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Marilyn N. Bulloch, PharmD, BCPS, FCCM, and Daleen Penoyer, PhD, RN, CCRP, FCNS, FAAN, FCCM, discuss how to develop and operationalize performance improvement teams to implement the Surviving Sepsis Campaign’s (SSC) Hour-1 Bundle, which was developed in 2021 to minimize time to treatment for patients with sepsis and septic shock. Explore how to overcome barriers teams encounter in implementing the bundle, including inflexibility, lack of awareness about the bundle, competing priorities, and insufficient staffing. This podcast is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies. 0.25 hours of accredited continuing education credit is available for this podcast through May 31, 2024. Visit sccm.org/store for details.
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Transcript:
Sponsor: This podcast is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies.
Dr. Bulloch: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Marilyn Bulloch. Today, I’ll be speaking with Dr. Daleen Penoyer, PhD, RN, FCNS, FAAN, FCCM. We will be discussing implementing the Sepsis Hour-1 Bundle and the components, efficacies, and barriers to implementation. Dr. Penoyer serves as the director of the Center for Nursing Research at Orlando Health in Orlando, Florida, and is an active nurse scientist. She holds a PhD in nursing and is certified as a clinical research professional. With more than 45 years of nursing experience, she has held roles in academia, advanced clinical practice, research, and executive leadership in acute and critical care. Welcome, Dr. Penoyer. Before we start, do you have any disclosures to report?
Dr. Penoyer: No, I don’t.
Dr. Bulloch: Is there anything you want to lead off with today?
Dr. Penoyer: Sure. Thank you, Marilyn, for your kind introduction. First, I want to thank SCCM for this opportunity to participate in this wonderful podcast, and the Gordon and Betty Moore Foundation for their generous contributions to sepsis care. I do want to mention that this podcast complements a webcast presented by me and Dr. Kristine Lombardozzi on May 17, 2023. It’ll focus more on the elements of the Hour-1 Bundle, the barriers, and facilitators. This podcast, however, is intended really to describe the ways that the Hour-1 Bundle can be operationalized within an organization.
Dr. Bulloch: I imagine that webcast is going to be fascinating. I encourage all of our listeners, if you have an opportunity to go to the SCCM website and listen and watch that webcast, I know it will be educational for us all. Most of our listeners have heard about the concept of the Hour-1 Bundle and have more than likely used it in practice. But sometimes in medicine, we don’t always do a good job. We don’t always have the time to talk about why we do things. Perhaps our trainees sometimes just learn, this is what you’re supposed to do. In settings that are critical, what the background behind something is or the rationale for why we do it, that gets lost. Can you briefly describe the background for the Hour-1 Bundle and what it’s all about?
Dr. Penoyer: Sure, Marilyn. It can get confusing because we have little tweaks and changes in guidelines over time. Really, for those who know about the sepsis bundles, there’s nothing really drastically different about them. What we’ve learned, I think, over time is even with the 3-hour window that we have for sepsis treatment in the usual bundles we’ve been using for years, we still seem to lag our treatment for patients who are in shock or at high risk of death, and we lose that opportunity to really make a difference in mortality and morbidity.
The biggest difference of the Hour-1 Bundle is focusing on sepsis as an emergency, a critical emergency. What this really prompts us to do is to identify sepsis really quickly and start that resuscitation bundle as quickly as we can with the goal of 1 hour being started on most or all of the things that are in the sepsis bundle. It’s not different from other kinds of emergency treatments we think of, like the golden hour of trauma, STEMI, and stroke. I remember the days when we would sit by while patients’ myocardial infarctions were extending; we did virtually nothing to try to improve their outcomes. But now that we know there’s a time sensitivity to the outcomes of that treatment, we get going really quickly with those nowadays, when in the past we didn’t. This is really what we are doing with the Hour-1 Bundle, knowing the impact of treating this time-sensitive situation before sepsis progresses to shock and ultimately death.
