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Running Head: ORGANIZATION EVALUATION

QI Group 3 Organization Evaluation: Sep-Sisters N468 Effectiveness in Complex Health Systems University of Missouri, Kansas City - School of Nursing

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Septicemia, also known as sepsis, has become a rising concern in the healthcare industry. Despite policy implications and strict monitoring, sepsis rates continue to rise across the country. Patients exposed to the hospital setting are put at a greater risk for developing an infection that can ultimately lead to sepsis. Any invasive procedure that produces a pathway into the body, such as an indwelling urinary catheter or an intravenous catheter, enables bacteria and foreign substances to enter the bloodstream. Bloodstream infections, if not treated in an appropriate time period, will lead to sepsis. A recent study was completed which looked at the potential for increased risk factors leading to sepsis among admitted hospital patients requiring a multiple day stay. Of the 600 patients that were included in this study, 300 were a confirmed case of sepsis. When looking at the results of this study, it was proven that “both indwelling medical device use pre- admission and postadmission were significantly associated with increased risk of sepsis diagnosis among patients who had extended hospital stays of [greater than 5 days]” (Ahiawodzi et. al, 2020, p. 1191). A generalized policy across the majority of hospitals requires that admitted patients have at least one intravenous catheter be placed to ensure access for medication and fluid administration. Within the Kansas City, Missouri healthcare system, many local hospitals have strict sepsis prevention policies, but are still a part of the rising trend of sepsis-related cases. We are evaluating St. Luke’s Hospital of Kansas City to determine what could be changed or added to their sepsis prevention policies in order to protect the hospital’s patients. As stated by their website, St. Luke’s Hospital of Kansas City (SLH) is one of 18 hospitals in the St. Luke’s Health System (SLHS, 2021). SLHS also includes multiple convenient care clinics, surgical centers, laboratory services, and pharmaceutical services. When looking at leadership in nursing, the Chief Nursing Officer at SLH is Debbie Wilson. If there should be a problem at SLH that needs to be addressed on a system wide level, the issue would be escalated

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to the Chief Nursing Officer of SLHS, Diane Trimble. SLH prides itself in being committed to risk management and quality improvement strategies. Every employee has access to several applications at work, one of which provides the necessary templates for incident reporting. Risk Master is the application used by SLH to create an incident report and field it to the appropriate risk management team led by Maggie Neustadt, J.D. who will investigate the event and use it for quality improvement strategies (Risk Master Manual). The Process Excellence Team is designed to constantly evaluate what employee and patient safety strategies are working or not (Quality and Patient Safety, 2021). They organize events that focus on improving issues like medication reconciliation, CAUTI, and more (Quality and Patient Safety, 2021). These issues are discussed during Kaizen events and A3 workshops that are structured to be most effective in finding solutions to presented problems for quality improvement (Quality and Patient Safety, 2021). These examples demonstrate that SLH has shown they are committed to providing the best care for their patients by providing ways that support constant ways for improvement. In 2017, SLH implemented a new sepsis screening program by partnering with Redivus Health. The goal of this new program was to identify sepsis in patients transferring into the SLH system from other hospitals or healthcare facilities. The key element of this program that allowed for its success was being able to begin the sepsis identification protocol before transfer patients even made it inside the SLH facilities. With the help of a sepsis app guided workflow, an alert will populate on the computer screen if sepsis risk factors have been identified. This message is then relayed to both the transferring doctor and the doctor receiving the patient at SLH. In addition to receiving report on this patient, the receiving SLH doctor will be able to request for a urinary analysis, chest x-ray, blood cultures, and lactate results before the patient arrives to them. Within the first six months of piloting this screening program, the hospital system increased their

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identification of sepsis by 150 percent, found that there was a 30 percent decrease in sepsis mortality rates, and allowed for physicians to accurately identify and treat sepsis (Siwicki, 2018). More recently, SLH has created their own plan for early detection of sepsis in the Emergency Department (ED) which began August 19th of 2020. This system is placed into the ED’s electronic medical records (EMR) and populates at the beginning of each patient's arrival to the ED. The early detection for sepsis screening asks the nurse a series of questions including; Did the patient have surgery in the past 30 days, does the patient have a temperature over 100.4 and, does the patient have any indwelling medical lines or tubes? If the patient screens positive for any one of the questions, then the nurse has an automatic standing order to obtain a STAT lactate for the patient. If the lactate lab comes back greater than or equal to 2.0, then the physician will be notified to begin a sepsis order set and start the clock for Clinical Time Zero (CTZ). CTZ is put in place so that the earliest documentation of sepsis indication will be charted and the sepsis order set will be timed. The nurses in the ED at SLH have been utilizing this new early sepsis detection standing order rather well. Many explained how making the lactate lab order a standing order made it easier and faster in obtaining information that could lead to a potential sepsis diagnosis. Though this policy is new, SLHS has seen great improvement in their sepsis patient population. There has been a documented decrease in “severe sepsis fall outs” at SLH, but they have not quite reached the goal of zero sepsis cases. At SLH, a current policy that is helpful in implementing sepsis prevention is the use of the SwipeSense. The SwipeSense is a device that SLH employees who work directly with patients attach to their badges. This device is able to track the amount of times that healthcare personnel washes their hands when entering and exiting a patient’s room. This policy is helpful in preventing sepsis as it increases the amount of times a healthcare professional will wash their

