2025 Community of Human and Organizational Learning 31st Annual Conference

Background-Timely identification and treatment of sepsis leads to improved outcomes. Despite having a sepsis screening process and sepsis management pathway in place for >10 years, we were not reaching our goals for time-to-antibiotics and time-to-bolus-completion.
Objective-Using a data-driven, team approach, we sought to improve the timely administration of fluids and antibiotics in emergency department patients with suspected sepsis.
method- Quality Nurse Champion and Quality Physician champion reviewed all charts from multiple sources which include Our practice Advisories (OPA) for sepsis occurred for in the ED, a final diagnosis and ED diagnosis for sepsis and two EMR sepsis data pathways when utilized. We identified what worked well that month and what could be done better. We give individual feedback to both physicians and nurses as well as our learners in the ED for those who did not meet the bench mark. Each month we can then review the ED data with our hospital quality group.
result-Timely feedback led to improved rates of completion of bedside sepsis huddles for OPA in the comer ED. To facilitate timely sepsis care, we added a reminder to use the Sepsis Pathway to our OPA. We also implemented antibiotic dose rounding to increase the number of patients who could receive nurse-prepared antibiotics. There were a few months in which we did not meet our goal which has currently led us to pushed toward using IM antibiotics if unable to get an IV. Data regarding compliance with our antibiotic timeliness goal is provided to individual PEM physicians relative to the anonymized group to drive improvement.
conclusion-The data and discussions gathered each week help make changes to the system and improve performance on a daily basis.