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Code Sepsis Checklist

North Shore University HospitalOctober/November

2017

NYS PARTNERSHIP FOR PATIENTS

Hospital Sepsis Team○ Salvatore Pardo, MD○ Lara Reda, MD○ Lee Jacobson, MD○ Alan Derzie, MD○ Chris Calandrella, MD○ Nicole Forte, RN○ Kris Maurice, RN○ Carol Thompson, RN○ Mary Nelson, Quality Management Coordinator○ Meryl Lenner, Quality Management Assistant Director○ Marissa Tang, RN○ Jennifer McKay, RN○ Shenique Rangerhutchinson, RN○ Justine McKittrick, Academic Associate○ Steven Miserendino, Project Coordinator○ Jeena Moss, Former Academic Associate, (worked on this initiative)

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Hospital Sepsis Team

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Project Description○ Developed and piloted a Code Sepsis checklist as a

quality improvement intervention in order to standardize management and documentation of SS/SS patients in the ED

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Project Implementation○ Pilot ran from August to December 2016○ Identification of SS/SS patients led to initiation of a

“Code Sepsis” protocol. Responders included nurses, clinicians, and ancillary staff members. Handwritten documentation occurred at bedside.

○ Code sepsis sheets were collected weekly and 3 HSB times were entered into Code Sepsis database.

○ Code Sepsis sheet 3 HSB times were compared with electronic medical record 3HSB times.

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Tools & Resources

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Successful Strategies &Tips○ Have a binder of readily available Code Sepsis

Checklists at every nurse station○ Periodically reeducate/remind staff on how and

when to use checklists and to make sure they are scanned into EMR

○ Added Severe Sepsis/Septic Shock criteria to back of checklist to assist clinicians

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Challenges & Barriers○ Staff uncertain when to call Code Sepsis, who

needs to be there, and what everyone’s roles are○ Code Sepsis Checklists not always used or scanned

into the EMR○ Certain times on Code Sepsis Checklist cannot be

used by data abstractors to improve compliance metrics

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Key Lessons Learned○ Code Sepsis reveals the notion that real-time care is

not always accurately captured in publicly reported sepsis data sourced from the EMR.

○ The Code Sepsis checklist pilot data validated the Code Sepsis form as an official source document for abstraction of quality metric data for NYSDOH and CMS.

○ Further investigation and intervention is necessary to improve electronic documentation, promoting consistency in publicly reported sepsis quality data.

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Outcomes & Data○ In total, 107 Code Sepsis calls were initiated.○ Across Months 1 through 5, on average, 32.7% of

cases were compliant based on EMR data while 79.4% of cases were compliant based on Code Sepsis data.

○ This represents a 142.9% increase in all-or-none 3HSB compliance when comparing the EMR to the Code Sepsis form as sources of quality data.

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Outcomes & Data

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Steps for Hardwiring & Spread○ Currently, the sepsis ED task force is conducting a

small-scale initiative to improve how Code Sepsis calls are run

○ This initiative involves reeducation measures, which include reminding staff when and how to use Code Sepsis Checklists

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Contact InformationJustine McKittrick (516)-562-2928jmckittric@northwell.edu

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