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Striking Out Sepsis

A team approach to fighting a deadly concern increased screenings & unified staff members

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A nurse recently received a worried call from her sister, who was not feeling well. Lucky for that sister, the nurse was from Sentara Healthcare, a not-for-profit health system with more than 100 sites of care in Virginia and North Carolina, where sepsis awareness was in full swing. She had just completed updated training, and jumping from supportive-sister mode to expert-nurse consultant, she conducted the Sentara sepsis screen.

"Then the nurse told her sister to go to the emergency room immediately," recounted Kathy McCoy, BSN, RN-BC, CCRN, director of safety and performance excellence for Sentara Healthcare and a sepsis awareness team operational leader. "It turns out she did have sepsis, and her sister's training helped her get early treatment. This is just one of the success stories I've heard after our new sepsis campaign."

Most nurses are familiar with sepsis. However, some may not understand the importance of early detection and the critical role they can play wherever they work. Consider the facts: more than 750,000 new sepsis cases develop every year; incidence of sepsis per 100,000 exceeds AIDS, breast cancer and first MIs; the mortality rate ranges from 28% to 50%; from 500 to 1,000 Americans die daily from severe sepsis; every hour antimicrobial administration is delayed is associated with an average decrease in survival of 7.6%.

Understanding that nurses' awareness and urgency in delivering care are keys to patient survival, Sentara Healthcare re-committed itself to exceeding national sepsis standards.

"In everything we do, we want to provide exceptional care without exception," said Genemarie McGee, MS, BSN, RN, chief nursing officer for Sentara Healthcare and nurse executive and vice president of patient care services at Sentara Leigh Hospital in Norfolk, Va. "This is true no matter where we help patients."

Archive ImageA

CHECKING FOR SIGNS: Sarah Karika, RN, PCCN, works closely checking on her patient's condition.

A Team Approach

Sentara executive leadership set a goal of consistency in sepsis care two years ago. They aimed to improve mortality, reduce complications and length of stay, and maintain or improve care costs. A cross-functional team with representatives from different specialties, care settings and care levels gathered to outline a new approach to sepsis management.

"We didn't want to look at our sepsis care from just one perspective," said Jen Pyle, a Sentara senior process improvement engineer and the team leader. "This is a true cross-continuum care issue. At the same time, we knew the importance of talking with those who are closest to the patients and those with best-practice knowledge."

The team designed an initiative for all 10 of Sentara's hospitals. Their work began by outlining a five-prong approach:

  1. standardize guidelines by designing best-practice solutions;
  2. create a need for change with awareness and communication tools;
  3. provide the knowledge and skills through education and training;
  4. provide the ability to enact knowledge by rolling out needed tools; and
  5. reinforce change by developing and reporting metrics.

Curious about employees' perceptions, the team surveyed clinical staff members at hospitals and long-term care and home health sites.

"Some thought that it was everyone else's problem," said Pyle. "We had an opportunity to educate them about why sepsis is a concern everywhere."

The survey itself served another purpose: Hospitals experienced a Hawthorne Effect of sorts, with sepsis measures improving just because employees noticed that a special team was interested in their efforts.

The Right Tools for the Job

But there was still much work to be done. The group pieced together a sepsis initiative. They led the creation of the theme "Strike Out Sepsis" and its supporting icon of a bug jumping away from a lightning bolt. The theme and icon were printed on posters, mouse pads and badge holders.

The team also leveraged Sentara's intranet by adding a sepsis button on the homepage that gave employees easy access to sepsis tips.

Photo Gallery

Striking Out Sepsis

Sentara Healthcare developed a team approach to combat sepsis.

At the heart of the program were new procedures and tools: upon arrival at an ED, nurses determine if patients are presenting sepsis symptoms and conduct a screening if warranted; if the patient is admitted for any reason, an ED nurse conducts a sepsis screen before transferring the patient; within four hours of being admitted, each patient, excluding those on comfort care, receives a sepsis screening - and continues to have one every 12 hours; additional screenings are completed after any medical response team (MRT) call and a change in clinical condition.

