Sepsis contributes to over a third of hospital deaths which represents 350,000 hospital deaths or discharges to hospice annually. In addition to patient outcomes, sepsis rates influence quality scores, performance and financials with the addition of the Sepsis/Septic Shock SEP-1 bundle compliance to value-based purchasing in 2024. Northern Dutchess Hospital will improve SEP-1 bundle compliance by establishing a project charter and creating driver diagrams to guide development of meaningful change ideas for improvement. An interdisciplinary workgroup will guide implementation of changes through Plan-Do-Study-Act cycles. The goal is to is to increase compliance to 70% by the end of FY2024.
Problem: Trying to solve problem of low compliance with Sepsis Septic Shock Bundle.
Measurement: Run charts for each of the SEP-1 bundle elements will be developed and identify where changes were implemented to track whether changes resulted in improvement with compliance.
Analysis: Compliance with each bundle element will be analyzed to develop primary and secondary driver diagrams. ED and inpatient data will be tracked separately to prioritize focus. Baseline knowledge surveys of staff was used to establish where to focus change ideas and education.
Implementation: Driver diagrams based on data led to new prioritized workplans. Elements that could be improved with quick fixes were implemented. The team conducted PDSA cycles for other change ideas. Obstacles are EMR changes and stakeholder engagement. Facilities can benefit by using project charters, interdisciplinary workgroups, and data driven change ideas.
Results/Discussion: Preliminary results are positive with compliance increasing from 37.5% to 78.26% in the first two months. Blood culture collection increased from 78% to 95% and antibiotic administration increased from 87.5% to 100%. It is still early but the primarily results are promising with many items still to be implemented.
