Elsevier

Journal of Surgical Research

Volume 231, November 2018, Pages 373-379
Journal of Surgical Research

Shock/Sepsis/Trauma/Critical Care
Sooner is better: use of a real-time automated bedside dashboard improves sepsis care

https://doi.org/10.1016/j.jss.2018.05.078Get rights and content

Abstract

Background

Minimizing the interval between diagnosis of sepsis and administration of antibiotics improves patient outcomes. We hypothesized that a commercially available bedside clinical surveillance visualization system (BSV) would hasten antibiotic administration and decrease length of stay (LOS) in surgical intensive care unit (SICU) patients.

Methods

A BSV, integrated with the electronic medical record and displayed at bedside, was implemented in our SICU in July 2016. A visual sepsis screen score (SSS) was added in July 2017. All patients admitted to SICU beds with bedside displays equipped with a BSV were analyzed to determine mean SSS, maximum SSS, time from positive SSS to antibiotic administration, SICU LOS, and mortality.

Results

During the study period, 232 patients were admitted to beds equipped with the clinical surveillance visualization system. Thirty patients demonstrated positive SSS followed by confirmed sepsis (23 Pre-SSS versus 7 Post-SSS). Mean and maximum SSS were similar. Time from positive SSS to antibiotic administration was decreased in patients with a visual SSS (55.3 ± 15.5 h versus 16.2 ± 9.2 h; P < 0.05). ICU and hospital LOS was also decreased (P < 0.01).

Conclusions

Implementation of a visual SSS into a BSV led to a decreased time interval between the positive SSS and administration of antibiotics and was associated with shorter SICU and hospital LOS. Integration of a visual decision support system may help providers adhere to Surviving Sepsis Guidelines.

Introduction

Despite advances in modern critical care, sepsis remains a leading contributor to in-hospital morbidity and mortality. It is estimated that 750,000 patients are treated for severe sepsis and septic shock in the United States each year.1 Sepsis is a common diagnosis among intensive care unit admissions, and mortality rates have been shown to be at least 25%.2, 3

The Surviving Sepsis Campaign was launched in 2004 and provided guidelines for the diagnosis and treatment of severe sepsis and septic shock.4 The Third International Consensus Definitions for Sepsis and Septic Shock defines sepsis as a serious blood infection and associated acute organ dysfunction as outlined by the Sequential Organ Failure Assessment (SOFA) score: vasopressors, mechanical ventilation, elevated creatinine, elevated total bilirubin, thrombocytopenia, and elevated lactate.5, 6, 7 The most recent guidelines were published in 2016 and emphasize early fluid resuscitation, source control, and administration of intravenous antibiotics.8 Previous studies have shown that optimal outcomes in the treatment of severe sepsis and septic shock are achieved when treatments are administered utilizing clinical care bundles.9 Unfortunately, widespread implementation and compliance with trauma clinical practice and sepsis treatment bundles is inconsistent.10, 11, 12 In the treatment of sepsis, Seymour et al. showed that rapid completion of sepsis treatment bundles was associated with lower in-hospital mortality.13 Time to antibiotic administration may be the most crucial variable, as further studies have demonstrated increases in mortality with each hour of delay in antibiotic administration.14

Clinical decision support tools have the potential to improve treatment of various medical conditions cared for in the intensive care setting.15, 16, 17 Their utility lies in enhancing awareness of worsening and critical disease states to clinicians. Because the treatment of severe sepsis and septic shock is multidisciplinary, clinical decision support tools visible to the patient, patient families, and the entire health care team may augment or expedite the delivery of appropriate, timely medical care. The effect of a visual clinical decision support tool on the time to antibiotic administration in patients with sepsis or potential sepsis is unknown. We hypothesized that implementation of a commercially available bedside clinical surveillance visualization system would be associated with improved patient outcomes, including earlier antibiotic administration, decreased length of stay (LOS), and reduced mortality in surgical intensive care unit (SICU) patients.

Section snippets

Automated clinical surveillance visualization system

In July 2016, an automated clinical surveillance visualization system (Decisio Health Inc, Houston, TX; www.decisiohealth.com) was implemented within the SICU at the University of Cincinnati Medical Center. This visualization system was integrated with our electronic medical record (EPIC, Verona, WI) and displays patient vital signs and laboratory values in real time on a 42-inch dedicated monitor mounted above the patient's hospital bed (Fig. 1). This visualization system has the ability to

Results

From July 2016 to September 2017, a total of 232 patients were admitted to beds with bedside clinical surveillance visualization systems in the SICU. Thirty patients (12.9%) demonstrated a positive SSS and were confirmed to have sepsis based on positive cultures. Twenty-three of 30 patients were admitted before the deployment of the SSS on the bedside display system (Pre-SSS), and seven of 30 patients were admitted after the SSS was activated on the bedside display (Post-SSS). Patient

Discussion

The present study examined the effect of implementation of an SSS within an automated visual clinical surveillance system in the SICU at a single center, large-volume, academic institution. The visible SSS was implemented into the bedside clinical surveillance system in July 2017. When comparing patients admitted to SICU beds with a bedside display only installed, the inclusion of the visible SSS was associated with a significant reduction in the time to antibiotic administration and decreased

Conclusion

Implementation of an SSS for a bedside clinical surveillance visualization decision support system was associated with a decreased time interval between the diagnosis of sepsis or septic shock and administration of antibiotics, resulting in decreased ICU and hospital LOS. Integration of clinical decision support systems in the ICU setting may help providers to adhere to Surviving Sepsis Guidelines for identification and treatment of surgical patients with infections and improve quality of care.

Acknowledgment

Authors' contributions: A.D.J. and J.B. involved in data analysis, preparation of article, and critical revisions of article. C.A.D. involved in concept design, data analysis, preparation of article, and critical revisions of article. V.N., J.J., M.D.G., and T.A.P. involved in concept design, data acquisition and analysis, preparation of article, and critical revisions of article. J.B.H. involved in concept design, preparation of article, and critical revisions of article.

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