Maggie McKay (Host): Meaningful Medicine is a Novant Health Podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm your host, Maggie McKay. Joining us today to talk about sepsis policy and healthcare reform are Dr. Daniel Feinstein, Systemwide Co-Director of Sepsis Care and Director of Pulmonary and Critical Care, and Elizabeth Outten, Lead for the Novant Health Center for Public Policy Solutions.

Thank you both so much for being here and joining us.

Elizabeth Outten: Glad to be here. Thank you.

Host: Dr. Feinstein, let's start with you. Let's start with a success story. How did New York's sepsis regulations save over 16,000 lives?

Dr. Daniel Feinstein: This actually started out really with a sad story that in the end does I think relate to significant success in New York. This is a story of a 12-year-old, Rory, who presented with sepsis to his local emergency room. And unfortunately the diagnosis was really missed and there was delays to his care.

And this, and this poor child did not survive. And from that, New York, really, said that we really need to do something about this. And they started very quickly in 2013 with regulations for the entire state. And what they did is they really mandated, they mandated significant improvements in sepsis care and, and that was about early recognition mandates, making sure that their patients in their state had rapid treatment.

 They also mandated data collection as well as public reporting. And that really just completely changed the landscape of how EMS and the public itself really looked at New York then as a leader in making change to improve the outcomes of their state.

Host: Elizabeth, do you have anything to add to that?

Elizabeth Outten: I think that what we saw in New York was what it takes to ensure consistency in care and because they were able to pass public policy to do that, it had such an impact on patients directly. It saved lives and that is what we're hoping that the Center can really highlight in the work that we're doing around sepsis.

Dr. Daniel Feinstein: From 2015 through 2019 is when they started to look and make comparisons to their baseline outcomes for sepsis, and they found significant lives saved as Elizabeth was mentioning, like 16,000 lives saved, which is just amazing.

Host: Elizabeth, why is the Center for Public Policy Solutions focused on this issue?

Elizabeth Outten: The Center for Public Policy Solutions listens to our providers and we listen to our patients. And what we heard about sepsis care specifically was that consistency in public policy and the consistencies in care that public policy can create are critical. They save lives. They ensure that regardless of where you're going for care, you're going to get high quality care and you're going to experience the kind of care that Dr. Feinstein and his team provides at Novant Health and that is something that we in policy solutions can really drive when we're all together and taking action.

Host: Dr. Feinstein, what does optimal sepsis care look like when clinicians can follow evidence-based protocols?

Dr. Daniel Feinstein: Optimal sepsis care starts with identification and defining the patient. Like we have to have proper definitions that Elizabeth is mentioning that the clinicians, and the data that we use and the literature suggests that of how we should be identifying this is a sepsis patient because without the identification, we miss all the treatment opportunities.

And so after having early identification and proper definitions, at that point, we want to make sure we have quick treatment in what we call the sepsis bundle. And it may sound real easy, but it really is not. It really takes a village. It takes significant teamwork from all kinds of providers. And that sepsis bundle includes urgent needs such as antibiotics immediately, fluids. Certain blood work and follow up for those patients to make sure that they're improving from the treatments they're getting. Additionally, we have to also make sure that patients have what's called source control. It just means that they need a surgery, they need a surgical intervention, that takes place as well. That's, that in the literature suggests that could be just as important even as the antibiotics. And then lastly, looking at an evidence-based program, a high performing program, we need data. We need to be able to look and see how are we doing, what potential improvements that we need to make.

And then fine tuning basically how our team is performing. And so when you get to this high performing program for sepsis, then you can see significant outcome improvements and I'm proud to say at Novant and within our system-wide sepsis committee, which has done some remarkable things, but we've taken 20 plus hospitals of all these leaders in this area, and we've all worked together, which is something that I've never really been a part of such a success of having so many different, different facilities and hospitals working together. From all of our changes that we've made over years with our program, we have found a 50% reduction in the mortality. And if you look at that, that's about 25, 26, 27 patients per month that are being taken care of at Novant that are now alive and surviving their sepsis episode, which is just remarkable care and something we're really proud about.

Host: You should be proud. That is amazing. Elizabeth, what made New York's Rory's regulations so effective, and how can other states replicate this success?

Elizabeth Outten: So what we saw in our research at the center was that they really centered on the definition of sepsis and at what point you define this patient has sepsis and there are varying definitions out there. The two that we really took a hard look at were sepsis two which starts interventions very early.

 And Dr. Feinstein can give you all the expert analysis of exactly how that works. And then looking at sepsis three which starts a little bit later, and things like organ failure have to be more prominent before that patient is defined as having sepsis. And so the policy changes that they made in New York centered on that sepsis two definition, so that consistency of care started earlier.

 It ensured how the protocols were designed were based on sepsis two, it ensured insurance coverage began when sepsis two definitions were used in that early part of sepsis being identified. And that was a game changer. It saved people's lives and it's what Novant Health protocols are based on as well, that sepsis two definition.

 And so the policy solutions that we're putting forward from the center would utilize that definition in a more consistent way. So that, that care is what it should be.

Host: Elizabeth, could you tell us a little bit about the Center for Public Policy Solutions approach to creating healthcare solutions?

