact on patients rather than the financial benefits to the organization, Sorensen says.

"One of our early missteps was to talk about this in terms of cost of care. Physicians don't care about what the cost is as long as the outcomes are right, and that is the correct approach. But we know that it almost always costs less to do it right."

Although the implementation of the sepsis team hasn't been a "bump-free process," Sorensen says Reading Health's physicians and nurses are now generally supportive of the effort to improve patient care.

"They are very engaged, and they are actually excited," he says. "This is the right thing to do by patients. If we truly think about it from the patient's perspective, then we have to be focusing on better quality, better access, less cost, and a higher degree of patient safety."

Quality is key to success in population health

While it's the insurance companies who currently profit the most from quality enhancements like the sepsis initiative, Sorensen says that will change over time as Reading Health engages in more risk-based payment contracts built around population health models.

"Many of these benefits go back to the insurance company because we don't have the right structures in place yet to share in some of that benefit … [but] it is how we are going to get paid in the future," he says.