Visiting Scholar Dr. Huancahuari Takes Closer Look at Sepsis Care
If a language barrier was contributing to delayed care at your institution, would you want to know? If you knew, what would you do about it?
ABMS Visiting Scholar Nadia Huancahuari, MD, MA, an instructor of Emergency Medicine at Brigham and Women’s Hospital (BWH) and Harvard Medical School in Boston, wanted to know if non-English speaking patients were more likely to experience delays in sepsis care compared with English speaking patients.
Dr. Huancahuari focused on sepsis because she encounters these critically-ill patients on a regular basis in the Emergency Department (ED). “In our field, we are often in the business of diagnosing life-threatening conditions and transitioning the patient’s care rapidly to a specialist for definitive treatment. For instance, if someone presents to the ED with a heart attack, we diagnose it and rely on the cardiologist to take the patient to the cath lab for revascularization. If it’s a stroke, we diagnose it and quickly transition the care to the neurologist in an attempt to regain as much functional capacity as possible,” said Dr. Huancahuari, who co-leads the ED's monthly Peer Review Committee and Continuous Quality Improvement Committee, as well as serves as the core faculty advisor for BWH’s monthly Mortality and Morbidity conferences. “However, if patients arrive to us in septic shock, no one is coming to whisk them away for definitive care. It is our opportunity to provide immediate, evidence based, life-sustaining care for these critically ill patients at a time when it counts. It is our opportunity to intervene, save lives, and dramatically affect patient outcomes.”
She also is interested in bridging the gap in health care disparities. “If a language barrier was contributing to delays in care, it’s something that could be addressed to improve patient care,” noted Dr. Huancahuari, whose interest here is more personally motivated. Shortly after immigrating to California from Peru when she was 13-years-old, she accompanied her grandmother to an ED. “I was so scared for my grandma as neither one of us could explain her symptoms,” she said. "It was the first time that I felt like I was in another country." While another patient translated for them and her grandmother received the necessary care, that memory stuck with Dr. Huancahuari and shaped her career path. She even became an interpreter volunteering one night a week at the same hospital throughout high school.
As part of her Visiting Scholars research project, Dr. Huancahuari conducted a retrospective chart review of English speaking and non-English speaking patients presenting with severe sepsis/septic shock to BWH between June 2015 and July 2016. The patients’ preferred language was obtained from their ED registration demographics. The Centers for Medicare & Medicaid Services’ severe sepsis definition of “time zero” was used. Four elements of the Severe Sepsis 3-Hour Resuscitation Bundle were extracted: lactic acid, blood cultures, broad spectrum antibiotics, and intravenous fluids.
While early results suggest that language did not affect completion of the 3-hour sepsis bundle, the study is still ongoing. “We are currently abstracting more charts so that the study will have sufficient power to yield a valid conclusion,” Dr. Huancahuari explained. “It would be great if we found no difference between the two groups because it would suggest that we are basing our initial management decisions on objective data instead of delaying care while waiting for interpreting services.”
In the meantime, Dr. Huancahuari is focusing on other preliminary study findings that suggest the 3-hour sepsis bundle completion rate for all patients could be improved. Inadequate intravenous fluids was the most common element contributing to the bundle failure. "We honestly believed we were meeting our marks and completing the bundle in a timely manner,” she said. "Sharing our findings with the ED staff was key for getting everyone invested and striving to make improvements," said Dr. Huancahuari, who is the Assistant Director of Quality Improvement and Patient Safety for the ED at BWH.
Through the Partners Continuing Professional Development Office, Dr. Huancahuari also is developing a general sepsis performance improvement module for the ED. Once the final study results have been collected, if there are indeed disparities due to language, she will develop a second module to address the specific deficiencies. Ultimately, Dr. Huancahuari would like to develop an Improvement in Medical Practice module that meets the requirements for the American Board of Emergency Medicine's Maintenance of Certification program. With the contacts she has made as an ABMS Visiting Scholar, she just might be able to achieve that goal.