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Quality Improvement process - Early Recognition of Sepsis

Jean Harken, Morgan Howe, Amy Kowalak
Ferris State University

Quality Improvement process - Early Recognition of Sepsis

There have been major problems in the quality and safety of patient care in America.
Quality improvement is a process done to educate nurses and staff on how to minimize potential
risks. In order to improve the quality of care the process of identifying a clinical need, establish
an interdisciplinary team, collect data using an appropriate tool, establish outcomes, design and
implement change, and evaluate the outcomes.
Clinical Need
Sepsis is a serious and life-threatening infection in the bloodstream. These patients are
usually treated in the intensive care unit. Hall, Williams, DeFrances and Golosinskiy (2011)


found that patients admitted for sepsis are eight times more likely to die during their hospital stay
than patients hospitalized for other reasons. These patients also tend to stay in the hospital
longer; as much as 75% longer than patients with other conditions (Hall, Williams, DeFrances, &
Golosinskiy, 2011).
According to Hall, Williams, DeFrances and Golosinskiy (2011) the rates of sepsis have
more than doubled between 2000 and 2008. There has not been much of a difference in the rates
for males and females but it does appear to increase with age. These patients are also more likely
to be discharged to another facility like a short stay hospital or a long term care unit. Sepsis
patients cost $14.6 billion to treat and this price is inflating 11.9% annually. With the rising cost
of treatment and the increased risk of death recognizing and treating sepsis early can greatly
reduce the number of lives lost and the amount of money spent on treatment.
According to (2014) Covenant of Saginaw has seen 2346 sepsis cases.
The percentage of these cases that died during their stay was 14.62. Death within 30 days from
sepsis was also listed at 19.52%. This is below Covenants projected mortality rates of 16.16%
and 21.99% respectively.
Interdisciplinary Team

The interdisciplinary team has been chosen by specialty and unique skills offered in
improving recognition of sepsis. This group of professionals brings a vast knowledge base to the
table. The team will consist of a nurse educator, a nurse manager, a quality specialist, two staff
nurses and an Information technology (IT) specialist. The Nurse Educator will be assisting with
ways to present the information to the staff. This information should be given in the fastest and
most effective way possible. The nurse educator will also be responsible for presenting the


information to staff. This is essential for a smooth implementation of any policy or procedural
changes. Timeliness is imperative as decreasing the time it takes to recognize sepsis could save
patients lives.
The Quality representative has knowledge and access to patient charts and can access
data pertinent to identifying areas of improvement. The quality representative is able to access
data on how long it takes from initial identification of signs and symptoms of sepsis to when
these symptoms were addressed. This person would also be the person dealing with any
Keystone guidelines. The quality representative should be well informed on all current
guidelines and will be able to advice on what the Keystone standards and what needs to be
changed in order to comply with these standards (MHA Keystone Center, 2014). Keystone is a
center that works in conjunction with safety organizations in Michigan hospitals to ensure care
that is being provided complies with current standards.
A nurse manager is needed to oversee the improvement process and approves changes
that may need to be made. Floor staff will provide insight into current practices. Nurses, as
front line managers, often are able to recognize things that work well or where changes need to
be made. The IT department will assist with getting information to the staff electronically. IT
can also assist with changes that are needed in the electronic medical records (EMR) to make
sure that the systemic inflammatory response syndrome (SIRS) criteria are identified and
Data Collection Method
There are several different data tools that could be utilized to analyze and review the
procedure for sepsis. A flowchart was chosen to recognize and treat sepsis at the first symptoms.
With this flowchart there are directional arrows and boxes that show the steps that are taken to


quickly start the treatment of sepsis when the first symptoms are recognized (see Appendix A).
Utilizing data tools is imperative to the quality improvement (QI) process (Yoder-Wise, 2014). It
is conceivable that after putting a chart together, and visualizing what is written down, to find
weaknesses in the system that need to be addressed. By utilizing the flowchart, a fairly complex
system appears simple and easy to follow. Most nurses are never trained on how to use one of
these charts or why it is important for the QI process. The flowchart is very simple to read and
no training is necessary to follow it. This is an efficient way to get across the key information
and minimize that amount of sepsis cases that get missed and turn severe or fatal.
The goals or outcomes desired would be a decrease in the number of sepsis patient deaths by
5% in the year following the institution of sepsis education. To make this overall goal possible:
1. ICU and ED nurses must take sepsis early recognition education courses within 3 months
of course availability. All other nursing staff must take sepsis courses within 6 months of
course availability.
2. All nurses must pass a competency test on sepsis (Kent & Fields, 2010) with a score of
80% or higher or retake to the course. A retake may only be done one time.
3. Nurses will be given a sepsis algorithm tag and must wear the sepsis algorithm with their
name badge as a quick reference during their practice. Informal shift meetings will be
used to educate nurses on sepsis algorithm (Kent & Fields, 2010) within one week of
implementation. All new staff will receive tag during hire-in process.
4. Nurses will be educated on SBAR as means for quick communication with physicians
(Kent & Fields, 2010) to obtain sepsis orders with sepsis algorithm tag handout and
annually thereafter.


