Improving Sepsis Bundle Compliance

Banner University Medical Center - South Emergency Department

Quality Improvement Project
Andrea Acero, Connie Lee, Mayra Martinez, Morgan
Perlman, and Jojo Robbins
Banner University Medical Center - South
• Unit: Emergency Department (ED)
⚬ 33 Official Beds
• Population: Adult Emergency
⚬ Pediatric and Maternity emergencies directed to
BUMC - Main
• Staff: Physicians, Pharmacist, Nurse Practitioners,
Nurses, Respiratory Therapists, Paramedics, EMTs,
and Social Workers Location: 2800 E Ajo Way, Tucson, AZ
• Nurse-Patient Ratio: 1:3-5

• Organizational Structure: Line-and-Staff Structure

(Banner Health, 2024; Huston & Marquis, 2021)
Quality Improvement Issue
• Issue for Improvement: 3 Hour Sepsis Bundle
Compliance
⚬ Unit is not meeting target goal and not using
current method in place for sepsis bundle
compliance
• Current Action: Paper Copy ED Sepsis Checklist that
would be checked off within 3 hours, then transferred to
Cerner FirstNet EHR
⚬ Includes labs, antibiotics, fluids, and re-assessment

(Banner Health, 2024; Munson Healthcare, 2024)

 Model For Improvement: Forming the Team

Information Technology (IT)

Nurse Educator Nursing Staff Physicians Pharmacy Staff
Staff
• Implementing updates to • Providing staff with training • Collecting assessment • Inputting orders, as well as • Managing and delivering
charting system regarding new protocols findings and carrying out assessing and rounding appropriate medications and
interventions fluids for care
 Model for Improvement: Setting Aims

Our Aim:
Increase rates of sepsis bundle completion within three hours for
patients in the BUMCT-South ED from 58.10% to 65% within 6
months of implementation of electronic charting alert system.

Aims to improve safety, effectiveness, efficiency, timeliness and

accessibility, equitability, and patient-centered care.
Model for Improvement: Establishing Measures

• Quality Improvement Measure: 3

Hour Sepsis Bundle Compliance
• 2023 YTD: 58.1%
• 2023 Target Goal: 63.8%
• National Benchmark: 60%

(Banner Health, 2023; U.S. Centers for Medicare and Medicaid Services, 2024)
Model for Improvement: Selecting Changes

Adopt mandatory
Implement EHR Alert
Improve delegatory educational sessions for
System that auto-
management of staff on the sepsis
populates sepsis-related
interventions to EMTs, bundle and
data and data to a
and Paramedics to consequences of late
specified sepsis charting
improve timely delivery intervention delivery on
section, creating task and
of interventions the individual and
treatment checklist alerts
organizational level

Concept 1 Concept 2 Concept 3

(Denicolo et al., 2021) (Taj et al., 2022) (Warstadt et al., 2022)
 PDSA- Plan
• Objective
⚬ Implement a Cerner alert system that auto-populates sepsis-related data and results to a
specified sepsis charting section, creates task and treatment checklist alerts, and
communicates to interdisciplinary teams regarding patient status to deliver efficient care.
• Measures

Outcome: Process: Balancing:

Average time it takes for ED staff
to screen patients for sepsis
Percentage of patients who
Percentage of ED Sepsis receive each element of sepsis
Bundle Compliance in 3 bundle within recommended time
hours or less Frequency at which staff engage
with new electronic charting
system
Time it takes for patients to be
seen by a provider
Perceived workload of ED staff
before and after implementation
Patient satisfaction with care
received including perception of
timeliness and effectiveness of
treatment
PDSA- Plan Finalize Protocol
• Consult interdisciplinary team for
feedback and questions.
Engage Stakeholders • Include steps, equipment, and
• Hold a one month development period prior to responsibilities
implementation in which the program is
developed with discussion and collaboration
between IT, the ED nurse manager, and the Training and Education
medical director. The informational packet for • Mandatory informational packet review
staff education to be sent via email would also be and e-signature attestations by all ED
developed at this time. stakeholders in the two week
• Hold an additional two week period prior to introductory period
implementation in which ED care team members
must review the informational packet and provide
an e-signature to attest to its review. This will Predictions
initiate the transition, explain the technicalities of • Decreased time to initiate sepsis
the new system, and gain support from the staff. intervention
• Increased sepsis bundle compliance
rates
PDSA- Do
• Implementation
⚬ Develop Cerner alert system through IT team.
• Autopopulation of sepsis-related data from other portions of the chart into a specific
sepsis section.
⚬ Assessments, lab results, medications
• Timed task and treatment checklist alerts.
• Updates to care team regarding patient status.
⚬ Flag patient chart with sepsis alert
⚬ Carecompass notification sent to primary nurse, attending physician(s), and
pharmacy
PDSA- Do
• Tracking
⚬ Track the amount of time it takes for initiation of sepsis bundle protocol
per patient
⚬ Track number of patients who receive the full sepsis protocol within the
first three hours of alert
⚬ Weekly interdisciplinary staff feedback with QI team as liaison
⚬ Evaluation of data on a two week basis for the first month of
implementation, followed by monthly evaluations by the QI team.
 PDSA- Study
Evaluation of data after 6 months of implementation
• Compile sepsis bundle compliance rate over
the 6 month implementation period
• Compare value to pre-intervention sepsis
bundle compliance rates
• Compile care team feedback
Determine if the objective was met
• After 6 months of implementation of the EHR
sepsis bundle alert system, was there a notable
increase in the three-hour sepsis bundle
compliance rates (above the goal value of 65%)
Identify challenges
• Evaluate barriers to continued
implementation
• Compile care team feedback
Next steps
• Communicate findings to auditors, CNO, nursing unit managers,
and within stakeholders
• Modifying the system for continuous improvement
⚬ Identify and focus on addressing specific parts of the bundle
lacking in compliance
• Expand the implementation of the EHR alert system to more
units
• Continued monitoring of data and outcomes
 Potential Barriers to Implementation

