1. MHA Immersion Pilot Project - Sepsis
Capital Region Medical Center

2. 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

3. 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

4. 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

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

6. 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

7. 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)

8. 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

9. Results

10. Results

11. Results

12. 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

13. 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

14. 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

15. 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