Dr. Bulloch: For those listeners who, again, may not be as familiar with the bundle, can you just briefly explain what activities are accomplished in the first hour?
Dr. Penoyer: Like I mentioned, the elements of the bundle haven’t really changed significantly. We’ll cover more of the specifics of the changes in the bundle elements in the webcast. To review, the elements of the Hour-1 Bundle are drawing a lactate, drawing blood cultures before administering antibiotics, antibiotics, as well as IV crystalloid fluids at 30 milliliters per kilo, and norepinephrine or a vasopressor to achieve the MAP before or after the IV fluids are administered. Basically, what we’re trying to accomplish is: do the labs, restore perfusion to the microvascular system, and then treat the infection.
Dr. Bulloch: Over the years, one of the things that many people have discussed is that, operationally, it can be difficult to do all of these tasks that you just spoke about within an hour. From an outsider looking in, it may not seem like a lot to ask but, in practice, it can be hard. Why do you think that is?
Dr. Penoyer: I’ve said this myself over time. I’ve been working with sepsis since 2005. Why in the world can’t we get this right? It’s only 4 or 5 things. As it turns out, there are a lot of barriers to getting these things started within an hour. You would think 1, 2, 3, 4, 5, get it done. But these tasks have many actions by various people in complex busy environments like the ICU and the emergency department. If you spend time in those areas, you know that there are many competing priorities and busy environments with other patients who need care.
After a decade or so, not even a decade of the core measure, we’re still only achieving about 50% of bundle compliance around the country, maybe a little more, but not much. While there are only 4 or 5 things that you do, there are many steps in completing each one of those, and they involve many disciplines and departments that have to work together and communicate with each other. I do want to mention a shoutout, a very interesting study by Tarrant. It’s an ethnographic qualitative study that was published in Implementation Science in 2016, and it shows the many complexities of completing the sepsis bundle. While it seems simple, there are a lot of individual steps to actually get those things done.
Dr. Bulloch: You’re right. From a big picture, it does just look very easy. But you made a very good point. It seems very complex when you think about the steps that go into it. We need a lot of people to get this accomplished. What have you found are the best methods for engaging staff to use and then accomplish the Hour-1 Bundle?
Dr. Penoyer: Some of the barriers we’ve seen with novice workforce and staffing challenges, I think this is across the country and maybe the world, is with temporary staffing and mixed education that they receive in sepsis management, we really want to include the frontline team members in sepsis planning and our PI teams, connecting them to the why about the importance of the timely interventions. I mean, we can say, well, let’s get the bundle done, but why is it a sense of urgency? Why do we need to establish perfusion and why is that important?
I think, really, increasing awareness of the responsibility of each member’s team role in accomplishing this. Because there are so many people who actually perform these tasks, there are many things that can be left out and communication problems result usually. One of the things I always say is make it easy to do the right thing, like having sepsis kits, having things all in one place, having medications available, having a pharmacist on staff and present to help get things done. These are things I think that really help people get engaged in the actual process itself.
Dr. Bulloch: It’s almost like you were reading my mind just now, talking about how to make things easy. We have been dealing with this core measure that you mentioned for a long time. We’re all trying to get it done. A lot of places do have formal sepsis teams and things like that. But for hospitals that don’t have them, don’t have a formal system in place, what is the best way to start operationalizing the Hour-1 Bundle?
Dr. Penoyer: For starters, if you do have a performance improvement team or a sepsis group that meets, go ahead and build on the things that you’re already doing. Most places are doing things to try to achieve the 3-Hour Bundle. Now, it’s like, “How can we zero that down to the Hour-1 Bundle to get things really moving quicker?” Really, for those who don’t have a formal system in place, I would suggest that you do, that you pull a team together of key stakeholders, folks who can start addressing what sepsis performance looks like, and start looking for input from the front line to find out what barriers they’re experiencing on the front line and how to overcome some of these things and to help them with determining ways to overcome these barriers and facilitate quicker time to treatment.
