One-hour sepsis

[hundreddaysoff]

As I've said before, the 1-hour sepsis protocol is the bane of my existence for about 3 different reasons, the most novel having to do with patient flow, mission creep, midlevel overzealousness/misunderstanding, and RN availability.

Last year SCCM, the people who created it, originally wrote a press release in conjunction with ACEP saying that 1-hour sepsis should not actually be implemented in hospitals, although the link to the original release seems to be broken now (and but see here). And of all the places I've worked, I'd only ever seen 1-hour sepsis used in the wild by HCA.

So I had assumed 1-hour sepsis was just an HCA money-grab via prematurely implementing an experimental protocol.

But now I just moonlighted at a sleepy little independent rural shop on the other side of the country, about as far as you can get from HCA, and lo and behold they had just implemented 1-hour sepsis! And that made me sad. ("They" meaning either the hospital owners or the medium-sized ~democratic group that owns the ER contract; haven't been there long enough to suss out who exactly.)

So what's the new word on 1-hour sepsis? Does your shop use it? Do you think it's justified? Is there any new evidence from SCCM/others that 1-hour sepsis actually saves more lives than the old 3-hour SEP-1? Am I too cynical in thinking it's still mostly just a money grab?

Just finished residency 2 years ago and of course it did not exist then. So it's possible I'm just out of touch and should get over myself and happily do lactate+NS+abx+BCx on anyone with an initial pulse of 90 who could have any kind of infection whatsoever and whom I'm not 100% committed to discharging.

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[deleted547339]

As I've said before, the 1-hour sepsis protocol is the bane of my existence for about 3 different reasons, the most novel having to do with patient flow, mission creep, midlevel overzealousness/misunderstanding, and RN availability.

Last year SCCM, the people who created it, originally wrote a press release in conjunction with ACEP saying that 1-hour sepsis should not actually be implemented in hospitals, although the link to the original release seems to be broken now (and but see here). And of all the places I've worked, I'd only ever seen 1-hour sepsis used in the wild by HCA.

So I had assumed 1-hour sepsis was just an HCA money-grab via prematurely implementing an experimental protocol.

But now I just moonlighted at a sleepy little independent rural shop on the other side of the country, about as far as you can get from HCA, and lo and behold they had just implemented 1-hour sepsis! And that made me sad. ("They" meaning either the hospital owners or the medium-sized ~democratic group that owns the ER contract; haven't been there long enough to suss out who exactly.)

So what's the new word on 1-hour sepsis? Does your shop use it? Do you think it's justified? Is there any new evidence from SCCM/others that 1-hour sepsis actually saves more lives than the old 3-hour SEP-1? Am I too cynical in thinking it's still mostly just a money grab?

Just finished residency 2 years ago and of course it did not exist then. So it's possible I'm just out of touch and should get over myself and happily do lactate+NS+abx+BCx on anyone with an initial pulse of 90 who could have any kind of infection whatsoever and whom I'm not 100% committed to discharging.

EM/CCM here. No. It’s insane. You’re right.

 

[docB]

This slave to the metric, "everyone gets everything" approach to sepsis is hurting patients. It's just wrong.

 

[deleted245139]

I'm the chair for my hospital systems Sepsis initiative.... We don't use it. We aim for a goal and time in under 1h, but hold people to under 3h. Took some references to the Chest and Lancet papers to get CMO and quality buy in, but was worth it. It's just not realistic.

 

[Ceke2002]

Excuse me for butting in a moment. I'm just curious, I've overheard Doctors talk in EDs here (Australia) about the annoyances of having some sort of paint by numbers sepsis checklist for anyone with XYZ symptoms, but they also seem to be pretty quick to spot sepsis and start treatment when they see it. So why the need for this whole protocol thing?

For example, and just to make this clear unless any of you happen to know how to raise the dead I'm certainly not asking for medical advice...anyway, say for example you had a 76 year old woman bought in by ambulance after an unwitnessed collapse in a nursing home. Late stage dementia, extremely frail, temp of 104, tachycardic, initial pulse ox of 87 corrected with supplemental oxygen, hypokalemic, Hypomagnesic, hypophosphatemia, elevated cardiac troponins, patient is combative, disoriented, and mostly incoherent except for being able to indicate severe pain in the legs, and stating that she's dying.

Seriously, do you guys even need some protocol in place to pick up that you've most likely got a sepsis case on your hands and to start treatment accordingly? I mean I'm a lay person, and as soon as the hospital told me my Mum's symptoms (yes the above example is my Mother) the first thing I said to my husband is 'I think this is sepsis'. Blind freddy could've picked up that it was sepsis, so yeah I really don't get the need for a 'sepsis' protocol, and hitting the panic button for anyone that comes in with a fever and a few other vague symptoms.

 

[TooMuchResearch]

They apply protocols like this to anyone who maybe could have sepsis. That includes someone with a heart rate of 90 (which isn't technically abnormal for anything other than possible infection), no fever, who an hour later is found to have a slightly elevated white blood cell count, who the doctor still isn't sure has a significant infection. I've described most patients with kidney (actually ureter) stones, the majority of whom do not have an infection.

Excuse me for butting in a moment. I'm just curious, I've overheard Doctors talk in EDs here (Australia) about the annoyances of having some sort of paint by numbers sepsis checklist for anyone with XYZ symptoms, but they also seem to be pretty quick to spot sepsis and start treatment when they see it. So why the need for this whole protocol thing?

For example, and just to make this clear unless any of you happen to know how to raise the dead I'm certainly not asking for medical advice...anyway, say for example you had a 76 year old woman bought in by ambulance after an unwitnessed collapse in a nursing home. Late stage dementia, extremely frail, temp of 104, tachycardic, initial pulse ox of 87 corrected with supplemental oxygen, hypokalemic, Hypomagnesic, hypophosphatemia, elevated cardiac troponins, patient is combative, disoriented, and mostly incoherent except for being able to indicate severe pain in the legs, and stating that she's dying.

