Sepsis reduction is among the items addressed in published studies
UF Health Jacksonville has made significant gains in recent years in a host of quality-related measures, including a reduction in infection rates. And in that time, much research has been conducted to prove the interventions are indeed working.
Faheem Guirgis, MD, an assistant professor of emergency medicine at the University of Florida College of Medicine – Jacksonville, has led the efforts on several of these studies, which have since been published in national peer-reviewed journals.
In 2017, for example, a study was featured in the Journal of Critical Care that explored the effects UF Health Jacksonville’s rapid response teams and a sepsis alert program have had on sepsis outcomes. Sepsis is a condition in which the body’s response to infection causes organ failure. It’s the primary cause of death from infection.
In this retrospective study, Guirgis and other UF Health researchers compared data from before and after the alert program was initiated, in November 2014. A sepsis alert is used to mobilize resources for efficient delivery of care to the septic patient, using nursing for support, pharmacists for rapid antibiotics and respiratory therapy for point-of-care testing and treatment. Following implementation, the number of sepsis-related deaths decreased by more than 10 percent.
“What we figured out was that sepsis mortality and inpatient mortality were very closely linked, and that improving sepsis mortality rates would improve overall hospital mortality rates as well,” Guirgis said. “We also knew that once we intervened, we could go back and study it.”
Key contributors also included Lisa Jones, MD, an associate professor of medicine and chief of pulmonary, critical care and sleep medicine; and Kelly Gray-Eurom, MD, MMM, a professor of emergency medicine and chief quality officer at UF Health Jacksonville.
Deciding on research
Guirgis said the decision to conduct a retrospective study is made while the intervention is in the planning and development stage. That allows investigators to ensure all the “pieces” are available and in place to effectively collect and analyze data later on.
After all the data were gathered for the sepsis study, it took more than a year to sort the information, assess it and write the paper. Guirgis submitted the study to the Journal of Critical Care in December 2016. It published the following April.
And even if this intervention had not yielded positive results, Guirgis said he still would have written a paper about it.
“Negative studies are just as important,” he said. “You need to show people where not to go. If an intervention didn’t work, it’s OK to say so. That’s just how science works.”
When considering whether to study a particular intervention, it’s key to search existing literature to see what’s already been done and what could make a future study unique. Guirgis said proactive rounding and rapid response teams have been studied before, so this campus’ favorable intervention outcome “moves the bar forward” with more evidence the research community can build on and reference in future investigations.
Petra Duran-Gehring, MD, an associate professor of emergency medicine, has had two papers published on the use of ultrasound in IV placement.
In one paper, she demonstrated a reduction in the time to insert central venous catheters. Physicians began using ultrasound at the patient’s bedside to confirm catheter placement, which eliminated the wait for a confirmatory chest X-ray. A central venous catheter, or central line, is a large IV inserted in one of the body’s main veins to draw blood, give fluids, administer medications and treat shock.
“Although often necessary, its use can lead to catheter-associated bloodstream infections, when bacteria or other germs travel down that line and enter the blood,” Duran-Gehring said. “Therefore, they should be used sparingly.”
Another study of hers demonstrated the safety and effectiveness of having emergency room technicians or EMTs place IVs under direct ultrasound guidance in patients who had IV access that was difficult to obtain.
Surveyed physicians said that without the ultrasound-guided IVs placed by the technicians, the patients would have required a central line. As a result, the rate of central line usage decreased by more than 50 percent in this 830-patient study and helped reduce UF Health Jacksonville’s overall catheter-associated infection rate.
The ultrasound-guided IV program has now expanded throughout the hospital. This further decreases central line usage via the placement of ultrasound-guided midlines, a long IV catheter that can stay in place for almost a month. Duran-Gehring has worked on this project with Cynthia Gerdik, DNP, MBA, associate vice president for nursing. They hope to publish their results in the near future.
Duran-Gehring is now working on the use of bedside ultrasound to aid in the assessment of ill children in the pediatric emergency room. She is using ultrasound to view their deep abdominal blood vessels to determine dehydration.
“We hope that this non-invasive measurement will lead to better management of dehydration in children presenting to the emergency room,” she said.
In another study published in the Journal of Patient Safety, Guirgis and others looked at the impact a rapid response team had on opioid-related cardiac arrests at UF Health Jacksonville.
The study centered on the drug naloxone, which is used to block the effects of opioids, especially in an overdose. The hospital’s Code Blue committee developed a system to page the rapid response team whenever naloxone was dispensed on the inpatient units. That committee’s leadership included Gerdik and Andy Godwin, MD, a professor and chair of emergency medicine.
Data was taken from the 12-month periods before and after the system was implemented. When adjusting for inpatient admissions and lengths of stay, opioid-related cardiac arrests decreased from 2.9 per 10,000 admissions to 0.1 — a difference that is statistically significant.
“The important point is that the care is improving,” Guirgis said. “It’s only after the fact that we show we have indeed improved.”
Regarding sepsis, Guirgis wants to now study incidents in which patients developed the condition while at UF Health Jacksonville. The previous study included those patients, but also accounted for the ones who may have already been septic at the time of admission. A goal is to identify the departments and units experiencing the most challenges with sepsis, and offer training and support to improve outcomes.
“For instance, we have observed that patients with cardiovascular disease and liver disease are more prone to developing sepsis,” Guirgis said. “We might end up doing something with that particular population. I’m not sure yet.”
Growing research on campus
A grant from the National Institutes of Health funds a large portion of Guirgis’ salary, with the understanding that about 75 percent of his time on campus is spent on research-related activity. The other 25 percent involves patient care.
“I do a lot of research and I love it,” Guirgis said. “There’s a push on this campus to get more people into these kinds of grants to engage in research as a career.”
He said it all boils down to improving patient outcomes. “As we go forward, we’re going to keep finding areas for improvement. And each time we do that, we’re going to study our interventions and publish the results.”
Petra E. Duran-Gehring, MD
Medical Director, Emergency Medicine Ultrasound