Improving the care of sepsis: Between system redesign and professional responsibility: A roundtable discussion in the world sepsis day, September 25, 2013, Riyadh, Saudi Arabia.

This paper summarizes the roundtable discussion in September 25, 2013, Riyadh, Saudi Arabia as part of the World Sepsis Day held in King Abdulaziz Medical City, Riyadh. The objectives of the roundtable discussion were to (1) review the chasm between the current management of sepsis and best practice, (2) discuss system redesign and role of the microsystem in sepsis management, (3) emphasize the multidisciplinary nature of the care of sepsis and that improvement of the care of sepsis is the responsibility of all, (4) discuss the bundle concept in sepsis management, and (5) reflect on the individual responsibility of the health care team toward sepsis with a focus on accountability and the moral agent.

More than 2,400 healthcare institutions in over 40 countries around the world held the World Sepsis Day in September 2013 to draw attention to this deadly disease, its impact on human life, and share progress in therapies.[1] King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia has launched a sepsis improvement project and as part of this initiative, the World Sepsis Day was held on September 25, 2013 to raise awareness of sepsis among its healthcare professionals, to highlight the progress of the improvement project and to sustain and spread the improvement.

The objectives of the roundtable discussion were to:

review the chasm between the current management of sepsis and best practice,

discuss system redesign and role of the microsystem in sepsis management,

emphasize the multidisciplinary nature of care of sepsis and that improvement of the care of sepsis is the responsibility of all,

discuss the bundle concept in sepsis management, and

reflect on the individual responsibility of the health care team toward sepsis with a focus on accountability and the moral agent.

The Scope of the Problem: The Chasm in the Care of Sepsis

Severe sepsis is a major cause of human death[2] with increasing incidence.[345] Despite advances in diagnostic and therapeutic modalities; the number of sepsis cases continues to increase dramatically - at a rate of 8-13% annually. Hospitalizations for sepsis have more than doubled over the last 10 years, and in many countries, more people are hospitalized each year for sepsis than for heart attack.[6] In fact, studies have shown that sepsis may be the most common cause of death in USA outnumbering acute myocardial infraction, and is responsible for 60-80% of death in the developing countries. Studies have shown that early timely appropriate therapy, especially with intravenous fluid and antimicrobial therapy is associated with reduction of the risk of deaths.[7] In addition, early sepsis treatment is cost-effective, and improves resource utilization by reducing the number of hospital and critical care bed days. As a result, clinical practice guidelines by the Surviving Sepsis Campaign emphasized early recognition and intervention through the timely implementation of a bundle of interventions in a time-bound fashion.[8910] Unfortunately, studies have shown that compliance with clinical practice guidelines for severe sepsis and septic shock is poor. This finding has been consistent in studies from around the world, including the United States, Europe, and Asia.[1112131415161718] This finding for severe sepsis and septic shock illustrates what was described by the Institute of Medicine as a chasm[19] between knowledge and practice. As such, improving sepsis management has become the target for several international campaigns.[10]

Appreciation of Systems

W. Edwards Deming was the first to highlight the importance of understanding of systems in moving the prevailing management style to quality. The 1999 report of the Institute of Medicine, To Err is Human, was a landmark in appreciation of systems in health care.[20] The report highlighted that faulty systems, processes, and conditions lead people to make mistakes or fail to prevent them. A system is an interdependent group of items, people, or processes working together toward a common purpose.[21] As such, understanding how systems work and interact has become at the heart of improvement science. Two issues face health systems when they try to improve the quality of care. First, there is the issue of the weak link in the chain of processes. The value of care in a health system is as good as the services generated by the small clinical units – or microsystems – of which it is composed;[22] an example of a microsystem is the intensive care unit (ICU). Therefore, when some of its microsystems are weak links, essential services of the health system will break down, or result in ineffective and costly workarounds.

The second issue is the need to get many processes and communications right in order to get the whole process right. For example, let's take a process that has six attributes and let's assume that the health system can reliably produce each of those six attributes 90% of the time. Using simple probability, the odds of all six attributes being present at the same time would be 90% to the 6th power, which is 53%. This means that, from the perspective of a patient, the odds is approximately 50% that one of the sex attributes will not be applied to his or her care.[23]

Sepsis management is an example of the increasing complexity with interlinking processes in the clinical management environment, where system failures are likely to occur. And, thus for us to improve care of septic patients, we have to understand the system and apply improvement methodology to redesign the care process to achieve reliability. Recognizing the system theory, the Surviving Sepsis Campaign guidelines call for performance improvement efforts in addressing severe sepsis to improve patient outcomes.[8] The sepsis improvement project at KAMC - Riyadh focused on system redesign to achieve early recognition and timely response to severe sepsis and septic shock. The project had implemented multiple changes in the process of care including electronic alert system and sepsis response team.