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hands as it promotes accountability. Every month, SLH provides each unit with the names of their employees and the percentage of how often they washed their hands based on the information provided by the SwipeSense. As for a policy that hinders the prevention of sepsis, the SLH emergency departments are required to place at least one IV access in each patient that arrives at their doors and requires medication. In some cases, when a patient is to be admitted to an ICU, two IV access points are initiated. This policy hinders the prevention of sepsis because the insertion of this IV can increase the risk of patients developing an infection that may eventually lead to sepsis. One policy that could be put into place that could assist in the prevention of sepsis at SLH is requiring all nurses to ensure that they are putting the green Curos caps on IVs when they are not in use. This small action could help to prevent sepsis from occurring as it ensures that the IV will remain clean. While creating our own sepsis protocol, it is important to look at current sepsis protocols to research best practice and what has been effective in the past. In one study, there was a sepsis bundle that was implemented in conjunction with the Surviving Sepsis Campaign which required certain tasks to be done within three hours and six hours, (Whitfield et al., 2019). Within the three hour mark of arriving to the emergency department, the bundle required blood cultures, initial lactic acid, broad spectrum antibiotics to be administered, and a fluid bolus of 30 milliliters per kilogram to be administered, (Whitfield et al., 2019). Within the six hour mark of arriving to the emergency department, the patient was to receive vasopressors, have a repeat lactic acid, and have a repeat assessment, (Whitfield et al., 2019). Between these few requirements there was both improvement on the patient outcomes and staff compliance of the protocol in treating sepsis. Though the length of stay was unchanged in this study and the cost of hospitalization was not significantly different, the hospital mortality rate due to sepsis was

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decreased from 12 patients to 0, (Whitfield et al., 2019). On top of the mortality rate being decreased, this study showed that the time it took to administer antibiotics was cut in half. From the time of triage to the time of antibiotic administration went from 124 minutes to 68 minutes by implementing this protocol, (Whitfield et al., 2019). By introducing a few simple steps in caring for patients with sepsis, mortality rate, hospital compliance, and medication administration time were all improved leading to overall better patient outcomes. As sepsis is one of the leading causes of death, it is important that there are tools and ways to prevent sepsis before it becomes a problem. In order to work on preventing sepsis, we need to look at what leads to this syndrome which is infection. By breaking down the cause of sepsis, we can look at how to prevent it by preventing infections in the first place. When we look at infection, we need to look at the host susceptibility in order to identify patients that are high risk (Dantes & Epstein, 2018). For the general hospital patient population, simple steps such as educating patients on hygiene and risk factors are an important interventions when preventing infection. One of the key parts of treatment for infections is knowing the “causative organisms and guide more effective and specific antibiotic therapy,” (Dantes & Epstein, 2018). The CDC initiative called “Get Ahead of Sepsis” highlights the crucial parts of prevention as knowing the current protocols and guidelines at the hospital you work at, notifying the physician when a patient is at high risk or sepsis is suspected, starting the sepsis protocol and antibiotics as soon as possible, and checking on your patients frequently to know their status and if their infections are being treated appropriately with their prescribed antibiotics,” (Centers for Disease Control and Prevention, 2017). By paying more attention to infections, being aware of risk factors, and education of both the patient and healthcare team sepsis prevention can be more effective and we will see better outcomes for our patients.

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Those that would be most supportive in assisting with the implementation of changes and actively working to improve St. Luke’s Hospital of Kansas City sepsis prevention policies would include “the nursing and medical staff on the hospital floors” (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). These individuals could also include “residential facility staff, first responders and emergency department workers” who as frontline staff not only implement sepsis prevention measures but also assess for early recognition and treatment of sepsis (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). A key variable to the supportive nature within the nursing and medical staff is early establishment of a reporting structure (Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals: Section 6. Facilitating change and Anticipating Challenges, 2018). “As seen at several UMLN II hospitals where multiple hospital units and/or staff with different roles were involved, having a supportive supervisor and/or senior leader who oversees multiple units or staff likely to be impacted by the changes can significantly improve the chances for much-needed coordination, cooperation, collaboration, and compliance” (Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals: Section 6. Facilitating change and Anticipating Challenges, 2018). Active participation of the nursing and medical staff on the hospital floors allows for staff feedback and generates modifications to adapt process changes as deemed necessary. These individuals will typically work in a positive environment, have high job satisfaction in their field and supportive leadership within their team. A unit with a significant sepsis patient population will also be more active when changes are implemented to a policy that those newly implemented changes are not observable but lead to improved outcomes for their patients (Early

