May 15, 2020
ON THE SIXTEENTH DAY of his hospitalization at Wake Forest Baptist Health (WFBH) in Winston-Salem, N.C., a 50-year-old man admitted for serious injuries from a car wreck was in trouble. His oxygen needs increased markedly, his fever spiked, and his heart rate rose as his blood pressure fell.
Clinicians suspected sepsis. At 1:30 p.m., they called a Code Sepsis, setting in motion a carefully orchestrated response by a team of physicians, nurses, pharmacists, and other clinical staff.
The patient’s physician requested antibiotics. The pharmacist reviewed the patient’s medical record and ordered piperacillin/tazobactam and vancomycin, which were sent by pneumatic tube to the nursing station. The nurse administered the drugs. The entire sequence, from recognition of sepsis to antibiotic delivery, took 19 minutes.
After careful monitoring and adjustments to his antibiotic regimen, the patient gradually improved and was discharged, sepsis-free, to a rehabilitation facility.
Reversing High Sepsis Mortality Rates
That was in the spring of 2013. A year earlier — before the hospital’s Code Sepsis initiative was fully established — this fast, focused choreography that brought antimicrobial therapy to bear against a lethal infection would not have happened. The outcomes for the patient might not have been as bright either.
Severe sepsis and septic shock are associated with a mortality rate of 25% and higher. Since each hour of delay is associated with a measurable increase in mortality, speed in initiating antibiotic therapy is critical.
James R. Beardsley, Pharm. D., BCPS
“This case exemplifies the efficiency of the Code Sepsis process. More people who develop sepsis survive here, because we get them appropriate care quickly,” said James R. Beardsley, Pharm.D., BCPS, Manager of Graduate and Postgraduate Education in the WFBH Department of Pharmacy and one of the Code Sepsis developers.
Bringing Clinical Resources to the Bedside
Modeled after code responses to cardiac arrest or stroke, Code Sepsis got its start at WFBH in late 2011, when data showed that the sepsis-related mortality index (the observed death rate divided by the expected death rate) at the 885-bed tertiary academic hospital was twice the average for the 10 top-performing members of the University HealthSystem Consortium (UHC).
At that time, the mean elapsed time from the arrival of a rapid response nurse to antibiotic administration for patients with sepsis was 6.6 hours, and only 5.4% of these patients received antibiotics within one hour. Something had to change.
Margaret Currie-Coyoy, M.B.A., P.M.P.
The medical center’s leadership assembled a multidisciplinary task force to figure out a way to get antibiotics to patients within 60 minutes after sepsis is suspected and to reduce sepsis-related mortality.
“We sought to bring valuable clinical resources to the bedside to ensure optimal treatment for each patient” and to remove barriers to rapid drug delivery, according to Margaret Currie-Coyoy, M.B.A., P.M.P., Associate Director of Performance Improvement at WFBH.
The solution is a single-minded focus on identifying sepsis patients more reliably and quickly providing them with definitive care. Under the plan, once sepsis is suspected, the bedside nurse activates the hospital’s emergency-response system, which generates a text page to all Code Sepsis team members.
Pharmacists Play Critical Role in New Protocol
As part of their responsibilities in a Code Sepsis situation to ensure timely administration of antibiotics, pharmacists assumed the somewhat unconventional role of timekeeper: If the pharmacy has not received an antibiotic order within 15 minutes of the Code Sepsis alert, the pharmacist calls the nursing unit to make sure the essential chain of events remains intact and that a drug order, if still needed, is forthcoming.
In addition, a protocol was developed that allows pharmacists to select antibiotics for Code Sepsis patients when prescribers are busy with other critical aspects of patient care.
“I may know what antibiotics I want to prescribe, but I’m so busy putting in a central line or intubating the patient that I can’t place the order,” said Catherine M. Jones, M.D., M.S., who was the Associate Chief Medical Officer at WFBM during Code Sepsis development and early implementation. She is now a Professor of Clinical Medicine at the University of Missouri Health Sciences Center.
Code Sepsis was implemented in noncritical care areas in April 2012 and then rolled out incrementally to surgical ICUs, the emergency department, coronary care units, and, finally, to medical intensive care units in August 2013.
The impact was dramatic: In noncritical care areas, the mean time from the arrival of a rapid-response nurse on the unit to antibiotic administration dropped to 51 minutes — nearly six hours less than the previous mark of 396 minutes.
In the ICUs, that time plummeted from 427 minutes to 31 minutes. The sepsis-related mortality index dropped by more than half from 1.65 to 0.8 (which translates to more than 200 lives saved annually), placing the hospital among the 10 top-performing UHC institutions.
Dr. Jones said that working on Code Sepsis gave her a better understanding of what’s involved with filling a medication order. “I had very little insight into all the work needed to get a drug order from the pharmacy to the floor. It just seemed to magically appear,” she said. “So many things can interrupt the process, and often physicians just don’t think about that. Code Sepsis gave my colleagues and me an appreciation for all that goes into the process and getting antibiotics to patients in under an hour.”
Dr. Beardsley emphasized that collaboration across disciplines was vital to the program’s success. “Without multidisciplinary cooperation, this wouldn’t have worked. It’s that simple,” he said. “We’re talking about patients’ lives, not some theoretical quality improvement initiative. When you present it that way, people are more likely to jump on board.”
–By Steve Frandzel
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