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Abstract

Introduction: We designed a Quality Improvement pilot initiative to improve response time and standardize early goal directed therapy (EGDT) for Emergency Department (ED) patients with severe sepsis needing immediate surgery ('surgical sepsis'). Our aim was to reduce mortality for surgical sepsis patients, similar to the reductions seen after initiating our EGDT program for medical sepsis patients Methods: In May 2011, we initiated the 'Surgical Sepsis' pilot initiative at the Kaiser Permanente Northern California Santa Clara Medical Center-one of our tertiary medical centers. This pilot included a 6 month period in which we used standard performance improvement methodology (e.g., small tests of change) to accelerate quality improvement. We screened ED patients to identify those who: (1) were jointly evaluated by the ED physician and the Surgical consultant; (2) were thought to require a direct transfer from the ED to the operating room (OR) because of a surgical source of infection; and (3) met criteria for high-risk severe sepsis or shock. These criteria included a serum lactate equal to or greater than 4 mmol/L, persistent hypotension after 2 liters of intravenous (IV) crystalloid infusion, or a predicted mortality >14% based on our BUN/Lactate grid stratifying risk of mortality based on BUN and Lactate values. Among these 'Surgical Sepsis' patients, we administered a bundle comprised of at least 40 mL/kg of IV fluids, appropriate antibiotics within one hour of surgical consult, insertion of a central venous catheter within 2 hours of surgical consult, and subsequent EGDT-based quantitative resuscitation. Results: We screened a total of 759 patients seen by the Surgical consultation service with 358 deemed appropriate for admission by the surgical service. The most frequent surgical services were general surgery (abdominal surgeries). Of these patients, 273 (76.3%) received antibiotics in the ED and 198 (55.3%) met SIRS criteria. Most SIRS patients had a lactate level checked (178, 89.9%). From this sample, seven patients received our Surgical Sepsis bundle including three who met traditional severe sepsis/shock criteria and four who met BUN/Lactate criteria. Their mean age was 52 (34-85) and their mean lactate level was 3.82 mmol/L (0.94-6.2). All patients underwent emergency surgery with general anesthesia. Thirty-day survival was 100%. Conclusions: A surgical sepsis pathway can effectively enhance patient identification and treatment through a quality improvement process in a nonacademic tertiary care medical center.