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Quality Improvement Project- Sepsis

Quality Improvement Project- Sepsis

One in every ten deaths is caused by severe sepsis. Surprising, given that this lethal condition is well understood and, in many cases, preventable. It comes as no surprise, then, that the early treatment and management of sepsis is a major daily concern for those working in the critical care setting. However, it is common for an obvious problem to exist and no solution to be found. The process is usually to blame. Quality improvement initiatives come into play here. The purpose of this paper is to properly dissect and discuss the many facets of a quality improvement project in a critical care environment using severe sepsis as a vehicle.

Background and Context of Sepsis

Severe sepsis has been found to have an overall hospital mortality rate of approximately 28%. (Levinson, Casserly, & Levy, 2011). That is, roughly one in every four people died as a result of severe sepsis, and countless more were permanently disabled as a result of multi-system failure. As one of the most common hospital admission diagnoses in the world, one can imagine the panic most medical professionals feel as they rush to treat this deadly condition. When dealing with such a broad and all-encompassing issue as sepsis, it quickly becomes clear that a process or initiative is desperately needed to put a stop to it. In an effort to guide quality initiative efforts, the Institute of Medicine (IOM) has proposed its Six Domains of Health Care Quality, which are as follows: safe, effective, patient-centered, timely, efficient, and equitable (Otto, 2011). This author will concentrate on two of those goals for the purposes of this discussion. The goal of effective care promotes the idea that care should be based on sound scientific evidence and practice. The medical community’s research and recommendations for sepsis management are numerous and easily accessible, as evidenced by the landmark study “Surviving Sepsis Campaign” (Rhodes et al., 2017). The concept of equitability is the second IOM domain to be discussed here. Equitable care requires that the care provided does not discriminate on the basis of gender, race, or, in this case, socioeconomic status. Surprisingly, one study discovered that low to middle-income areas have the worst capacity for combating sepsis escalation in patients (Schultz et al., 2017).

As previously stated, this paper focuses on the critical care microsystem, specifically the Intensive Care Unit (ICU). This decision was made due to the nature of sepsis, specifically severe sepsis, and septic shock, the most severe manifestation of sepsis. When these patients arrive in such a decompensated state, they almost always end up in the ICU. The goal should be to save as many lives as possible. For an explanation of the 5 P’s as they apply to the ICU, please see the appendix at the end of this paper.

Theory of Change

Change can occur spontaneously; however, the spontaneity of impromptu change is unreliable within a concerted effort to produce tangible change. Change theory seeks to comprehend the mechanics of change and to provide guidance for its implementation. Kurt Lewin’s Change Theory was revolutionary when it was first introduced, and its concepts and assertions remain valid today. Lewin’s theory is based on an unfreezing, changing, and refreezing model (Evans et al., 2016). The central idea is that by unfreezing old habits or methods, a window of opportunity for change opens. Change is then implemented. Finally, the refreezing phase solidifies the new habit as the norm. In terms of sepsis management, Lewin’s theory simply allows old unproven methods to be abandoned in favor of proven scientific concepts and treatment bundles. Staff engagement is critical to the success of the change because they are the ones who will put this new information into action. As a result, embracing these ideals will become an absolute requirement for adequate commitment to the policies and procedures. Empowering employees to own new ideas is critical for any organization seeking to implement change.

Analysis of the Root Causes

Organizations can use improvement tools to better understand how to adjust and improve their quality improvement initiatives. The Root Cause Analysis (RCA) is a well-known and effective improvement tool that has long been used by many facilities worldwide. The RCA’s basic premise is to first identify causation and then develop ways to best rectify the situation through committees and research. Following the correct identification of the facts, an action plan is developed, and once implemented, follow-up evaluations are required. If necessary, the procedure is repeated (VA National Center for Patient Safety, 2015). The RCA can be a useful tool in evaluating and correcting any issues that arise during the implementation of a sepsis quality improvement project. One of the many ways an RCA can be a valuable asset to a sepsis program is by identifying and correcting areas where the protocol is not progressing as expected.

PDSA

Quality improvement models, such as the PDSA (Plan, Do, Study, Act) model, provide a broad framework within which implementers can work. The PDSA model is divided into four distinct stages, the first of which is the PLAN stage. The planning stage for quality improvement with a focus on sepsis prevention would begin with an evaluation of current methods and what, if anything, could be improved. DO is the next stage of the process in which the intervention is carried out. The DO stage would be characterized by the implementation of new policies and procedures, possibly a sepsis bundle aimed at quickly and easily preventing sepsis in high-risk patients as sepsis improves. The third stage is STUDY, which is similar to an RCA in practice. The overseers examine the results to determine what occurred and why. During the implementation phase, the study stage seeks information on what is and is not working. Finally, the fourth stage is the ACT, which is the act of deciding what actions to take as a result of the previous three stages (Coury et al., 2017). This would manifest as members of the Sepsis Initiative team making new recommendations on how to proceed.

