Spotlight on Hillcrest Hospital Cushing’s Sepsis Improvement Program

Posted on: 12/13/19


Photo caption: Jay Johnson (left), OHA board chairman, presents an Excellence in Quality Award to Hillcrest Hospital Cushing leaders (left to right) Stephanie Orsini, BSN, RN, infection preventionist; and Renee Russell, quality manager.
Over the next several weeks, the Clinical Initiatives Corner will feature each of the Excellence in Quality Award submissions to highlight and share successful quality initiatives. Each week, we will describe how the problem was identified, the improvement goal(s), interventions and outcomes. Please feel free to use this information, duplicate interventions, and share with your staff.

The 2019 Excellence in Quality Award in the 26-100 bed category was presented to Hillcrest Hospital Cushing. Stephane Orsini, BSN, RN, quality coordinator/infection preventionist, submitted the following information about the hospital’s Sepsis Improvement Program, and stated, “Our hope is that by sharing these first small successes, our staff will be inspired to maintain momentum. We have more work to do, and new goals to achieve.”

Identifying the Problem: Mortality rate from sepsis increased in the second quarter of 2018. The sepsis bundle compliance rate was 13% on CMS Hospital Compare. Antibiotics were administered before blood cultures were obtained. Practitioners were resistant to practice change and new protocol order set.

The Goal: Increase Sepsis Bundle compliance implementation to 80% by the end of 2019.

Interventions: An interdisciplinary team was formed. Alerts were integrated into the EMR. Staff/physicians were trained in evidence-based sepsis protocol/order sets. A paper sepsis screening tool was implemented. Educational tools were provided to staff and patient records were audited for compliance.

The Outcome: Sepsis Bundle compliance rates increased from an average of 50% in 2018 to 70% through September 2019.

Comments: Congratulations on creating an interdisciplinary Fall Prevention Team that included physician and front-line leadership. Inclusion of primary care and front-line providers facilitates use of evidence-based interventions and educational tools by peers.

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