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One hospital's journey to create a sustainable sepsis program

Moore, Alexis BSN, RN; Johnson, Jenna BSN, RN; Rumbaugh, Carey MSN, RN-BC

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doi: 10.1097/01.NURSE.0000529809.90912.30
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THE SEPSIS PROGRAM at Medical Center Health System in Odessa, Tex., was created in 2008 due to increasing numbers of patients with sepsis. In 2011, the sepsis program was expanded and a sepsis coordinator position was added. For the first time, a full-time medical-surgical educator would spend part of his or her time managing the sepsis program for the facility.

In 2011, the CDC reported a dramatic increase in hospital admissions for patients with sepsis from 621,000 in 2000 to 1,141,000 in 2008.1 The sepsis program evolved along with this increased incidence: The sepsis coordinator role was added to monitor patients throughout the hospital who were potentially septic. One of the physicians representing the ICU recognized an ongoing concern about admissions and transfers of patients with sepsis and suggested the facility implement a sepsis program. This physician championed the effort to begin a monitoring and management program.

The sepsis surveillance nurse's role, added after the program began to grow, is to assist in patient-tracking efforts alongside the sepsis coordinator for patients age 18 or older with severe sepsis (SS) and septic shock (SSH). Currently, the program is run by two full-time nurses in multidisciplinary collaboration with nursing, medicine, the respiratory department, the lab, the administration, and the public.

What do we do?

Because the disease process can present differently in each patient, sepsis education can be a very difficult task. We use a multimodal education approach to ensure sepsis education reaches all nursing staff. The sepsis coordinator and the sepsis surveillance nurse educate new staff bimonthly at the orientation for new hires, providing a brief overview of sepsis and the metrics that are followed. Monthly case studies are presented, and attendance is required for clinical staff's annual review. These case studies provide in-depth information about changes in evidence-based practice. Cases involving our patients are included, detailing the care provided and patients' outcomes.

Sepsis champions are also developed as a strictly nurse-driven initiative. The sepsis champion role is voluntary. In their initial class, the newly designated sepsis champions learn additional information about sepsis pathophysiology and recognition. Sepsis champions are required to be involved in bimonthly educational activities and sepsis article presentations, and yearly updates. Currently, 74 active sepsis champions are employed throughout the hospital, empowering themselves and their peers through active education efforts and serving as advanced sepsis knowledge resources.

Throughout the year, the sepsis program participates in local and regional community events and health fairs, which provide additional opportunities to educate healthcare personnel and the general public about sepsis. This education focuses on the severity of sepsis and the importance of sepsis monitoring and management. Each year, more than 1 million Americans will be affected by SS, with a 28% to 50% risk of dying.2 This is more than the number of deaths from prostate cancer, breast cancer, and HIV/AIDS combined.3

Our process

Evidence-based practice from the Surviving Sepsis Campaign and the Centers for Medicare and Medicaid Services (CMS) provide the basis for our process.2,4 We educate physicians and nurses about the importance of complying with current bundle guidelines to help ensure best patient outcomes. We also reinforce the recognition of the signs and symptoms of sepsis.

Initial bundles for our patients with SS and SSH followed the Surviving Sepsis Campaign. They included an initial (within 3 hours) lactate level measurement, blood cultures prior to antibiotic administration, appropriate and timely I.V. fluids and I.V. antibiotics, and achievement of mean arterial pressure greater than 65 mm Hg.4 They required that patients with SSH have a central venous access device inserted and central venous pressure and central venous oxygen saturation measured within 6 hours of the identification of signs and symptoms.2

Change is inevitable when medicine, knowledge, and technology advance, and in the arena of sepsis, we've grown quite accustomed to accommodating various changes in guidelines and processes. On October 1, 2015, CMS introduced sepsis as a required core measure for hospitals participating in its quality reporting program. The sepsis core measure tracks both SS and SSH.

Because of quality reporting requirements, staff members were required to make many practice changes to meet the more stringent guidelines. A multidisciplinary group was tasked with providing insight from different points of view as we attempted to influence a culture change. This group consisted of physicians, nursing directors, and nurse educators from the ED and ICU; the chief medical officer; the performance improvement department's quality analyst; and two nurse members of the sepsis program. The nurses from the sepsis program were responsible for coordinating meetings and being the voice of the clinical nurses. They presented nursing concerns and critiqued current practice.