Seriously, do you guys even need some protocol in place to pick up that you've most likely got a sepsis case on your hands and to start treatment accordingly? I mean I'm a lay person, and as soon as the hospital told me my Mum's symptoms (yes the above example is my Mother) the first thing I said to my husband is 'I think this is sepsis'. Blind freddy could've picked up that it was sepsis, so yeah I really don't get the need for a 'sepsis' protocol, and hitting the panic button for anyone that comes in with a fever and a few other vague symptoms.

 

[TooMuchResearch]

We're not doing doing one hour sepsis. We've at this point kept the hospital systems on our side and the patients side.

 

[bravotwozero]

Yeah fortunately no one hour sepsis at my place either. 3 hours is usually enough time for me to figure out a possible source, pick the right antibiotic, determine if fluid boluses should be given etc. Can't imagine doing that in 1 hour.

 

[bougiecric]

Yeah fortunately no one hour sepsis at my place either. 3 hours is usually enough time for me to figure out a possible source, pick the right antibiotic, determine if fluid boluses should be given etc. Can't imagine doing that in 1 hour.

Here's how it works in practice at an HCA facility: if you have SIRS criteria on arrival you immediately get a dose of ceftriaxone. This is not sarcasm. This is how it's actually done.

 

[RustedFox]

Here's how it works in practice at an HCA facility: if you have SIRS criteria on arrival you immediately get a dose of ceftriaxone. This is not sarcasm. This is how it's actually done.

Quoted for truth.
They tried to tell us that it was as harmless as a dose of aspirin in a conference call.

I opened my mouth to point out this obvious falsehood and was told:

"There's no cheese at the end of this mousehole, Rusty."

I was livid.

 

[ShockIndex]

EM/CCM here. No. It’s insane. You’re right.

I’m seriously hoping that CLOVERS curtails some of the insanity. Unfortunately, I think that it’s poorly designed and likely to be a negative study.

 

[hundreddaysoff]

Here's how it works in practice at an HCA facility: if you have SIRS criteria on arrival you immediately get a dose of ceftriaxone. This is not sarcasm. This is how it's actually done.

Yes, depending on the provider this actually happens.

Most attendings are good enough not to order this on any patient they think has a viral infection and plan to discharge. Eg, a 21yo male w/ the flu who is here for a work note.

Some midlevels, not so much. Then the 21yo male ends up staying in the ER for >2 hours and several other bad things happen as well.

And you don't even need both SIRS criteria to get ceftriaxone on arrival, just one, as we haven't checked the white count yet, and yes of course we're gonna check the white count, and then there might be leukocytosis!

 

[GeneralVeers]

I actively intervene when they call "code sepsis" overhead on young, healthy patients with fevers. I cancel any and all blood culture and antibiotic orders on them. I don't use the "sepsis orderset" as I really don't want any order with the word "sepsis" on it for a patient I'm likely discharge.

It takes 1-2 hours to get labs back. What is so wrong about waiting for some lab results before calling sepsis?

 

[docB]

Seriously, do you guys even need some protocol in place to pick up that you've most likely got a sepsis case on your hands and to start treatment accordingly?

We don't need it. The problem is that here in the states the government made sepsis treatment a measure of hospital quality. If a patient is felt to have been septic later on or if they turn septic later in their admission and we did not implement certain treatments our hospitals get punished and consequently they punish us. To meet these dubious metrics we become obligated to do things that can be bad for patients like giving them massive amounts of IV fluids and big doses of kidney toxic antibiotics. And we are forced to do these things to many patients unnecessarily because some of them might be or might become septic later. There is relatively little blow back for applying these "treatments" to patients who don't need them, other than trying to sleep at night, while the cost of missing even one is steep.

Quoted for truth.
They tried to tell us that it was as harmless as a dose of aspirin in a conference call.

I opened my mouth to point out this obvious falsehood and was told:

"There's no cheese at the end of this mousehole, Rusty."

I was livid.

I attest to this. I have been in the exact same meeting. In ours we were told that lactate costs the patient only $4 and that the order for 30mL/Kg NS IVF only activates for the nurses if the patient has a hypotensive MAP. When both of these turned out to be false we were told that we are to order the lactates no matter what so cost is irrelevant and that if a sepsis patient gets overloaded they are to be intubated as the hypovolemia is worse than being on the vent. When we asked about the non septic patients who generate the dreaded "sepsis alert" getting all that fluid we were assured that they would get back to us. 2 years now, they haven't gotten back.

I actively intervene when they call "code sepsis" overhead on young, healthy patients with fevers. I cancel any and all blood culture and antibiotic orders on them. I don't use the "sepsis orderset" as I really don't want any order with the word "sepsis" on it for a patient I'm likely discharge.

It takes 1-2 hours to get labs back. What is so wrong about waiting for some lab results before calling sepsis?

I was as you are. But I now have 2 OPPE events which will affect my next recredential. One time a patient that actually was septic got 50mL less than 30mL/Kg. I'm not sure why but it was assigned to me as a miss. The other one was a patient who met "sepsis criteria" although what was really driving their problems was a separate issue. They had a lactate of 2.1 and I failed to order a repeat. We have a utilization review feature in our EMR that makes us reaffirm any duplicate testing. Since I really didn't care about the 2.1 (top normal for us is 2) I clicked that I didn't need it repeated. That click has cost me dearly.

