Sepsis Mortality Reduction Project Charter - Patientsafetycouncil.org

Sepsis Mortality Reduction Project Charter
Project Title: Sepsis
Sponsor: Hospital Association of San Diego
& Imperial Counties
Process Owner: Hospital, Critical Care, ED
and Acute Care
Facilitator: Nancy Pratt, RN, MSN from
Feb/10; Cynthia Cadwell, CNS, NP, MS,
CPHQ from Aug/10
Project Start Date: 16 February 2010
Project End Date: 31 December 2010
Problem Statement:
Sepsis is the nation’s number one cause of intensive
care death outside of coronary ICUs. In San Diego
County acute care facilities, approximately 4-5
patients die on a daily basis in due to sepsis.
Team Members:
• Alvarado Hospital
• Fallbrook Hospital
• Hospital Association of San Diego &
Imperial Counties
• Palomar Pomerado Health
• Rady Children’s Hospital San Diego
• Scripps Health
• Sharp HealthCare
• Tri-City Medical Center
• UCSD Medical Center
• VA Healthcare San Diego
Project Scope:
This project includes the following acute care
inpatient population admitted to the ED, Med/Surg
and Critical care units:
• Adult/Geriatrics
• Pediatrics (and note differences)
• Multiple Co-morbidities
• 1 st and 2 nd diagnosis Sepsis
• Oncology-neutropenic
• Immuno-suppression
• Bone Marrow Transplant
• Therapeutic hypothermia
• Cardiac arrest
This project excludes neonatal patients and
individuals on hospice or comfort care. Note: Pt
Safety 1 st initiative does not exclude hospice or
comfort care.
Customer(s) and Requirements:
Hospital health care professionals need a
straightforward protocol that can be
consistently executed and change
acceleration strategies to improve adoption of
best practices.
Deliverables:
• Best practice and guidelines of care
• Screening tool(s) – to evaluate patient for
sepsis vs. SIRS
• Order set
• Implementation plans
• Education on process / algorithm
• Definitions – based on best practice
• Data gathering assistance
• Elevator speech
• Outcomes and tools to measure outcomes
Goal and Other Potential Benefits:
To develop evidenced-based project tools and
organization-specific measures to reduce the
occurrence and mortality of sepsis in the acute care
patient by 25 percent across the county. Pt Safety 1 st
initiative goal is 30% reduction for the state.
Furthermore, focused intervention measures with the
SIRS and sepsis patient will reduce the progression
of illness to severe sepsis/sepsis shock.

Population
• Treating SIRS can reduce patient progressing to Sepsis Shock
• Coding based on MD diagnosis Sepsis (get codes for sepsis)
• Most MDs state sepsis typically as severe sepsis
• Providers not aware of documenting SIRS or Sepsis
• Patient admitted into ICU with Sepsis
• Y = all patients in the hospital with sepsis
Any diagnosis - primary or secondary, etc.
• X = mortality
Goal
• Reduce the incidence and mortality of sepsis in the acute care patient by 25% across the county; during
the acute care hospital length of stay
• Need current number – administrative data – for primary and secondary diagnosis of sepsis –
what portion of patient have sepsis as secondary
• Side goal: Reduce incidence of Severe Sepsis/Sepsis Shock
• Each organization: rate of SIRS, Sepsis, etc. as primary diagnosis
How can this project help us at our facility?
• Need implementation tools for change acceleration
Elevator Speech
Recommend producing an elevator speech for each target audience.
• What our project is about… early identification and treatment of severe systemic infections
(Sepsis) to reduce Sepsis incidence and related deaths countywide by 25 percent, as well as
overall patient outcomes.
• Why it is important to do… because Sepsis is treatable with appropriate and early intervention,
yet today it is the number one cause of death in ICUs nationally with approximately four to five
patients dying per day of Sepsis in San Diego County.
• What success will look like… increased countywide compliance with evidenced-based best
practices resulting in reduced incidence and mortality of sepsis with institutions realizing an
overall decrease in patient hospital stay and costs.
• What we need from you… a commitment to understand, support, and comply with best
practices to reduce sepsis mortality including early identification of high-risk patients,
collaborating with colleagues, and providing accurate classification of sepsis.
Staging Project
Considering evidence available it’s clear what needs to be done…
Timeline
Description
April • How to care for the patient?
• Surviving Sepsis Campaign
• Order set available in most facilities
• Literature
June • Early identification of Sepsis/Order Sets
August • Finalize Toolkit
• Change management/Implementation
October • Measurement
• Stakeholder analysis
December • Project status evaluation
• Review change management