An Electronic Tool for the Evaluation and Treatment of Sepsis in the ICU

A Randomized Controlled Trial

Matthew W. Semler, MD; Liza Weavind, MBBCh, MMHC; Michael H. Hooper, MD, MSc; Todd W. Rice, MD, MSc; Supriya Srinivasa Gowda, MBBS; Andras Nadas, MSc; Yanna Song, MS; Jason B. Martin, MD; Gordon R. Bernard, MD; Arthur P. Wheeler, MD

Disclosures

Crit Care Med. 2015;43(8):1595-1602. 

In This Article

Abstract and Introduction

Abstract

Objectives: To determine whether addition of an electronic sepsis evaluation and management tool to electronic sepsis alerting improves compliance with treatment guidelines and clinical outcomes in septic ICU patients.

Design: A pragmatic randomized trial.

Setting: Medical and surgical ICUs of an academic, tertiary care medical center.

Patients: Four hundred and seven patients admitted during a 4-month period to the medical or surgical ICU with a diagnosis of sepsis established at the time of admission or in response to an electronic sepsis alert.

Interventions: Patients were randomized to usual care or the availability of an electronic tool capable of importing, synthesizing, and displaying sepsis-related data from the medical record, using logic rules to offer individualized evaluations of sepsis severity and response to therapy, informing users about evidence-based guidelines, and facilitating rapid order entry.

Measurements and Main Results: There was no difference between the electronic tool (218 patients) and usual care (189 patients) with regard to the primary outcome of time to completion of all indicated Surviving Sepsis Campaign 6-hour Sepsis Resuscitation Bundle elements (hazard ratio, 1.98; 95% CI, 0.75–5.20; p = 0.159) or time to completion of each element individually. ICU mortality, ICU-free days, and ventilator-free days did not differ between intervention and control. Providers used the tool to enter orders in only 28% of available cases.

Conclusions: A comprehensive electronic sepsis evaluation and management tool is feasible and safe but did not influence guideline compliance or clinical outcomes, perhaps due to low utilization.

Introduction

Sepsis is a common and lethal illness frequently managed in the ICU.[1–3] Early resuscitation[4,5] and prompt antibiotic administration[6–8] improve mortality. To aid clinicians in consistent implementation of these interventions, the Surviving Sepsis Campaign (SSC) outlined in 2005 a 6-hour Sepsis Resuscitation Bundle incorporating rapid sepsis recognition, early cultures and antibiotics, and goal-directed fluid administration and hemodynamic support.[9,10] Implementation of SSC 6-hour Resuscitation Bundle elements using a written protocol has been shown to improve compliance with recommendations[11–13] and mortality.[14] However, in the absence of ongoing feedback to clinicians, even after intensive education in sepsis detection and management, compliance with guidelines remains low.[15] The use of electronic tools to address this challenge interests physicians and hospitals. Electronic tools have been successfully employed in the ICU for ventilator weaning[16] and identification of acute respiratory distress syndrome.[17] One prior study in sepsis has evaluated a computerized translation of a written protocol for early resuscitation.[18] With recent advances in information technology, a single electronic tool can now couple real-time monitoring of the medical record to identify patients with potential sepsis[19] with decision-support to guide clinicians through severity evaluation, provide education about sepsis guidelines generally and identify interventions indicated in a specific patient, facilitate rapid entry of sepsis-management orders, and monitor the patient's response to interventions throughout the ICU course. We hypothesized that implementation of such an electronic evaluation and management tool in adult ICU patients with sepsis would improve compliance with sepsis treatment guidelines and clinical outcomes.

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