1. MHA Immersion Pilot Project
Early Recognition and Intervention of Sepsis
Liberty Hospital, Liberty, Missouri

2. Project Focus/Problem Statement
To increase the recognition of and improve the healthcare team management of sepsis patients.
Decrease sepsis related deaths.

3. What initial barriers were identified to project implementation?
Lack of recognition of sepsis by the healthcare team
Lack of support by the medical staff for the sepsis recommendations especially with concerns related to fluid overload
Inconsistent use of LH sepsis screening tool
Inconsistent medical management of sepsis patients with inconsistent use of Sepsis Order Sets
Inconsistent documentation by nursing and physicians
Unclear role expectations with the ACE team
Clarity and accuracy of coding
Communications throughout the continuum

4. Hospital Information/Team Members
Liberty Hospital is a 226-bed Community Hospital
2016 Awards include Spring 2016 Leapfrog “A” for patient safety and voted as Best Hospital in the Northland for 3 consecutive years.
Team Members: Miranda Hamilton, ICU Manger/ACE Team, Alley DaSilva, Critical Care Educator, Mary Syme, ED educator, Gwen Helmuth, Quality/PI Sepsis Data Abstractor, Marilyn Stockman Director Quality/PI, Andrew Battles, Director Critical Care Services, Amy Benson, Director Pharmacy, Shirley Heintz, CNO, all nurse managers, nurse champions from each unit, Sandy Waisner and CeCe Sesson, IT, Dr. B. Carlson, Dr. Adiga, Dr. Marx, Dr. Spencer, Dr. Loggan, and Dr. Day.
Please insert your organization’s logo here
Please insert a team picture here

5. Key Solutions Implemented
Had physician champions reach out to professional groups with concerns and share their learning
Updated Sepsis assessment tool and re-educated all staff
Updated sepsis order set with new recommendations and re-educated all nursing/medical staff
Updated ACE Nurse role with Sepsis and medical staff approval to initiate Sepsis Order set
Developed Sepsis Champions
Updated Sepsis Brochure with current recommendations.
Created charting tips reference sheet for staff.
Updated ACE team on sepsis changes and have them help with real time audits for sepsis changes and core measure documentation completion
Sepsis cases reviewed by Medical Staff in their Quality Performance Committee with follow up for improved performance.
Sepsis education of medical staff committees by medical staff champions.

6. Key Lessons Learned Persevere.
Clear communication between all members of the team leads to successful outcomes.
Establishing a relationship with the physicians as an ally is an important foundational step.
Ongoing education and monitoring documentation requirements is essential.
Stay focused and celebrating our wins.

7. (Health Research & Educational Trust, 2016)
Results
Overall sepsis rate has increased with improved recognition by the healthcare team.
(Health Research & Educational Trust, 2016)

8. (Health Research & Educational Trust, 2016)
Results
Overall sepsis mortality rate was below the target
(Health Research & Educational Trust, 2016)

9. Team Accomplishments Decreased mortality
Increased awareness and a commitment from the entire healthcare team
Improved communications amongst the team
Improved consistency of medical management
Improved documentation.

10. Sustainability and Spread Plan
Sepsis Committee will continue to meet monthly and continue the work started/evaluate outcomes/implement changes as needed.
ACE Team will continue ongoing care reviews.
Quality/Performance Improvement staff will continue to provide retrospective chart reviews
Quality Performance Committee of the medical staff will continue to review cases monthly and monitor performance

11. Next Steps/Future Plans
Badge Buddy for Sepsis Quick Reference .
Revision of sepsis education for new hires.
Monitor and evaluate outcomes.