Quality Improvement process - Early Recongnition of Spesis



Quality Improvement process - Early Recognition of SepsisJean Harken, Morgan Howe, Amy KowalakFerris State UniversityQuality Improvement process - Early Recognition of SepsisThere 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 NeedSepsis 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 TeamThe 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 tracked.Data Collection MethodThere 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. 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.Goals/OutcomesThe 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: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. 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. 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. 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 StrategiesMany 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) are 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).EvaluationTo evaluate the effectiveness of the sepsis screening initiative, the quality assurance team will gather data by conducting chart reviews 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 facility’s 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.ConclusionWith 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.ReferencesDellinger, 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 , 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 , 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 nchs/data/databriefs/db62. (2014) Covenant healthcare: Saginaw. Retrieved from , N., Fields, W. (2012). Early recognition of sepsis in the emergency department: An evidence-based project. Journal of emergency nursing. 38. 139-143. Doi:10.1016/j.jen.2010.07.022McClelland, H., & Maxon, A. (2014). Early identification and treatment of sepsis. Retrieved from Keystone Center (2014). Improving Safety & Quality. Retrieved from , 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.2011.05.010U.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: Elsevier-Mosby. ................
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