Evidence-based care, changing culture enhances patient safety

By Jennifer Towne

 

Patient safety and quality initiatives in a hospital unit are one thing. Developing a system-wide approach to improving patient safety is a whole other thing. 

 

Leaders at Cherry Hill, N.J.-based Kennedy Health set about to do just that – decrease hospital-acquired sepsis rates by implementing evidence-based care models and changing culture. It required a multidisciplinary approach, based on data, with support from leadership.

 

In 2012, Kennedy Health created a multidisciplinary sepsis committee to improve the sepsis rate in its emergency departments (ED) and intensive care units (ICU). Bundles were introduced and caregivers were educated about implementing the sepsis bundles. 

 

This ED-ICU committee was chaired by Henry Schuitema, M.D., the system section head of emergency medicine and medical director at Kennedy’s Stratford campus and Marianne Kraemer, RN, the chief nursing officer at Kennedy University Hospital Stratford. The committee was charged with reviewing sepsis cases and achieving 100% adherence to bundle compliance. 

 

The committee achieved initial success, partly because it included members from all aspects of the organization, such as the ED, pulmonary /critical care/infectious disease physicians, ED/ICU nursing, quality, laboratory, pharmacy and performance improvement staffs, along with physician and nursing champions. 

 

These members reviewed data, understood the positive impact the bundles were having on reducing ED and ICU sepsis rates and tweaked and continuously improved upon protocol to achieve greater success. After a year and a half of implementing the quality initiative in these two units, it was time to look at sepsis rates on inpatient units. 

 

Through review of the data, the group was surprised to discover that the survival rate for patients was lower if sepsis was acquired in the hospital. Using the lessons learned from the success of the ED-ICU committee work, Cindy Hou, M.D., an infectious disease physician, spread the success to the inpatient population. Hou and Kraemer began the “Sepsis on the Floors” taskforce in July 2014. 

 

Making sure to include a multidisciplinary group, the taskforce consists of clinical nurses, nurse aides, critical care intensivists, critical care fellows, microbiology lab and performance improvement staff. Its goal: Decrease the mortality rate of hospital-acquired sepsis in Kennedy Health’s three hospitals with its 607 total beds. It would tackle the problem by improving recognition of sepsis, severe sepsis and septic shock; promoting evidence-based care models; and fostering collaboration between the nursing and physician staff through joint education with registered nurses and physician lectures. 

 

Around this time, the New Jersey Hospital Association’s Institute for Quality and Patient Safety began a state-wide learning collaborative to assist its members in lowering sepsis rates. The goals of the collaborative were aligned with what the Sepsis on the Floors taskforce were trying to achieve – implement early recognition screening and standardized sepsis treatment protocols to reduced severe sepsis mortality rates in New Jersey by 20%. With the support of Kennedy President and CEO Joseph Devine, the taskforce joined the collaborative in January 2015. 

 

The taskforce began education sessions to heighten caregiver awareness of sepsis so they could identify it earlier and implement bundle elements. During the sessions, attendees review current literature and best practices as it relates to the data the taskforce collects.

 

The taskforce believes that data review is essential to continuous improvement. When cases were not compliant with the bundle process, a “deep dive” is conducted to determine the roadblock. 

 

The taskforce uses the plan-do-study-act (PDSA) tool to determine the process breakdown and find ways to improve. That’s shorthand for testing a change by developing a plan to test it (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

 

For example, after applying a PDSA cycle, it was determined that nursing staff weren’t getting timely orders for lactate tests and sepsis wasn’t being discovered until later stages. This resulted in the nurse-initiated lactic acid policy, where, if a patient is showing signs of two of systemic inflammatory response syndrome and a source of infection, the nursing staff may draw a lactate test without waiting for a physician order.

 

This type of continuous improvement cycle does several things. First and foremost, the patient receives excellent care. “It’s all about the patient, not the caregiver,” explains Kraemer. “We focus on the lessons learned and nothing is punitive. The idea is to set processes and then get better at them.” 

 

Hou says the caregivers are empowered and this brings about a culture change that gets hard wired into all caregiver work. “It is our belief that we can always be better and we consistently strive to do so,” she says. “This instills a sense of commitment at every level in the organization.” 

 

Kennedy Health’s sepsis program is extremely successful. To date, 93.9% of cases meet the three-hour bundle compliance. The state average is 49.9%. Additionally, the health system estimates 130.4 lives have been saved and its mortality rate is 11.9 %. Hou and Kraemer credit the taskforce’s success on several factors. 

 

The model is sustainable and successful because it’s systematic and continuously improved based on input from those using it. Additionally, sepsis rates are constantly measured and tracked. All health system staff are engaged because they see the progress and understand how it positively impacts patients. Frontline staff are empowered because they can apply evidence-based protocols to immediately help their patients.

 

For more information, contact Hou at c.hou@kennedyhealth.org, Kraemer at m.kraemer@kennedyhealth.org and Schuitema at h.schuitema@kennedyhealth.org.