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Impact Story

ECRI helps multi-state health system save 700 lives and $30M with sepsis management innovation

Problem

A multi-state non-profit health system faced a significant challenge with sepsis management. Sepsis is a life-threatening condition that requires rapid diagnosis and treatment, but the health system’s Severe Sepsis/Septic Shock Mortality Index had increased. It was 1.28 in 2019, decreased to 1.26 in 2020, but then rose to 1.47 in 2021. This increase highlighted the need for a better system to detect and treat sepsis more efficiently.

To address this challenge, the health system introduced a new Sepsis Navigator (SN) tool within their electronic health record system. The goal of this tool was to reduce the time it took clinicians to recognize and begin treatment for sepsis, bringing it in line with the urgency applied to conditions like heart attacks and strokes. However, soon after its implementation, problems emerged. Although the tool was effective in the early identification of patients with sepsis, it was causing frustration and alert fatigue among clinicians due to poor usability and high numbers of false alarms. Moreover, nurses found the tool’s hard stops disruptive to their workflow, which led them to develop workarounds. In short, the initial SN and sepsis workflow were not sustainable solutions for reducing sepsis mortality.

Solution

In response to these challenges, the health system partnered with ECRI to improve the usability of the SN, expecting the ECRI team to focus on the tool itself. However, ECRI’s Human Factors Engineering (HFE) team took a broader systems perspective. Between October 2021 and April 2022, they analyzed not only the SN but also the workflows of the users, the other tools 
and technologies involved, the physical spaces where the work occurred, and the relevant organizational policies. This comprehensive approach allowed ECRI to identify a range of contributing factors and propose more robust, system-wide solutions for improvement.

Human Factors Engineering System Analysis

When performing a System Analysis, ECRI HFEs investigate how different components of healthcare systems contribute individually—people, tools and technologies, tasks and processes, physical environments, organizational programs and policies, and external influences—as well as how these components interact with each other to contribute to safety risks. The System Analysis identifies an increased number of contributing factors to an adverse event compared to typical root cause analyses, which provides a deeper understanding. That understanding affords a greater number of potential solutions and better insight on how to implement effective and sustainable solutions. By participating in HFE System Analysis, healthcare professionals learn to use systems thinking to address patient safety challenges (a Total Systems Safety [TSS] approach).

Clinically Informed Human Factors Engineering

To address the health system’s SN issues, ECRI HFEs requested and reviewed documentation about the new SN and the new sepsis workflow that were rolled out simultaneously, observed demonstrations illustrating how the SN was intended to be used, and conducted a series of interviews and focus groups. The health system informaticists participated in most of these activities and often implemented changes to the SN based upon what they heard. As a result, the SN evolved throughout 
the collaboration.

Key Issues

ECRI identified the following key issues after analyzing the information gleaned from document reviews, demonstrations, interviews, and focus groups:

  • False alarms were overwhelming clinicians, leading to alert fatigue.
  • Frontline staff had not fully understood, nor bought into, the new workflow that was introduced alongside the SN.
  • Nurses adopted a workaround that prevented them from accessing the SN because the sepsis alerts were very disruptive to their workflow.
  • The negative consequences of an alert with BOTH a hard stop and a high false alarm rate upon frontline staff were poorly understood.

Selected Recommendations

To address these issues, ECRI made several recommendations:

  1. Increase specificity of sepsis alerts to reduce false alarm rate.
  2. Include the data that triggered the sepsis alert in the alert notification, so clinicians can quickly review these data to determine whether sepsis treatment is warranted.
  3. Involve clinical staff more directly in tool redesign and, in particular, in workflow redesign, to gain buy-in, which will improve compliance.
  4. Modify the option to dismiss a sepsis alert so it reads “another diagnosis more likely than sepsis” rather than “definitely not sepsis.”

Result

As a result of ECRI’s recommendations, the health system implemented changes to the SN and the sepsis workflow. These modifications increased usability, reduced the number of false alarms, and made considering sepsis as a possibility less disruptive to clinician daily tasks—all of which significantly increased clinician satisfaction and confidence that the sepsis tools would be effective in reducing preventable harm. 

Moreover, these changes had a tangible impact on patient safety:

  • 25% reduction in sepsis mortality since 2021
  • 700 lives estimated to have been saved because of the reduction
  • $30 million in cost savings realized by reducing hospital stays, improving treatment protocols, and optimizing they system

By addressing all of the factors that contributed to challenges associated with the initial solutions, the partnership between the health system and ECRI not only improved patient outcomes but also enhanced the clinician experience, helping to ensure the new sepsis workflow was effectively integrated into daily operations.