The Centers for Disease Control and Prevention (CDC) released the Hospital Sepsis Program Core Elements: 2023 to monitor and optimize hospital management and improve outcomes of sepsis. The Sepsis Core Elements (as it is referred to – I will abbreviate as SCE) are intended to “complement existing sepsis guidelines” and to help organizations develop additional guidelines for best-practice clinical care.
Sepsis is a leading cause of hospitalization and contributes to over a third of all hospital deaths. The SCE publication opens with the definition of sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” It reviews the evolution of clinical guidelines and notes that there has been great interest in developing clinical decision support tools to recognize and guide treatment of sepsis. The SCE notes that hospital sepsis quality improvement programs reduce hospital mortality, length of stay, and costs.
The SCE also lays out the process to develop a sepsis initiative. First, the individuals who will lead the program must be identified, and institutional leadership support must be procured. Having co-leaders be a physician and nurse is strongly recommended. Representatives from invested service lines should be gathered, such as infectious disease, critical care, emergency and hospital medicine, other primary services, nursing, pharmacy, and social work.
A needs analysis of the current state of the facility and the applicable regulatory and reporting requirements must be performed. Ambitious goals must be established based on the needs analysis. Sepsis must be a hospital priority, and staff buy-in must be effectuated.
Sufficient resources also must be allocated. This includes personnel, analytic support, and time. Sepsis activities must be integrated with other quality improvement and safety initiatives, like antimicrobial stewardship and Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1). Staff must be well-trained and held accountable. There must be collaboration across services, units, and the hospital system. Continual reassessment and updates of goals should be done at regular intervals.
The SCE spells out the steps and gives examples, but recommends that a formal structure for a quality improvement process be utilized. In the action step, they recommend implementation of a standardized screening process. This may be a paper-based or electronic tool, and may need to be done at recurring intervals if sepsis is initially not felt to be present. There are no clinically validated screening tools, but my strong advice is that regardless of what is used to trigger a second look (e.g., SIRS, SOFA, qSOFA), organ dysfunction needs to be present to diagnose sepsis.
Their next advice is to create and maintain a standardized care guideline in terms of clinical evaluation, treatment, and discharge planning. Hospital order sets can be designed and tailored to specific patient populations. Antibiotics should be administered promptly, followed by the next dose at the appropriate interval, continued for a reasonable duration, and discontinued when appropriate.
Development of a “code sepsis” protocol is also discussed. This harmonizes with a best-practice clinical care guideline and facilitates expedient treatment. The SCE also covers the common sequelae of sepsis and actions that can support recovery. Responsible care handoff is crucial to ensuring a patient has the best chance of returning to pre-sepsis or maximal function.
The section on tracking gives an overview of which metrics should be monitored and how to assess the success of the sepsis program. It may not be feasible to review every sepsis admission, but chart reviews of an adequate sample with root-cause analysis and process improvement consideration is recommended. Clinicians should receive feedback and education, informed by the chart reviews. Obviously, tracking must be combined with reporting.
It was noted that increased awareness of sepsis may lead to earlier recognition or inclusion of milder disease, which can lower perceived mortality from the disease. I will also add that including cases that only have SIRS without organ dysfunction (which many do not consider sepsis) will have the same effect.
The final step in the SCE is education. They do not limit it to healthcare providers, but include all patient-facing staff, trainees, patients, families, and caregivers. Patients who have had one episode of sepsis are at a higher risk for recurrent sepsis.
There are many resources offered in the SCE. The final offering is the Hospital Sepsis Program Core Elements Assessment Tool. It is a blueprint for hospitals to assess and optimize elements of sepsis care.
This publication is a welcome addition to the sepsis resources we have. Whether your institution uses “Sepsis-2” (which I strongly discourage) or has a pretty robust sepsis plan, I think the clinical leaders should read this document and review the guidelines. One-third of hospital deaths are due at least in part to sepsis – it’s time to do something about it.