1. Aurora Medical Center - Summit Friday, June 9th 2017
Improvement Action Network (IAN)
Sepsis
Aurora Medical Center - Summit
Friday, June 9th 2017

2. Agenda

3. Round Robin – Gap Analysis and Goals
Each hospital team reports off on the completed gap analysis and goal to accomplish today.

4. Mark Hlava, MD

7. Sepsis Checklist
September, 2015 AMCS implemented a paper sepsis checklist titled “Sepsis Checklist-IP”
Checklist was developed to:
Assist with communication between ED and admitting inpatient units regarding best practices that need to be done
Ensure measures were met at specified time points and ensure continuity of care for septic patients

9. Sepsis Checklist
Printed on bright yellow/gold paper so stands out from other documents
Goes wherever the patient goes
Nurses keep checklist on patient clipboard (ICU) or in paper documentation folders (med/surg unit)
If patient admitted from ED and no checklist came with the patient, then inpatient RN will contact ED to see if one was filled out or inpatient RN will start a checklist
Feedback given to unit managers regarding compliance with usage as well as follow up with staff.

10. Sepsis Checklist
If patient is inpatient or admitted directly from clinic, the inpatient RN will start the checklist
Unit manager and/or CNS/educator will alert Quality Coordinator regarding sepsis admissions for real-time auditing of chart if at all possible
Once completed and checklist no longer needed, RNs give to unit manager who in turn gives to Quality Coordinator for review with each sepsis case
Checklist has been edited 5+ times based on bedside RN feedback for ease of use as well as updates to sepsis measures.

11. Appropriate Antibiotic Administration
One of our early challenges was that nurses did not know which antibiotics were considered “broad spectrum,” which should be given first
A compatibility chart was developed to guide nurses
Identification of broad spectrum agents
Co-administration if able (based on line compatibility)
Adapted to AHC’s formulary and the available combinations on the sepsis order set
Since has been adopted system-wide

13. Other Pharmacy Implications
Your pharmacy staff can help to ensure prompt and appropriate administration of antibiotics
Availability of any/all anti-infectives on sepsis order set
Preference for premixed, Mini-bag Plus, Add-Vantage or batched preparations
Have available in ED unit based cabinet

14. ICU Sepsis Screenings
April, 2017 AMCS ICU implemented every 4 hour sepsis screenings on all ICU patients
Q4 hours chosen since this is the ICU standard assessment/reassessment time frame for most of our ICU patients
ICU RNs utilize “Sepsis Screening Nursing” tool located within Epic Flowsheets

16. ICU Sepsis Screenings Goals:
Make it habitual to assess ALL ICU patients
Catch any changes to alert RN/MD to address thus minimize poor outcomes, as well as remain in compliance with the time requirement for Sepsis care

17. ICU Sepsis Screenings
ICU manager and educator audit compliance with screenings
To date: Opportunities for improvement to remind RNs to remember to complete Q4 hours and also what to do if screening is positive

18. Fallout Feedback

23. Thank You Aurora Summit!

24. Break
15 minutes

25. Workgroup Activity
Work with other hospitals and your hospital team to brainstorm and develop action plans on how to move forward with Sepsis initiatives.

26. Report Out – Action Plans
Hospital teams describe what they worked on, communicate action plans and if you have the support and necessary tools to move forward.

27. Resources WHA Quality Center MHA Community Page
Patients/Sepsis.aspx
Sepsis Starter Pack
Sepsis IAN information and details
Archived Webinars
Discussion Board

28. Next Steps… Scanning of your Action Plans 30 day follow up:
Phone call with Improvement Advisor on your action plans and small tests of change
60 day follow up:
Virtual event/call with all hospitals to highlighting hospitals successes. Details to come.
Date: August 17th 1-2pm
Resources from IAN on WHA Quality Center Website

29. Evaluation +/-

30. Contacts Beth Dibbert Improvement Advisor/Quality Director
Shruthi Murali
Improvement Advisor
Jill Hanson
Bobby Redwood
Physician Improvement
Advisor
Nadine Allen
Kelly Court
Chief Quality Officer