Dr. Bulloch: Let’s talk a little bit more about the concept of the sepsis team, or whatever it is a hospital wants to call it. The 2021 Surviving Sepsis Campaign guidelines included a best practice statement that said institutions should have a performance improvement program for sepsis that included things like screening for acutely ill and high-risk patients and how management should be approached. What role do these teams and performance improvement programs have in sepsis? And how can the Hour-1 Bundle help accomplish important goals and objectives?
Dr. Penoyer: That’s really an important thing, Marilyn. Like I said, if you don’t have a team at your organization, you should consider putting one together. These best practice statements are generally those that are accepted by most practitioners. They may not have a whole lot of evidence behind them, but they’re generally common sense things based on experience. The studies have shown that having these collaborative practice teams of multiprofessional team members to address the sepsis bundles have improved adherence to the bundles and patient outcomes. The PI process can help teams focus on learning strategies to perform at the highest level and overcome obstacles.
The first thing is that PI or performance improvement is not a one-and-done process; it usually involves cycles of improvements over time, sometimes over years, to accomplish the things that you want to do. These teams can set priorities to establish goals for all phases of sepsis care across the continuum. Focusing on the Hour-1 Bundle is a great starting point really for a PI team to get to work on improving sepsis care, even emphasizing that early treatment is likely to really yield the best outcomes for patients.
Sepsis teams are a great way to provide expertise at the bedside, things that we can do are having awareness campaigns for all levels of care within an organization, especially acute care because sepsis happens everywhere in the hospital. Things that we’ve done include participating in World Sepsis Day to increase awareness, having educational programs, things like that, to increase awareness across the system. One thing that we had implemented some time ago was an electronic telemonitoring system, whereby the rapid response team could contact the physician, much like use of a robot for remote telemonitoring. They would call in and help direct care right there at the bedside.
Coming up with really good ideas to expedite treatment by teams of really smart professionals sitting in a room where they can sit there and say, “Well, this is why you’re not getting your lab on time, our machine isn’t working” or “We don’t have the right machine to measure lactate” or “We don’t have the right process for getting blood cultures processed in a timely manner.” These teams can really drill down to the nitty-gritty of what you’re doing and what obstacles you might have and then start a program to overcome these over time.
Dr. Bulloch: I was listening to you talk, and I’m from a small town and I work at a large community teaching hospital now, but I’m very much aware that many of our smaller community and rural hospitals don’t have the resources of large academic medical centers. I really appreciated that you were touching on some things that I think are very practical that those smaller institutions could do to help improve their care in sepsis. You and I both know that every hospital does things just a little bit differently. We’re a state away. You’re in Florida, I’m in Alabama. But even if you were down the road, we would probably do things completely differently. In your experience, who should be part of any sepsis improvement or performance improvement team?
Dr. Penoyer: Marilyn, you bring up a good point. Many times, sepsis occurs in rural or very small hospital settings, and that doesn’t mean that you can’t have excellent sepsis care in those areas. It’s all about getting the right people around the table with a common purpose in mind. First, you’ve got to start with a good, strong leader, someone who cares about sepsis, someone who knows how to lead people and move teams forward, how to do performance improvement and those sorts of things. Then, it’s really important to get the right people at the table, key stakeholders who even touched the patient anywhere. My mantra is if you touched the patient during sepsis resuscitation in any way, you need to have a seat at the table.
Think about all those people, who they would be, for example, physicians from multiple disciplines. Emergency care is where most of our sepsis takes place, so having sepsis leaders from the emergency department. For example, we have residents and quality team members from the emergency department on our team. Having intensivists, where emergent care is continued in the ICU, is critical. Internal medicine, especially for patients who are on hospital units who are hospitalists and things like that, they also have to be actively engaged. We include also infectious disease and advanced practice providers.
If you have advanced practice providers, like nurse practitioners or clinical nurse specialists or PAs, physician assistants, working on your teams, they can be an invaluable contributor to the sepsis team; they can be deployed to expedite treatment on the units when a physician might not be present. Other things, of course, nurses in all those different settings. Having your rapid response team, if you have one in your organization, having those people at the table to handle inpatient sepsis emergencies is really important. We have pharmacists, you pull a pharmacist who deals with medications in the ED, particularly with antibiotic selection.
