Improving Timeliness of Sepsis Care Through RN Screening and Protocol

Abstract

Session F presented Friday, September 28, 11:30 am-12:30 pm Purpose:Delay in treatment of patients with sepsis in the Emergency Department (ED) leads to increased morbidity and mortality. Therefore, this project aims to improve: 1) timeliness of recognition and treatment of patients with sepsis or septic shock in the ED, and 2) adherence with the Centers for Medicare and Medicaid Services (CMS) Sepsis Core Measure (SEP-1). Design: This ongoing quality improvement project uses pre- and post evaluation and is guided by Lewin’s Theory of Change. The affiliated Institutional Review Board reviewed this project and determined it to be quality improvement. Setting: This initiative takes place in a suburban community hospital ED affiliated with an urban tertiary academic medical center. Participants/Subjects: To address Aim #1, all ED nurses are being educated on a new screening tool and order set. This screening tool and order set have the inclusion criteria of adult patients presenting to the ED. The pre- and post-implementation chart audit uses a random sample of adult patients diagnosed with sepsis or septic shock during their hospitalization. For Aim #2, CMS adherence is trended for all patients who met the criteria of the SEP-1 Core Measure. Methods: ED nurses receive unit-based education including an education module to review the sepsis screening tool and order set. The electronic medical record based screening tool and the nurse protocol order set expedite screening and treatment of septic patients. Nurses answer two screening questions during triage: 1) does the patient have a risk for or suspected infection, and 2) does the patient have a new onset altered mental status. Based on these screening questions and the vital signs, a sepsis best practice advisory (BPA) alerts the nurse of the patient’s risk. Directly from this BPA the nurse orders initial laboratory testing including a CBC, CMP, venous lactic, blood cultures, and optional sputum and urine cultures. The educational module will be incorporated into new hire orientation, annual unit-based mandatory education days, and the pre-existing sepsis class. During implementation the clinical coordinators and project lead will provide ongoing support. Using monthly chart audits, time-to-treatment is evaluated for patients who are diagnosed with sepsis or septic shock. Time-to-treatment is measured as the number of minutes between initiation of triage and the start of fluid bolus administration, lactic acid measurement, and antibiotic administration. Descriptive analysis will be used to compare data pre- and post-implementation, and trend plots will be used to assess adherence to the SEP-1 Core Measure. Results/Outcomes: Based on the randomized pre-implementation chart audit, the mean time-to-treatment from arrival to fluid bolus administration was 82 minutes, antibiotic administration was 148 minutes, and lactic acid measurement was 102 minutes. Currently, 75% of ED nurses have completed unit-based education. Implications: Based on findings of similar quality improvement projects, we expect a decrease in door-to-fluids times by 30 minutes (37% decrease), door-to-antibiotics by 60 minutes (41% decrease), and door-to-lactic acid draw times by 30 minutes (29% decrease). We anticipate the use of at-triage sepsis screening to streamline sepsis care and improve timeliness of care.