MHA Immersion Pilot Project - Sepsis Capital Region Medical Center

Project Focus/Problem Statement To reduce sepsis related mortality by 25% within 18 months by (previously established by ED POE): Increasing education on early recognition Increasing performance of early interventions and treatment by EMS staff and ED staff (3º bundle) Developing inpatient sepsis screening tool Offering tools/prompts to assist staff in adhering to the bundles and evidence-based guidelines To successfully meet the sepsis core measures

What initial barriers were identified to project implementation? Sepsis committee was not multidisciplinary ED triage screening tool was limited to 6 chief complaints and did not include all adult patients Committee did not have strong support from medical staff serving in the attending role Sepsis committee did not have an administrative champion

Hospital Information/Team Members CRMC – 100 beds, Not-for- Profit community hospital, 21,000 annual admissions Committee Members: VP- Nursing, ED Nurse Director, Inpatient Nurse Managers, ED Medical Director, Hospitalists, Pharmacy, Lab, IT, RT, Education, EMS, Quality

Percent of Project Quarterly Tasks Completed List first quarter task completion 100% List second quarter task completion 90% List third quarter task completion 100%

Key Solutions Implemented Established multidisciplinary committee and monthly meetings Revised ED triage screening tool to include all adults (positive screens are color coded for nursing staff and physicians in EMR) Established critical lab value for lactate > 4mmol/L Physician order sets reviewed and updated Implemented “code sepsis” in ED

Key Solutions Implemented Provided education for nursing and medical staff Developed & implemented sepsis checklist - a guide for nurses and physicians Provided education to EMS partners in May Developed inpatient nursing screening tool (similar to ED triage tool) implemented 8/15 Automatic reflex of repeat lactate 3º from initial lactate order (part of the 6º bundle)

Key Lessons Learned A multidisciplinary team is critical Allow adequate time for staff & physician education – provide ongoing reminders Efforts have to be about improving patient care not just meeting core measures Utilize EMR to full advantage for sepsis related notifications and required documentation

Results

Results

Results

Return on Investment Implementation of the “code sepsis” in the ED has increased response time for the measures in the 3º bundle Implementation of the inpatient sepsis screen allows for early identification of changes in patient condition

Team Accomplishments Bringing all the necessary disciplines together to work towards the sepsis related goals Implementation of inpatient sepsis screening Collaboration with EMR vendor to improve documentation for elements of core measures Collaboration with EMS

Sustainability and Spread Plan Sepsis Committee meets monthly with many activities occurring between meetings Strong support from Administration Participation in the HEN has provided a framework for the committee Plan to participate in the next HIIN sepsis project

Next Steps/Future Plans Review uncompleted tasks from HEN Committee will be co-chaired by ED Nurse Director and ICU Manager with strong support from VP-Nursing and administrative team Continue to follow best practices for sepsis