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identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). Also, in order for the nursing and medical staff to be actively involved is to “engage diverse staff throughout the planning, design, and implementation of patient flow improvement strategies is critical to facilitating successful and lasting change. Engaging staff likely to be impacted by the changes can provide valuable perspectives, knowledge, understanding, and expertise while reducing the likelihood of encountering staff resistance later” (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). Those that may resist in the support and actively participate in a plan for septic protocol policy changes falls under education barriers within the nursing and medical staff (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). “Concurrent education is essential while nurses become accustomed to new screening processes”; and they should be open to understanding the pathophysiology, early identification of sepsis, adequate communication within the team and effective, timely treatments for patients (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). By “developing enhanced education to improve knowledge of risks and sepsis recognition, implementing standardized sepsis screening tools and treatment protocol” and educating staff concurrently on the most recent sepsis protocol policy will help assist with those barriers of resistance among staff (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). In order for the nursing and medical staff to be well-informed of the issues at hand that are being addressed and calling for a change in policy; there are a few key elements necessary to

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proceed forward. The nursing staff should be fully engaged, actively involved in preparing, planning, educating and implementing various changes (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). These various elements will assist in the knowledge necessary to understand the why’s and see first hand how necessary or effective the change may be. Through general education “of the natural history of sepsis and the effect that early identification and common interventions such as fluids and antibiotics can have on outcomes motivates nurses” to not only be actively involved but also to be well-informed (Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle, 2019). Each member of the Sep-Sisters team was able to contribute an equal role to this assignment. Christine Hartung, one of our team facilitators, formulated the introduction paragraph which provided the summary of our quality improvement problem and identified sepsis prevention as the focus of our project. Natalie Patton, another one of our facilitators, discussed the structure of Saint Luke’s Hospital in the second paragraph. As for the research found in regards to SLH’s sepsis policies, our team leader, Catherine Balino, and Abby Hocklander, one of our timekeepers, worked together to find internal sources. With this research, they were able to find two internal sources that provided information about SLH’s sepsis policies. Catherine and Abby also identified policies that currently exist at SLH that help, as well as barriers that exist in the prevention of sepsis. They also worked together to identify a policy that is missing that could be implemented in order to further assist in the prevention of sepsis. Chelsea Schupp, our second timekeeper, identified two resources that provide insight on best practices and standards on sepsis prevention. Briana Clancy, our devil’s advocate, identified and evaluated people who may be helpful and who may resist the changes required to make in order

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to implement our quality improvement project.

References

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Ahiawodzi, P. D. (1), Okafor, I. (2), Chandler, S. (2), Kelly, K. (3), & Thompson, D. K. (4). (n.d.). Indwelling medical device use and sepsis risk at a health professional shortage area hospital: Possible interaction with length of hospitalization. American Journal of Infection Control, 48(10), 1189–1194. https://doiorg.proxy.library.umkc.edu/10.1016/j.ajic.2020.02.014 Centers for Disease Control and Prevention. (2017, August 31). Get Ahead of Sepsis - Know the Risks. Spot the Signs. Act Fast. Retrieved March 8, 2021, from https://www.cdc.gov/patientsafety/features/get-ahead-of-sepsis.html Dantes, R. B., & Epstein, L. (2018). Combatting Sepsis: A Public Health Perspective. Clinical Infectious Diseases, 67(8), 1300-1302. https://doi.org/10.1093/cid/ciy342 Early identification of Sepsis on the Hospital Floors: Insights for Implementation of the Hour-1 Bundle. (2019). https://www.sccm.org/getattachment/SurvivingSepsisCampaign/Resources/Implementatio n-Guide/Surviving-Sepsis-Early-Identify-Sepsis-Hospital-Floor.pdf?lang=en-US. Epulse.saint. (n.d.). Retrieved March 07, 2021, from https://epulse.saintlukes.org/news/new-early-detection-sepsis-workflow-launches-aug-19 Quality and Patient Safety. (2021) https://epulse.saint-lukes.org/departments/qualitypatient-safety Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals: Section 6. Facilitating change and Anticipating Challenges. (2018, July). https://www.ahrq.gov/research/findings/final-reports/ptflow/section6.html.

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Risk Master Manual. https://epulse.saint-lukes.org/documents/riskmaster-manual Saint Luke's Health System. (2021, March 04). https://www.saintlukeskc.org Siwicki, B. (2018, October 4). Sepsis Clinical Decision Support Tool Saves 20 Lives in 6 Months at Saint Luke’s Health System. Retrieved March 07, 2021, from https://redivus.com/blog/sepsis-clinical-decision-support-tool-saves-20-lives/ Whitfield, P. L., PharmD, Ratliff, P. D., PharmD, BCCCP, Lockhart, L. L., RN, MSN, MHA, Andrews, D., MBA, BSN, RN, Komyathy, K. L., PharmD, Sloan, M. A., MD, . . . Judd, W. R., PharmD. (2020). Implementation of an adult code sepsis protocol and its impact on SEP-1 core measure perfect score attainment in the ED. The American Journal of Emergency Medicine, 38(5), 879-882. https://doi.org/10.1016/j.ajem.2019.07.002...