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Chief nursing officer Rhonda Collins discusses her article “Nurse-initiated protocols for sepsis: a strategic imperative for patient care and hospital operations.” Rhonda explains why sepsis, the leading cause of death in U.S. hospitals and a $62 billion annual burden, demands the same urgency as stroke and STEMI. She highlights the power of nurse-initiated standing orders to speed recognition and treatment, reduce ED congestion, improve outcomes and cut costs. Drawing on real-world results from Franciscan Missionaries of Our Lady Health System, she shows how standardized sepsis protocols supported by FDA-cleared technology reduced mortality by 39 percent, shortened length of stay and saved thousands per patient. Rhonda emphasizes that national standardization, objective tools and empowering nurses to practice at the top of their license are essential to making sepsis the “third S” in emergency care.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Rhonda Collins. She’s a chief nursing officer. Today’s KevinMD article is “Nurse-initiated protocols for sepsis: a strategic imperative for patient care and hospital operations.” Rhonda, welcome to the show.

Rhonda Collins: Thank you so much. It’s a privilege to be here. Thank you.

Kevin Pho: All right. Let’s start by briefly sharing your story and then jumping into the article that you shared with us on KevinMD.

Rhonda Collins: Sure. I’ve been a nurse for almost forty years. Obviously, I’ve been around a while. I started in labor and delivery; I was a high-risk labor and delivery nurse. If you were a woman just having a baby, I was probably not your nurse. You had to be ill with HELLP syndrome or high blood pressure, something. It was through that, because I had one or more patients that I could not see, I could not touch. I had to rely on technology to give me insight to that unseen patient, the baby.

Through that, I became very interested in technology and nurse adoption of technology. That really drove my career for the next twenty-five years, just understanding how nurses initiate workflows, how we change workflows, and how we use technology to our benefit. So much of my doctoral work and my publications have been on nurse adoption of technology and understanding how we do not confuse or complicate workflow when we instigate new protocols or new technologies, but how we make it where it’s an augmentation to how we work and not a frustration.

So I would say that’s really driven my career. I’ve worked with different products and different philosophies and different organizations. I’ve had the privilege of working in international roles, so I get to see how nurses around the world work and adopt technology. And it’s really informed everything that I’ve done for now and in the future.

Kevin Pho: All right, so in your KevinMD article, you talk specifically about sepsis. So talk about that article and of course, how that intersects with your background in integrating technology and workflows.

Rhonda Collins: Right. What I was writing about was really fundamentally workflow. How do nurse-initiated protocols improve the patient experience or the patient outcome, and how do we manage that in the environment? We know that 66 to 70 percent of all patients presenting to the hospital come through the emergency department. There are only a couple of ways patients get in the hospital: direct admit, usually for surgery, or through the emergency room.

We do have protocols for STEMI and stroke. If you look, since we’ve implemented those protocols, STEMI is now actually initiated in the field frequently with the emergency services. They come into the hospital and less than 1 percent are now admitted with an actual STEMI because we’ve done all this work to understand how workflow and protocols can enhance the process. If you look at stroke or stroke mimics, that’s a little bit harder to figure out. Some of the medications are so powerful they cannot be initiated in the field, but the early protocols can be initiated. They get to the hospital, and nurses then move forward with moving the patient through the system with those initiated protocols. We now know that ultimately about 2.5 percent of all those patients actually have a stroke.

So, we can see how we’ve improved outcomes and treatment and urgency. My article was really focused on this huge population of patients who are either infected or become septic. The numbers for accurately diagnosing sepsis have such a range. Make it the third ‘S’: STEMI, stroke, sepsis. And let’s standardize protocols. Let’s standardize nurse-initiated protocols because we have some in some hospitals, but we don’t in others. So where we see these protocols initiated, nurses are seeing a reduction in patient admissions, we’re seeing improved treatment of patients, we’re seeing shorter length of stay, all of these things based on being able to accurately triage and look at the patient.

