Download Liberty Hospital - Missouri Hospital Association

MHA Immersion Pilot Project
Early Recognition and Intervention of Sepsis
Liberty Hospital, Liberty, Missouri
Project Focus/Problem Statement
 To increase the recognition of and improve the
healthcare team management of sepsis patients.
 Decrease sepsis related deaths.
What initial barriers were identified
to project implementation?
 Lack of recognition of sepsis by the healthcare team
 Lack of support by the medical staff for the sepsis
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recommendations especially with concerns related to fluid
overload
Inconsistent use of LH sepsis screening tool
Inconsistent medical management of sepsis patients with
inconsistent use of Sepsis Order Sets
Inconsistent documentation by nursing and physicians
Unclear role expectations with the ACE team
Clarity and accuracy of coding
Communications throughout the continuum
Hospital Information/Team
Members
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Liberty Hospital is a 226-bed Community Hospital
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Team Members: Miranda Hamilton, ICU Manger/ACE Team, Alley DaSilva, Critical
Care Educator, Mary Syme, ED educator, Gwen Helmuth, Quality/PI Sepsis Data
Abstractor, Marilyn Stockman Director Quality/PI, Andrew Battles, Director Critical
Care Services, Amy Benson, Director Pharmacy, Shirley Heintz, CNO, all nurse
managers, nurse champions from each unit, Sandy Waisner and CeCe Sesson, IT,
Dr. B. Carlson, Dr. Adiga, Dr. Marx, Dr. Spencer, Dr. Loggan, and Dr. Day.
2016 Awards include Spring 2016 Leapfrog “A” for patient safety and voted as Best
Hospital in the Northland for 3 consecutive years.
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organization’s logo here
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Key Solutions Implemented
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Had physician champions reach out to professional groups with concerns and share
their learning
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Updated Sepsis assessment tool and re-educated all staff
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Updated ACE Nurse role with Sepsis and medical staff approval to initiate Sepsis Order
set
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Developed Sepsis Champions
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Sepsis cases reviewed by Medical Staff in their Quality Performance Committee with
follow up for improved performance.
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Sepsis education of medical staff committees by medical staff champions.
Updated sepsis order set with new recommendations and re-educated all
nursing/medical staff
Updated Sepsis Brochure with current recommendations.
Created charting tips reference sheet for staff.
Updated ACE team on sepsis changes and have them help with real time audits for
sepsis changes and core measure documentation completion
Key Lessons Learned
 Persevere.
 Clear communication between all members of
the team leads to successful outcomes.
 Establishing a relationship with the physicians as
an ally is an important foundational step.
 Ongoing education and monitoring
documentation requirements is essential.
 Stay focused and celebrating our wins.
Results
 Overall sepsis rate has increased with improved
recognition by the healthcare team.
(Health Research & Educational Trust, 2016)
Results
 Overall sepsis mortality rate was below the
target
(Health Research & Educational Trust, 2016)
Team Accomplishments
 Decreased mortality
 Increased awareness and a commitment from
the entire
 Improved
 Improved
 Improved
healthcare team
communications amongst the team
consistency of medical management
documentation.
Sustainability and Spread Plan
 Sepsis Committee will continue to meet monthly
and continue the work started/evaluate
outcomes/implement changes as needed.
 ACE Team will continue ongoing care reviews.
 Quality/Performance Improvement staff will
continue to provide retrospective chart reviews
 Quality Performance Committee of the medical
staff will continue to review cases monthly and
monitor performance
Next Steps/Future Plans
 Badge Buddy for Sepsis Quick Reference .
 Revision of sepsis education for new hires.
 Monitor and evaluate outcomes.