Quality initiative to improve emergency department sepsis bundle compliance through utilisation of an electronic health record tool

Promoting Antibiotic Stewardship and Implementation of Sepsis Pathway in the Emergency Department: A Quality Improvement Initiative

Introduction Sepsis is a preventable cause of mortality and presents challenges in triage and management. The Surviving Sepsis Campaign care bundles improve patient outcomes; however, non-compliance with guidelines, understaffing, and scarcity of training opportunities undermine care quality in resource-limited countries. We aimed to implement the sepsis hour-1 care bundle in the emergency department of a tertiary-care hospital in Pakistan and develop hospital antimicrobial guidelines. Methods The baseline assessment included a survey of knowledge and confidence in sepsis management and a retrospective audit of inpatient medical records. The inclusion criteria were age ≥ 18 years with a systemic inflammatory response score ≥ 2 or a National Early Warning Score ≥ 3. Improvement strategies included (a) educational intervention, (b) adult sepsis screening tool and sepsis 1-hour bundle checklist, and (c) recommendations for empirical antibiotics. These were implemented and assessed via Plan-Do-Study-Act (PDSA) cycles: (a) multi-tiered educational campaigns, (b) implementation of hospital protocols/guidelines, and (c) antimicrobial policy and sustainability. The process measures were hour-1 bundle components and the outcome measures were in-hospital mortality, ICU admission, length of hospital stay, and ICU stay. Results The baseline survey revealed that the majority of participants had formal training and felt confident in managing septic patients but none of the respondents had used a sepsis scoring system, and only 29.4% had used an hour-1 bundle previously. There was a sustained improvement in bundle compliance from 0% at baseline to 57.7% at PDSA-3. Inappreciable variation (p > 0.05) was reflected in the length of hospital and ICU stay and in-hospital mortality, whereas ICU admission decreased insignificantly (p > 0.05). The antimicrobial therapy practice, as per the guidelines, increased remarkably (p < 0.05). Conclusion Regular training and feedback are pivotal for practice change, yet integrating structured screening tools and bundled checklists into current workflows can significantly improve compliance.

Improving Compliance with the CMS SEP-1 Sepsis Bundle at a Community-Based Teaching Hospital Emergency Department

INTRODUCTION

The Centers for Medicare & Medicaid Services (CMS) designed Hospital Quality Initiatives (HQI) to assure delivery of quality health care for institutions receiving Medicare payments. Like many teaching institutions, the SEP-1 compliance rates at McLaren Oakland in Pontiac fluctuated monthly and were not achieving institutional target expectations.

METHODS

The project team designed a Sepsis Macro and a Sepsis Order Set in the electronic medical record system. The project team also implemented an educational initiative targeted at emergency medicine resident and attending physicians. The educational initiative instructed emergency medicine resident and attending physicians in the metrics measured in the SEP-1 bundle as well as how to properly use the newly designed Sepsis Macro and Sepsis Order Set.

RESULTS

After implementation of the Sepsis Macro and Sepsis Order Set, the overall compliance with the SEP-1 bundle improved from 57% to 62%, above national averages and at the institutional target expectations. However, there were not statistically significant differences (p = 0.562) between the compliance rate before and after program implementation (Pre = 57% (SD = 0.27); 95% CI: 0.29 - 0.85); Post= 62% (SD = 0.11); 95% CI: 0.55 - 0.70). After program implementation the SEP-1 compliance rate was met in 82% of the months in comparison with 50% of the months in the pre-intervention (p = 0.28).

CONCLUSIONS

Although not achieving statistical significance, this intervention demonstrated that simple, cost-effective measures of education and standardization in documentation and order entry in EMR’s can improve clinically significant compliance to CMS HQI metrics in community-based teaching institutions.