Just to give you some numbers, about 41 percent of all patients presenting to the ED have a suspicion of infection. But as you know, infection doesn’t mean sepsis. Sepsis is a dysregulated immune response that has to be studied. There’s the SEP-1, there’s SIRS, there’s all of these things. But even with all of these protocols we still have, are you ready for this? Somewhere between 4 and 49 percent end up being septic. Isn’t that crazy? So that just tells you how variable it is.

We have new technologies, we have new testing that allows us to see more accurately if this patient to rule in sepsis or rule out sepsis, just a simple blood test. So as we integrate that into the standing orders and the protocols, we integrate it with our SIRS and our SEP-1 to be able to do just a simple blood test with a purple top that goes to the lab and comes back. We can rule in and rule out. So when I look at workflow, it’s like, can nurses initiate this process and how do we improve the outcome, improve the operational workflow, free up beds, and really make sure that we’re treating patients in the right way when it comes to sepsis? And again, it’s because there’s such a variable there. I’ve had people say to me, “Well, I know sepsis when I see it.” No, I wouldn’t always rely on that. So let’s adopt new ways of looking at an old problem and improve that process.

Kevin Pho: And when you compare sepsis to the other ‘S’s that you mentioned, ST-elevation MI and stroke, traditionally there are more challenges and more ambiguity when it comes to the diagnosis of sepsis compared to the other two. So when talking about a nurse-initiated protocol for sepsis, tell us the type of triggers that would alert the nurse to start that protocol.

Rhonda Collins: Exactly. When patients present to the ED, if the nurse even just suspects infection based on vital signs or a quick assessment, they should be able to go ahead and initiate that protocol through their EHR system and be able to then order any testing that could be presented to the physician that would say rule in or rule out, so we don’t have to wait for the doctor to get to the patient. That’s what we’re looking at.

The American Nurses Association is very supportive of nurse-initiated protocols working with the doctor community, working within your organization to understand how do we set this up so the physicians feel like patients are not either being overtreated or undertreated before they can get to them. But clearly with all the staffing issues that we have in hospitals, from the medical side and the nursing side, we all have to work together to ensure that there aren’t any gaps. And this is just another way to close a gap and ensure that a patient doesn’t fall through the crack because many times, as you know, we’re waiting for results to come back on lactic acid or blood cultures, and it just delays this entire process. Sometimes patients are sent to the waiting room who shouldn’t be sitting in the waiting room because again, sepsis is a complication that can come on very rapidly. And once it’s there, it’s very difficult to manage, depending on other comorbidities with the patient.

Kevin Pho: So you talk about emerging technology when it comes to diagnosing sepsis. So talk about that technology and how it contrasts with the traditional way we diagnose sepsis.

Rhonda Collins: It’s a simple blood test that can be augmented in addition to the assessment, the protocols that you currently use. It’s just a purple top that is drawn with your CBC or whatever you’re doing, and in the lab, you can get results within eight minutes or so. What this test tells us is patients will fall into three bands: band one, band two, and band three. Band one is not a likelihood of sepsis. Treat the patient as though they’re infected, but not septic. Band three is a high likelihood of sepsis.

So once you have that information and can start treating, then you can order the expensive blood cultures. Then you order all the other testing that is routine with sepsis. So it does a couple of things. You have a more definitive diagnosis, and you’re saving money for the hospital. As you know, blood cultures can get very expensive. They’re easily contaminated. All of these things we can do at the right time, instead of just doing it because we don’t have a better solution. So that’s what we’re talking about, is allowing a simple blood test to make that definition and then work off of that information and continue to monitor the patient. We’ve actually seen in hospitals using this testing that about 50 percent or more of the patients fall into band one, which is not septic. So we’re able to see that yes, they’re sick, yes, we need to treat them, but it’s not sepsis. Those are the things that we can look at through workflow and protocol and new technologies and new testing that we can improve what we do and augment our process.

Kevin Pho: One of the things that you talk about in your article is antibiotic stewardship as a concern, of course, for sepsis management. So talk to us about how these nurse-driven protocols can avoid antibiotic overuse.

