By Dee Russell

It can start out as just an elevated heart rate or slight fever and can progress into what appears to be the flu or a urinary tract infection. When not treated fast enough, widespread inflammation can cause tissue damage, organ failure and even death in a matter of hours.
Every year, around 1.5 million Americans are diagnosed with sepsis, a life-threatening response to infection, and 250,000 of them die from it, according to the Centers for Disease Control and Prevention. At UF Health Jacksonville, the number of patients developing and dying from sepsis has dropped by 30 percent since 2014.
In 2014, UF Health Jacksonville was ranked 79th in mortality by Vizient, which evaluates more than 100 academic health systems and community hospitals in the country. This year, the hospital is ranked 44th.
“Our physicians are very responsive,” said Rhemar Esma, UF Health Jacksonville’s lead quality measures abstractor. “Their participation in the development and execution of Azreal is the reason we are seeing success.”
Azreal is a program Esma developed to run in the background of Epic, the hospital’s electronic medical records system. It scans every patient’s vital signs hourly and sends a notification of possible sepsis to providers. This alerts them to go to the bedside when someone’s condition begins to deteriorate.
“Currently, best practice is to monitor a patient for sepsis development every six hours,” Esma said. “We initially programmed Azreal to scan our patients every four hours, but quickly changed it to two and then every hour to ensure we are able to catch and treat the infection in time.”
Each department sets up its own possible sepsis notifications based on the type of illnesses and procedures its patients experience and undergo. The most challenging group to monitor are postoperative patients, who regularly have temperature and blood pressure spikes during recovery.
“Alerts for patients who have had major surgery do not begin to go out until 24 hours after the procedure,” Esma said. “Azreal then monitors those patients every four hours. These modifications would not be possible without active feedback from our nurses and physicians.”
Mortality is an important domain on most patient safety and quality reports. Vizient breaks down its mortality data into diagnosis rating groups, with most of them tied to complications from surgery.
“We all care for patients here, it’s not just the surgeons,” said Scott Lind, M.D., chair of surgery at UF Health Jacksonville. “Data allows us to look at trends and find ways to improve negative ones.”
Several patient safety and quality initiatives for surgery are now in place, such as providing patients with an antiseptic to use before a procedure to reduce surgical site infections; using an educational worksheet encouraging anticoagulant injections that prevent potentially fatal blood clots; and increasing coordination with case management to ensure patients have the proper environment and supervision after discharge from the hospital.
“All of this is the result of better communication of the data and education to help us find the solutions,” Lind said.
When a patient dies, their medical records are coded for billing and insurance, data collection and research. The records are reviewed by coders within 24 hours to ensure the details are accurate and thorough. When information in the records needs to be clarified, it is sent to Clinical Documentation Improvement staff, which includes a team of critical care nurses and a physician. The team then works with the physicians involved to ensure complete and accurate documentation.
“A person can read between the lines, but an account cannot be coded without specific information,” said Jean Aclin, a senior inpatient coder for Health Information Management at UF Health Jacksonville. “When there appears to be a conflict in the documentation, we work directly with the doctors involved, so the codes best reflect what actually happened.”
This information provides a play-by-play of the care a patient received and can help departments identify opportunities for improvement. “It is encouraging to see that the scores reflect the accuracy of the coding, which, in turn, represents the conditions of the patients we serve at UF Health,” Aclin said.
“Better documentation through better coding leads to better outcomes for the next patient,” Esma said. “Doctors can’t be in two places at once, but by working together, we can maximize our resources and improve the medical care for all patients.”