By: Sarma Velamuri, M.D., Natalie Cheng
September 1st 2021
Have you heard of the Swiss Cheese model? Just in case you were wondering, it doesn’t pertain to food exactly. The Swiss Cheese model actually describes a hospital’s defenses against failure when modeled as a series of barriers with each barrier represented as slices of Swiss cheese.
The hole in the slice of cheese represents a weakness in that barrier. When the holes do not all fall in the same line, the barriers are effective at preventing bad outcomes. When the holes do line up, bad things happen.
When these areas line up and a threat makes it through the defenses, this leads to higher mortality, morbidity, and costs.
So how does the Swiss Cheese Model relate to sepsis in the hospital?
Here are some areas where accidents can occur in relation to sepsis screening and management:
Blind Spots in Sepsis Screening
- Patients admitted outside of regular workflows eg. Transfers in to the building from another facility or post-procedure patients fall through the cracks due to a lack of a predefined time to perform predefined sepsis screening according to the sepsis protocol.
- Patients with extended Emergency Department stays occasionally bounce from the Emergency Department to the floor to the ICU due to a change in clinical status that wasn’t identified at the time of leaving the ER.
- Patients whose sepsis alert is muted by the nurse or doctor are at risk of being missed.
Deviations from Sepsis Care Protocol
- Different providers take care of the same patient situation differently due to a lack of measurement of protocol adherence in real-time (i).
Lost time and effort
- Securing the assistance of each team member in hospitals that have a rapid response team requires interaction with an answering service, a multi-person page, and a call back. This wastes a lot of time and causes a long human daisy chain resulting in delayed care.
- Repetitive sepsis score calculations produce fatigue. The Rapid Response team is often required to perform many instances of sepsis screening daily, which leads to fatigue and burnout.
- Diagnostic criteria for SIRS and sepsis can be met by many variables which can be difficult to calculate without an automated system. For example, a patient could have a heart rate greater than two standard deviations above normal value for their age or an SBP decrease that is greater than 40 mmHg or less than 2 standard deviations below normal for their age and a nurse would not know how to calculate those numbers in real-time (ii).
- Rapid response nurses can’t be everywhere all the time in case of multiple rapid response calls at the same time.
Overutilization of telemetry
- Patients who need more frequent sepsis screening are admitted to telemetry which has not shown clinical benefit and creates increased length of stay and can cost a hospital over $1.2MM a year in costs of boarding patients in the emergency room (iii).
Retrospective Chart Review
- PDSA cycles are slow, which ultimately leads to slower institution of improvements.
All these areas where accidents can occur will lead to more people developing sepsis and succumbing to septic shock, which is something that we don’t want. The sepsis screening and management process must change. It needs to cover these blind spots, deviations in care, and everything discussed earlier.
If you’re looking for a sepsis management solution that can help you detect and treat sepsis faster, reduce alert fatigue, and have a positive return on investment, then please reach out to us. We would love to help.
(i) – Melamed, A. and F.J. Sorvillo. “The burden of sepsis-associated mortality in the United States from 1999 to 2005: an analysis of multiple-cause-of-death data.” Crit Care 13(1): R28. 2009
(ii) – Churpek, Yuen, Winslow, et al. “Developing a Risk Stratification Tool for Ward Patients.” Am J Respir Crit Care Med Vol 190, Iss 6, pp 649–655, Sep 15, 2013
(iii) – Journal of Hospital Medicine 2018;13:531-536.