1/7/2016
StCharlesHealthSystem
AinaAlipertiRN,MSN,CNS,CCRN
Date:January15,2016
St.CharlesHealthSystem
Bend Campus
Redmond Campus
Prineville Campus
Madras Campus
Sepsis:EarlyIdentificationandManagement
saveslives
WhySepsis:
*CMSCoreMeasuresImplementation‐ Oct2015
*2015MeritGoalforallunitleaders:Identifyyour
department’stop10diagnoses
• Implementanationalbestpractice
• Demonstrateimprovement
Whowasinvolved:
*ICU,IMCU,MedicalFloor,ED,nurses,leadership,
physicians(all4facilities),infectioncontrol,
Qualitydataabstractors.Didnotinvolvepatients.
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1
1/7/2016
Reviewofcurrentpractices
• Formedamultidisciplinaryteam
– reviewedcurrentpracticesandgaps
• includedlookingatordersets,currentprotocol,and9monthsof
chartreviews.
Failure Rate
Facility
July
Denomin.
Bend
Redmond
August
Failure
% Failure
Denomin.
Sept
Failure
% Failure
Denomin.
15
10
66.67%
15
14
93.33%
15
Failure
12
% Failure
80%
9
8
89.89%
8
7
87.50%
6
6
100%
Madres
3
3
100%
2
0
0%
0
0
0%
Prineville
2
1
50%
4
2
50%
0
0
0%
4
Whathavewedone
• Revised our order sets:
ER Protocol
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1/7/2016
Adult Sepsis Management Pathway
Successes
• ERprotocol,startsatthetriagedesk
• PaperversionoftheAdultSepsisManagement
Pathway(toodifficulttofinddatainthecomputer)
• Involvementoftheabstractorswasandcontinues
tobekeytoourprocess
• Monthlyreportsonsuccessandfailures
• Involvementfromalllevelsoftheorganization
helpedhardwirechangesinthesystem
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BarriersandSolutions
Barriers
Solutions
• Understanding the exact terminology that CMS is looking for related to each of the measures
• Changing CMS requirements and updates for measures • On going education for staff and practitioners • Continue to work with abstractors and fine tune our documentation and orders so that we meet the measures
• Monthly educational updates and abstractor attendance at Service Line meetings 9
3
1/7/2016
AdviceforOthers&
LessonsLearned
• UnderstandtheMeasures
• Reviewthechartwhilepatientisinthe
hospitalsoyoucangiverealtimefeedback
• Educate,educate,educate
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PlanforSpread/Sustainment
• Nextsteps:Considerimplementingan
in‐houseSepsis1,continuetoreviewwith
theabstractorsallcasesthatmeet
inclusion.
• Continuetoeducatestaffoncontinuous
processimprovementaswereviewcharts
andanalyzemetricdata
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ContactInfo
• AinaAlipertiRN,MSN,CNS,CCRN
2500NENeffRd
BendOR,97701
[email protected]
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