Improving Emergency Department Staff Compliance to the Sepsis Core Measure: A Quality Improvement Project

The Centers for Medicare & Medicaid Services (CMS) has reported the percentage of patients who received appropriate care for severe sepsis and septic shock for each Joint Commission-accredited hospital during its latest data collection period from 04/01/2017 - 03/31/2018. This has prompted many healthcare organizations in the United States to make compliance to the CMS mandated sepsis core measure a priority and explore different improvement strategies and techniques. A small community-based hospital in northern California is among these organizations and has focused specifically on its emergency department (ED). An internal audit was performed to identify areas of deficiency, and an assessment of the ED as a clinical microsystem was done to examine staff routine and workflow. An issue concerning the availability and accessibility of the forms required for proper documentation of care was discovered, and a project introducing the use of sepsis packets was implemented to address the issue. Staff education on the sepsis core measure, the hospital’s sepsis protocol, and the required documentation on sepsis patients was provided and was reinforced as needed to ensure staff compliance. One month after the project’s implementation date, data was collected and compared to the baseline data from the initial audit. Results revealed that the project was effective in increasing staff compliance to several components of the sepsis core measure