We know that sepsis is a significant and frequent cause of hospitalization, and is responsible for hundreds of thousands of admissions and deaths annually in the United States.1,2 We also know that the treatment of sepsis and septic shock accounts for a huge financial burden to the healthcare system, with an annual cost approaching $20 billion.3,4
One driving factor in this huge financial liability is the length of stay (LOS) of these patients, which is reported as 75% longer for patients admitted with sepsis than those with other conditions.3 The Centers for Medicare and Medicaid Services (CMS) has therefore prioritized improvement of sepsis care by adopting specific sepsis and infection control measures.
The National Quality Forum created the “Early Management Bundle for Severe Sepsis and Septic Shock” measure as part of the Hospital Inpatient Quality Reporting (Hospital IQR) program in 2015.
The early identification and treatment of sepsis has been shown to improve outcomes and potentially reduce LOS.5 The bundle measure was created to encourage this evidence-based approach.
These bundle measures are meant to drive improvement in the quality of patient care by tying reimbursement to the completion of specific guidelines thought to improve outcomes. In this case, the CMS measure aligns hospital reimbursements with Surviving Sepsis Campaign guidelines.5 Through this sometimes controversial approach, hospitals are incentivized monetarily to provide appropriate clinical care.
What This Means for EMS
So how does this relate to prehospital providers and their ability to screen for septic patients? The fact is that it’s been shown that the majority of septic patients present to the ED,2 and the rate of patients presenting to the ED with sepsis has doubled since the year 2000.3
This suggests that initial diagnosis and sepsis care at the earliest possible point-of-contact should be a focus for all hospitals and emergency physicians. In fact, the CMS sepsis bundle includes metrics that must be met within a specific time period, so earlier diagnosis is likely to improve compliance.
More importantly, because a significant number of these patients are transported to the ED by EMS,6 prehospital screening for potentially septic patients is a viable plan to reduce time to diagnosis and lifesaving interventions, improve CMS sepsis bundle compliance, and assist hospitals in successful sepsis detection and management.
Benefit of Sepsis Alerts
The CMS sepsis bundle is based on two time periods: a three-hour window and a six-hour window. The guidelines require obtaining blood cultures, measuring lactate levels, and administering IV fluids and antibiotics within three hours of severe sepsis diagnosis.
That means the diagnosis first must be made or suspected, then lab work has to be sent off and interventions initiated. Several administrative tasks need to be accomplished before that can happen, including patient registration, evaluation by a provider, and obtaining IV access.
Within six hours of hospital arrival, the patient must also be reassessed for adequate tissue perfusion after a specific volume challenge, elevated lactate levels must be repeated, and vasopressor medication initiated if hypoperfusion is documented.
What these time periods mean for patient care, overall patient outcome, and hospital guideline compliance and reimbursement exhibit why hospitals should actively support the prehospital recognition and treatment of patients with suspected sepsis.
Not only can EMS play an active role in dramatically improving hospital compliance with several of these requirements and increase hospital revenue through CMS reimbursements received, but, more importantly, the combined efforts can save lives through early recognition and activating a hospital septic alert process.
Upon appropriate suspicion of severe sepsis made through evidence-based algorithms,7,8 EMTs and paramedics can provide pre-arrival notification to the receiving facility similar to what EMS and hospitals successfully developed for systems of care such as trauma, stroke and ST elevation myocardial infarction (STEMI). Each of these actions dramatically reduces the time to diagnosis and intervention.
Receiving hospitals can ensure immediate offload, registration and evaluation of the patient, reducing time to antibiotics and lab measurements. IV access obtained by EMS may reduce time to blood culture and lab draws, and the prehospital administration of IV fluids prior to arrival can minimize the time to initiation of this intervention, benefit the patient by early treatment and expedite time to appropriate re-evaluation after initial fluid resuscitation as dictated by the CMS bundle.
In effect, this collaboration creates a new system of care for sepsis treatment, linking prehospital evaluation, screening and intervention with definitive care in the hospital, and facilitating compliance with CMS-dictated standards.
Improved Outcomes Imminent
The most effective way for EMS providers to improve patient outcomes on a large scale is to build upon their systems of care. It’s our responsibility to screen patients for disease processes that may have improved outcomes with early identification and specific intervention in the field, and ensure they’re taken to the appropriate destination.
Along with STEMI, stroke and traumatic injuries, sepsis now falls into this category. However, there can be no improvement in the system of care without hospital cooperation. EMS systems must work with local hospitals to ensure that patients with positive screens for severe sepsis are approached in a manner that will improve evidence-based care.
Hospitals must be educated that prehospital involvement, and a protocol for early hospital alerting to potentially septic patients, may improve their ability to assess, treat and dramatically impact the severity and mortality of sepsis and meet CMS requirements for reimbursement.
The financial incentive to hospitals should be used as a tool to encourage hospitals to work with us. Collectively, we can see the same dramatic effects in the outcomes of septic patients that we have witnessed in trauma, STEMI and stroke care.
1. Angus D, Linde-Zwirble W, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310.
2. Wang HE, Shapiro NI, Angus DC, et al. National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007;35(8):1928–1936.
3. Hall MJ, Williams SN, DeFrances CJ, et al. Inpatient care for septicemia: A challenge for patients and hospitals. NCHS Data Brief. 2011;(62):1–8.
4. Torio CM, Andrews RM. (August 2013.) National inpatient hospital costs: The most expensive conditions by payer, 2011: Statistical brief #160. Healthcare Cost and Utilization Project. Retrieved July 26, 2016, from www.hcup-us.ahrq.gov/reports/statbriefs/sb160.pdf.
5. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637.
6. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study. J Crit Care. 2010;25(4):553–562.
7. Guerra WF, Mayfield TR, Meyers MS, et al. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013;44(6):1116–1125.
8. Hunter CL, Silvestri S, Ralls G, et al. A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis. Am J Emerg Med. 2016;34(5):813–819.