Kent and Fields (2010) believe that the implementation of the sepsis algorithm performed by

trained nurses will lead to earlier treatment (p. 143), and fewer deaths for the patient as well as
lower cost for the hospital.
Implementation Strategies
Many patients with sepsis related symptoms get over looked, especially in the critical
care units due to the multiple co-morbidities that are present. This disease process can cause a
patient to rapidly deteriorate causing multiple organ systems to fail and even death if not
recognize and treated effectively and quickly (Mayo Clinic, 2014). The elderly population (those
over 65) is at a significantly higher risk of developing sepsis (Gauer, 2013). With nurses playing
such a huge role in identification of sepsis, education on early recognition is imperative to
improve outcomes (McClelland & Maxon, 2014). Education will be done by providing hands
on class as well as a video with a post quiz online. These courses will allow the nurses to become
familiar with the algorithm that will be used to identify early signs of sepsis.
The interdisciplinary team will construct an algorithm. This algorithm will walk staff
through the sepsis guidelines and instruct them how to respond. While doing an admission
assessment the SIRS will be targeted and will bring attention to staff if any of these issuers are
identified and prompt staff to address these (Gauer, 2013). By providing early screening to all
patients, subtle changes, such as fever can be found. This can then be investigated and
treated early if found to be a septic patient. Many studies have demonstrated early recognition
and treatment can reduce the mortality with sepsis significantly (Dellinger et al., 2013).


To evaluate the effectiveness of the sepsis screening initiative, the quality assurance team
will gather data by conducting chart reviews (see Appendix B) and recording analysis of patients
diagnosed with sepsis following the implementation of this new standard of care. The use of
standardized chart audit forms for this process would ensure consistent and thorough data
collection (U.S. Department of Health and Human Services, 2011). The forms include
answering whether or not there was compliance with utilizing the algorithm on all patients,
accuracy of its use, the positive or negative result of the screen, and if treatment was properly
implemented for positive screenings.
During chart analysis, auditors will also collect the data to measure the number of deaths
associated with a sepsis diagnosis. This data would then be compared to the previous year to
evaluate whether or not improvement in the screening tool or the educational process was
required. The process of benchmarking will also be useful in measuring the facilitys outcomes
against examples of quality standards of other organizations (Yoder-Wise, 2014).
Root cause analysis (RCA) is another method of evaluation in the event of recorded
deaths or other sentinel events associated with a sepsis diagnosis. In this circumstance
interviews will be performed with health care providers directly involved in the event, as well as
a record analysis of what led up to the event. After completion of the RCA, a report is then
generated. This end product of the investigation is the tool through which recommendations are
circulated for implementation (Nicolini, D., Waring, J., & Mengis, J., 2011, p. 221). This report
is then utilized in the revision of the risk-reduction strategy as needed (Yoder-Wise, 2014).
If during the evaluation process the team recognizes a high incidence of failure on the
nursing competency test, a revision of the test may be required to accommodate this. Other


revisions might include the development of a continual educational series for staff to ensure

familiarization with signs and symptoms as well as protocol. Measurement of utilization of the
SBAR form would also be completed to determine compliance as well as pinpoint any breaks in
the communication with physicians. Ideally, the SBAR form should provide the nurse with
specific terminology and scripting to approach the physician when recommending additional
treatment or interventions (Kent, N. & Fields, W., 2010, p. 143). If nurses prove to use the form
consistently, further education for physicians may also be required to meet an improved standard
of care.
With sepsis remaining on the rise as one of the leading causes of hospital deaths, and the
high cost of treatment, it is vitally important that strong efforts are made to implement efficient
screening tools as well as aggressive and early treatment. Continuing efforts at advancing
education techniques and a willingness to learn from past mistakes will prove to create the
positive patient outcomes that organizations are striving for.



Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M.,... Moreno, R.
(2013). Surviving Sepsis Campaign: International Guidelines for Management of Severe
Sepsis and Septic Shock: 2012. Retrieved from
Gauer, R. L. (2013, July 1). Early Recognition and Management if Sepsis in Adults: The First
Six Hours. American Family Physician, 88, 44-53. Retrieved from
Hall, M.J., Williams,S.N., DeFrances, C.J., Golosinskiy, A. (2011). Inpatient care for septicemia
or sepsis: A challenge for patients and hospitals. NCHS Data Brief. 62. Retrieved from (2014) Covenant healthcare: Saginaw. Retrieved from
Kent, N., Fields, W. (2012). Early recognition of sepsis in the emergency department: An
evidence-based project. Journal of emergency nursing. 38. 139-143.
McClelland, H., & Maxon, A. (2014). Early identification and treatment of sepsis. Retrieved
MHA Keystone Center (2014). Improving Safety & Quality. Retrieved from


Nicolini, D., Waring, J., Mengis, J. (2011). Policy and practice in the use of root cause analysis
to investigate clinical adverse events: Mind the gap. Social science and medicine. 73(2).
217-225. Doi: 10.1016/j.socsimed.2011.05.010
U.S. Department of Health and Human Services. (2011). Managing data for performance
improvement. Retrieved from:

Yoder-Wise, P.S. (2014). Leading and managing in nursing. (5th Rev ed.). St Louis, MO:


Appendix A
Sepsis Algorithm
Review patients chart
and history for
potential disorders or
treatments that may

1) Does the patient

have a temperature
<36 or >38 degrees
celcius and/or chills?

2) Is the patient
tachypneic and/or
have an 02 saturation

3) Is the patient's
urine output less than

4) Is the patients
systolic BP < 90 mm

5) Is the WBC count

higher than 12,000 or
more than 10%

If 4/5 of the above are

yes, administer
supplemental 02 PRN,
monitor patient and
VS closely and
contact MD STAT.




Appendix B
Chart Audit Form
1) Was the sepsis
screening tool
2) Were all portions
of the algorithm
3) Was the
positive for
severe sepsis? If
yes, continue to
question 4.
4) Was the
physician notified
within 1 hour of
the positive
5) Was treatment
after physician
6) How long after
physician ordered
treatment did the
treatment occur?

MR# _____________________
Reviewers Name _______________
Date _____________________