By: Debra O’Connell and Lauren Small
US hospitals are challenged by evolving, and often disparate, sepsis guidelines, including the Surviving Sepsis Campaign, CMS SEP-1 Core Measure, and The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
Recognizing the need for a comprehensive approach to sepsis care, Frederick Memorial Hospital designed a three-pronged strategy that consisted of establishing best practices, improving sepsis awareness, and instituting a corporate goal of reducing sepsis mortality.
Establishing Best Practices
FMH’s Performance Improvement Department formed a multidisciplinary Sepsis Steering Committee (SSC), including physician champions, clinical nurse specialists, the clinical application team, and respiratory therapists. This team set out to establish best practices in the areas of sepsis screening, order set bundles, chart review, and documentation.
FMH also joined forces with the Maryland Patient Safety Collaborative to further develop sepsis strategies, and aligned with MEDITECH’s Sepsis Management Toolkit when it was released in 2016. The hospital’s SSC continues to modify these tools to align with the CMS SEP-1 Core Measure and avoid reimbursement penalties.
As a first step, the SSC built a sepsis screening tool into an ED assessment based on chief complaint; every patient with a suspected infection was assessed. A score of two or more sepsis-like symptoms would alert nurses to notify the physician to initiate the protocol. The screening tool was then rolled out to the rest of the hospital.
In 2017, the hospital revised the embedded sepsis screening tool to include SIRS criteria, aligning with MEDITECH’s Sepsis Management Toolkit and Surviving Sepsis Campaign guidelines. Every patient is screened for sepsis on admission, and then twice a day throughout their inpatient stay.
Order Set Bundles
To align with SEP-1 and MEDITECH’s toolkit, FMH combined the three-hour and six-hour sepsis order set bundles into one, and then created two versions — one for inpatients, the other for ED patients.
Upon receiving an alert regarding an at-risk sepsis patient, the physician initiates an advanced screening protocol. With embedded rules in place, the MEDITECH EHR automatically reflexes a repeat lactate order three hours after the initial lactate is resulted, or if the patient’s initial lactate is greater than 2 mmol/L.
Physician buy-in was instrumental to the success of a sepsis protocol that permitted nurses to administer one liter of bolus to patients upon suspicion of sepsis — before contacting the physician. This new methodology represented a culture shift at the hospital. It was approved by the Medical Executive Committee, based on the pilot’s positive outcomes.
Physicians and nurses have access to a sepsis clinical panel — a powerful tool for viewing longitudinal trends of patient data — to understand the patient’s status and determine where the patient lies on the sepsis spectrum.
To address the need for a consistent documentation component, FMH used time-stamped, order-based physician documentation templates. With the less stringent 2019 CMS SEP-1 guidelines for physician attestation, the hospital focused on keeping the process as streamlined as possible to improve physician compliance.
Improving Sepsis Awareness
FMH built patient education on sepsis into nursing workflows, thereby disseminating publications on sepsis prevention and increasing community outreach. As numbers improved, the hospital shared its strategies with peers at other organizations.
To promote staff accountability, leadership modified clinical workflows to include concurrent daily reviews of all patients who screened positive for possible sepsis. Performance improvement coordinators provide feedback to try to prevent quality measure fallouts.
The SSC continues to meet with IT on a monthly basis. These meetings focus on improving processes, encouraging better documentation, and identifying new ways to leverage MEDITECH’s EHR in combating sepsis.
Surpassing the Sep-1 Core Measure
In 2018, FMH’s CEO set a corporate goal to achieve 80 percent compliance with the CMS sepsis core measure. His commitment motivated other groups to include it as a departmental goal, which further contributed to buy-in.
FMH’s collaborative and multidisciplinary approach decreased sepsis rates and improved core measure compliance, while changing the organization’s culture:
- SEP-1 core measure compliance rates rose from 32 percent to 80 percent overall, but have reached as high as 91 percent.
- Observed rates of sepsis have been cut in half. They are now consistently 7 percent or under, and have dropped as low as 1.25 percent.
- The sepsis mortality rate decreased 65 percent, from almost 16 percent down to 4.76 percent.
Transformed from a below-average performer to a recognized leader in the fight against sepsis, FMH used this sepsis initiative as a launching point for achieving HIMSS Stage 7 designation.
Debra O’Connell, RN, CPHQ, Manager Performance Improvement, Frederick Memorial Hospital
Lauren Small, RN, IT Director of Applications, Frederick Memorial Hospital