Resources

In order for any change to occur, resources must be applied and sacrificed. To fund the research, development, and maintenance of quality improvement projects, financial resources must be sacrificed. To facilitate the desired methods and processes, structural resources, such as the construction of new hospital wings or centers, could be developed. Perhaps most importantly, human resources must be directed in order to achieve the project’s objectives. For those reasons, all three would be essential components of any quality improvement effort in the case of sepsis prevention.

Evaluation

There has been a comprehensive set of quality measurements designed to determine the effectiveness of every quality improvement initiative that has existed. Quantitative or numerical measures, as well as qualitative or non-numerical interview-based measures, are important predictors of success. Quantitative measures could include antibiotic administration compliance percentages, lactic acid lab retrieval, fluid bolus administration, and blood culture collection (Welch & Bauer, 2016). Interviews with staff and patients to assess their feelings and concerns about how the sepsis bundle implementation is progressing could be used as qualitative measurements; these qualitative findings would be critical to the project’s feedback and revision process. Outcome measurements explain how a project is performing in terms of the effectiveness of its stated goal, whereas process measures, perhaps more importantly, quantify how we are progressing toward that goal. A 90-day mortality rate, ICU length of stay before and after diagnosis, mortality rates in the ICU, and compliance with the bundle’s stated goals are some examples of outcome measurements for a sepsis initiative (Sheer et al., 2017). Process measurements could include things like assessing Emergency Department (ED) screening tool compliance, sepsis protocol implementation and conformity, and SEP-1 compliance rates (Levenson, 2016).

Visual displays of information can frequently project more useful information to a reader more quickly; after all, a picture is worth a thousand words. A pie chart could accurately represent current hospital compliance with bundle measurements, allowing implementers to quickly and effectively determine the overall performance of process measurements. A bar graph, on the other hand, would be extremely useful in displaying ICU sepsis mortality rates before and after the quality improvement initiative was implemented.

Conclusion

Quality improvement projects, as briefly illustrated here, are an essential and effective process for enacting change through theory and measurement. It is evidence-based and comprehensive, with a methodical approach that leaves no stone unturned in the effort to cement the remodeling of long-held beliefs. The beauty of quality improvement projects is their iterative nature; if initial interventions are ineffective, adjustments can be easily implemented as the process repeats itself. Quality improvement, which combines multiple disciplines and influences, should be viewed as an essential tool for anyone, not just in healthcare but in any situation where change is desired.

References

Coury, J., Schneider, J., Rivelli, J., Petrik, A., Seibel, E., D’Agostini, B.,     Coronado, G. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC Health Services Research, 17(411), 1-10. http://dx.doi.org/10.1186/s12913-017-2364-3

Evans, J., Ball, L., & Wicher, C. (2016, February). Implementation of Medical Orders for Life-Sustaining Treatment. Clinical Journal of Oncology Nursing, 20(1), 74-78. http://dx.doi.org/10.1188/16.CJON.74-78

Levenson, D. (2016, February). Using the ante on sepsis. Clinical Laboratory News, 12-14.

Levinson, A., Casserly, B., & Levy, M. (2011). Reducing Mortality in Severe Sepsis and Septic Shock. Semin Respir Crit Care Med, 32(2), 195-205.

Otto, C. (2011, Spring). Patient Safety and the Medical Laboratory Using the IOM Aims. Clinical Laboratory Science, 24(2), 108-113. Retrieved from http://libproxy.usouthal.edu

Rhodes, A., Evans, L., Alhazzani, W., Levy, M., Antonelli, M., Ferrer, R.,……………… Beale, R. (2017, March). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. CCM Journal, 45(3), 3-552. http://dx.doi.org/10.1097/CCM.0000000000002255

Schultz, M., Dunser, M., Dondorp, A., Adhikari, N., Iyer, S., Kwizera, A.,…. Baker, T. (2017). Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future. Intensive Care Med, 43, 612-624. http://dx.doi.org/DOI 10.1007/s00134-017-4750-z

Sheer, C., Fuchs, C., Kuhn, S., Vollmer, M., Rehberg, S., Friesecke, S.,…. Gr?ndling, M. (2017). Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study. CCM Journal, 45(2), 241-251. http://dx.doi.org/10.1097/CCM.0000000000002069

VA National Center for Patient Safety. (2015). Root Cause Analysis Tools. Retrieved from http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2389

Welch, S., & Bauer, S. (2016). Initial Care for Patients with Severe Sepsis and Septic Shock: The Next ICU Quality Measure. Hospital Pharmacy, 51(1), 19-25. http://dx.doi.org/doi: 10.1310/hpj5101-19

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Content Requirements:

Identify strengths, weaknesses, opportunities, and threats for improvement related to sepsis protocol

Quality Improvement Project- Sepsis

Quality Improvement Project- Sepsis

Analyze the SWOT data to provide the foundation for an action plan for quality improvement

to be 2 – 3 pages in length, excluding the title, abstract, and references page.

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