 

[Fox800]

We don't need it. The problem is that here in the states the government made sepsis treatment a measure of hospital quality. If a patient is felt to have been septic later on or if they turn septic later in their admission and we did not implement certain treatments our hospitals get punished and consequently they punish us. To meet these dubious metrics we become obligated to do things that can be bad for patients like giving them massive amounts of IV fluids and big doses of kidney toxic antibiotics. And we are forced to do these things to many patients unnecessarily because some of them might be or might become septic later. There is relatively little blow back for applying these "treatments" to patients who don't need them, other than trying to sleep at night, while the cost of missing even one is steep.

I attest to this. I have been in the exact same meeting. In ours we were told that lactate costs the patient only $4 and that the order for 30mL/Kg NS IVF only activates for the nurses if the patient has a hypotensive MAP. When both of these turned out to be false we were told that we are to order the lactates no matter what so cost is irrelevant and that if a sepsis patient gets overloaded they are to be intubated as the hypovolemia is worse than being on the vent. When we asked about the non septic patients who generate the dreaded "sepsis alert" getting all that fluid we were assured that they would get back to us. 2 years now, they haven't gotten back.

I was as you are. But I now have 2 OPPE events which will affect my next recredential. One time a patient that actually was septic got 50mL less than 30mL/Kg. I'm not sure why but it was assigned to me as a miss. The other one was a patient who met "sepsis criteria" although what was really driving their problems was a separate issue. They had a lactate of 2.1 and I failed to order a repeat. We have a utilization review feature in our EMR that makes us reaffirm any duplicate testing. Since I really didn't care about the 2.1 (top normal for us is 2) I clicked that I didn't need it repeated. That click has cost me dearly.

Time to find a new job. Or a new medical director/chairman. Or both.

 

[hundreddaysoff]

I attest to this. I have been in the exact same meeting. In ours we were told that lactate costs the patient only $4 and that the order for 30mL/Kg NS IVF only activates for the nurses if the patient has a hypotensive MAP. When both of these turned out to be false we were told that we are to order the lactates no matter what so cost is irrelevant and that if a sepsis patient gets overloaded they are to be intubated as the hypovolemia is worse than being on the vent. When we asked about the non septic patients who generate the dreaded "sepsis alert" getting all that fluid we were assured that they would get back to us. 2 years now, they haven't gotten back.

We are given many of the same talking points at our staff meetings, although I never heard the one about lactate only costing $4.

The intubation talking point is one they repeat all the time. At our last meeting, my hospital's medical director showed a bunch of fancy-looking charts allegedly suggesting that outcomes in fluid-overloaded patients who are given this sepsis protocol are still better off than if they were not given the fluids. So pushing back against this argument seems particularly important to our HCA admin, although I didn't bother to write down any of their references.

My understanding is that vs the old 3-hour protocol, HCA's version of the 1-hour requires that the 30mL/kg bolus be given for any severe sepsis (ie lactate >4), regardless of whether hypotension is present currently.

Don't get me wrong, I'm a big enough bastard that I have no trouble sleeping after doing stuff like this, although sometimes I randomly start to perseverate on the phrase "constructive intent" when I'm awake.

 

[hundreddaysoff]

I'm the chair for my hospital systems Sepsis initiative.... We don't use it. We aim for a goal and time in under 1h, but hold people to under 3h. Took some references to the Chest and Lancet papers to get CMO and quality buy in, but was worth it. It's just not realistic.

Did you get any sense of how your CMO, quality, etc admins learned about 1-hour sepsis and how they got the notion it might be a good idea?

I'm interested in whether admin is attracted to 1-hour sepsis more for profit reasons, more for CYA/PR reasons, or some other reason entirely.

I suspect an insidious outcome of 1-hour sepsis goes like this:

1. 21yo male w/ the flu who just wanted a work note goes home 3 hours later and tells all his friends and family, "they thought I had sepsis!" (Or maybe even "I have sepsis!" if our communication w/ him was less than perfect.)

2. Friends and family get concerned they might have sepsis too and so they go to the ER. Maybe some of them even have a pulse of 90 because they get so anxious about it.

3. $$$

 

[RustedFox]

Did you get any sense of how your CMO, quality, etc admins learned about 1-hour sepsis and how they got the notion it might be a good idea?

I'm interested in whether admin is attracted to 1-hour sepsis more for profit reasons, more for CYA/PR reasons, or some other reason entirely.

I suspect an insidious outcome of 1-hour sepsis goes like this:

1. 21yo male w/ the flu who just wanted a work note goes home 3 hours later and tells all his friends and family, "they thought I had sepsis!" (Or maybe even "I have sepsis!" if our communication w/ him was less than perfect.)

2. Friends and family get concerned they might have sepsis too and so they go to the ER. Maybe some of them even have a pulse of 90 because they get so anxious about it.

3. $$$

It's number three.
Oldest trick in the book.

1. Create a meaningless metric.
2. Flog doctors to meet this goal, or else.
3. Tie your own bonus to meeting the metric.
4. Point out how good you were at managing your team to achieve this goal, this justifying your bonus.
5. Profit.

 

[Brigade4Radiant]

I actively intervene when they call "code sepsis" overhead on young, healthy patients with fevers. I cancel any and all blood culture and antibiotic orders on them. I don't use the "sepsis orderset" as I really don't want any order with the word "sepsis" on it for a patient I'm likely discharge.

It takes 1-2 hours to get labs back. What is so wrong about waiting for some lab results before calling sepsis?

Yeah definitely not an HCA shop.

 

[hundreddaysoff]

3. Tie your own bonus to meeting the metric.

Sure, I understand the trick in theory, but it's this step that still confuses me.

How does the C-suite convince the board to give them more money if they meet the metric, but without risk to themselves if they don't?

Does C-suite tell board straight-up "1-hour sepsis will make us more profitable"? Do they hand out 10 year old clippings of editorials about Rory Staunton? Do they use some other BS evidence that doctors are not privy to? If they don't do any of this, then why would the board agree to 1-hour sepsis if it's not clear that it will either increase the company's short-term profit or decrease their legal/PR risk?