Elizabeth Outten: Absolutely. So the Center was formed to elevate our clinician voices to start. They are the experts. They know, have been to med school, have been to nursing school have really studied how to treat patients and they have a passion for it. They would not have entered this kind of job if they didn't have a passion for taking care of people.

And so their voices are critical. Their voices are among the most important things at Novant Health, and they are really important voice in public policy that we've seen can be left out. And we wanted to make sure that as we're talking about the solutions that lawmakers should consider; that voice was a louder one and one that was significant in how policies are shaped.

We also listen to our patients. We've all been patients, our family members have been patients. We've experienced care when it's good and we've all probably experienced care when it's not. And for something like sepsis, not good care is not acceptable. That outcome can be fatal.

 And so when we incorporate our patient's perspectives, when we bring in those clinician voices, we are able to combine them and make sure that policy is the best it can be to improve healthcare.

Host: Dr. Feinstein, what opportunities do you see for North Carolina to lead on sepsis policy?

Dr. Daniel Feinstein: Yeah, I really see a lot of opportunity for us specifically in our state. Just reflecting a little bit more on the definition, we have an opportunity in front of us to define this as what the clinicians see as the best definition, which is a step two definition, which is just so important because this is how a patient is identified early on in their sepsis presentation.

The step three definition is really a patient who is more advanced in their sepsis event. And certainly we know it's so important of timing and how we treat patients rapidly matters. So we really want to identify them early. So I think our state has an opportunity to make the definition consistent with the clinicians and get treatment to our patients earlier rather than later on.

 I also want to reflect on North Carolina and we have a lot of patients in North Carolina who develop sepsis, and unfortunately as compared to other states in our nation, we have some of the worst outcomes. And I think a lot of this depends on the rural nature of North Carolina.

There are some disparities, economic disparities and other things that don't allow patients to rapidly get to see a healthcare provider or to even an emergency room. And so of all the states in our country, North Carolina's a state who should be raising their hand and saying, wait a second here, we want to do better.

Because this is specific to the needs of our North Carolinians. And then lastly, the opportunities I think that we have is really trying to take complications of payers, insurance, et cetera, out of the definition of sepsis. Allow the clinicians to define it, allow us to concentrate of the care of patients and not have any other concerns in regards to payers and what their definition may or may not be for sepsis.

These things would certainly allow our patients within our communities in North Carolina to benefit from this legislation changes.

Elizabeth Outten: And I'd add to that, you know, I think that's a key for the center. The Center's focus is to ensure that patient care is the best that it can be. And we know that when a patient's Doctor or nurse or APP is able to define what that care is and how that care should go without having to think about those outside things that can complicate that care, the patient's going to receive exactly what they should. And so this solution specifically as we start centering on the sepsis two protocols really enables that. And we are very much looking forward to partnering with North Carolina to get that done.

Host: Elizabeth, how can healthcare systems, clinicians, and other advocates work together to push for these proven solutions?

Elizabeth Outten: I think the key thing is to speak up. I think the most important thing any of us can do in a public policy space is to use our voices. That's why the center was created, because I think our clinicians so often are so focused on patient care that they may not feel empowered to use those voices outside of the walls of a hospital or their clinic.

And so we wanted to create that avenue so that they could do it in a meaningful way with those in the halls of government that are making such critical decisions. So I think it's raising their voices and being willing to raise their hand when they see that there's an issue. And making sure and thinking of public policy as a solution driver, not necessarily a barrier.

 It can often be a barrier, but there are ways to fix that, and that's what the Slit Center is very much focused on. So we are thrilled to be partnering with our providers and our patients to create that avenue for their voices.

Host: In closing, would either of you like to add anything that maybe we didn't cover or you would like people to know?

Dr. Daniel Feinstein: Yeah, I would just like to close really highlighting some of the things Elizabeth also just highlighted, which is allowing the clinicians at the bedside, the physicians, the nurses, respiratory therapists, pharmacists, the people who do this work on a daily basis, to really drive the definitions and I really think good things can happen in the future in terms of other mandated legislation that's specific to North Carolina for our sepsis patients.

Elizabeth Outten: I think it's important to remember that our clinicians selected the jobs that they selected in order to care for patients. That is a center in everything that they do, and even the best meaning public policy can get in the way of that.

And so being able to impact that and shape it with that frontline experience. I think when you're designing anything, you want to talk to those who have the most experience in it, so you understand a rounder picture of it and can shape it so that it really works. And that's our goal here, to make sure that public policy is really working for the patients who need this care.

So these voices are critical. The approach that we can partner to improve things is very much what we're focused on in the center. And we're grateful for doctors like Dr. Feinstein who are stepping up to try to shape these policies.

Host: Well, this has been so encouraging and hopeful. Thank you both so much for sharing your expertise. We really appreciate it.

Elizabeth Outten: Thank you so much for having us, Maggie.

Host: Absolutely. Again, that's Dr. Feinstein and Elizabeth Outten. To find a physician, visit novanthealth.org. And for more health and wellness information from our experts, visit healthyheadlines.org. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Meaningful Medicine.