Electronic bundle worklist increases adherence with CMS Sep-1 Measures in the emergency department
Delfa S. Seto, MSN, RN, CEN; Lauren Bazzell, BSN, RN; Alicia M. Kim, ADN, RN, CEN; Marisol Fernandez-Lagunas, BSN, RN; Sadeeka Al-Majid, PhD, RN
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Session I presented Wednesday, October 2, 10:00-11:00 am
Purpose: Severe sepsis and septic shock result in approximately 250,000 deaths nationwide. Evidence shows that implementing Centers of Medicare & Medicaid Services Severe Sepsis/Septic Shock Early Management Bundle (CMS-Sep-1) improves outcomes in this patient population. Only 69% of patients presenting to our emergency department (ED) received all the elements of the CMS-Sep-1 bundle; this average was below our goal of 75%. Data analyzed by our Quality department revealed that staff adherence to implementing some elements of the bundle was suboptimal. The purpose of this performance improvement (PI) project was to increase adherence to the CMS-Sep-1 bundle by implementing standard work and improving communication among ED staff.
Design: This PI project involved creating standard work and an electronic checklist containing the elements of the CMS-Sep-1 bundle to facilitate better communication among ED nurses with the aim of increasing adherence to the CMS-Sep-1 bundle.
Setting: Emergency department of a Magnet designated community hospital in Southern California.
Participants/Subjects: All ED nurses (n=71) and patients presented with sepsis or septic shock.
Methods: The Plan-Do-Study-Act (PDSA) model was used to guide this project, which involved a multi-faceted approach collaborating with several departments. These departments included Nursing, Laboratory, Information Technology, Quality and Medicine. We developed standard work related to adherence to CMS-Sep-1. This included educating ED physicians, physician assistant and nurses, monthly reviews of fall-outs, and monthly discussions of barriers and opportunities for improvement. Fall-outs were assessed monthly by our Quality department, an ED physician champion assisted with the provider fall-out review and the ED nurse educator assisted with RN fall-outs. Fall-outs were discussed at the ED Medicine Committee to identify areas of opportunity and clarification regarding documentation requirements for the Sep-1. The ED Sep-1 performance was shared with nurses at the monthly Unit Based Council meetings. In addition to the standard work, we created a checklist of all the elements of the CMS-Sep-1 bundle. This checklist, which was added to the electronic medical record (EMR) of patients meeting any of the sepsis criteria, was made accessible to all nurses involved in the care of the patient. This allowed to track completed elements and coordinate the remaining care.
Results/Outcomes: Adherence to the CMS-Sep-1 bundle increased from an average of 69% prior to implementation in September 2018, to an average of 87% in October and November of 2018. Physicians and nurses whose charts had been abstracted by the quality department and found to have met all the elements of the CMS-Sep-1 bundle were publicly acknowledged.
Implications: Implementation of standard work, ability of nurses to track all care using an electronic checklist and educating ED nurses and doctors about CMS-Sep-1 measures improves adherence. Utilizing a shared electronic checklist to coordinate the elements of the CMS-Sep-1-bundle enables better communication among nursing staff. We recommend extending the use of such a checklist to in-patient units to promote ongoing and seamless care. We also recommend trending and analyzing patient outcomes to determine efficacy of implementing standard work and use of a shared checklist.
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