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Penn Medicine
The Impact of an Early Warning System
for Sepsis
CHOP Healthcare Informatics
April 25 , 2014
Joel Betesh, MD
Gordon Tait, BS
Asaf Hanish, MPH
Benjamin French, PhD
Neil Fishman MD
Barry Fuchs, MD
Christine Vanzandbergen, PA, MPH
Craig A Umscheid, MD, MS
http://www.uphs.upenn.edu/cep
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The University of Pennsylvania Health System
 Three acute care hospitals:
• Hospital of the University of Pennsylvania
• Penn Presbyterian Medical Center
• Pennsylvania Hospital
• 1,540 acute care beds
• 80,020 acute care admissions in 2012
• 73 ACGME accredited training programs
http://www.uphs.upenn.edu/cep
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http://www.uphs.upenn.edu/cep
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Sepsis Mortality Index (SMI)
 Definition of Sepsis Mortality Index includes
patients with:
• Discharge status of ‘Expired’
• Principal and/or secondary diagnosis/diagnoses
related to sepsis
Observed
SMI 
Expected
 Expected rate based upon MS-DRG-based
algorithm
http://www.uphs.upenn.edu/cep
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Penn Medicine SMI for FY 2011
 Goal: Lower the high Sepsis Mortality Index
(SMI) at the University of Pennsylvania as
determined by University HealthSystem
Consortium (UHC)
 UHC SMI data for FY11
• SMI: 1.50 (UPHS), 1.54 (HUP)
• UHC Median: 1.19
– Top 5 Performers: 0.53, 0.65, 0.77, 0.78, 0.78
• UHC Rank for Penn: 67/113
• Target (Best Quartile): 0.98
http://www.uphs.upenn.edu/cep
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The Opportunity
• Since the fall of 2011, we have vital sign,
covering provider and covering nurse data
in our inpatient EHR, Sunrise Clinical
Manager.
• Other hospitals have begun to use
automated alerts for Sepsis based on data
in their EHRs.
http://www.uphs.upenn.edu/cep
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The SIRS Criteria
 2 or more of the following criteria:
• Temperature > 100.4°F or < 96.8
• HR > 90
• RR > 20 or PaCO2 < 32
• WBC > 12000 < 4000, or > 10% immature (band) forms
http://www.uphs.upenn.edu/cep
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Penn Medicine Criteria for Presumed Sepsis
Variable
Point
Temperature <36°C or >38°C
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Heart Rate >90 beats per minute
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RR >20 breaths/min; or PACO2 <32 mmHg
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WBC count <4000 or >12,000 or >10% bands
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Lactate >2.2
1
Systolic blood pressure <100
1
RR: respiratory Rate; WBC: white blood cell
Criterion for presumed sepsis: >4 points
http://www.uphs.upenn.edu/cep
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Results of Retrospective Analysis
(4 week period Oct 2011)
4,700 patients. Criterion for presumed sepsis: >4 points. 193
patients scored 4 or more.
A score of 4 or more had a positive predictive value of about 23%
for death, transfer to ICU or RRT.
On average these events occurred over 48 hours after the score
of 4 was first met.
We felt there were an additional 20% of patients who had sepsis
and would be identified by this trigger and could benefit from
early diagnosis and treatment.
This early warning system was likely to also identify patients who
had new episodes of bleeding, cardiac ischemia and pulmonary
emboli.
