Reducing Sepsis Mortality: A Cloud-Based Alert Approach

REDUCING SEPSIS MORTALITY: A CLOUD-BASED ALERT APPROACH By Janet A. Zink, Ph.D. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2018 Major Director: Dr. Jonathan P. DeShazo Associate Professor, Department of Health Administration Sepsis is a fatal whole-body inflammation caused by severe infection. Every year, about a quarter of a million Americans are stricken with severe sepsis, and up to 50 percent of them die as a direct result. Factors such as increased life expectancy, antibiotic resistance, and broader use of immunosuppressive agents have caused the number of cases to continue to rise by eight percent per year. Therefore, timely recognition of sepsis is crucial to the initiation of evidencebased therapeutic measures that can prevent the eventual breakdown of organ systems, shock, and resultant death. The aim of this study is to examine the impact of a cloud-based clinical decision support (CDS) alerting system for systemic inflammatory response syndrome (SIRS), a precursor to sepsis, and sepsis itself, on adult patient and process outcomes at Virginia Commonwealth University (VCU) Health System. The two main hypotheses are: 1) the implementation of cloudbased SIRS and sepsis alerts will lead to lower sepsis-related mortality and lower average length of stay, and 2) the implementation of cloud-based SIRS and sepsis alerts will lead to more frequent ordering of the Sepsis Initial Resuscitation PowerPlan (order set bundle) and more recording of sepsis diagnoses. To measure these outcomes, data were collected from September 2013 through December 2016 after the implementation of a sepsis cloud-based alerting system within the Cerner EMR. A pre-implementation group diagnosed with sepsis within the year leading up to the alert intervention consisted of 1,551 unique inpatient visits, and the three-year post-implementation sample size was 9,711 visits, for a total cohort of 11,262 visits over the course of four years. Logistic regression and multiple linear regression were used to test the hypotheses. Linking cloud-generated SIRS and sepsis alerts with clinical outcomes fills a unique gap in the informatics literature. It does so by measuring the clinical performance of an evidencebased alerting method for promoting maximally effective prevention and treatment practices to combat sepsis-related mortality. Study results showed that, post-alert activation, sepsis-related mortality was slightly higher after the implementation of SIRS alerts, but the presence of sepsis alerts did not have a significant relationship to mortality. The average length of stay and the total number of recorded sepsis diagnoses were higher after the implementation of both SIRS and sepsis alerts, while ordering of the Sepsis Initial Resuscitation PowerPlan was lower. There is preliminary evidence from this study that more sepsis diagnoses are made as a result of alert adoption, suggesting that clinicians can consider the implementation of cloud-based SIRS and sepsis alerts in order to capture a higher number of sepsis diagnoses.