Hospital Spotlight: Ascension Standish Hospital Aims to Increase Sepsis Bundle Compliance

Posted on May 02, 2019

Hospital SpotlightSepsis is a dangerous health condition that can be fatal if not treated quickly and appropriately. Sepsis is a progression of infection that leads to organ damage, shock and death. Nationally, 1.7 million adults every year develop sepsis; 270,000 of them die.

The Society of Critical Care Medicine’s Surviving Sepsis Campaign kicked off in 2002 — it intends to reduce sepsis mortality worldwide, as well as improve awareness and outcomes in sepsis by providing guidelines and key recommendations for sepsis care.

Sepsis bundles have been an integral part of the campaign — they assist healthcare professionals with the complex process of treating patients with sepsis. A bundle is a selected set of elements of care that, when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone.

The Centers for Medicare & Medicaid Services (CMS) requires hospitals to report compliance with the SEP-1 bundle and core measure, which aims to standardize severe sepsis and septic shock treatment. In addition, all metrics of the bundle must be met to receive credit from the CMS.

In 2018, Ascension Standish Hospital, a critical access hospital in Northern Michigan, aimed to perfect its SEP-1 compliance. As part of an effort throughout the Ascension health system, Ascension Standish Hospital adopted best practices and focused on improving processes for the early identification and management of sepsis.

The staff initially recognized that, with the hospital’s low volumes, the focus on adhering to all elements of the bundle was particularly important.

To accomplish this, a multidisciplinary approach was created organizationwide in March 2018. Current protocols, tools and processes were assessed. Interdisciplinary and emergency department (ED) teams were formed. SEP-1 compliance rates were also reviewed at ED and inpatient unit meetings, along with infection prevention, patient safety and quality, and medical executive committees. The emergency medical director was engaged and held peer-to-peer reviews with physicians.

This step identified opportunities within the electronic medical record system that would allow physicians to order treatment for sepsis bundles.

Immediate action was taken in mid-March working with the electronic medical records team. The information technology department turned on the order set; staff were trained in the ED, inpatient units and medical staff meetings; and an increase in compliance was noticed almost immediately.

Fiscal year to date, Ascension Standish Hospital has achieved 93% SEP-1 compliance and sustained 100% compliance in both quarter four of 2018 and quarter one of 2019.

Ascension Standish Hospital is a part of Ascension, a faith-based healthcare organization dedicated to transformation through innovation across the continuum of care. In Michigan, Ascension operates 15 hospitals and hundreds of related healthcare facilities that together employ more than 20,000 associates.

This article was featured in the new MHA Keystone Center Newsletter. To subscribe, please contact Ashley Sandborn, MHA Keystone Center communications specialist.


  • Hospital Spotlight: Ascension Standish Hospital Aims to Increase Sepsis Bundle Compliance

Tags: sepsis, Hospital Spotlight, Ascension Standish Hospital

Posted in: Patient Safety & Quality

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