And how is it that out of what must be several hundred eminent and successful board members who have received this pitch at >=10 hospitals, none have been credulous enough to check the actual evidence and unintended damage like we do?

"Unlike our competitor hospital, we don't have a rule requiring doctors to charge patients thousands of dollars they don't have to drown them and give them drugs and testing they don't need" would be pretty damn effective advertising, I would think. But we never see that.

 

[Zebra Hunter]

Yeah definitely not an HCA shop.

I do the same thing, and I’m at an HCA shop.

 

[RustedFox]

Sure, I understand the trick in theory, but it's this step that still confuses me.

How does the C-suite convince the board to give them more money if they meet the metric, but without risk to themselves if they don't?

Does C-suite tell board straight-up "1-hour sepsis will make us more profitable"? Do they hand out 10 year old clippings of editorials about Rory Staunton? Do they use some other BS evidence that doctors are not privy to? If they don't do any of this, then why would the board agree to 1-hour sepsis if it's not clear that it will either increase the company's short-term profit or decrease their legal/PR risk?

And how is it that out of what must be several hundred eminent and successful board members who have received this pitch at >=10 hospitals, none have been credulous enough to check the actual evidence and unintended damage like we do?

"Unlike our competitor hospital, we don't have a rule requiring doctors to charge patients thousands of dollars they don't have to drown them and give them drugs and testing they don't need" would be pretty damn effective advertising, I would think. But we never see that.

I respect your posts and input, but you far underestimate cronyism and billing opacity.

The "risk" to them is as simple as "I don't get my bonus if I fail to manage my docs to success. Success that I define."

You think the B-school jackasses care about EVIDENCE?

The only thing that they care about is stroking themselves.

I have zero respect for any of these people.

Wait... The hammer just struck the hot metal.

Good post coming tomorrow on this topic. Stay tuned to this thread.

 

[TooMuchResearch]

That's some good Bluth Frozen Banana Stand level advertising.

Sure, I understand the trick in theory, but it's this step that still confuses me.

How does the C-suite convince the board to give them more money if they meet the metric, but without risk to themselves if they don't?

Does C-suite tell board straight-up "1-hour sepsis will make us more profitable"? Do they hand out 10 year old clippings of editorials about Rory Staunton? Do they use some other BS evidence that doctors are not privy to? If they don't do any of this, then why would the board agree to 1-hour sepsis if it's not clear that it will either increase the company's short-term profit or decrease their legal/PR risk?

And how is it that out of what must be several hundred eminent and successful board members who have received this pitch at >=10 hospitals, none have been credulous enough to check the actual evidence and unintended damage like we do?

"Unlike our competitor hospital, we don't have a rule requiring doctors to charge patients thousands of dollars they don't have to drown them and give them drugs and testing they don't need" would be pretty damn effective advertising, I would think. But we never see that.

 

[TooMuchResearch]

Looking forward to it!

I respect your posts and input, but you far underestimate cronyism and billing opacity.

The "risk" to them is as simple as "I don't get my bonus if I fail to manage my docs to success. Success that I define."

You think the B-school jackasses care about EVIDENCE?

The only thing that they care about is stroking themselves.

I have zero respect for any of these people.

Wait... The hammer just struck the hot metal.

Good post coming tomorrow on this topic. Stay tuned to this thread.

 

[deleted245139]

Did you get any sense of how your CMO, quality, etc admins learned about 1-hour sepsis and how they got the notion it might be a good idea?

I'm interested in whether admin is attracted to 1-hour sepsis more for profit reasons, more for CYA/PR reasons, or some other reason entirely.

I suspect an insidious outcome of 1-hour sepsis goes like this:

1. 21yo male w/ the flu who just wanted a work note goes home 3 hours later and tells all his friends and family, "they thought I had sepsis!" (Or maybe even "I have sepsis!" if our communication w/ him was less than perfect.)

2. Friends and family get concerned they might have sepsis too and so they go to the ER. Maybe some of them even have a pulse of 90 because they get so anxious about it.

3. $$$

TBH, it really came across as a misguided goal of a few quality people who misinterpreted the data.

I think they meant well, but it's like a shiny new toy. I actually leaned into my infectious dz group regarding antibiotic stewardship, and it pushed us just enough to clear the iceberg lol.

The reality is, labs can straight up TAKE an hour to result. So to tell people to have the definition right (and have evidence of organ inj) before treatment, but also not miss it, it becomes an impossible task.

I'll be frank too... I feel conflicted because when you see mortality numbers month over month in people who had a 72h slow crash in a Unit, with their death attributable to a PNA or a UTI.... Well yeah. Great. Know what they needed? A code discussion months prior. A Pal care consultation the hospitalization prior. Or prior to that. We need antibiotic stewardship. I want these things to work for my kids.

I've done A LOT of committee and leadership work.... This has by far been one of the toughest.

 

[ShockIndex]

I respect your posts and input, but you far underestimate cronyism and billing opacity.

The "risk" to them is as simple as "I don't get my bonus if I fail to manage my docs to success. Success that I define."

You think the B-school jackasses care about EVIDENCE?

The only thing that they care about is stroking themselves.

I have zero respect for any of these people.

Wait... The hammer just struck the hot metal.

Good post coming tomorrow on this topic. Stay tuned to this thread.

This is why having EP leadership in the hospital is vital to physician wellbeing. I can’t stress how important it is to inquire about EP leadership in the hospital at any job interview. Having the ED Director on Med Exec Committee is the bare minimum leadership - without it you have no voice. DO NOT TAKE A JOB WHERE THE ED DIRECTOR IS NOT ON THE HOSPITAL MEDICAL EXECUTIVE COMMITTEE. That means the hospital does not see the ED as an important service line. That also an ominous sign for the contract.