All or None Bundle Concept

The concept of bundle has been introduced by the Institute for Healthcare Improvement to help health care providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks.[24] A bundle is a small set of evidence-based practices – generally three to five, that, when performed collectively and reliably, have been proven to improve patient outcomes.[25] The bundle resembles a list, but has certain characteristics.[24] First, all bundle elements are all necessary and all sufficient, that must all be completed to succeed. Second, all the elements are evidence-based. Third, the bundle includes the all-or-nothing measurement. Fourth, the bundle components occur in the same time and space continuum.[24] The bundle is a tool for implementation and measurement. The sepsis resuscitation bundle is a good example; as it consists of several evidence-based practice interventions that are time-bound. By measuring compliance of the sepsis resuscitation bundle, the improvement can be guided objectively.

The Care of Sepsis is Multidisciplinary: Improvement is the Responsibility of All

The nature of the care of sepsis is multidisciplinary. Patients with sepsis are often first seen in the emergency department and are usually admitted to different medical and surgical specialties with the severe cases admitted to the ICUs. Further, the process of care of sepsis requires a multidisciplinary team to be carried out effectively in a timely fashion; that involves physicians, nurses, pharmacists, and others. By performing timely assessment and recording vital signs, the nurses play a key role in early recognition of sepsis. In addition, the nurses’ role in timely administration of fluids and antibiotics as well as obtaining the necessary lab work is central to the success of any improvement project for sepsis. The physician role starts with early and accurate assessment followed by early intervention of the septic patients (resuscitation and referral) that may save lives. In addition, identifying the source of infection and achieving source control are critical in management of the septic patient. The pharmacists have an essential role in ensuring the correct selection and timely delivery of antibiotics to the nursing unit. Diagnostic services, including the laboratory and radiology play a pivotal role in early diagnosis and in identification of the source of sepsis.

Professional Responsibility: Accountability and the Moral Agent

Accountability

The Institute of Medicine's Report To Err Is Human[20] triggered a paradigm shift in quality and safety from the traditional focus on identifying who is at fault to focus on improving systems. As a result, quality improvement projects have utilized interventions such as computerized systems and checklists and a few institutions even brought in human-factors engineers to improve processes of care.

However, in the last few years, several prominent healthcare leaders began to question the singular focus on systems. It has been suggested that of similar importance to system thinking is having a more aggressive approach to poorly performing physicians and creating accountability.[26]

It is evident that adhering to the sepsis bundle saves lives. However, we know that compliance with the standards remains suboptimal even after system improvement. In medicine, it is estimated by research that we only practice 50% of the known evidence. It has been suggested that in order to move forward and address the chasm in quality and safety; the focus should be on three points: First, practice standards, i.e., making sure that our care follow the standard guidelines – the sepsis resuscitation bundle is one example. Second, measurement of process and outcomes and third, transparent communication and feedback these results to the system to improve it and keep our care customer-oriented, helping the patients have better health and safer recovery. However, having standards, measurements and transparent communication do not guarantee full compliance. What would be the attitude toward all people who don’t comply with the bundle interventions? How to deal with noncompliance? Is education or advising enough or more aggressive steps like penalty are needed?

Health care professionals have a busy nature of work. They do not take care of one patient population (like sepsis); they have other complex sick patients like postoperative patients, congestive heart failure to name a few. Most often than not, the noncompliance with standards is not deliberate, i.e., healthcare professionals either forget or underestimate the importance of the standards. In such case, checklists and protocols are likely to help.

However, sometimes healthcare professionals resist the change. For example, many academic physicians are highly influenced by pro and con debates like the role of central venous pressure measurement, or even the whole concept of early goal directed therapy. Most of the time, the con side does not have alternative or factual evidence. May authorities now call for nonaccepting such unfounded resistance. Although, the best approach to address the accountability question is still unclear, several approaches have been suggested such as public reporting and individual practitioner compliance measurement.

The Moral Agent

Accountability focuses on the external monitoring. Of similar importance, or perhaps of greater importance, is the internal monitoring, the moral agent. Medicine is a moral profession and physicians are agents of commitment to do what is in the best interest of their patients. Although medicine requires scientific and technological knowledge, it is first and foremost oriented toward a “healing relationship” with patients that demands moral accountability. Batalden and Leach suggested that we should have a daily conversation with ourselves discerning the truth and putting what is good for the patient ahead of what is good for us.[27] For patients with severe sepsis, we know that the provision of evidence-based practice, the sepsis bundle, is in the best interest of the patient, therefore, we need to make all efforts in providing that level of care.

Summary and Recommendations

There is a chasm between the care we have for severe sepsis and septic shock and the care we could have. Therefore, hospitals should undertake performance improvement efforts for severe sepsis and septic shock.

Improving the care of sepsis requires the appreciation of systems. System redesign is required to achieve breakthrough results.

The care of sepsis is multidisciplinary, and therefore, improvement is the responsibility of all.

In addition to focus on system redesign, serious consideration should be given to measurement and accountability.

Healthcare professionals need to maintain their commitment to do what is best for patients consistent with their moral agent