Sepsis, redefined in 2016 because of new recommendations aimed to enhance its diagnosis, is “a life-threatening organ dysfunction caused by a dysregulated host response to infection,” taking the lives of over 258,000 Americans each year. Pinpointing sepsis is problematic because it requires a series of interventions to effectively manage its unpredictable progression with no single test that can accurately identify its diagnosis.
During his chief resident year in 2001, Chris Fee, MD, presented a lecture at a case conference on what could’ve been done differently for a patient presented to the Emergency Department with septic shock. At the time, a practice-changing article written by Emanuel Rivers, MD, on a systems-based approach called, early goal-directed therapy (EGDT) was released. This management strategy was associated with a dramatic reduction in mortality and over the next several years became widely adopted as the standard of care for the early management of severe sepsis and septic shock. Since the publication’s release, significant interest and scientific discussion was generated around the management of sepsis, a term only 55% of American’s have heard today.
The hospital institutions who adopted early goal-directed therapy were said to have observed more positive patient outcomes as well as a statistically significant reduction in mortality in the patients treated. Despite opposition from other hospitals to embrace this new standard of care for the treatment of sepsis, Fee saw enormous potential in this systematic practice and saw no harm in taking additional measures in order to recognize sepsis early on, avoiding the negative outcomes of premature death or long-term disability patients may endure when faced with sepsis.
Chris Fee, MD, is the Professor of Clinical Emergency Medicine at the University of California, San Francisco (UCSF), Co-chair of the PSMF’s Early Detection & Treatment of Sepsis Workgroup, and is a lead physician for the sepsis quality improvement efforts at UCSF. Among his many achievements, over the course of his medical career, Fee admits his most influential work lies in his efforts related to early detection and the treatment of sepsis. As UCSF’s Emergency Medicine Residency Program Director, Fee mentor’s medical students and residents in quality improvement initiatives and research relating to sepsis management.
The controversy surrounding aspects of the bundles within Rivers’ early goal-directed therapy wasn’t enough to stop Fee from continuing his research on infectious disease and infection control. Soon after his lecture in 2001, Fee became involved in the Infection Control Committee at UCSF and, in this role, worked to prevent infection or identify it early on – learning various systems in the emergency department (ED) and throughout the hospital.
The next chapter of his career unfolded before his very eyes. Fee started going to quality improvement meetings where the Joint Commission, CMS, and institution officials at UCSF, looked into clinical measures and asked why the emergency department at UCSF wasn’t performing well on them. Questions such as, “why weren’t patients presenting with pneumonia administered antibiotics within four hours? “were raised and through this experience of individual case and operational reviews, Fee realized it wasn’t that the ED was underperforming, rather it was the measure itself that was flawed.
Reconciling the two meant that they could either get rid of the measures or change the measures completely. Fee opted to work towards the latter and, in time, the measures used to assess care provided to patients with pneumonia were reformed.
His pursuit for a way to identify patients early in their course of treatment (prior to developing full-blown septic shock which portends the highest mortality among the sepsis spectrum) started with taking advantage of a homegrown electronic health record which, at the very least, had the potential to automatically recognize triage vital sign abnormalities, and would flag an alert to triage nurses, physicians, and ED pharmacists if there was any suspicion of an infection. However, because it was homegrown, it came with its fair share of limitations; there was no computerized order entry, it lacked the ability to synchronize and link nursing notes, and it couldn’t track subsequent vital signs. So, if your vitals were normal at triage, only to become abnormal an hour later, it wouldn’t flag it.
“Hey this patient meets the criteria for supplementary testing and may be sicker than you think, was really the basis of this simple screening system. “
Fee and the ED sepsis team adapted their rudimentary electronic screen in 2012 to their new fully integrated ED electronic health record. Fee watched as the screening tool he had helped develop, evolved as more and more feedback on what to include was identified. It had the ability to pull vital signs throughout the ED visit (rather than only at triage as with their initial tool) and screen for white blood cell counts.
“As a medical provider, abnormal vital signs should catch your attention right away – it’s not rocket science. But in a hectic, chaotic environment, the constant interruptions lead to human systems failure – where you can miss patients early on.”
Fee realized it would take a much more robust electronic health system in order to continuously troll a patient’s vital signs as well as their lab values.
The current system Fee works with has both capabilities and more. It now not only identifies patients meeting SIRS criteria (which, if due to an infection defines sepsis), but also those who had evidence of end organ dysfunction (which defines severe sepsis or septic shock in the case of fluid non-responsive hypotension), and reminds providers to recheck lactate levels and assess for volume status following the administration of IV fluids. As soon as a patient meets criterion for SIRS or severe sepsis/septic shock, his entire department is alerted. The implementation of this screening system in the ED and subsequent dissemination throughout the medical center has been associated with substantial improvements in early recognition and compliance with recommended interventions. More importantly, mortality among these patients has significantly decreased. But, it took a village to get there, and Fee feels incredibly fortunate that the CMO, leadership team, the director of ICU, inpatient medical personnel both from nursing and from the physician leadership side, supported the new system and screening protocols.
“Having a system that can do the work for you and hit you on the head and say, hey dummy you’re missing this, can be very helpful. It’s definitely a cultural shift to trust the technology in that way.”