Improving CMS Sepsis Bundle compliance at St.
Mary’s Hospital: A QI Project Proposal
Abstract
QI Project Objectives: propose a way to improve
CMS sepsis bundle compliance in St. Mary’s.
Introduction: Sepsis bundle compliance nationally
is ( 59% ) compared to St. Mary’s Hospital (57%)
Data and Analysis: Implementation of a team of
experts that harness the knowledge/skills and are
able to educate the treatment team.
Root Cause: Lack of completion of Sepsis bundle
elements.
Proposed Solution: Implement a Sepsis Response
Team.
Conclusion: After a conductive research
evaluation, we concluded that by implementing an
individual Sepsis Response Team, it will help
increase Sepsis Bundle compliance when
completing proper sepsis care as determined by
CMS.
Introduction and Description of
the Issue
Macro Description:“On average over 200,000
die every year of sepsis in the United
States,”("Timely & Effective Care", 2020). “The
National Average for patients who received
appropriate care for severe sepsis and septic
shock is 59%”, (“Hospital Compare Quality of
Care Profile Page”, n.d.). This score is measuring
overall sepsis bundle compliance nationally.
Micro Description: “St. Mary’s percentage of
patients who received appropriate care for
severe sepsis and septic shock is 57%,”
(“Hospital Compare Quality of Care Profile
Page”, n.d.). St.Mary’s ranks lower in
comparison to the national average of their
sepsis bundle compliance.
Claire Brunetti, Julia Jones, Alexa Komski & Makenzie Ludwig
Bon Secours Memorial College of Nursing
Data and Analysis of the Issue
Problem Statement: St. Mary’s percentage of
patients who received appropriate care for
severe sepsis and septic shock (57%) is lower than
the national average (60%)
The aspect of care requires improvement is:
Patients with Sepsis/Septic Shock
The people and aspects that are affected are:
Patients, Nursing staff, educational initiatives,
budget, wait time, hospital policies, and CMS
data: in which we are comparing St. Mary’s vs.
The national average
Based on previous research:
- The American College of Emergency Physicians
created a concept called “DART” which stands
for Detect, Act, Reassess, and Titrate
- An Example by Dewalder and Hulton, who
implemented a Sepsis Response Team,
indicated that antibiotics were provided to
more patients who met Sepsis criteria. Fluid
resuscitation volume increased from a baseline
of 31% to 81%. Lastly, timely or total
completion of second lactate had an
improvement from 22% to 73%.
Root Cause
Factors related to a Decrease in Sepsis
Bundle Compliance:
- Lack of Knowledge
- Lack of Education
- Lack of Collaboration
- Issues in Time Management
- Poor/limited Staffing
- Delayed Identification in Triage
Root Cause:
Lack of completion of Sepsis bundle
elements.
Proposed Solution
Implementation of a Sepsis Response Team for
Your Text Goes Here. You can change the size,
Sepsis/Septic
font, and color Shock treatment
- The creation of a team within St. Mary’s Hospital,
rounding on the entire hospital.
- Team members: Critical Care Certified Registered
Nurses (CCRN’s)
- Not placed in Staffing (no assignments)
- Respond to Code Sepsis and assist Primary Nurse
- Monitor hospital charts
- Implement annual education to all Nursing staff.
Logistics
-Team development
-Job Description Development
-Employee Education
-Replacement of Clinical Positions
Stakeholders: Nurse managers,
Chief Nurse, Administrative
Director, Hospital Director, Critical
Care Director, Emergency
Department Director
Potential costs: 4 CCRNs;
estimated 63,000 anually per
CCRN; education module
estimated cost $4,500
Timeline: January 1, 2021:
Implement Sepsis Response Team.
April 1, 2021: 1st Check-In.
August 1, 2021: 2nd Check-in.
January 1, 2022: Evaluate
effectiveness of SRT.
Data Collection: Bi-Weekly
chart reviews with time tracking of
antibiotic admin and lactic testing.
Yearly results from SMH sepsis care
with ideal improvement from 57%
to 60%.
Conclusion
As a result from the data that was
gathered, we determined that creating a
sepsis treatment team for the immediate
treatment of Sepsis/Septic Shock
diagnosed in the Emergency Department,
will help to increase the overall
compliance with the individual facilities
sepsis bundle. Therefore, increasing the
percentage of patients who receive
proper care for the diagnosis of sepsis as
determined by CMS.
References
Clinical Resources. (2020). Retrieved 10 October 2020, from
https://www.cdc.gov/sepsis/clinicaltools/index.html
Delawder, Jill, DNP, RN, ACCNS-AG, CCRN-CSC, Hulton, Linda,
PhD, RN. (2020). An Interdisciplinary code sepsis team to
improve sepsis-bundle compliance: A quality improvement
project. Journal of Emergency Nursing, 46,
91-98.https://doi.org/10.1016/j.jen.2019.07.001
“Evidence-Based Care Bundles: IHI.” Institute for Healthcare
Improvement,
www.ihi.org/Topics/Bundles/Pages/default.aspx.
Reich E.N., Then K.L. & Rankin J.A. (2018). Barriers to clinical
practice guideline implementation for septic patients in
the emergency department. Journal of Emergency
Nursing. https://doi.org/10.1016/j.jen.2018.04.004
Sepsis is a medical emergency. Time matters. (2020).
Retrieved 31 October 2020, from
https://www.cdc.gov/sepsis/what-is-sepsis.html
U.S Centers for Medicare & Medicaid Services. (2020,
September 25). Hospital compare: St. Mary’s Medical Center
Survey of Patient
Experiences
“What Is Sepsis?” Center for Disease Control and Prevention, 27
August 2020, www.cdc.gov/sepsis/what-is-sepsis.html