Published in the April 2014 issue of Today’s Hospitalist
ARTHUR CHILDS, DO, likes to quote this startling statistic: It can take 17 years or more for clinicians to actually put evidenced-based medicine into practice.
Dr. Childs thinks that’s largely due to the limited resources that community hospitals have for continuing medical education.
At academic centers, continuing medical education remains a top priority with funding resources and CME departments. “But at community hospitals,” he points out, “education consists of doctors going away for a few days a year, doing courses online, or finding brief moments to scan e-mails, journal abstracts, and medical news briefs for clinically relevant material.” Dr. Childs is director of critical care at Cape Regional Medical Center in Cape May Court House, N.J.
Even when that spotty education sticks, the teams that doctors have to rely on “nurses and therapists “don’t receive the same training. And with administrators pressured to cut costs, making the case to pay to train an entire clinical staff is only getting harder.
Dr. Childs and his colleagues set out to resolve that dilemma. First, they designed a performance improvement initiative on sepsis, with its high mortality and costs, to get the attention of clinicians and administrators.
They then brought a simulator in-house in 2012 to train all ED and ICU staff. (Hospitalists treat most patients in Cape Regional’s ICU.) They continued to assess clinician knowledge of sepsis bundles every six months after that training, and they collected before-and-after data on bundle compliance and sepsis outcomes.
Two years later, sepsis best practices in their hospital are a reality. The number of clinicians who now implement all key elements of the Surviving Sepsis Campaign’s six-hour bundle has shot up from 25% to 75%. And, Dr. Childs says, “we’ve seen a 15% reduction in sepsis mortality.”
Dr. Childs and his colleagues opted for simulation training because they find hands-on learning to be more effective than just textbooks or lectures. To bring a simulator onsite, he reached out to Medical Simulation Corporation, a Denver-based company that offers simulation training through a series of advanced quality programs, including one on sepsis.
Dr. Childs designed a study around the initiative to see how sepsis treatment in the hospital could be improved. The company provided the simulation training and other services at no cost as part of the study.
First, ED and ICU clinicians “doctors, nurses, respiratory therapists “took an online pretest to gauge their knowledge of sepsis best practices. They then attended a 30-minute didactic session.
Then, “we had the simulator team here for two weeks and scheduled two three-to-four hour sessions every day, with up to eight clinicians attending each session,” says Dr. Childs. A patient simulator complete with monitors was set up in a hospital room.
That simulator, he explains, is a full representation of a patient from head to toe, with active functioning and changeable clinical signs. Those include eye and pupillary reflexes, breath sounds, palpable pulses and the ability to answer questions.
“You can listen to different breath sounds and hear if the ‘patient’ has pneumonia,” Dr. Childs explains. “You also hang IV bags and put a sensor on the simulator’s arm, registering that you gave antibiotics, fluids and various vasopressors.” A computer hooked up to the simulator generates different clinical scenarios that trainees must respond to, while an instructor leads them through different therapies and techniques.
Identifying sepsis sooner
One big advantage of the program was that it featured “cross-functional team training,” says Dr. Childs. Instead of doctors first attending sessions, then nurses and so on, the teams working together in the ED and ICU all trained together.”
That improves the team’s interaction later on when dealing with actual scenarios,” he points out. “Nurses became much more likely to tell doctors, ‘I think this patient has severe sepsis. Do you want me to get the blood cultures and lactate tests started?’ ”
He credits that improved interaction for post-training findings that patients diagnosed with sepsis at Cape Regional are being identified earlier and discharged with a lower acuity. Before the training program, 72% of the hospital’s sepsis patients had septicemia or severe sepsis with major complications or comorbidities. After training, that percentage fell to 63%, with fewer patients progressing to septic shock and multiorgan failure.
And during simulation training, clinicians take turns leading protocols and doing the nurses’ and respiratory therapists’ jobs. “Everyone gets to play the part of other team members, including the physicians,” Dr. Childs says. “You realize there’s more to what your team mates are doing than meets the eye.”
But some physicians were skeptical at first. “Many think they know everything,” he says. “But when doctors were interviewed after, they admitted they hadn’t known everything and that it was stimulating to train as part of a multidisciplinary team.”
To help get reluctant doctors on board, Dr. Childs arranged CME credits through the University of Pennsylvania’s Perelman School of Medicine. He also convinced medical leadership to make sepsis simulation training a requirement for staff doctors caring for critically ill patients in the ED and ICU. He also urges hospitals to peg a sizeable portion of doctors’ performance bonuses to simulation training or other educational activities that can improve evidence-based performance.
“If you don’t get CME or incentives involved,” he says, “you’ll get poor performance and attendance.”
A model for community hospitals
Another group that may need convincing is administrators. “They’re hard-pressed to see the reasoning behind spending money to educate physicians, who are supposedly already educated,” Dr. Childs says.
The research project was designed to change their minds. “Paying for education up-front should be part of the bottom line,” he explains. “This project proved that the cost of bringing a simulator to a community hospital is well worth it, given the lives saved and the improvement in quality and morbidity.”
The training program helped reduce Cape Regional’s sepsis mortality rates from 10.5% to 8.9%. And according to study data, the program helped avert $280,000 by reducing length of stay and complications.
“That was just for the 180 sepsis patients in the study,” Dr. Childs says.
The hospital is now bringing the simulator team back, this time to train clinicians on the wards and those ED or ICU clinicians who were not present or available the first time around.
“Diagnosing sepsis on the floor is still a huge problem,” Dr. Childs notes. “The seriousness of early sepsis signs and symptoms that patients on the floor may exhibit is not recognized. We have to become much more aggressive.”
Throughout the hospital, he adds, the goal should be to bring the same urgency to sepsis as to STEMIs. “The data show,” he says, “that ‘time is tissue’ for patients with severe sepsis and septic shock just like it is for the heart in a STEMI and the brain in stroke.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.