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Early Identification of Sepsis: The Journey Since the Sepsis on the Wards Collaborative

Michelle Foss, RN
Kristen Frost, APRN
 
AdventHealth Shawnee Mission in Shawnee Mission, Kansas, USA, had a unique opportunity to impact the care provided to patients with sepsis in partnership with the Surviving Sepsis Campaigns (SSC) Sepsis on the Wards Collaborative. Three years later, building on this foundation, processes are still being streamlined to improve the care of this challenging population.
 
Sepsis is a life-threatening condition that requires early recognition and immediate intervention. At AdventHealth Shawnee Mission, we were challenged by our health system and the SSC to find ways to recognize these patients on a non-intensive care medical unit. We identified sepsis stakeholders and launched a hospital-wide Sepsis Committee composed of nurses, physicians, pharmacists, laboratory staff, informatics staff, and administrators. This multidisciplinary team developed a severe sepsis screening tool and then worked with the progressive care unit (PCU), a medical surgical stepdown unit, as a cohort ward for sepsis patients identified in the emergency department (ED).
 
Initial education for the PCU staff focused on this new sepsis screening tool and the expectation to screen every patient on every shift. A video was created and distributed to emphasize the importance of recognizing the transition of simple to severe sepsis early and prompt treatment for this vulnerable population. Nurses screening every patient gave them the confidence to notify the provider of concrete findings consistent with new or worsening sepsis.
 
Organizationally, the informatics department supported the initiative by collaborating with its internal Sepsis Committee to create an electronic tool that prepopulated key physiology values (eg, vital signs, laboratory values, sepsis alerts), which removed the need for the paper tool. Additionally, the electronic tool enabled validation of these screenings for accuracy. Barriers to the process and opportunities for modifications to the screening tool were discussed during monthly sepsis meetings. As a solution, case studies, direct feedback, and posted scorecards were used for staff to see data and celebrate successes.
 
The Medical Executive Committee collaborated on this initiative by approving a nurse-driven protocol for patients who screened positive for sepsis. Nurses were able to order laboratory tests to assist with the identification of organ dysfunction and to obtain blood cultures when new antibiotics were ordered. A rap-id response team (RRT) was called for all patients who transitioned from simple to severe sepsis, and order sets were standardized to include the required treatment bundle elements needed to expedite care.
 
The PCU staff embraced their new role with a sense of satisfaction in their achievements, and this created passionate frontline sepsis champions. The PCU Collaborative was so successful that ED physicians had increased confidence in the expertise and proficiency of the staff to identify transitioning sepsis. This led to an increase in admissions of patients with sepsis to this unit, including those who may have benefited from a higher level of care.
 
The hospitalists were also more comfortable leaving patients in the PCU who developed organ dysfunction as the treatment bundle was being implemented. This was a challenge we were not prepared for. While PCU nurses were experts at identifying sepsis and initiating sepsis care, they were limited in their ability to expedite more advanced therapy. Additionally, we saw an increase in the number of patients with sepsis who deteriorated quickly after admission from the ED. This led to a recommendation to admit all patients with sepsis and hypotension to the intensive care unit (ICU), including those who were hemodynamically stable after fluid resuscitation. While some deteriorated, many did not require further therapy and transferred quickly out of the ICU. This new process resulted in increased admissions to the ICU of patients who did not require active ICU-level therapy, but we were confident they were in the right place for closer surveillance.
 
The outcome of this collaborative has created an excitement and energy around sepsis, not just in this unit but hospital-wide, as successful strategies were implemented. Sepsis screenings are now completed for every patient on every shift across all units. Additionally, as new employees undergo orientation, our sepsis care is highlighted, and a culture of awareness and action has been created. This has widened our safety net for this population. No longer does the responsibility for identification reside in any one discipline, but the entire team has ownership.
 
Our momentum from this success laid the groundwork for our desire to pursue sepsis disease-specific certification from the Joint Commission. The best practices and excitement regarding sepsis were already built into the hospital culture, making certification the next natural step. Facility-specific performance measures were selected to have the most impact on patients in the local community. Through continued rounding, the staff ’s passion and enthusiasm grew. It was continually emphasized to staff that the certification survey is about highlighting the wonderful care they were already providing. The Joint Commission conducted a one-day sepsis survey and certification was awarded in November 2017, marking this facility as the first hospital in all of Kansas and Missouri to achieve this certification.
 
After obtaining disease-specific certification, hospitals must submit monthly performance metrics to ensure a continued pursuit of excellence in the care of patients with sepsis. The Sepsis Committee noted that the logical next step would be to implement a code sepsis response team in the ED. The inpatient units had an existing RRT process for timely intervention for newly transitioned sepsis patients. The RRT, however, was designed only for the inpatient units and not the ED, where most patients meet time zero.
 
We determined that the best use of our resources was to designate a responder who could help coordinate other disciplines needed to meet the bundle elements (eg laboratory, pharmacy). Currently our greatest challenge is that the ED nurses feel micromanaged. When the code sepsis responder arrives, they are focused on the bundle checklist rather than providing direct care for the patient (eg, starting an IV, drawing blood cultures, administering antibiotics). This process continues to be revised by the team and frontline staff to maximize the benefit to both ED nurses and patients, in addition to meeting Centers for Medicare and Medicaid Services requirements.
 
We have defined our pathway and process for sepsis care as evidenced by our culture and our outcomes. Success in early recognition and implementation of the bundle elements has allowed us to shift some of our energy. We are now able to focus on individualizing patient education and sepsis community awareness efforts. Hopefully, this will have an even broader and far-reaching impact on sepsis in our little corner of the world.