MANAGED CARE October 2012. ©MediMedia USA
Clinical Bundling Pays Off, In Antisepsis Campaign
Intermountain Healthcare’s checklist for providers cut mortality rates for this fast-moving, and sometimes lethal, condition
In November 2001, when the New England Journal of Medicine published a study about how to better treat severe sepsis, clinician executives at Intermountain Healthcare took note. Intermountain, an integrated system that owns its hospitals, operates 22 emergency departments that evaluate about 450,000 patients a year. In 2009 and 2010, about 2,000 patients with sepsis were treated.
“It doesn’t happen with alarming regularity, but when it does, the consequences can be dire,” says Todd L. Allen, MD, assistant quality officer at the Institute for Healthcare Delivery and Research at Intermountain.
In 2004, the health system got to work, conducting a systemwide survey, planning a course of action. Intensive deployment of the program started in 2008. The effort revolves around a sepsis protocol that cut the mortality rate from 25 percent to around 9 percent in 2011.
The Intermountain process required 11 clinical elements during the first 24 hours of treatment. “We call it a sepsis bundle,” Allen says, “a bundle being a collection of a number of important care elements within a clinical process.”
Some were diagnostic goals such as laboratory testing and collecting blood cultures. Some were therapeutic goals like early administration of antibiotics that support fluid resuscitation. “If you missed just one element by even a minute, the bundle was considered a fail,” he says.
Allen credits Intermountain’s decades-long effort to provide doctors with up-to-date data as one reason for the success. Also, he cites a delivery mechanism that he calls clinical programs, which function like specialty departments, except that Intermountain does not organize by specialty but rather around clinical work processes.
The treatment bundle is overseen by Intermountain’s intensive medicine clinical program. “It’s made up of emergency medicine physicians, hospitalists, critical care physicians, transport specialists, respiratory therapists, radiologists, laboratory technicians, and other providers.”
The program runs in all 22 hospitals that Intermountain owns. “While most of the bundle is standardized, we tried to leave a lot of room for adaptation to the individual hospital. If the hospital wanted to identify the patient with sepsis and almost immediately tried to transfer him to the ICU and some of the early bundled elements occurred in the ICU, as long as they were done successfully in the first six hours, that was considered OK.”
He considers the sepsis program “absolutely transferable” to nonintegrated health plans if they provide instant clinical feedback so providers can clearly see what they’re doing and how they’re doing it. “Anybody could do similar work,” says Allen.
“Much of what we do in health care can technically be considered quality waste. Projects like sepsis are really designed for eliminating waste.”