Rhonda Collins: Exactly. It’s the same process where we assess and we test. Assess and test. And once you have the definitive diagnosis that it’s an infection or this patient is ill, then you can treat appropriately. As you know, we overuse antibiotics in general because we’re not exactly sure what we’re dealing with. And sometimes we have to change up antibiotics in the middle of the stream because it’s not treating whatever we’ve looked at. I think all of us have had that experience, but what we’re saying is reduce the reaction of, “Let’s just administer the antibiotic because we’re inspecting and we’re not sure exactly what’s going on.” So when we talk about antibiotic stewardship, it’s use it when it’s necessary, be conservative when it’s not. We can give you a definitive diagnosis so you can feel more comfortable in exercising that stewardship.

Kevin Pho: So what are some of the obstacles that prevent more medical institutions from instituting some of these protocols that we’re talking about today?

Rhonda Collins: You know, there’s always the trust between the physicians and the nurses and whether the right decisions are being made at the right time. So that’s always an issue to work on. Staffing affects it profoundly. The other part of it is whenever you have new testing or new technology, we’re all comfortable in how we treat patients or how we manage patients because it’s based on our experience, our education, and all of that. So when something new comes into the environment, there is this innate distrust of it.

So I would say embrace the change, embrace the notion and the opportunity, and allow it to continue to teach you rather than just resting on, “This is what I’ve always done.” I just think that “what I’ve always done” is a trap that many of us in health care and in medicine fall into. It’s just because we’re busy, we’re urgent, and we’re just trying to get it done and our past experience tells us what has or has not worked and we get comfortable with it. Part of my work around technology adoption is understanding why health care providers adopt and why they reject. And as you know, the line between adoption and rejection is razor thin. It’s not even broad; it is razor thin. Usually you get one opportunity and they’ll fall off one side or the other. So that’s what I would say, is just be willing to embrace the notion that there is something else here that’s going to give you more information that’s easily integrated into your workflow.

Kevin Pho: And in your article, you cite a real-world case study from a hospital, the Franciscan Missionaries of Our Lady Health System, where these standardized protocols reduced mortality by 39 percent and shortened length of stay and saved thousands of dollars per patient, right?

Rhonda Collins: That’s exactly right. And I’ve actually worked with the director of the ED and the chief nursing officer there to tell their story because they continue to see improvements. They continue to see savings based on not initiating unnecessary blood cultures. I think in general, those are around 2,500 dollars per test. They’re seeing better use of antibiotics. They’re seeing a more complete throughput in their ED because they’re able to free up beds and move patients through. So, I’ve actually done a webinar with them telling that story and hopefully giving them other opportunities to share that because they just continue to see the improvements. We have other hospitals in Texas who are showing these same improvements just by being willing to embrace a new way of looking at an old problem.

Kevin Pho: We’re talking to Rhonda Collins. She’s a chief nursing officer, and today’s KevinMD article is “Nurse-initiated protocols for sepsis: a strategic imperative for patient care and hospital operations.” Rhonda, let’s end with some take-home messages for the KevinMD audience.

Rhonda Collins: Yeah. I think right now, as I look across the landscape of what’s happening in health care, we continue to struggle with all the issues post-COVID that have to do with staffing and fatigue. I’ve had so many nurses say to me, “I don’t need a workbook on how to be resilient. I don’t need somebody sending me for five minutes of quiet time because I’m burned out. I need people to make it easier to do my job.” That is my number one imperative. “Give me the tools I need to do my job.”

So really in my professional work, I focus on working with organizations who have new and innovative, easy to adopt, easy to use tools that give exceptional results. That’s what I’m talking about is being willing to look at what the potential could be and look at how it could enhance not disrupt your workflow and your care of patients. I think that’s the primary message I would leave.

As we move into a new world of AI and how we adopt that, I speak on that occasionally for nurses talking about code compassion. How do we integrate technology into what is traditionally for nurses known as a caring profession? I do think that technology doesn’t take that away for either physicians or nurses. It does allow you to be even more present when you choose to use the information that that new test, that new technology, that new protocol or process gives to you. So that’s my takeaway message is: Adopt it, use it, and embrace that information that it gives to you because it’s going to keep changing. Nothing is ever static in this world.

Kevin Pho: Rhonda, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Rhonda Collins: Thank you. I appreciate it.