We have respiratory therapists for oxygenation as well as sometimes they’ll draw lactates for us, laboraticians to process labs in an expeditious fashion, radiology so we can do scans that are needed to look for sources, ultrasound, the vascular access team, often we have to call them to come start IVs in patients who are in profound shock. Informatics, I cannot stress the importance if you have an electronic health record. If you have any components of sepsis that are within those records, you need to have those people at the table so they can hear the whys behind what you’re doing and facilitate getting those things on your electronic health record.
I’ll finish by saying your quality leaders are very important, including your core measures abstractors. I have those people come to the meeting because if we can’t find time zero, they will find it for you. They can tell you where they’re finding, they’re doing these chart abstractions, where your problems really lie. I know this sounds like a lot of people involved, but I can tell you when you have those people around the table to face these things, you get a whole lot better outcomes when everybody’s hearing the same issues being discussed.
Dr. Bulloch: No, I think you bring up a lot of good points. These are very important roles that traditionally people haven’t thought of, but when we do get them at the table, we do see outcomes improve. We’ve learned more and more that this is a team effort. Sepsis is complicated and so it requires a diverse team. You already touched on this just a little bit, but related to the Hour-1 Bundle specifically, not just sepsis globally, what kind of activities can the sepsis team do to improve how we perform on that bundle?
Dr. Penoyer: That’s a really good thought because when you get right down to it, somebody has to be present right there to expedite treatment. I think if you have a sepsis team that can be deployed even in the emergency department, having a sepsis coordinator or sepsis teams that respond when a sepsis alert is called, and that’s what we do. We have a sepsis alert if a patient meets certain criteria coming in the door. If they look like they’re potentially septic based on screens that we have in triage, having providers on this team to be able to come and expedite treatment is really important.
There are limitations with what nurses can do at the front line in terms of beginning sepsis treatment, depending on their scope of practice in the state. Having an advanced practice provider, if you cannot have a provider right there, can help you expedite getting the first things done that might require a physician’s order like IV fluid boluses and antibiotics. Collaborating with that frontline team for their input to address barriers is really important, to say, “Well, you tell us what is holding you up from getting the blood cultures done? Why are we seeing them done after antibiotics were missing?” They will tell you, they know exactly what is getting in their way and efforts can be done to improve that.
Other things we can do, I think, within the hospital is doing regular sepsis screening. The guidelines also emphasize screening patients who are in acute care areas that are high risk. I can’t think of any patient that is not at high risk for sepsis who are on inpatient units right now. Screening every patient, every day, every shift, is probably a good thing to detect. If you’re looking for it, you’re more likely to see it. Our RRT are really our eyes and ears for looking for sepsis in the hospital, and that’s where we have the biggest challenges. Our emergency department tends to do very well because they’re always looking for problems, right? They’re always looking for deterioration. But proactive surveillance by the rapid response team is very helpful, and they also help the frontline team understand why they’re doing what they’re doing and things that they can do next time to facilitate sepsis identification.
Dr. Bulloch: Dr. Penoyer, I want to circle back to something you mentioned earlier. You said we need to treat sepsis as an emergency, and you’re absolutely right. But I wonder if you’ll agree with me that it doesn’t always have that classical feel of an emergency, like a major trauma, a stroke, or you talked about heart attacks. What are some things that we can employ to detect sepsis quicker? You mentioned doing this in every patient, so we do treat it more like the emergency that it is.
Dr. Penoyer: Therein lies a problem. You have a trauma patient with blood going everywhere, people start moving. But it’s kind of an occult war that’s going on in the intravascular space, so people can’t see this war that’s going on, and it’s really challenging. So, really having people always thinking about sepsis, especially with sepsis screening tools like I’ve talked about, incorporating those with deterioration scores and things like that. If you have an early warning system like NEWS or MEWS or electronic surveillance systems, those are really important for your staff to know. When you see these sort of things, get moving, start screening for sepsis and get help as soon as possible.