The CMS changes were somewhat challenging because the new CMS metric based several requirements on presentation time. Presentation time can be explained as the time all the elements of sepsis come together, including systemic inflammatory response syndrome, suspected or known infection, and organ dysfunction.4 The Surviving Sepsis Campaign changed its guidelines and bundles to align with those of CMS, alleviating the need to choose between them or combine bundles. Some recommendations that the Surviving Sepsis Campaign incorporated into its update for care in 2016 for patients with sepsis were to continue to aim for antibiotics to be administered within 1 hour as well as for albumin to be administered for patients with SSH who are in a hypotensive state.2,4 To reduce confusion with the clinical staff, these recommendations aren't included in the bundle metrics that are tracked and for which education is provided. The CMS core measure doesn't reflect these recommendations, and adding this as a requirement for our patient population wasn't deemed necessary.4 These changes included a change in the bundle completion time, along with the added requirement of a physician documentation note for patients with SSH to reflect fluid volume and tissue perfusion effectiveness.4 These changes, along with early sepsis recognition, are reported both as a CMS quality improvement project and as an internal measure in an effort to fully maximize patient outcomes.4

New metrics now require immediate follow-up and timed documentation by the physician or midlevel provider. The changes also require that multidisciplinary staff be educated on the new CMS sepsis requirements.4

Because we're a teaching facility, more education was required. For instance, medical residents needed to be aware of, successfully meet, and complete the new metrics. Because attending physicians rely on the residents to complete the physician documentation portion of the metric, the residents received additional education focused on the documentation metric to help ensure they were monitoring properly.

The CMS requirements also include some patient population exclusions within the measure. The performance improvement department, along with the sepsis program, came to a consensus on internal monitoring and data analysis, believing that the total patient population should be examined. We made a combined effort to review data abstraction to help ensure that data about patients with SS and SSH who were reported to CMS aligned with the data abstracted by the sepsis program team.

Education through repetition

Efforts to educate staff, especially nurses and physicians, began as soon as the new metrics were available to post on each unit. Nursing staff quickly proved to be easier to reach. We provided staff development programs for nursing staff on each shift and rotation, presenting the changes and allowing time for questions and clarification. Badge buddies, quick references that attach to nurses' badges, were also provided to serve as quick reminders of ways to identify SS and SSH along with the required metrics. The information was well received when staff members understood that the new changes implemented came from CMS. After the staff development program, unit rounding at regular intervals ensured that staff members were aware of changes and had no further questions.

Physicians were a difficult group to reach due to the variety of their specialties, rotations, and clinic hours. Regularly scheduled and appropriately timed meetings were essential to ensure that attendance was satisfactory so education could take place and any of their questions could be answered.

Results: past to present

In 2011, sepsis bundle compliance measurement and analysis began to help us to determine areas needing improvement. Data collected in the first quarter reflected an 18% compliance rate with the 1-hour bundle; a mortality of 22% was also identified. We notified staff of opportunities for improved healthcare by sending a detailed letter to nurses and physicians involved in any patient's care with identified areas of improvement with measure compliance.

The compliance rates continue to vary from month to month. With the new CMS requirements, data analysis changed based on the revised bundle metrics. Although care improvement letters are still sent out, another nurse-driven process was initiated that primarily targets the ED. Data analysis showed that most of our patients with SS and SSH came from the ED. Noticing differences in the ED and inpatient units' medical records systems, we decided to use the fast-paced style of the ED for the required metrics of patients with SS and SSH.

To help align ED processes with the metric, a sepsis flowsheet was created. The bright green flowsheet details all required metrics for patients with SS and SSH, and it then becomes part of the patient's permanent medical record. The primary nurse completes the flowsheet and faxes the document to the sepsis program team, allowing patients to be identified more quickly and helping to ensure that metrics to improve patient outcomes are met. Sepsis flowsheet use has been successful, as shown by increased rates of metric compliance of 83%. Nurses have reported positive outcomes and increased personal satisfaction in metrics compliance due to the flowsheet that specifically identifies all areas that need to be completed for the patient.

Compliance rates are now separated into the categories of SS and SSH. The latest internal data abstraction for October 2017 shows SS compliance at 83% and SSH compliance at 35%. Although these rates aren't 100%, the true impact can be assessed by the decrease in patient mortality, which is currently 16%, a decrease from the 2011 mortality of 22%.

Take-away points

Building a sustainable program within the facility meant finding ways to create an effective program that impacted the entire hospital. The program was identified as a critical resource for nurses, physicians, and, most important, the patients we serve. Through our joint efforts, the importance of each department's part in our collective endeavor to improve patient care has been seen in the overall decrease in patient mortality and increase in CMS metric compliance. Creating and sustaining the sepsis program benefits both local and rural communities, and we're confident that the sepsis program will continue to evolve and improve.


1. Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS Data Brief. 2011;(62):1–8.
2. QualityNet. Specifications manual for discharges. 2017.
3. National Institute of General Medical Sciences. Sepsis. 2017.
4. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486–552.
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