A Need for Speed

By: Lynnette Torres, Quality Improvement Manager for Memorial Hospital of Carbondale

Sepsis – a dreaded word for patients, families and health care providers alike. Sepsis is an infection caused by microorganisms or germs (usually bacteria) invading the body. It can be limited to a particular body region or be widespread in the bloodstream.

Addressing the Challenge
In addition to outcomes, the Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $24 billion in 2013 increasing on average annually by 11.9%. It has been estimated that if the U.S. as a whole achieved earlier sepsis identification and evidenced based treatment, there would be 92,000 fewer deaths annually, 1.25 million fewer hospital days annually, and reductions in hospital expenditures of over $1.5 billion.2 Research has shown that mortality from sepsis increases 7% every hour that treatment is delayed. As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatment.3 Understanding this severity, Memorial Hospital of Carbondale, Illinois, began addressing the sepsis
challenge several years before it became a focus for the Centers for Medicare Services (CMS). A multi-disciplinary improvement team began studying sepsis, and realized how much more difficult and unique it is to meet all the requirements than the previously required core measures from CMS.

Making it Easier
The team began working on revising all order sets that are used for patients who may be septic, including the required measures of the Sepsis Bundle: blood cultures, lactic acid, antibiotics, fluid resuscitation, and vasopressors. A Kaizen project focused on the work flow for septic patients as well as components of the evidenced-based sepsis care bundle. Revised sepsis order sets for patients in triage, the ED and inpatient nursing units now include the required measures. These changes make it easier to ensure the proper care is provided in a timely manner. All nursing staff, hospitalists and ED physicians were educated on the sepsis requirements and new order sets. One-on-one education was provided when necessary. “Cheat sheets” and guides for sepsis care were created for physicians and nursing staff. The sepsis care path was laminated and placed on computers as a visual reminder. A checklist was created for nurses and physicians in the ED; these checklists double as a hand-off tool to communicate the continuum of care between providers.

Memorial has concurrent and retrospective nurse abstractors in the Quality Department. The concurrent abstractor reviews the patients who meet sepsis criteria daily, along with tracking use of the sepsis order sets.  Order set compliance data is shared with the providers.

“There are approximately 750,000 new sepsis cases each year in the US, with at least 210,000 fatalities. As medicine becomes more aggressive, with invasive procedures and immunosuppression, the incidence of sepsis is likely to increase even more. Reducing mortality due to severe sepsis requires an organized process that guarantees the early recognition of sepsis along with the uniform and consistent application of evidence-based practices.”

Moving Forward
The team continues to meet and seek ways to simplify the order sets to increase compliance. One of the challenges is missing the required lactic acid timeframe for admitted patients who have the first blood drawn in the ED but are not in their inpatient room when the Lab phlebotomists go to draw for the second order. The phlebotomists now place a sign above the bed indicating that they have been there, asking nurses to please contact the Lab so the second draw may be done in a timely manner.

The Results
Since the sepsis core measure is “all or nothing” for compliance, it is a challenge. However, the results at Memorial Hospital are consistently improving. Use of the revised sepsis order sets started in the low teens and has increased to about 65%. Total compliance with the Sepsis Bundle has increased to the mid-50’s. The team continues to meet every other week and gather input from the ED physicians and hospitalists to address the challenges, one of which is early recognition of sepsis so the timeframes can be met.

For More Information
Lynnette Torres is the Quality Improvement Manager for Memorial Hospital of Carbondale. For more information, including the tools used by Memorial Hospital of Carbondale, contact Lynette at 618-549-0721 Ext. 65472 or 618-684-3156 Ext. 55610. Memorial Hospital of Carbondale is a 140-bed tertiary care hospital, serving as the flagship hospital for Southern Illinois Healthcare and regional center for the 16-county southern Illinois region.

The U.S. FDA published safety information regarding heater-cooler devices

The U.S. Food and Drug Administration (FDA) published safety information to heighten awareness about infections associated with heater-cooler devices used during open-chest cardiac surgical procedures that utilize an extracorporeal bypass circuit. There is the potential for nontuberculous mycobacteria (NTM) organisms to grow in the water tanks of the heater-cooler device. While the water in the heater-cooler device is not intended to come into direct contact with the patient, if water within the heater-cooler tanks is contaminated with NTM, there is the potential for it to become aerosolized into the operating room and enter the sterile field (e.g., open-chest cavity and/or a sterile implant). NTM infections may cause serious illness or death. NTM infections are difficult to detect because patients infected may not develop signs and symptoms of infection for months to years after initial exposure. For more information about FDA’s understanding of the issue and recommendations to reduce risk of infection to patients, please visit: The FDA’s Web page on heater-cooler devices.