Having an EP as a current or past Chief of Staff is great; having an EP CMO is often pure gold. They have the Boards ear and can head off crazy talk from admin. My experience is that docs are happiest when EPs sit in one of these spots.

 

[RustedFox]

Having an EP as a current or past Chief of Staff is great; having an EP CMO is often pure gold. They have the Boards ear and can head off crazy talk from admin. My experience is that docs are happiest when EPs sit in one of these spots.

I was saving this for later on today, but at my HCA gig we had an EP (retired) CMO. Instead of pure gold, it was the kiss of Judas.

 

[ShockIndex]

Notice I carefully qualified my comment with the word “often.” I’m very aware that completion of an EM residency is not proof against douchiness.

 

[littlejuan]

I'm glad I don't have to deal with this crap at my gig. If WE think it is sepsis, the goals are 30cc/kg by 2 hours and antibiotics by 3. If the lactic acid is elevated, the sepsis alert is only triggered once the nurse confirms with us that we believe it is sepsis.

 

[RustedFox]

I'm glad I don't have to deal with this crap at my gig. If WE think it is sepsis, the goals are 30cc/kg by 2 hours and antibiotics by 3. If the lactic acid is elevated, the sepsis alert is only triggered once the nurse confirms with us that we believe it is sepsis.

You mean a physician makes clinical decisions in real time and not a panel of old fat vasculopaths who don't know their olecranon from their occiput?

Sign me up.

 

[TooMuchResearch]

Wtf is a sepsis alert?

 

[thegenius]

Time to find a new job. Or a new medical director/chairman. Or both.

If only that were really easy. Or even moderately easy. Or like 6 months in the future you'll have a new job.

Sometimes that is very difficult to do

 

[littlejuan]

Wtf is a sepsis alert?

the entire ER apparently has to know that we got the sepsis. I guess they think it makes the nurses work harder? I dunno.

 

[hundreddaysoff]

Wtf is a sepsis alert?

At my shop, it's a little clickybox that HCA made pop up for any pt w/ pulse of 90 and WBC of 13.

They used to actually page them overhead, but I guess they were paging too much and it was waking up the admin on call too often or something.

 

[TooMuchResearch]

What does it do?

At my shop, it's a little clickybox that HCA made pop up for any pt w/ pulse of 90 and WBC of 13.

They used to actually page them overhead, but I guess they were paging too much and it was waking up the admin on call too often or something.

 

[hundreddaysoff]

What does it do?

It warns me that I'm probably gonna get a sepsis re-education email from our sepsis coordinator (if s/he hasn't quit in frustration yet?) and possibly one from my medical director if I cause a "sepsis fallout", ie admit this pt w/o having done the whole sepsis shtick within 1h of triage.

 

[docB]

Sorry. Responding to a lot of good or interesting points here. Bear with me.

Time to find a new job. Or a new medical director/chairman. Or both.

This ties into the comments about having EPs in leadership.

This is why having EP leadership in the hospital is vital to physician wellbeing. I can’t stress how important it is to inquire about EP leadership in the hospital at any job interview. Having the ED Director on Med Exec Committee is the bare minimum leadership - without it you have no voice. DO NOT TAKE A JOB WHERE THE ED DIRECTOR IS NOT ON THE HOSPITAL MEDICAL EXECUTIVE COMMITTEE. That means the hospital does not see the ED as an important service line. That also an ominous sign for the contract.

Having an EP as a current or past Chief of Staff is great; having an EP CMO is often pure gold. They have the Boards ear and can head off crazy talk from admin. My experience is that docs are happiest when EPs sit in one of these spots.

I was saving this for later on today, but at my HCA gig we had an EP (retired) CMO. Instead of pure gold, it was the kiss of Judas.

We have this, and they oppose stuff when they should, but they've been steamrolled by this. I have noticed that even good leadership is powerless in the face of national, corporate or CMS actions. In my system every ED site dir is on Med Exec. We have 1 chief of staff, the system Chief Quality Officer and the Chairman of Pharmacy and Therapeutics. They try and do prevent a lot of badness and silliness from hitting us. Luckily ours aren't Judases (Judi?). But they're powerless on many things.

We are given many of the same talking points at our staff meetings, although I never heard the one about lactate only costing $4.

The intubation talking point is one they repeat all the time. At our last meeting, my hospital's medical director showed a bunch of fancy-looking charts allegedly suggesting that outcomes in fluid-overloaded patients who are given this sepsis protocol are still better off than if they were not given the fluids. So pushing back against this argument seems particularly important to our HCA admin, although I didn't bother to write down any of their references.

My understanding is that vs the old 3-hour protocol, HCA's version of the 1-hour requires that the 30mL/kg bolus be given for any severe sepsis (ie lactate >4), regardless of whether hypotension is present currently.

I think there has been a lot of effort to make all of these metrics shorter term so they can be completed in the EDs. We tend to be easier to control than the doctors inside the hospitals. We're not the only ones who are contract docs anymore but it's easy to stick us with short term metrics (e.g. 1 or 3 hours) whereas the inpatient docs tend to be tied to discharge metrics.

Sure, I understand the trick in theory, but it's this step that still confuses me.

How does the C-suite convince the board to give them more money if they meet the metric, but without risk to themselves if they don't?

Does C-suite tell board straight-up "1-hour sepsis will make us more profitable"? Do they hand out 10 year old clippings of editorials about Rory Staunton? Do they use some other BS evidence that doctors are not privy to? If they don't do any of this, then why would the board agree to 1-hour sepsis if it's not clear that it will either increase the company's short-term profit or decrease their legal/PR risk?

