Quality improvement leaders at Spectrum Health, based in Grand Rapids, MI, are seeing success with several initiatives addressing sepsis, preventive screenings, and fall prevention. Their experiences may offer lessons for other hospitals.
To help prevent mortality from sepsis, clinicians at Spectrum Health use a checklist to ensure all components of the sepsis treatment bundles have been completed within the three-hour and six-hour windows for care, says Julie B. Bonewell, MBA, BSN, RN, CPHQ, senior director for quality improvement at Spectrum Health.
“We noticed a couple years ago that our sepsis rates were going in a direction we didn’t want, so we launched a concentrated effort to reduce our sepsis mortality rates,” Bonewell says. “This started right after we had an [electronic health record] go live, which was an opportunity to refocus on quality improvement. One of the key things we learned was the importance of hiring a sepsis coordinator.”
Spectrum had taken a similar path before with hiring a full-time stroke coordinator, with responsibilities for both improving and coordinating care with stroke patients. The same approach was used for sepsis. A prime role for the sepsis coordinator is to follow compliance with sepsis prevention bundles and protocols, says Leslie M. Jurecko, MD, MBA, senior vice president for system quality, safety, and experience at Spectrum Health.
“A lot of hospitals use these bundles and track them, but she follows them in real time. She works with a couple of physician leaders and they do almost instant feedback with providers when they have fallout following the sepsis bundle of care,” Jurecko says. “That’s been really well received. It’s either the coordinator or a physician letting a physician know that they may have missed one or more opportunities to lessen mortality and morbidity from sepsis. The feedback loop has been fabulous and really moved the needle on this project.”
The team also uses a swarm approach for patients at risk for sepsis, which Bonewell describes as similar to calling a code. A page is sent to targeted team members so that everyone needed to assess the risk and institute preventive measures is in one room to discuss the patient’s condition and implement the protocol.
“The team can discuss and determine that the lab needs to do this, nursing needs to do this, and all the questions can be answered right then. It facilitates getting the care initiated more quickly, rather than someone having another question and paging the provider, then someone else having a question and waiting to hear the answer before they do anything,” Bonewell says. “We’ve spread that model now to our ICU and inpatient spaces as well.”
Jurecko notes that clinicians usually refer to the gathering as a “Code Sepsis” and respond with urgency similar to other code calls.
Spectrum Health’s sepsis mortality rate had been as high as 30%. After making changes, that rate has decreased to 15% across the system, Bonewell reports. Part of the reduction can be attributed to ensuring the appropriate care starts at regional facilities and continues as sepsis patients are transferred for treatment to the health system’s main tertiary care campus.
“The clock starts in the regional spaces on these patients. That has been a great culture shift for us,” Jurecko says. “The coordinator and some of the other changes all came together about a year ago. If you look at where we were with that baseline and where we are now, we’ve saved about 118 lives in the last year from sepsis mortality.”
Surgical site infections also were addressed in a similar way at Spectrum Health, with a checklist to ensure all the appropriate preoperative interventions are completed. Now, Spectrum is trying to reduce surgical site infections by addressing the optimization period before surgery, not just the perioperative period. “Recently, we decided to move toward setting hard cutoffs for elective surgery regarding [body mass index], hemoglobin A1c, and smoking status. We’ve ramped up our surgical optimization center to make sure patients are on plan to meet those goals so they can move forward with the surgery they’re requesting,” Jurecko explains. “We had seen some significant improvements in infection rates with the perioperative work. Then, we plateaued and realized we needed to look at the entire continuum of care. The team put out a model of what needed to be done and when.”
Spectrum Health also studied nutritional status, implementing changes such as providing colorectal patients a liquid nutrition supplement to improve their immunological status before surgery, Jurecko explains.
Bonewell notes the surgical site infection efforts were led by physicians; there was no reluctance from surgeons to follow the checklist and other protocols, including an intraoperative timeout. The interventions were introduced first with colorectal patients; now, these techniques are adopted for all surgery.
Compliance is monitored, and the results have been encouraging, Jurecko says. For instance, orthopedics recently reported 100% compliance with the universal protocol.
“We have nurses document it, and then we’re able to show those compliance rates transparently. We have a physician leader follow up with physicians who are falling out of the compliance range we want,” Jurecko says.
The efforts have reduced colorectal surgical site infections enough to get Spectrum out of a Hospital-Acquired Condition Reduction Program penalty imposed by CMS a couple years ago, Bonewell notes.
Additionally, Spectrum Health improved preventive screenings. At one point, the health system had become overwhelmed with all the different expectations of health plans, which called for their patients to undergo certain preventive screenings at specific times. Spectrum created a more efficient way to handle the demand.
“Every insurance company has different targets. We got to the point where we just couldn’t manage individual payer programs. There was way too much complexity,” Bonewell says. “We created our Integrated Payer Program and a tool called Gaps in Care, which takes the most stringent expectation from payers. If one payer wants the A1c below 11 and one wants it below 9, we take the one that’s below 9.”
Medical assistants at Spectrum Health use a report generated by that tool that quickly shows which tests are due for a patient. “We can call patients in when they are due for a screening, and we can look at the patients who are already coming in today and make sure we take care of any gaps in care during this visit,” Bonewell says.
This approach has resulted in higher compliance with preventive screening as well as better control of chronic diseases such as high blood pressure and diabetes. In addition to improving the screening of individual patients, the program helps clinical teams hit their targets for preventive screenings, Jurecko says.
“It’s one of our best stories of team-based care,” she notes. “The teams use an operational deployment system with a board called our Managing for Daily Improvement board. The team in that office huddles around the board to discuss where they are with getting their blood pressure screenings, cancer screenings, and other targets.”
Spectrum Health also has been addressing fall prevention with its “Go Green” initiative, playing off the idea that visual cues are a great way to help staff with ensuring interventions are in place for patient safety. Nursing leadership piloted the initiative on a unit in which all beds with a patient in them had to have a green light.
This green light indicated that the team had programmed the bed in the safest position for the patient, which would be unique to the patient, and included bed alarm, number of side rails, and bed height. Team members can hold each other accountable if they notice an orange flashing light on the bed, as well as remedy the safety concern in real time, Jurecko explains.
Nurses program the bed for the settings appropriate to that patient and then push a button that activates the green light. The light stays green as long as those settings are not changed, indicating at a glance that the safety measures are in place. If anyone changes those settings, the light turns orange to signify that attention is needed.
“The beauty of this initiative was that it crossed over all disciplines, engaging environmental service, pharmacists — anyone who spent any time on the unit, as well as the patients and families,” Jurecko says. “If all the components of the bed are not properly engaged, the light at the end of the bed will flash orange instead of being green. Anybody who sees it ... is supposed to stop everything, get help from staff, and be near the patient so the patient doesn’t fall out of bed.”
For the six months prior to the Go Green initiative, the Spectrum Health unit experienced four to five falls each month, a rate higher than the national benchmark. After implementing the program, falls decreased significantly. For December 2018 and January, February, and March 2019, the unit performed better than the national benchmark for falls. Leaders are expanding the techniques to other units.