Staff Focus Intervention Information and Information Intervention

• Highly dependent on nurse • Use compliance as a factor for yearly Technology • Work closely with IT to ensure seamless
implementation performance evaluations for nurses,
transition
• Adds to the long to-do list of emergency affecting yearly raise • Highly dependent on electronic health
• Get weekly feedback from QI team
room nurses record technology
 OBJECTIVE
Increase rates of initial sepsis screening and intervention
delivery within three hours for patients in the BUMCT-South
ED from 58.10% to 65% within 6 months of implementation
of electronic charting alert system.

ONE MONTH BEFORE

RESOURCES
Utilize software creation, time for software update,
TWO WEEKS PRIOR
ENGAGEMENT additional equipment for sepsis bundle software as
Preliminary period in which program is developed via needed
discussion and collaboration between stakeholders. An
informational packet is developed to be sent to staff via
email. EDUCATION
PROTOCOL
ED care team members review informational packet that
Consult nursing team for feedback and questions
explains new system. They must provide an e-signature
Finalize enforcement and responsibilities of team
to attest to its review.

REQUIRED PERSONNEL
Information Technology
Nurses
Nurse Educator
Pharmacy
Physicians
NOW WHAT
-Communicate findings to CNO,
IMPLEMENTATION nursing unit managers, and QI team
Implement a Cerner alert system that auto-populates sepsis-related data and results to a specified sepsis -Modify system for continuous
charting section, creates task and treatment checklist alerts, and communicates to interdisciplinary teams improvement
regarding patient status to deliver efficient care. -Expand implementation of EHR alert
system to more units
TRACK DATA -Continually monitor data and
-Amount of time it takes for initial outcomes
implementation of sepsis protocol
per patient End of Month 2, 3, 4, & 5 DETERMINE IF OBJECTIVE WAS MET
Week 4 -Data collection Was there a notable increase in the three-hour sepsis
-Track number of patients who Week 2 -Second set of data collection
receive full sepsis protocol within -Continue to collect feedback bundle compliance rates (above the goal value of 65%)?
-Collect and analyze first set of -Continue receiving feedback End of Month 6
first three hours of alert data from team -Compile sepsis bundle
-Allow care team feedback compliance rate over the six
month implementation period
Week 1 -Compare value to pre-
Ensure staff has provided
intervention sepsis bundle
e-signatures
compliance rates
-Compile care team feedback
 References
• Banner Health. (2024). Banner - university medical center south emergency room. https://www.bannerhealth.com/locations/tucson/banner-university-medical-center-south-er
• Delawder, J. M., & Hulton, L. (2020). An interdisciplinary code sepsis team to improve sepsis-bundle compliance: A quality improvement project. Journal of Emergency
Nursing, 46(1), 91–98. https://doi.org/10.1016/j.jen.2019.07.001
• Denicolo, K. S., Corboy, J. B., Simon, N.-J. E., Balsley, K. J., Skarzynski, D. J., Roben, E. C., & Alpern, E. R. (2021). Multidisciplinary kaizen event to improve adherence to a
sepsis clinical care guideline. Pediatric Quality & Safety, 6(4), e435. https://doi.org/10.1097/pq9.0000000000000435
• Huston, C. J., & Marquis, B. L. (2021). Leadership roles and management functions in nursing : Theory and application (10th ed.). Wolters Kluwer Health.
• Munson Healthcare. (2024). Sepsis for ED and hospital nurses cerner firstnet and powerchart education.
https://www.munsonhealthcare.org/media/file/Sepsis%20for%20Nursing%20.pdf
• Taj, M., Brenner, M., Sulaiman, Z., & Pandian, V. (2022). Sepsis protocols to reduce mortality in resource-restricted settings: A systematic review. Intensive and Critical Care
Nursing, 72, 103255. https://doi.org/10.1016/j.iccn.2022.103255
• U.S. Centers for Medicare and Medicaid Services. (2024). Care compare. Medicare.gov.
https://www.medicare.gov/care-compare/compare?providerType=Hospital&providerIds=030111
• Warstadt, N. M., Caldwell, J. R., Tang, N., Mandola, S., Jamin, C., & Dahn, C. (2022). Quality initiative to improve emergency department sepsis bundle compliance through
utilisation of an electronic health record tool. BMJ Open Quality, 11(1). https://doi.org/10.1136/bmjoq-2021-001624

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