At our hospital and our local areas, we have partnered with our ambulance services to do prehospital screening en route to the hospital. What they’ll do is they’ll look for patients, particularly like from nursing homes who might have a fever, who have a urinary tract infection and things like that. They’ll call into the hospital and say, “We’re bringing someone who’s a possible sepsis alert.” That gets us already thinking maybe this patient’s septic. Then, upon arrival, triage with sepsis, we triage every patient who comes in our emergency room using a tool that was developed here called the BOMBARD, and it is specifically designed to at least have some factors that the patient may have upon arrival in triage to make us start thinking about sepsis, and we go ahead and take those patients back and start doing sepsis screens and evaluating whether the patient has infection or actual sepsis.
Having sepsis alert teams I think are super important. Once sepsis is even suspected, really having someone you can call or a team that you can deploy to come check on these patients right away with expert eyes and start implementing the sepsis treatment process. There are some electronic and manual surveillance systems out there for SIRS and sepsis, but they’re only as good as the person who looks at them and acts on them. I think putting all these things together would really help us identify sepsis a whole lot earlier and then get the ball rolling.
Dr. Bulloch: You just mentioned a lot of screening and other tools, and these have been the source of a lot of discussion and, if we’re just being really honest, disagreement over the years, and I feel like this has grown a lot. When I was in training, I think we just had SIRS, right? Now we have a whole laundry list that we can choose from. From a practical perspective, which have you found to be the most beneficial in real life, at the bedside? Because we need ones that are going to be easy to implement, that are going to provide robust and useful data. Otherwise, I just don’t think clinicians are going to use them. What have you found to be most contributory to managing a sepsis patient?
Dr. Penoyer: There are so many things that you have to do. But first, people have to be aware of what sepsis is. While education is not the one-and-done thing to actually overcome these things, there’s some degree of awareness and education that needs to be done, especially with our staffing challenges and temporary staff and things like that. You have to make sure that anybody coming in the door upon hire, and then regularly, knows that this is how we recognize and treat sepsis in our organization. All these campaigns and awareness all the time, this is what your role is and this is how you can save lives from sepsis. We had a lot of things going on in our organization about, you can save a life, keep calm and do the big four, right? Things like that, so people think about sepsis, it’s always on their mind.
In our hospital systems, in larger systems, a corporate team isn’t enough because you cannot reach everyone. What we did is we started having local sepsis teams at the various hospitals that are microcosms of their own population, they can overcome these challenges that they see. Really, those sorts of things and getting your RRT engaged in the process for inpatient alerts, that awareness through daily reviews, during safety huddles and Gemba boards, we call them here, if you review the progress, this is how we did on sepsis this month, what’s keeping us from getting our lactates done reliably, this is continued awareness, I think, to keep sepsis front and center in everybody’s mind.
Dr. Bulloch: I want to shift gears just a little bit. We’re talking about a bundle that has a time associated with it, and that time certainly has to start somewhere, and we call that time zero usually. One of the difficulties people have had over the years is identifying when time zero actually is. Why do you feel this is such a critical part of sepsis management?
Dr. Penoyer: Therein lies the big problem. You can’t tell if you’re on your Hour-1 bundle if you don’t know what time it is. Time zero is huge. It’s one of the things we tend to skirt around a lot because it’s hard to nail down. It’s a time anchor, right? Without this, you don’t have a clock to determine how you’re doing. So it’s critical to have a method to declare time zero. While patients are being worked up for sepsis, sometimes some of the elements of the bundle are already being done, right? Maybe blood cultures have already been drawn, maybe the lactate has been drawn.
Someone in a leadership role for the management of that patient, the provider, the physician, once they suspect that they have sepsis, my thought is that they should declare time zero. I call this timeout for time zero. Everybody looks. “Okay, the time is 10:00, what have we done and what needs to be done now?” Once we do this and you have a strong leader who’s moving things along, that is really one of the key contributors to achieving the Hour-1 Bundle.
