Pathway for early sepsis identification and treatment in the skilled nursing facility
Behrendt R, Cerasale M, Craft S, and Beg M. Pathway for early sepsis identification and treatment in the skilled nursing facility. J Hosp Med 2017; 12(s2)
J Hosp Med
Background: Following hospitalization, a reported 20% of all Medicare patients are discharged to skilled nursing facilities (SNFs). Sepsis was the cause of 25-68% of readmissions from SNFs based on a review of Medicare readmissions from patients at 96 SNFs in southeast Michigan. Sepsis is also the most common all-cause admission diagnosis and represents over $20 billion in hospital-related costs. There is limited literature on processes for the identification and treatment of sepsis in the post-acute care setting, and nearly all interventions implemented in SNFs were designed for acute care. Appropriate treatment of sepsis in early stages for all patients, but importantly those at SNFs, is a clear opportunity to improve patient care and cost. Purpose: The purpose of the project is to develop a protocol for the early identification and treatment of sepsis that fits into the clinical resources available at SNFs to reduce hospital transfers. Description: The pathway was designed to include evidence-based interventions to fit within resources easily available at SNFs. A resource assessment was performed by interviewing SNF nurses to identify barriers to effective implementation, which included different staffing models, complex interventions, and limited access to critical care. A model was built on three main activities of screen, treat, and transfer (Figure 1). An initial assessment tool was based on easy to collect patient variables: temperature, white blood cell count, and mental status. Treatment and monitoring steps were based on recommendations from the Surviving Sepsis Campaign. Transfer criteria were clearly defined to include end-organ dysfunction or vital sign instability. The entire pathway is encapsulated into a two-page worksheet for easy use at the facility (Figure 2). Implementation at the SNFs was completed in a train-the-trainer style session. Initial education sessions at pilot sites were completed to develop presentation style, which included a variety of learning modalities, simulated cases, and workflow demonstrations. Throughout the training, key stakeholders were identified and their unique roles within the pathway were more clearly defined. Initial data collection at each SNF will include facility census, number of hospital transfers, and number of patients who received care through the pathway. Conclusions: To implement a complex protocol in a specialized clinical setting, SNFs, requires a deep understanding of the available resources and identification and engagement of key stakeholders: certified nursing aids, nurses, and post-acute care physicians.