1. MHA Immersion Pilot Project Poster Template
Sepsis Immersion Project

2. Project Focus/Problem Statement
Saint Francis Medical Center (SFMC) Emergency Department observed a 67% 3-hour bundle compliance. Additionally, SFMC identified that Sepsis recognition was our chief opportunity.
Goal/Aim Statement:
Improve 3-hour Sepsis Bundle Compliance by 50% on or before 1 September 2016.

3. What initial barriers were identified to project implementation?
Early recognition (ED & Transfer Center)
Physician and nursing education related to Sepsis.
Surviving Sepsis criteria v. “rule of 100s”
Sepsis until proven otherwise
3-hour Sepsis bundle
Identification and management of Septic Shock
Develop standardized work - ordering lactic acid v. procalcitonin.
Partnered with Lab to develop hardstop in EHR

4. Team Members
Pictured here are (left to right) Marvin Miller, Jeannie Fadler, Jera Wilburn, Kim Mathews, Leigh-Ann White, Cathy Tenkhoff, Charity Worley, Dr. Steven Rothert, Denise Ernst, Carla Crump, Dr. Schaun Flaim, and Jenni Myracle

5. Percent of Project Quarterly Tasks Completed
Form process improvement teams & Develop team structure
Complete
Complete a mini-failure modes effects analysis
Define the project Scope
Review Surviving Sepsis Bundle & develop plan for implementation
Implement use of a Rapid Response Kit
Select Educational resources to be utilized for staff
Select patient & Family educational resources
Define Sepsis Audit tools for tracking compliance
Process in place to ensure broad spectrum abx administered
High level of situational awareness regarding sepsis recognition and intervention
Staff education survey regarding early recognition of signs and symptoms of sepsis
Confirmed and validated your daily audit tools
complete
Engage ED/ EMS leadership
Observe audits being completed, review for trends.
Spot check observations for real time audits
Review barriers
Review project implementation for ROI & patient safety achievement

6. Key Solutions Implemented
House wide education on Sepsis.
Sepsis screening tool built into EMR.
Sepsis tick sheet developed to drive compliance with 3-hour bundle.
Activated “Best Practice Advisory” when SIRS criteria met.
Implemented nurse-driven Sepsis protocols for use in ED and inpatient departments.
Complete case reviews on all fall outs and identify areas of improvement.

7. Key Lessons Learned What worked? Triage Screening tool for ED
Observed shift in early recognition
Continuous “focused” education
Closed feedback loop following fallout reviews
Sepsis Tick Sheets
Assisted in hardwiring standard work

8. Key Lessons Learned What surprised you?
Culture and level of awareness related to Sepsis management.
Did you learn something you didn’t know before?
Sepsis is an emergency medical condition and demands respect!
“Sepsis until proven otherwise.”

9. Key Lessons Learned
What did you change in your project because of these lessons learned? How did you learn from them? What came out of your PDCA cycles?
Identified Physician Champion to provide Sepsis CME.
Importance of case reviews to enhance performance.
Enhanced direct admission process through Transfer Center.

10. Results: Observed 35% improvement in recognition.

11. Results: Observed ~80% improved initiation of 3-hour Bundle.

12. Results: 53% Reduction of 3-hour Bundle Fallouts

13. Team Accomplishments Improved Sepsis recognition
Early goal directed therapy
Achieved >50% overall 3-hour Bundle Compliance goal.

14. Sustainability and Spread Plan
Monthly report to Patient Safety Committee
Integration across Medical Center to recognize and rescue Sepsis patients.
Robust training provided during annual competencies.
Sepsis training provided to clinical staff during orientation.

15. Next Steps/Future Plans
Design processes to mitigate blood culture and antibiotic fallouts.
Begin concurrent monitoring of screening tools.
Recruit the Transfer Center to assist appropriate placement of Septic patients.
Hardwire 6-hour Bundle compliance.

16. Future Return on Investment
Did you identify any return on your investment with the project?
Project Plan:
After 6-hour Bundle implementation begin measuring:
Length of Stay
Vent Days
Cost per Case
Codes outside the ICU related to Sepsis
Sepsis recognition rate