Quality Infographic

Monument Health Shares Their Quality Improvement Journey

A person dies from sepsis every 2 minutes.  Anyone can develop sepsis, a life-threatening, complex and challenging condition to manage. There are significant human and financial costs associated with it. Every year, more than 1.7 million adults in the U.S. develop sepsis, leading to over 270,000 deaths and roughly 19% of sepsis survivors are readmitted to the hospital within 30 days, leading to a $3.1 billion annual cost.

Amanda KarrelsAmanda Karrels, RN, Clinical Quality Coordinator (pictured) and her colleague Katie Noyes, Sepsis Coordinator, were recently featured on a national Hospital Quality Improvement Contract (HQIC)-led panel to share Monument Health’s efforts to improve sepsis rates and reduce readmissions. Access the recording and the presentation from the April 27 session here.

Monument Health is the largest health care system in Western South Dakota with 5 hospitals, 25 clinics 6, urgent cares and 8 specialty treatment centers. Their first priority of Monument Health is to deliver high quality care, which serves as the driver of their quality improvement project to enhance compliance with early sepsis management. The team set a goal to provide consistent and high-quality care to patients with sepsis, including those who are admitted to the Sturgis Hospital and those who are transferred to a higher level of care.

Well-defined system processes and compliance for the severe sepsis/septic shock early management bundle are crucial to delivering high quality care and reducing readmissions. This was a starting point for the Monument Health team as a preliminary review of data showed inconsistencies. They made a commitment to increase compliance for sepsis-related readmission using the treatment bundle. A sepsis “bundle” refers to a series of responses that a medical team takes in order to treat sepsis. There is a three-hour bundle and six-hour bundle, both of which include different steps, including specific testing and administering IV fluids and antibiotics.

“Part of my every day responsibilities is analyzing patients charts, collecting data and reporting to the Centers for Medicare & Medicaid Services (CMS) and Hospital Quality Improvement Contractor (HQIC). Noticing there was a trend in data, I facilitated a performance improvement team. We identified and analyzed quality issues and developed action plans to address them. I educated nurses and physicians on current reporting standards and evidence-based practice guidelines. We printed reference sheets to keep in the emergency department and urgent care. I helped to implement order sets and documentation capture by utilizing standardized verbiage that helps providers document necessary information consistently and correctly. I would ensure that quality improvement processes and procedures were followed by conducting quality audits and giving case specific feedback to our nurses and physicians. I collated the data and would present this information to leadership and our QAPI team,” Karrels explained.

Action items:

  • Continued measurement and participation in HQIC database as well as CMS reporting for patients admitted to the Sturgis Hospital
  • Added measurement of sepsis charts for patients transferred to higher levels of care for both the 3-and 6-hour bundles
  • Physician and nurse peer feedback on opportunities identified in chart reviews, including those chart that are not reported i.e. transferred patients
  • Targeted education during department meetings with emphasis on documentation and the resources available
  • Physician and nurse peer feedback on great care
  • Continued participation and collaboration with system and Hills’ market sepsis team
  • Regular reporting of data to medical and nursing staff
  • Inclusion of Sturgis Urgent Care Services
  • Creation of reference sheets for Emergency Department and for Urgent Care Services

Through collaboration, data monitoring and a feedback loop, strong improvements in quality can be demonstrated. As a result of this effort, Monument Health saw a decrease in sepsis mortality and sepsis-related readmissions and reported improvement in both the 6-hour and the 3-hour bundle for patients admitted. Sturgis Hospital has been at 100 percent for the 3-hour bundle for 17 months in a row. This is something to celebrate!

Karrels and team also displayed their Sepsis process improvement poster at the CMS Quality Conference Gallery Walk in May. This conference is the premier health care quality conference focused on improving quality, equity and innovation. Leaders in the health care space will explore and educate how advocates, providers, researchers, and champions in health care quality improvement can develop and spread solution to address America’s most pervasion health system challenges.

Karrels concluded, “There is always more work to be done, but I am so pleased with this effort and our team at Monument Health. We are offering great, high-quality care to our patients and we have so much to be proud of.”