Advocate Aurora Health

A Pilot Project to Decrease Incidence of Community-Acquired Sepsis in an Ambulatory Setting

Project Lead: Debra O’Connor, DO

Project Aim(s)

Aim 1: Screen target population in outpatient setting for sepsis
  • Identify COVID-19 clinics and non-COVID-19 ambulatory sites to electronically screen patients for sepsis using the SIRS criteria.
  • Retrospectively and prospectively identify and screen patients for sepsis at all designated sites using SIRS criteria.

Aim 2: Follow patients who screen positive on care journey electronically

  • All patients who meet SIRS criteria will be further explored to identify pattern and trends which may have caused a misidentification in the clinical setting. 
Aim 3: Close loop with clinical staff after sepsis case is missed
  • Once a missing sepsis case is identified, a meeting will take place to identify the cause and an action plan will be created and disseminated to clinical team.
  • Synthesize lessons learned from Step 3.
Aim 4: Develop an educational campaign, ambulatory intervention, and workflow screening processes for post-COVID-19 ambulatory sites.
  • Based upon patterns and trends identified from "missed case" review, workflow process interventions will be identified, and an educational campaign developed. This is to be rolled out at three designated sites once staff has more bandwidth to implement the changes.

Narrative Description

It is believed that most cases of sepsis are acquired in the community versus in a health care setting. Patients are known to have functioned for weeks with no discernible signs of infection, ultimately resulting in sepsis and symptoms so severe that emergency care was needed. These sepsis cases should be diagnosed in ambulatory settings, before a person presents to an ED or an inpatient setting.  The elimination of preventable sepsis cases can be accomplished, in part, through early identification of sepsis patients in an ambulatory setting, by identifying, triaging, and following- up with patients who are diagnosed with sepsis in an outpatient clinic.  The team aimed to screen EMR data of patients in one outpatient clinic retrospectively and prospectively for sepsis using the SIRS criteria.  Positive screens were analyzed electronically to identify patterns and trends which may have caused a misidentification in the clinical setting.  If a case of sepsis was missed, the clinical team is notified and an action plan developed to address.  To support this process an educational campaign based on patterns and trends identified from the “missed case” review, the ambulatory intervention, and workflow screening processes for post-COVID-19 ambulatory sites will be developed for the remaining ambulatory clinics. 

Over the period of the project, 86,250 patients were seen but only 73,602 (85.34%) of patients had complete vitals (HR, RR, and temperature).  Of these, 1,619 (1.88%) patients met SIRS criteria.  Among patients who met SIRS criteria, 56% were female and 44 was the average age. Regarding vitals of those who met SIRS criteria, average pulse was 103.1 beats/minute, average temperature was 98.7 degrees Fahrenheit, and average respiratory rate was 20.9 breaths/minute.  Educational materials were integrated into care team huddles. However, there was no way to quantify the impact this had on communication because the planned intervention to notify clinical teams and develop action plans was put on hold due to the COVID-19 pandemic. Key findings from the analysis include: 

  1. Respiratory rate was the most missing vital, which is integral to assessing community acquired sepsis
  2. Patients presenting with symptoms indicative of sepsis (as indicated by the SIRS criteria) tend to be younger than assumed by some front-line staff.
  3. At our intervention site, 12.98% of pulse data and 15.52% of their respiratory rate data was missing however after the intervention, missing data decreased to 11.31% and 14.18%, respectively.  There may be many reasons for this but it is trending in the correct direction.

Because implementation of the intervention was delayed by the COVID-19 pandemic, the team convened a focus group where the nurses and MAs were able to explain their process of rooming patients and were eager to encourage their physician oversights to check vitals that were concerning to them. The focus group seemed to really empower staff to look for signs of sepsis and severity of sepsis.  Learnings include: 

  1. Clinical staff is very concerned about sepsis and was/is eager to do something to identify and combat it.
  2. Research findings can be better integrated into clinical operations.  Reporting is not done through research, which is standard, but research has the skills to explore datasets in a way that standard reporting may not which may be helpful to clinical staff.
  3. Nurses and MAs are eager to incorporate SIRS criteria into daily huddles
  4. Nurses and MAs felt that printouts of the SIRS criteria were better than integration into EMR, but the study teams feels like a combination of both will work best.  
  5. There is a lot of clinical variation when it comes to patient information at an appointment.  This only became clear to the project team – then the clinical staff – when presented with the findings for potential sepsis patients.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Workflow (includes testing, follow-up, and referrals)

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)