A sepsis screening tool embedded in Sentara's electronic medical records system makes the regular screenings manageable. The tool asks three questions:

  1. Are there signs/symptoms of infection?
  2. Are there signs/symptoms of systemic inflammatory response syndrome (SIRS)?
  3. Are there signs/symptoms of organ dysfunction?

Each yes response earns one point. A score of zero to one signifies a low risk or SIRS; two, at-risk or early sepsis; and three, severe sepsis. Instructions are given for each score, including what to observe, when to perform a more in-depth assessment and when to notify a physician.

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SHARING INFORMATION: Jennifer Kenworthy, RN, (middle) and Sarah Karika, RN, PCCN, look over patient records with Jorge Zarate, MD.

Building Buy-in

Physicians were included in the planning stages for both the insight they could offer and in hopes of addressing any misgivings.

"They were skeptical about an increase in inappropriate calls, but they haven't seen that," said McCoy, the safety and performance excellence director. "The calls they get are appropriate."

Credit Sentara's well-planned and thorough education effort. "Nurse champions" were selected on each hospital unit and were the first to learn the screening process. The champions taught their fellow nurses in simulation labs. In addition to reviewing the three screening questions, nurses introduced the "High Five for Handoff" to improve nurse-to-nurse and physician-to-physician communication and the sBAR communication system for organizing nurse-to-doctor notes (see box). Computer-based training, which many physicians took advantage of, and a resource notebook were included as well.

"We have seen a steady trend upward with screening compliance," shared Johnsa Greene-Morris, MBA, BSN, RN, CCRN, director of patient care services, medicine at Sentara Norfolk General, one of two hospitals that served as pilots before the complete roll-out began in September 2012. "We have greater than 90% compliance at our hospital."

The numbers are encouraging all around: At hospitals that have gone live, 98% of patients are being screened within four hours of admission, and 97% are being screened twice a day. Greene-Morris is confident gains will continue because the staff has embraced the message. She serves on a performance improvement team, along with the sepsis team, and when asked to develop an idea, the improvement team suggested adding sepsis screenings to MRT calls. Plus, the nurses on all but one floor at her hospital entered a bulletin board contest to illustrate their work fighting sepsis.

The same spirit seems to be found throughout Sentara.

"I'm proud of our teamwork," said Amy Smith Peard, MSN, RN, CNS, ENP, CEN, clinical nurse specialist at Sentara Leigh Hospital and a sepsis team member and operational lead. "In the past, we might have worked in silos. ED can't just fight sepsis alone; the med/surg floor can't; and ICU can't, but if we work together, we all can."

Kristen De Deyn Kirk is a freelance writer.


The Sepsis High-Five Handoff
Questions for nurse-to-nurse and physician-to-physician handoff of patients:

  • Has your patient been screened for sepsis?
  • What is the identified source of infection?
  • What orders and meds are currently being used to strike out sepsis?
  • What is your patient's current status?
  • What are the next steps in patient care and recommendations for level of care?

The sBAR tool
Suggested form of documentation and communication from nurse to physician:

  • Situation
  • Background
  • Assessment
  • Recommendation
  • Sepsis-specific information in the sBAR: Sepsis-related labs (i.e., lactic acid, CBC, CMP); Sepsis screening score; last 24 hours of vital signs; and recommendations for care to assist the nurse in discussing plan of care with the physician (i.e., labs, sepsis order sets, critical care consult)


 

Does anyone have a screening tool for nursing homes to use?

Elaine January 24, 2015
Madeira , FL



We are a receiving hospital for many outlying hospitals and I am curious if you have any screening tools used for intake when receiving patients from area facilities? Do you have any advice on how to get staff buy-in and create a culture change? Did you create a protocol that allowed nurses to order lactates if the patients met SIRS criteria?

Tracie Bishop,  BSN,  Mercy Springfield MOMay 02, 2013
Ozark, MO




     

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