Dr. Bulloch: I want to move on and talk about some of the more practical aspects of the bundle. I know when I think about things, I’m like, that sounds wonderful but how do we do it at the bedside? What are some of the practices that you’ve seen best help accomplish the goals of the Hour-1 Bundle?
Dr. Penoyer: To go back to something I said earlier about making it easy to do the right thing, we’ve had sepsis order sets for years, and getting people to use them is really important, right? Piecemealing sepsis care ends up being very individualized rather than completing the bundle elements. Having protocols and sepsis order sets are really important, having clinical guidelines. We found that when you preselect items on the order set once it’s deployed for things that nurses can go ahead and start doing without the physician having to direct them is really a time saver.
Other things you can do is make sure that the antibiotics that you tend to use for sepsis are available. Some of these antibiotics are IV push, and we found that sometimes it’s a lot easier to give an IV push antibiotic than waiting to get IV access and hanging the bag and waiting for it to go in. Other things you might do include having a sepsis clock. Let’s say, Dr. Bulloch, you say timeout for time zero is right now, some people have a literal sepsis clock that you can set the timer and say, “Okay, start now.” These are little practical things that you can do to help facilitate people getting going pretty quickly.
Dr. Bulloch: You mentioned antibiotics. That’s always, I think, a struggle for a lot of places, right? You’ve got to get the antibiotics ordered and then you’ve got to get them up from pharmacy and then they’ve got to get into the patient, and that takes time. I think in some places that might be the rate-limiting step for the bundle. Have you found any useful things at your hospital that have helped maybe reduce this barrier?
Dr. Penoyer: Yes, I think first of all having the drugs that you use at the hand of the nurses, that you don’t have to go to a pharmacy to get those drugs, and having a pharmacist on staff. We have a pharmacist in the emergency room that is also on call for sepsis when these alerts are called. They’ll come and help facilitate getting the antibiotic reconciled with the patient, make sure that all those kind of steps are done. And of course, like I mentioned, the antibiotics that are IV push, there has been some discussion about somewhat of a nonlethal, if you will, dose of vancomycin just to get vancomycin started on patients and then adjusting doses down the road is something we’ve considered doing. Having them right at hand so that someone can grab them and administer as soon as possible with a reconciliation by the pharmacist is key.
Dr. Bulloch: We are coming to the end of this episode, which is unfortunate, because I think you’ve given a lot of practical advice. I could listen to you all day, things I could take back to my own institution. I do want to thank you for being our guest today. Before we leave, I want to give you an opportunity to leave our listeners with any final thoughts.
Dr. Penoyer: Thank you, Marilyn. It’s been my pleasure. I think really every organization should have some team established to be able to look at your sepsis results for the Hour-1 Bundle, how are you performing on your core measures, and examining opportunities for improvement. Having the right people at the table to guide sepsis care is key. The second thing I would mention is definitely developing tools for the bedside practitioner to make it easy to do the right thing. Having screening tools that are meaningful, processes that they follow if a patient meets certain criteria, being able to mobilize resources to respond to sepsis as soon as possible, those things are really important to bring the services to the bedside for the patient once time zero is established. Finally, coming up with a way to establish time zero so that everybody knows what time it is and what their role is to implement the Sepsis Hour-1 Bundle.
Dr. Bulloch: Thank you, Dr. Penoyer, again for being our guest. You were wonderful. This concludes another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Marilyn Bulloch. Thank you for listening.
Sponsor: This podcast is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies.
Marilyn N. Bulloch, PharmD, BCPS, FCCM, is an associate clinical professor and director of strategic operations at Auburn University Harrison School of Pharmacy. She is also an adjunct associate professor in the Department of Family, Internal and Rural Medicine at the University of Alabama in Tuscaloosa, Alabama, USA, and the University of Alabama Birmingham School of Medicine.
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