Managing MRSA

There’s new promising research for a better way to manage MRSA.  The new protocol uses polyhexanide-based products beyond hospital stays into the outpatient, long-term and home  settings.  “IMM is a promising concept to improve decolonization rates of MRSA-carriers for patients who leave the hospital before decolonization is completed,” the study authors concluded.  Read more about it in the Antimicrobial Resistance and Infection Control Journal.

Live Learning Opportunity for LTC: Disrupting Infections

The Advancing Excellence in Long-Term Care Collaborative is offering a two-hour session at Meramec Bluffs in Ballwin, MO with national expert Bill Thomas on stopping infections in long-term care.  More information is available here.  There is a charge to register.

Stop the Spread of Antibiotic Resistance – A Call to Action from the CDC

Premier’s latest SafetyShare highlights the CDC’s August Call to Action, Stop the Spread of Antibiotic Resistance.  Did you know more than 2 million illnesses and at least 23,000 deaths are caused each year in the US from antibiotic resistance germs?  Up to 70% of patients could be saved from getting certain infections over 5 years if facilities coordinated prevention activities.?  37,000 lives could be saved from antibiotic resistance infections over 5 years by the appropriate treatment of infection and use of antibiotics. Read more about the CDC recommendations.

A Message from the AHA – Patient Safety Begins with YOU.

All of us have the power to think and act in ways that keep patients safe. That means that everyone must use every tool at our disposal to avoid infection. That includes following CDC recommendations to get an annual flu vaccine. Our responsibility for patient safety means that we all must employ appropriate infection control procedures, not just when an infectious disease such as Ebola is in the headlines, but every single day. It means that hospital leaders must be vigilant in keeping clinical and nonclinical staff updated on policies, procedures and protocols relating to infectious diseases. And it means putting all of this into practice through training and exercises. Please check the AHA website for updated Ebola preparedness resources.


Exciting Opportunity for Nursing Home Infection Prevention!

The Center is excited to be spending Tuesday July 15th in Chicago with colleagues from the Missouri Hospital Association, AHA’s Health Research and Education Trust and others to bring home everything we need to support interested nursing home in a collaborative opportunity focused on safety culture and infection prevention. The collaborative will bring national experts, evidence-based practices and expert support to participating nursing homes! Look for more information and recruitment information soon!

WHO Saves Lives Campaign Highlights Hand Hygiene and Resources

The World Health Organization has compiled resources from its May 5 Save Lives Campaign focusing on hand hygiene. These resources include:

  • WHO webpages with a photo story of hand hygiene improvement from Costa Rica   HERE
  • More than 30 countries organized activities, many initiated by WHO CleanHandsNet, including from New Zealand, Hong Kong, Singapore, Argentina, Malta, Belgium, Croatia, Austria, Romania, Serbia, France, Viet Nam, South Africa, Wales, Albania, Macedonia, Spain, England, Scotland, Egypt, Ireland, India, Switzerland, Brazil, Germany, Northern Ireland and Italy.
  • Web page information from societies and leading organizations HERE
  • Many translated WHO posters in to their local language HERE
  • WHO Private Organizations for Patient Safety (POPS) played a key role in spreading messages HERE
  • Professor Pittet’s Webber teleclass on 5 May featured many examples of activities and is an excellent summary. Additional training resources also available.

FREE Webinar: MERS-CoV-Implications for infection preventionists

May 28, 2014 12pm CST Register now!

APIC  and CDC are teaming up to provide this free webinar on infection control considerations for MERS-CoV.  Dr. Michael Bell  MD, Deputy Director, CDC’s Division of Healthcare Quality Promotion, will review infection prevention and preparedness strategies to help facilities know what to look for and what to do to protect healthcare providers and patients in their facilities.

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in US

The CDC has announced a second case of MERS-CoV infection found in the United States.   The first case was reported on May 2, 2014.

MERS is a viral respiratory illness first reported in Saudi Arabia in 2012.   The CDC reports MERS “is caused by a coronavirus called MERS-CoV. Most people who have been confirmed to have MERS-CoV infection developed sever acute respiratory illness. They had fever, cough, and shortness of breath. More than 30% of these people died.” MERS spreads from the infected individual to those with close contact such as care givers and family members residing with the infected individual.   There is still much that is unknown about the virus.   The CDC continues to research the virus and monitor the situation.   Healthcare professionals should report any person evaluated for MERS-CoV infection to their state or local health department if they are a patient under investigation (PUI).   Health professionals should review the CDCs Interim Guidance for Health Professionals.

Stay up to date with the latest case information and review the CDCs Frequently Asked Questions about MERS.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.