sepsis - early recognition in in- patient settings - early recognition in in-patient settings ......
TRANSCRIPT
Sepsis - Early Recognition in In-
Patient Settings
Lenox Hill Hospital
October/November
2017
NYS PARTNERSHIP FOR PATIENTS
Lenox Hill Hospital
October/November 2017
Lenox Hill Hospital is a 652-bed, acute care hospital
located on Manhattan's Upper East Side.
The mission of Lenox Hill Hospital is to
o Deliver outstanding healthcare with compassion and respect
o Promote wellness in its communities
o Advance the field of medicine through education and research.
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Hospital Sepsis Team
October/November 2017 3
o Frankie Hamilton BSN, RN, CNML, PCCN, CCRN-K (Quality Specialist –
Sepsis)
o Nazish Ilyas, MD (Hospitalist – Medicine; Assoc. Program Director)
o Kathryn Maranga, RN CPHQ, CPPS, CJCP (Director, Quality Mgmt)
o Sahil Parikh (Academic Associate, ED)
o Grace Son (Academic Associate, Quality)
o Sidia Strong RN (Quality Specialist – Emergency Department)
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Project Description
October/November 2017 4
o At Northwell, the health system policy is to screen for
sepsis when a patient has a MEWS score higher than 7.
o In order to assess the specificity of this MEWS 7+ policy
this pilot project had nurses perform a sepsis screen on
all patients on two in-patient Medicine Unit every shift.
Each pilot was implemented for 30 days.
o Patient Charts were concurrently reviewed to determine
true positive screen results and whether these screens
prompted treatment bundle elements in the in-patient
setting
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Project Implementation
October/November 2017 5
Patient is admitted into In-Patient Unit
Patient is admitted into In-Patient Unit
RN assesses first VS of every Shift for SIRS
Criteria and Suspicion of infection
RN assesses first VS of every Shift for SIRS
Criteria and Suspicion of infection
Is patient positive for Sepsis
Screen?
Is patient positive for Sepsis
Screen?
RN writes Sepsis Screen Positive in COMMENTS
section of Sunrise flowsheet
RN writes Sepsis Screen Positive in COMMENTS
section of Sunrise flowsheet
RN writes Sepsis Screen Negative in
COMMENTS section of Sunrise flowsheet
RN writes Sepsis Screen Negative in
COMMENTS section of Sunrise flowsheet
RN Completes Provider Contact Note to notify provider of positive
sepsis screen
RN Completes Provider Contact Note to notify provider of positive
sepsis screen
YES
NO
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Project Implementation
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Tools & Resources
October/November 2017 7
o Allscripts Sunrise EMR
o Sepsis Flow Sheets
o Sepsis Tool Box
o In-Patient Sepsis Algorithm
o Nurse Education
o 2 workshops (45 minute session on Sepsis)
o 1:1 education on floors by Sepsis Quality Specialist and
Academic Associate
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Successful Strategies &Tips
October/November 2017
o Education of nurses is critical to gain buy-in for
complex pilot projects
o Frequent rounds by Quality Team helped engage
nurses through the pilot project and permanently
build the sepsis screens into the nurse workflow
even after the 1 month pilot session ended.
o Continuous and accurate feedback to Nurse
Managers helped to reinforce the sepsis screens
and reward nurses.
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Challenges & Barriers
October/November 2017
o Current PDSA was very large in scope with 2 separate units (30 beds & 16 beds) and 50+ RNs which included students and float RNs
o Time consuming - fulltime staff to look through charts, note compliance, and perform concurrent reviews of bundle compliance.
o PDSA for first unit only required nurses to note “Sepsis Screen Done” instead of “Sepsis Screen Positive/Negative”. This led to missed educational opportunities because RN documentation did not show RN’s line of thinking and follow-up discussions did not occur.
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Key Lessons Learned
October/November 2017
o MEWS 7+ policy is not sufficiently sensitive for sepsis recognition in In-Patient Setting. 76% of patients screening positive for sepsis had MEWS less than 7. o MEWS Scorecard notes Heart Rate 50-100 under NORMAL
criteria. However, SIRS Criteria is met when HR>90. This may explain the lack of sensitivity of MEWS Score of 7 policy.
o Overall, sepsis screens on in-patient settings prompt initiation of bundle elements
o Difficult to distinguish between “NEW” infection and/or “NEW” SIRS criteria/end organ dysfunction in In-Patient cases that have complex comorbidities
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Outcomes & Data: RN Screening Recognition
October/November 2017 11
28 24
16 16
22
0
5
10
15
20
25
30
7 Uris: 7/10-8/24 (30 Beds)
6 6 3 3 4
0
5
10
15
20
25
30
7 Wollman: 7/31-8/25 (8 Beds)
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Outcomes & Data:
Positive Screens vs. MEWS 7 Policy
October/November 2017 12
MEWS <7 76%
Sepsis Criteria Met with MEWS <7
Sepsis Screen
Performed 88.2%
Sepsis Screen Performed
Positive Recognition
63%
Sepsis Recognized from Screened Cases
7 Uris & 7 Wollman
* MEWS 7+ policy for sepsis screens are not sufficiently sensitive. .
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Outcomes & Data:
Positive Screens and Bundle Elements
October/November 2017 13
1
2
2
2
5
4
4
3
Bld Cx
Abx
Lactate
Fluids*
Sepsis-Related Clinical Actions Before/After Positive Screens (* 7 Uris IP cases only)
Before After
Fluids* - 1 patient did not receive fluids
* Preliminary data shows qshift sepsis screens do prompt treatment bundle elements.
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Steps for Hardwiring & Spread
October/November 2017
o 7 Uris and 7 Wollman RNs are continuing to do
qshift Sepsis Screens
o Further discussion into whether the pilot program
should be expanded hospital-wide.
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Contact Information
October/November 2017 15
o Kathryn Maranga – Director, Quality Mgmt
o Grace Son – Academic Associate, Quality Mgmt