NEW Emergency Department Sepsis Best Practice Advisories (BPAs) launched on 3 January 2023. The Tip Sheet reflecting 2 BPA’s are for patients that meet criteria are for 1. Septic Shock and 2. Sepsis. It can be found here.
UMMS is taking action within its member hospitals to standardize the System’s response to sepsis, which a 2020 study reaffirms as one of the leading causes of mortality in hospitals worldwide. Current processes to identify, evaluate and intervene to decrease deaths from sepsis vary across UMMS member organizations. Therefore, UMMS developed the Sepsis Program to develop a consistent practice across the System to decrease morbidity and mortality secondary to sepsis.
“Tackling the overall sepsis clinical performance improvement initiative is one of the most important tasks that falls under the umbrella of clinical transformation for the University of Maryland Medical System.”
Andrew N. Pollak, M.D.
UMMS Chief Clinical Officer
The introduction of this definition is supported by the flyer, education slide deck and FAQ provided.
Since June 2021, Dr Jason Heavner led a subgroup of content experts as part of the UMMS Sepsis Program, engaging with Hospitalists, ICU Directors and EMLOC leaders to research, vet, define and approve the following clinically-led definition that has now been endorsed by the system Clinical Performance Council, CMO/CNO Council and UMMS Quality Board.
The definition provides greater specificity; removing the necessity for severe sepsis. Establishing a shared system definition will increase our ability to measure performance and reduce the variability in the rates of infection diagnosis across the system. We are confident that this clinically-led definition will promote a more sensitive and consistent level of sepsis diagnosis; laying the ground work for further improvement within the EMR.
Please help us by:
- Posting the attached Sepsis Definition Flyer where it can be easily seen in provider break rooms, on provider notice boards and near computers
- Include the Sepsis Definition Flyer in related provider newsletters and in updates to medical committees
- Review the attached Sepsis Definition Education slide deck during medical team meetings, huddles, orientations and trainings
- Note the definition is supported by a new smartphrase - .sepsisdx
- Note that HIM and Coding colleagues will also be reinforcing this education and be updating their templates and policy to support of this change and their queries.
Timely Antibiotic Administration – Mary Ghaffari, PharmD
Infection Management – Jason Heavner, MD
Diagnostics – Co-Leads: Kristie Johnson, PhD and Kimberly Claeys, PharmD
This UMMS Sepsis Program’s objective is early identification, standardized evaluation and rapid, standardized intervention to decrease morbidity and mortality:
- Decrease mortality rates to O/E < 0.8
- Decrease readmissions to O/E < 0.8
- Decrease ICU Utilization by unplanned admissions
- Increase median days free of organ support
A Tableau dashboard aids the interrogation of data for promoting timely antibiotic administration within 60 minutes. Related diagnostic processes reduce the time from blood culture order to bacterial identification and antimicrobial susceptibility results.
The program’s core components include:
- Patients presenting to UMMS hospitals via ED or on IP floor with signs of sepsis (patients transferred into the hospital with severe sepsis aren’t currently a part of this evaluation)
- A workflow for evaluating potentially avoidable deaths from sepsis
- A workflow regarding the causes & how to potentially decrease sepsis mortality
- Assessment of the efficacy of the work implemented
- Establishing best practice for earlier implementation of the sepsis bundle
This content is for Internal Use only.