And how is it that out of what must be several hundred eminent and successful board members who have received this pitch at >=10 hospitals, none have been credulous enough to check the actual evidence and unintended damage like we do?

"Unlike our competitor hospital, we don't have a rule requiring doctors to charge patients thousands of dollars they don't have to drown them and give them drugs and testing they don't need" would be pretty damn effective advertising, I would think. But we never see that.

I think they're being fed info that the sepsis pathways cut length of stay and ICU length of stay. MBAs can't really look at medical data and understand the weaknesses. They also don't get that cutting down a septic patient's ICU stay when you tube 2 fluid overloaded patients and dialyze a vanco renal patient isn't a net positive.

TBH, it really came across as a misguided goal of a few quality people who misinterpreted the data.

Just like how Core Measures rolled out.

Wtf is a sepsis alert?

In our EMR there is an algorithm that causes a symbol to appear on a patient's track listing that denotes they are felt to be high risk for sepsis. We are not required, but it is highly recommended, that we order the Sepsis Protocol on all of these patients. No one that we have been able to reach, including our "sepsis coordinators," have been able to find out what exactly is in this algorithm. It seems really conservative and hits on most meth patients in the summertime, seizures, heat exhaustions and others that hit some SIRS points.

 

[ShockIndex]

What does it do?

I tells the nurse to collect the piss in the urinal and send it to the lab...

 

[turkeyjerky]

My old shop started with a process where every single sepsis metric fallout automatically got sent to peer review. At least half were for issues from later in the hospitalization or for RN specific issues. Most of the remainder were for patients who got good care, such as not getting fluid boluses for their CHF exacerbation or zosyn for their c diff, etc. OFI's ("opportunity for improvement" eg a negative peer review for the doc) were pretty uncommon (despite admin really pushing us to give negative reviews) but we were wasting an hour or two going over these cases every month. (not to mention the immeasurable time spent defensively charting on patients to defend against the possibility of a fallout)

Eventually we were able to get them to stop this goat rodeo and just let each doc know in a public email if they had a fallout. (Honestly, this wasn't so bad as you got to see each of your own and everyone else's fallouts without the stress of worrying about peer review).

After about 9 months, they changed back and just said that every single sepsis fallout would be an automatic OFI. No discussion, no matter if care was completely appropriate. Thank god I got out of there soon after.

 

[Janders]

It's amazing how twisted the sepsis metrics have become in various systems/hospitals

SEP-1 is NOT a pay for performance measure, nor has CMS actually stated the goal adherence rate. Yes, they've actually come out and stated 100% compliance is NOT the goal, as they understand some cases have medial reasons not to complete each step.

it took a fair amount of work, but it is NOT an issue where I work. Why? Well we DID review all the fall outs for a few months. And we fixed the various system issues that needed fixing:
--Making and automated serial lactate order, if the first is abnoral
--encourage processes where blood cx are timed/collected before abx
--arrange 30mL/kg bolus orders to be available, so people don't order 2L and miss by 50mL.
--Educate on allowable loopholes (you can use 30mL/kg of IBW in the obese with BMI >30! Patient refusal is a valid loophole!)
etc

This improved our "success" rate to 50% or so. And guess what? We all agreed we were doing awesome. The fallouts were BS, or valid reasons (not giving Zosyn to Cdiff patients; appropriately treating MRSA with Vancomycin alone; not flooding DNI patients).

And so we agreed (clinical MD leadership, Quality, C-suite, RN leadership) that our goal is High Quality Patient Care, not hitting a metric and harming patients. So we stopped worrying about "imperfect" scores.

The KEY is that it is currently not a pay-for-performance metric. When no massive cash is up for grabs, you can convince everyone to do the right thing... at least we've had that experience.

Now some metrics ARE pay-4-performance and... its hard to avoid those.

 

[Ceke2002]

We don't need it. The problem is that here in the states the government made sepsis treatment a measure of hospital quality. If a patient is felt to have been septic later on or if they turn septic later in their admission and we did not implement certain treatments our hospitals get punished and consequently they punish us. To meet these dubious metrics we become obligated to do things that can be bad for patients like giving them massive amounts of IV fluids and big doses of kidney toxic antibiotics. And we are forced to do these things to many patients unnecessarily because some of them might be or might become septic later. There is relatively little blow back for applying these "treatments" to patients who don't need them, other than trying to sleep at night, while the cost of missing even one is steep.

But like, sorry I'm just trying to wrap my head around this, don't they trust you to apply the medical knowledge that you have in determining the best course for each individual patient's care? So they expect you to just start a treatment protocol before you've even had any sort of confirmation that you are dealing with Sepsis? That seems a bit overboard to me, I mean they can't wait 15 or so minutes for tests to come back and the possibility of Sepsis to be confirmed, or at least heavily indicated, before you start loading a patient up with fluids and antibiotics?

I'm just thinking of the situation with my Mum. From the time I got the call to say she had arrived at hospital, to the time I received a call from one of the treating Doctors was only about 25-30 minutes, and in that time they'd already completed a full examination, got blood test results back and started treatment. Now about an hour after she arrived at hospital Mum's blood pressure crashed, and she did go into full septic shock and then acute renal failure, but I don't think Doctors not starting treatment the second she was wheeled in was gonna make any difference to that outcome. Treatment was started in a timely manner, in my opinion, but for various reasons Mum was simply too unwell for the outcome to have been any different at that stage (I was the one who ultimately made the decision to withdraw treatment & go to end of life care). That's not the fault of the medical staff, or not having some BS sounding protocol in place.

Is it more of a CYA situation in the states? Hospital admins et al think they need to have these sorts of protocols in place so people don't sue when they're loved one dies? I guess I just don't get how the US system works sometimes.

