WASHINGTON, D.C.—“If you are not at the table, you are on the table.” That is how Eric D. Katz, MD, FACEP, chairman of the department of emergency medicine at Maricopa Integrated Health Systems and executive chairman and professor of the department of emergency medicine at the University of Arizona College of Medicine in Tucson, summarized the sepsis bundle debate among emergency physicians. Dr. Katz contended that the sepsis bundle has had both positive and negative consequences in the care of severely septic patient in the emergency setting.
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The Centers for Medicare and Medicaid Services (CMS) Core Measure Sepsis Bundle was implemented in October 2015. The focus was on early identification of patients in severe sepsis or septic shock, and it emphasized early treatment in the form of three- and six-hour bundles of care. National compliance hovers around 41 percent, with the initiation of fluid bolus therapy being missed the most in the three-hour bundle.
Dr. Katz said the way the sepsis bundle was implemented at his facility was consistent with other centers—a top-down, management-driven process that brought front line physicians late into the process. There was significant initial resistance from the medical staff who felt that the implementation was focused on compliance rather than quality patient care. Nevertheless, outcomes did improve in patients in severe sepsis, not because of the compliance, but rather due to a better understanding of how to identify and treat these situations.
Rather than focusing on bundle compliance, Dr. Katz recommended that the knowledge about why such changes are important be distributed to the staff tasked with implementation early, and framed within a patient-centered approach instead of compliance. Identifying the level of risk versus benefit to patients enrolled in the bundle can help reduce concerns; for example, a young patient with pharyngitis who meets criteria experiences low risk with a fluid bolus, while an older patient with suspected pneumonia and sepsis may experience high benefit.
Getting the emergency department team onto the same page is critical. Dr. Katz’s experience in his department was that the nurses were better able to identify patients meeting criteria when compared to the physicians during the triage process. The physician can down triage the patient upon reassessment. The result was that there was better compliance with bundle enrollment and decreased mortality.
Dr. Katz said that there needs to be better support from institutional leadership for front line staff to implement major changes in care. Physicians should be brought into planning discussions early, with a focus on patient care rather than compliance.
Severe sepsis management in the emergency department has improved significantly as knowledge and experience has expanded in this area. The negative consequences have been minor and positive outcomes have been significant. It was Dr. Katz’s belief that the CMS sepsis bundle will disappear as its required elements become the norm.