Opportunities in The Management of Sepsis
By Erin Macsay, System Infection Prevention and Disease Clinical Nurse Specialist, Premier Health
Sepsis is one of the leading causes of mortality in hospitalized patients. Across the United States, 86% of cases of sepsis are present on admission, and up to 80% of these patients receive their initial care through the Emergency Department (ED). At Premier Health for 2024, approximately 77% of the cases of sepsis mortalities presented through the ED.
The Centers for Medicare and Medicaid Services has proposed to include the Severe Sepsis and Septic Shock: Management Bundle, also known as SEP-1 bundle, in the Hospital Value Based Purchasing Program in FY2026. Included in the SEP-1 bundle are blood cultures, lactic acid, broad-spectrum antibiotics, and intravenous fluid resuscitation. In 2024, Premier Health increased our Core Sepsis Early Management Bundle target to 84.4%. Over the past two years, the average bundle compliance has been 71.2%. By improving SEP-1 bundle compliance, we can significantly enhance the care we provide for our patients and potentially increase our future reimbursement. This presents a promising opportunity for us to make a substantial difference in patient outcomes.
One way to improve SEP-1 bundle compliance is using Epic order sets. The ED System Sepsis / Septic Shock [12105] and System Sepsis / Septic Shock [12991] order sets are reviewed bi-annually to ensure evidence-based interventions are included in the care for patients with sepsis. For 2024, across the system, the ED Sepsis order set is used approximately 60% of the time, and the Inpatient System Sepsis order set is used approximately 40% of the time. Even if sepsis is worked up and diagnosed in the ED, the inpatient provider is expected to also order the System Sepsis order set to ensure appropriate antibiotic continuation occurs and nursing monitoring orders are placed. When an opportunity for improvement (OFI) is identified by the quality department, the quality data abstractor reviews to see if the sepsis order set was used. The majority of these OFIs would have been prevented with the use of the sepsis order set.
One of the top OFIs identified in 2024 is related to the administration and documentation of intravenous crystalloid fluid resuscitation. The SEP-1 bundle requires that 30 mL/kg of crystalloid fluids be administered within six hours prior through three hours after the event that triggers the identification of septic shock. According to the Specification Manual for National Inpatient Quality Measures, providers can order less than 30 mL/kg of crystalloid fluids if they document the specific volume or a weight-based volume ordered and a reason for ordering less than 30 mL/kg of crystalloid fluids. Reasons include but are not limited to concern for fluid overload, heart failure, renal failure, blood pressure responding to lesser volume, or a portion of the crystalloid fluid volume being administered as colloids. The volume and reason for less than the target must be documented in a single source. This includes documentation in a note or using the Sepsis Fluid Bolus section of the sepsis order set. The Sepsis Fluid Bolus for Advanced or End State Heart Failure or Chronic Kidney Disease order is a single source of documentation to order a fluid volume and use a pre-approved text in the Administration Instructions to justify the reason for giving less than target fluid resuscitation. Appropriate documentation is key to meeting the metric and completing the SEP-1 bundle successfully.
Another way to improve the outcomes of our patients with sepsis is through patient and caregiver education. In a system wide gap analysis using the CDC Hospital Sepsis Program Core Elements assessment tool, we identified a need for improved sepsis education for patients and caregivers. As a result, the Premier Education Council and the Premier Sepsis Committee collaborated to update the Sepsis Zone tool. More information about life after sepsis, specifically post-sepsis syndrome, was added to the updated Zone Tool. The updated Sepsis Zone Tools, available in both English and Spanish, will soon be available on SharePoint's Premier Patient Education page in the Zone tab. The sepsis diagnosis and education can also be added in the After Visit Summary upon discharge through Healthwise. For additional assistance with sepsis education, please contact Jodi Snyder, System Program Manager for Patient and Family Education, at jdsynder@PremierHealth.com.
Back to the July 2024 issue of Premier Pulse
