Baptist Memorial Hospital
Memphis, Tennessee, USA
Emmel B. Golden, Jr., MD, ICU Medical Director
Mary Ann Northern, Performance Improvement, Key Contact
Melanie Polzin, ICU Head Nurse, Day-to-Day Leader
Debbie Nance, System Quality Support
Jan Padgett, ICU Manager
Sheila Borges, Director, Critical Care
Medhat Elsabawy, Clinical Pharmacy
Karen Clark, Pathology
Larry Hopper, Director, Respiratory Care
Lindsay Edwards, Nursing, Emergency Department
Cindy Miskell, Nursing, CVICU
Joy Lindsey, Case Management
Kathy Nunnikhoven, Food and Nutrition
Paul Spreckelmeyer, Speech Therapy
Cleolyn Young, Physical Therapy
William Hawks, Nursing, ICU
Carole Schule, Nursing, ICU
Mary Mickle, Nursing, ICU
To promote patient- and family-centered care, prevent harm, and improve patient outcomes by providing safe, efficient, evidence-based care.
Specific goals to achieve by September 2007:
Our ICU launched a program in 2002, guided by the Institute for Healthcare Improvement (IHI), to improve the care and safety of critically ill patients. The ICU implemented several changes, including the Ventilator Bundle, Central Line Bundle, multidisciplinary rounds, and a daily goal sheet, that resulted in improved outcomes.
In November 2005, through participation in the IHI Critical Care Learning and Innovation Community, our team set out to reduce sepsis mortality by improving the identification of sepsis and implementing sepsis bundles based on Surviving Sepsis Campaign guidelines
- Revised and implemented a Severe Sepsis and Septic Shock order set that includes all components of the Sepsis Resuscitation and Sepsis Management Bundles
- Targeted early sepsis recognition
- Instituted sepsis screening in the ICU, using the IHI screening tool, on all new admissions and patients with greater than three-day length of stay (LOS)
- Incorporated screening into multidisciplinary rounds and the Patient Daily Goals/Plan of Care
- Implemented a “Sepsis Alert” screening tool in the Emergency Department (ED): Posted Sepsis Alert Screen in ED rooms and on ED chart backs as prompters to staff
- Added sepsis screening to the ED standardized T-System documentation for all ED patients
- Implemented screening on Medical Response Team (MRT) calls
- Instituted ED chart review of patients admitted with a sepsis diagnosis to monitor compliance with appropriate screening and initiation of the Sepsis Resuscitation Bundle; gave feedback to ED staff and physicians
- Prioritized ED/ICU collaboration for timely transfer of septic patients to ICU; ED nurse notified the ICU float charge nurse of positive sepsis screens
- Initiated sepsis resuscitation (lactates, blood cultures, antibiotics, fluid resuscitation) in the ED as indicated
- ED staff and physicians were educated to the Sepsis Resuscitation Bundle
- Intensivists assisted the ED as needed
- Focus was on prompt transfer of patients to ICU for insertion of central venous oximetry catheters
- Placed prompters in the ED to collect blood cultures prior to first dose antibiotic administration
- Implemented components of the Sepsis Resuscitation and Sepsis Management Bundles in ICU using a systematic, incremental approach
- Began by obtaining orders for lactates for all positive sepsis screens
- Tracked the volume of lactates collected in ED and ICU
- Added absolute neutrophils to CBC and CBCI reports
- Added prompters for the Resuscitation Bundle to the sepsis screening tools in ED and ICU
- Promoted utilization of central venous oximetry catheters by setting out the catheter for intensivists to use instead of a triple lumen catheter
- Educated physicians to the purpose and benefits of using the central venous oximetry catheter
- Established a sepsis resuscitation box (lab tubes, type and cross-match supplies, catheters, fluids, etc.)
- Revised the Pre-extubation Worksheet for lower tidal volumes and inspiratory plateau pressures — Respiratory Care monitored and followed up on compliance
- Posted criteria for steroids in ICU and added steroid order to the sepsis pre-printed order set
- Implemented Clinical Pharmacy review of cases for drotrecogin alfa based on established criteria
- Implemented a standing order process for nurse to automatically initiate the Insulin Drip Protocol for ICU patients with two blood glucose (BG) levels >150 mg/dL
- Addressed glycemic control in all rounds
- Consulted Clinical Pharmacy for insulin protocol patients with BG >150 mg/dL — also, the Pathology Department emailed a daily list of uncontrolled patients to Nursing and Clinical Pharmacy.
- Implemented Clinical Pharmacy screening of all new total parenteral nutrition (TPN) orders for appropriateness and ongoing screening for early switching to enteral feedings
- Implemented a process for Infection Control Practitioner to call a huddle meeting with Nursing and the ICU Medical Director for initial positive blood isolates of ICU patients — the purpose was to determine the source of infection, discontinue lines as indicated, initiate antibiotics, etc.
- Installed the Surviving Sepsis database to concurrently enter and track data from ICU patient charts on sepsis bundle compliance and mortality — feedback to staff and physicians
Summary of Results / Lessons Learned / Next Steps
By improving the identification of severe sepsis and implementing the Sepsis Resuscitation and Sepsis Management Bundles, Baptist Memorial Hospital-Memphis, achieved a reduction in sepsis mortality. For the 89 patients with completed data through December 2006 in the Surviving Sepsis Campaign database, there was over a 40 percent reduction in mortality compared to baseline rates. Compliance with the bundles improved as process changes for each of the bundle components were implemented. The value of consistent reliable application of evidence-based practices in the ICU has improved patient safety and outcomes.
- First the staff must be able to recognize sepsis “putting the pieces together” for early sepsis recognition.
- Start small. Systematic, incremental change has a big impact.
- Collaborate with the ED for early identification of sepsis, initiation of the resuscitation bundle and quick transfer to ICU.
- Share successful outcomes to increase staff and physician buy-in.
- Educate and constantly communicate with the staff.
- Celebrate success!
The next step is to spread sepsis screening hospital-wide to all patient care areas. We plan to identify three patient care units, design the spread, learn from the spread to those units, and then spread hospital-wide.