1. Carroll County Memorial Hospital
Spotlight Hospital
Carroll County Memorial Hospital

2. Sepsis: Every Second Counts

3. Cindy Gilman RN
Director of Quality for 1 year At CCMH
RN for 17 years
Director of Nursing/MDS Coordinator for 14 years in long-term care

4. Welcome to Carroll County Memorial Hospital
CCMH is a 25-bed critical access hospital with over 180 employees
Serves four counties
Provides Rural Health Clinics
Provides the community with 14 different outpatient services

5. Services of CCMH 24/7 Emergency department Acute care
Skilled nursing care
Home health
Primary care clinics
Outpatient Services including: Cardiology, Dermatology, Endocrinology, gastroenterology, hematology, interventional pain, neurology, oncology, orthopedic, pathology, podiatry, pulmonology, radiology, rheumatology, senior life solutions, surgical, urology, women’s health and wound care

6. Need For Improvement
The Sepsis Core Measure was identified as a topic for improvement due to the details surrounding abstraction of the measure.
During abstraction, it was determined that hospital staff were not completing the requirements to meet the measure.
I am responsible for abstracting this measure and I thought it should be a top priority of improvement for our patients and organization.

7. HEN 2.0 Attended the Hen 2.0 kickoff in Columbia on October 15, 2015.
The Hen 2.0 was encouraging immersions projects for hospital participants.
Sepsis was an option.
Tammy Crawford, Infection Control Director and I selected hospital employees and invited them to participate on the Hen 2.0/Sepsis committee.

9. Tactics

11. Strategy: Test Nursing Knowledge A Sepsis Quiz

12. Quiz Results! Goal 75% Participation and Average Score Retest in October of 2016

13. Reward for participation

14. Hen 2.0/Sepsis Committee First meeting was held November 11, 2015
Tasks were assigned to Committee Members

15. Sepsis Order Set discussion and development began.
Policy for Treatment of Adult Sepsis and Septic Shock development began.
Education to Providers on Bundling and Education placed at dictation desks.

16. Sepsis Provider Champion

17. Email to Provider’s Regarding Initiation of Adult Sepsis Pathway Management Form

18. Adult Sepsis Pathway Management Form Initiated 12/17/15

19. Nursing Champions Initiating Form—Email Sent 12/18/15
Congratulations to Amy Price, Brad Lyon, and Mikki Sue for completing our first Adult Sepsis Management Pathway Form.  You are the first Sepsis Champions!  Thank you for all you do to ensure our patient’s always receive the best care possible!

20. Email Recognizing All nursing Staff form utilizing the form 01/04/16
Thank you for completing the Adult Sepsis Management Pathway form!  You have done an excellent job identifying patients with Sepsis!  Tammy and I appreciate your hard work and dedication to improving patient outcomes!
Just a reminder, you will not get a SIRS alert from Cerner.  Please use the date and time you identify the 2 criteria listed on the form.  That is your SIRS alert for Sepsis.  Please remember to list the date, time, and initials when the provider is notified.   
Thank you for all you do!

21. Mini-Bundles Created by Heather Vandeventer RN
Distributed to Nurses to place behind badges

22. Your Role As a Clinic Nurse in the sepsis Bundle … Slide show presentation
Use the Adult Sepsis Management Pathway Form to identify those patient’s presenting to the clinic with 2 SIRS criteria and suspected sepsis.
Initiate the form when the criteria is met. The form should follow the patient to the ED Department or the West Unit, depending on provider orders. Communicate with hospital nursing staff that you have initiated the SIRS Alert. By communicating this information to the hospital nursing staff, they can be prepared to initiate the sepsis bundle.
This tool can also be used for nursing home patients. If the nursing home calls with information on a patient that meets this criteria, and the provider gives orders for ED evaluation and treatment, alert the ED staff that the SIRS criteria was met.
By communicating this vital information to hospital nursing staff, you can improve patient outcomes!!!

24. Sepsis Tracer Initiated

25. Alerts
Education given to providers regarding available Severe Sepsis and Septic Shock Alerts through EMR.

26. Sepsis Order Set Completion and Initiation
August 2016

27. Results

30. Data is collected daily and analyzed for accuracy
Follow up completed as necessary with each Bundle initiation.
Education provided immediately for failed Bundles.

31. Existing Goals Sepsis Core Measure Compliance >80% monthly.
95% participation in Repeat Sepsis quiz with 90% Average Score.

32. Transparency at CCMH
Data shared at Medical Staff, Board Meetings, Nursing Practice Counsel and Quality Meeting.
Dashboard in progress to display results via hospital-wide communication boards.

33. Future Plans Educate, Educate, Educate EMS personnel
Nursing Home personnel
Use stipend money for Sims lab education for nurses
Complete sepsis Quiz during Annual Skills Fair on October 11th and 12th.
Produce our own Sepsis Video
Possibly initiate Severe Sepsis and Septic Shock Alerts for providers.
Approve Policy.
Monitor for unnecessary lactate draws and provide continued education.

34. We owe our success to … celebrating our wins.
provider and Administrative Support.
engaged staff.
Dr. Horine and Tanya Land FNP for representing providers on the Sepsis Committee.
The hospital providing us with the support and equipment needed to stop sepsis and save lives.

37. Quality Culture
Better Patient care and outcomes due to early recognition of signs and symptoms of sepsis.
Improved employee education regarding the importance of sepsis and early recognition.
Increased staff engagement.

38. Challenges
Initiation of this committee was my first task as a new employee here at CCMH.
I learned that sometimes you can have too many individuals on a committee.
Follow-through and ensuring the wheels keep on turning.

39. Cindy Gilman RN (660)542-1695 ext 3008 cindyg@ccmhospital.org
Contact Information:
Cindy Gilman RN (660) ext 3008