 

[hundreddaysoff]

But like, sorry I'm just trying to wrap my head around this, don't they trust you to apply the medical knowledge that you have in determining the best course for each individual patient's care? So they expect you to just start a treatment protocol before you've even had any sort of confirmation that you are dealing with Sepsis? That seems a bit overboard to me, I mean they can't wait 15 or so minutes for tests to come back and the possibility of Sepsis to be confirmed, or at least heavily indicated, before you start loading a patient up with fluids and antibiotics?

TL;DR No, the powers that be do not trust us to use our best judgment here. In fact, the end result of 1-hour sepsis is that it does not even give us time to make a judgment. All these rules seem a bit overboard to many of us doctors in the trenches as well. More than that, we are afraid that these mindless rules are actively harming some of our patients in a number of ways and that they may also be a detriment to global health in the next few decades by spreading antibiotic resistance.

The party line in the US since a famous study in the 2000s (Rivers et al) is that sepsis is a hidden killer, doctors are very bad at diagnosing it because the symptoms are very nonspecific (ie, there is no single test for it even if tests actually resulted in 15 minutes rather than 1-2 hours as they often do here), and it can escalate from mild symptoms to multiorgan failure within a matter of hours.

The Rivers et al study has since become a bit controversial. The main alternate hypothesis is that as long as doctors consider sepsis in patients at risk for it and excellent and attentive nursing is provided for hospitalized patients, there is no difference in outcomes between using the common-sense approach that you mention and applying a sepsis protocol.

This all became a bit twisted with the bizarre death in 2012 of Rory Staunton, a boy from an affluent family in NY who died of sepsis shortly after being seen in the ER for what appeared to be a mild wound. The NY Times picked up and ran with his story as one of their reporters was a family friend. This event did make the whole thing a bit of a CYA situation. Since then, hospitals, the government, and other organizations have been creating stricter and stricter protocols to treat sepsis in patients who have any chance whatsoever, however tiny, of being septic. As Janders mentions, the main government sepsis protocol (SEP-1) has no bad financial repercussions to hospitals if it is not followed; it is a reporting mandate only. However, many medical people misinterpret this and think hospitals do lose government money or otherwise get punished for sepsis fallouts, and AFAICT hospital admin do nothing to disabuse them of this notion, possibly because...

...It also just so happens that there is some potential profit involved here for hospitals, as they are in the business of selling antibiotics and IV fluids. So the incentives in our healthcare system can get a bit perverse. More tests/drugs given = more "care" = more money for hospitals and, admittedly, for myself.

And even if there was no money involved, I agree w/ above posters that a lot of this is like a game of telephone. You have "quality" admins and other do-gooders, who do not actually provide patient care and may never even have been trained on how to read a scientific paper, misinterpreting the actual data, perhaps willfully, as well as ignoring the hidden harms done by all these policies, perhaps in order to signal to themselves or others that they really care about patients and can really change the world and make a difference in things blah blah blah. They often make policies without the input of the doctors and nurses in the trenches, and given hospital admin's perverse incentives, hospital admin really has no reason to veto their policies. And doctors, nurses, and patients are the ones who actually need to live with the consequences of these policies.

Don't get me wrong, I'm not complaining and I still like my job. But I have very little autonomy and many of "my" medical decisions are ultimately driven by other people's fear, greed, solipsism, and misplaced idealism that approaches magical thinking.

And of course the extent to which this rant applies varies among US hospitals, as you can see from the great anecdotes in this thread.

 

[Ceke2002]

TL;DR No, the powers that be do not trust us to use our best judgment here. In fact, the end result of 1-hour sepsis is it does not even give us time to make a judgment. All these rules seem a bit overboard to most of us doctors in the trenches as well. More than that, we are afraid that these mindless rules are actively harming some of our patients in a number of ways and that they may also be a detriment to global health in the next few decades by spreading antibiotic resistance.

The party line in the US since a famous study in the 2000s (Rivers et al) is that sepsis is a hidden killer, doctors are very bad at diagnosing it because the symptoms are very nonspecific (ie, there is no single test for it even if tests actually resulted in 15 minutes rather than 1-2 hours as they often do here), and it can escalate from mild symptoms to multiorgan failure within a matter of hours.

The Rivers et al study has since become a bit controversial. The main alternate hypothesis is that as long as doctors consider sepsis in patients at risk for it and excellent and attentive nursing is provided for hospitalized patients, there is no difference in outcomes between using the common-sense approach that you mention and applying a sepsis protocol.

This all became a bit twisted with the bizarre death in 2012 of Rory Staunton, a boy from an affluent family in NY who died of sepsis shortly after being seen in the ER for what appeared to be a mild wound. The NY Times picked up and ran with his story as one of their reporters was a family friend. This event did make the whole thing a bit of a CYA situation. Since then, hospitals, the government, and other organizations have been creating stricter and stricter protocols to treat sepsis in patients who have any chance whatsoever, however tiny, of being septic. As Janders mentions, the main government sepsis protocol (SEP-1) has no bad financial repercussions to hospitals if it is not followed; it is a reporting mandate only. However, many medical people misinterpret this and think hospitals do lose government money or otherwise get punished for sepsis fallouts, and AFAICT hospital admin do nothing to disabuse them of this notion, possibly because...

...It also just so happens that there is some potential profit involved here for hospitals, as they are in the business of selling antibiotics and IV fluids. So the incentives in our healthcare system can get a bit perverse. More tests/drugs given = more "care" = more money for hospitals and, admittedly, for myself.