http://www.uphs.upenn.edu/cep
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EWS Data Gathering and Goals
• Decrease total and sepsis related inpatient mortality
• Decrease time to antibiotics
• Decrease ICU transfers (ICU transfers could also increase)
• Decrease RRTs (RRTs could also increase)
http://www.uphs.upenn.edu/cep
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Decisions Made
 Score of 4+ had an acceptable Positive Predictive Value
• 23% for hard outcomes of death, ICU transfer or RRT
• Anticipated additional 20-30% for sepsis
 Exclude ICUs, Maternity, PACU, ER, Hospice, and patients <18
years
 Fire ONCE per visit to start
 Alert to bring to bedside within 30 minutes patient’s intern and
nurse manager (notified by pager) and patient’s nurse (notified
by pop up alert in EHR)
 Limit to patients admitted at go-live or after (9/5/2012)
– To gradually ramp up and not overwhelm staff
http://www.uphs.upenn.edu/cep
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EWS System Architecture
http://www.uphs.upenn.edu/cep
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Alarm Process (I)
1) The Alarm Process will:
Auto-enter the “Early Warning System Assessment” order
• Will generate a primary task for the Covering Nurse (see below):
Task Form-based
 Will retrieve offending criteria
 Will fetch and display:
 Last 24 hours of Vital
Signs
 Last 48 hours of relevant
Labs
http://www.uphs.upenn.edu/cep
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Alarm Process (II)
2)
Primary task completion will create a follow-up task (aka Survey)
– See below:
http://www.uphs.upenn.edu/cep
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Primary Process Evaluation
NOTIFICATION
•Coordinator page sent - 99%
•Small, well defined group with limited devices
•Nursing pop-up notification viewed - 72%
•Relies on accurate nursing assignment in SCM
•Covering provider notification sent - 83%
•Relies on accurate assignment in SCM
•Large number of devices and carriers
SCM Task completion
•Primary RN task - 95%
•Follow up coordinator task - 95%
Team gathered at bedside within 30 minutes - 90%
http://www.uphs.upenn.edu/cep
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Preliminary results of EWS alert
 Silent/control period:
• Admitted between Jun 06, 2012 and Sep 04, 2012
• Discharged by Oct 04, 2012
• 15,570 admissions
• 595 patients triggered the alert
http://www.uphs.upenn.edu/cep
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Preliminary results of EWS alert
 Loud/intervention period:
• Admitted between Sep 12, 2012 and Dec 11, 2012
• Discharged by Jan 10, 2013
• 16,103 admissions
• 731 patients triggered the alert.
 Chi square compared proportions and Wilcoxon Rank Sum to
compare medians before and after the alert went live
 Results adjusted for age, gender, admitting service and
Charlson index
http://www.uphs.upenn.edu/cep
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EWS Process and Outcome Measures
http://www.uphs.upenn.edu/cep
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% RRT < 6hrs
20%
18%
16%
14%
% Inpatients
12%
10%
OUTCOME
MEASURES
8%
6%
4.0%
4%
2%
2.2%
2.0%
1.6%
1.1%
0.8%
1.0%
0.8%
Post-period at HUP restricted to Nov/Dec.
0%
HUP
PAH
PMC
UPHS
Facility
Pre/Silent
Post/Loud
Trend downward but did not achieve significance.
http://www.uphs.upenn.edu/cep
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Subset Analysis
We looked at subsets of patients who might show
more of a benefit for the alert such as:
 Elective admissions
 Emergency admissions
 Medicine admissions
 Surgery admissions
 Patients with a discharge diagnosis of sepsis
http://www.uphs.upenn.edu/cep
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Subgroup Analysis
Patients with a Discharge Diagnosis of Sepsis
Mortality
Entity
Studyperiod
Septic
patients
HUP
Pre/Silent
179
27
23.7
1.14
HUP
Post/Loud
214
35
28.0
1.25
PAH
Pre/Silent
21
4
2.2
1.82
PAH
Post/Loud
30
2
3.1
0.65
PMC
Pre/Silent
28
8
2.4
3.36
PMC
Post/Loud
41
3
4.2
0.71
UPHS
Pre/Silent
228
39
28.3
1.38
UPHS
Post/Loud
285
40
35.4
1.13
Observed
Expected
O-E
http://www.uphs.upenn.edu/cep
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Since go live in 2012
 Done:
 Alert added in the ER
 Added alert in Acute Rehab and LTach Units
 Added second alert after 10 day buffer at Rehab and LTACH
 Being Discussed:
 Allowing a second trigger during a single hospital stay
 Heavy analysis of data with a view to decrease false positives
and increasing sensitivity of alert
 Using change in systolic BP rather than absolute value
 Machine learning approach to identify new/better parameters
for the alert
http://www.uphs.upenn.edu/cep
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Penn Medicine Sepsis Mortality Index for FY 2013
http://www.uphs.upenn.edu/cep
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Acknowledgments
 Katherine Clark
 Jessica Guidi
 Mark Upton
 Hilary Faust
 Denise Feeley
 Meghan Lane-Fall
 Mark Mikkelsen
 William Schweickert
 Patrick Donnelly
 Jean Romano
 Kirsten Smith
 Barry Fuchs
 And many others
http://www.uphs.upenn.edu/cep
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Questions? Suggestions?
Contact:
[email protected]
Joanne. [email protected]
[email protected]
[email protected]
http://www.uphs.upenn.edu/cep
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