And even if there was no money involved, I agree w/ above posters that a lot of this is like a game of telephone. You have "quality" admins and other do-gooders, who do not actually provide patient care and may never even have been trained on how to read a scientific paper, misinterpreting the actual data, perhaps willfully, as well as ignoring the hidden harms done by all these policies, perhaps in order to signal to themselves or others that they really care about patients and can really change the world and make a difference in things blah blah blah. They often make policies without the input of the doctors and nurses in the trenches, and given hospital admin's perverse incentives, hospital admin really has no reason to veto their policies. And doctors, nurses, and patients are the ones who actually need to live with the consequences of these policies.

Don't get me wrong, I'm not complaining and I still like my job. But I have very little autonomy and many of "my" medical decisions are ultimately driven by other people's fear, greed, solipsism, and misplaced idealism that approaches magical thinking.

Honestly that just sounds convoluted and insane. I get that something not being caught in time that results in death should require at least a review of certain things, but it seems like they just went way too far the other way and like you said are now exposing patients to risks like antibiotic resistance.

I should've mentioned as well that the 15 or so minute turn around for my Mum's blood results was likely because she was bought in, and triaged as a priority one emergency (highest level, pretty much straight to resuc) so they would've had a rush put on those. My understanding as well is that initially they only ran basics like electrolytes and cardiac enzymes, partly to determine her condition more fully and partly so they knew what treatment to implement without overloading her system. Like I said though I have no issue at all with the treatment she received, and I have never, and will never think that there was anything more that could have been done to save her. In all honesty I think the die was already cast the moment she collapsed at the nursing home.

Now having said that if it was, say for example, my niece, who is young, fit and well, and something major was missed that resulted in her death, well yeah I'd probably want some answers in that regard but not to the point of 'let's overhaul the system to the point of stupidity'. It does strike me as well that the US isn't just concerned with preventable deaths in cases like this, but that there's almost a denial or phobia of death across the board in a lot of cases. Like there's a non acceptance that sometimes death just happens regardless, so they system has all this stuff built into it to deny the reality of that.

 

[GeneralVeers]

Honestly that just sounds convoluted and insane. I get that something not being caught in time that results in death should require at least a review of certain things, but it seems like they just went way too far the other way and like you said are now exposing patients to risks like antibiotic resistance.

This is the insanity of American medicine. It's not that we don't provide enough care to people, but that we provide too much care. All of those unnecessary blood cultures, admissions, and antibiotics are very expensive and mostly unjustified. The stick of liability and the carrot of reimbursement drive hospitals to initiate insane protocols everything, including chest pain, stroke, and sepsis. Compound that with medically harmful efforts to improve patient satisfaction, and we waste billions of dollars.

 

[Ceke2002]

This is the insanity of American medicine. It's not that we don't provide enough care to people, but that we provide too much care. All of those unnecessary blood cultures, admissions, and antibiotics are very expensive and mostly unjustified. The stick of liability and the carrot of reimbursement drive hospitals to initiate insane protocols everything, including chest pain, stroke, and sepsis. Compound that with medically harmful efforts to improve patient satisfaction, and we waste billions of dollars.

Yeah I think that's a big difference between the US and Australia in that, at least with the two Australian States I've lived in (Adelaide, South Australia and now Melbourne, Victoria) there's more emphasis on patient outcomes not patient satisfaction. I remember one hospital in Adelaide trying to bring in a patient satisfaction survey in the ED, and seeing the patients in there one night (including myself) getting handed these surveys and just looking at the medical staff like, "Are you joking right now, what is this nonsense?" For all but the most entitled type folks the idea of viewing medicine as some sort of customer service gig is an anathema to most of us. We go to hospital to be treated for illness, not to purchase a consumer product.

 

[GeneralVeers]

" For all but the most entitled type folks the idea of viewing medicine as some sort of customer service gig is an anathema to most of us. We go to hospital to be treated for illness, not to purchase a consumer product.

That was my experience too on a med school rotation in Sydney. It's the main reason Australia is my backup plan when things get too bad here.

 

[docB]

As Janders mentions, the main government sepsis protocol (SEP-1) has no bad financial repercussions to hospitals if it is not followed; it is a reporting mandate only. However, many medical people misinterpret this and think hospitals do lose government money or otherwise get punished for sepsis fallouts, and AFAICT hospital admin do nothing to disabuse them of this notion, possibly because...

...It also just so happens that there is some potential profit involved here for hospitals, as they are in the business of selling antibiotics and IV fluids. So the incentives in our healthcare system can get a bit perverse. More tests/drugs given = more "care" = more money for hospitals and, admittedly, for myself.

I disagree. There is punishment for hospitals when there are fallouts. Just because it isn't in the form of reimbursements doesn't mean they take it less seriously or heap fewer consequences on the doctors. The compliance rates are published and available to the general public, insurers, competitors, etc. Want to see your hospital's compliance rate on this and other metrics and compare it to the other hospitals in your town? Go here:
www.medicare.gov/hospitalcompare/search.html
Enter your zip code and there you go.
Hospitals are as terrified of poor ratings on these metrics as they are of negative Yelp reviews. In my town one of the major insurers has recently put negative ratings on billboards to shame certain hospitals as a negotiating tactic. These fall outs are also used by reviewers for various entities like the Joint Commission and state licensing boards to look for problems. Many of hospitals I work in have a dedicated FTE to sepsis alone.

After about 9 months, they changed back and just said that every single sepsis fallout would be an automatic OFI. No discussion, no matter if care was completely appropriate. Thank god I got out of there soon after.

We are mired in this situation.

It's amazing how twisted the sepsis metrics have become in various systems/hospitals

SEP-1 is NOT a pay for performance measure, nor has CMS actually stated the goal adherence rate. Yes, they've actually come out and stated 100% compliance is NOT the goal, as they understand some cases have medial reasons not to complete each step.

Good point. You'll notice that on the CMS website above where you can compare hospitals they report compliance rates in raw percentages. There is no explanation to the public that 100% isn't the goal.