Why Improve Sepsis Protocols and Detection Methods

Written in collaboration by Sepsis Alliance and Cynosure

The question of why might be something you hear throughout your organization. Maybe what follows is that sepsis protocols are “good enough” or that there isn’t bandwidth to improve.

The truth of the matter is, sepsis continues to be a public health crisis that needs our attention. In fact, more than 1.7 million people in the U.S. are diagnosed with sepsis each year. In the United States, sepsis takes a life every two minutes - this is more than opioid overdoses, breast cancer, and prostate cancer combined.

If those facts aren’t enough, sepsis is the number one cause of hospital readmissions, costing more than $3.5 billion each year.

As Sepsis Awareness Month begins, we ask that you to take another look at your sepsis protocols and detection methods. We encourage you to see if there are any obvious areas for improvement. Improving our sepsis protocols and detection methods can (and will) save lives.

More about Sepsis Alliance

Sepsis Alliance is the leading sepsis organization in the U.S., working in all 50 states to save lives and reduce suffering from sepsis. The organization was founded in 2007 by Dr. Carl Flatley, whose daughter Erin died unnecessarily of sepsis when she was 23 years old. Sepsis awareness can and does save lives, yet only 63% of American adults have ever heard the word sepsis.

The Sepsis Alliance team works to produce information for both healthcare professionals and the public to elevate sepsis care with education, resources, and networking.

We encourage you to register for an upcoming educational event - the Sepsis Alliance Summit! Join Sepsis Alliance for a FREE, virtual conference on sepsis held on September 27 and 28, 2023. Sepsis Alliance Summit features two days of virtual expert-led sepsis content and opportunities to engage with other healthcare professionals. Free continuing nursing education credits will also be available!

Where to Start to Improve your Sepsis Protocols and Detection Methods

Sepsis Awareness Month is a great time to begin to examine your current efforts and gain ideas and inspiration for further improvements. As you begin to take further action to improve awareness of sepsis mortality and morbidity, a great first step is to assess your current practices using the Cynosure Sepsis Discovery Tool to provide a real time evaluation of your current processes and by reviewing the 2023 Cynosure Sepsis Safe Hospital Self-Assessment.

Next, connect with the right information and tools to support your efforts. Sepsis Alliance has released a Sepsis Awareness Month tool kit to help inspire your Sepsis Awareness month activities.

Then, join us as we highlight hospital best practices in our Cynosure Sepsis “How to” Series:

  • Sepsis Screening & Implementing an Hour One Bundle will be featured on September 21 @ 1:00 pm EST register here
  • Handoff checklists and Post Sepsis Support Groups will be featured on September 28 @ 1:00 pm EST register here  

Now is the time to get started! You can learn more about sepsis and find other ways to get involved at sepsis.org.

Emerging Problems in the US Health Care System: 3 Ways to Mitigate Diagnostic Errors in Medicine

Diagnostic harm and diagnostic improvement have become buzzwords in patient safety and risk management and with good reason. A recent study by Johns Hopkins showed that medical providers misdiagnose 11% of the time, but this rate differs widely from 1.5% diagnostic error rate for heart attacks to 62% diagnostic error rate for spinal abscesses. This is cause for considerable problems in the US health care system, especially when it’s already feeling fragile post-pandemic.

The good news is that we in the medical community recognize a problem, and we’re ready to do something about it. So, how do we mitigate diagnostic harm and help reduce diagnostic errors in medicine?

1. Develop Tactics to Identify and Learn from Diagnostic Errors or Near Misses

We have so much data at our fingertips, and we can use this to learn from or identify any diagnostic errors. Here are a few places you can find a diagnostic error or a near miss:

  • Use data: Review adverse event reports or any medical malpractice data. Gaining knowledge and learning from the data at hand helps ensure history isn’t repeated.
  • Learn from your patients: Review patient complaint logs. They can tell you so much about the patient’s feelings, where a diagnostic error might have happened, and what steps could help in the future.

Now we know where to find them, but what do we do with it? We suggest a regular cadence of review of these data points. Gather a team that will review together and then strategize different ways to mitigate this instance in the future.

2. More Effective Teamwork during Diagnostic Process

A lot of times, more eyes, more ears, more brains, and more experiences coming together can create a better overall diagnosis for a patient. We suggest having a process where multiple health care professionals are involved with a diagnosis, especially a more difficult case or one you’ve rarely seen. No matter how many years of experience you have, there can always be something missed or symptoms you haven’t been presented with before that can cause a misdiagnosis.

A great place to start is working with your Quality Director to create a small test of change in how to gather a diagnostic team.

 3. Enhancing Health Care Professional Education and Training Around Diagnostic Process

More training and education is usually a great answer when there’s a problem to tackle. When it comes to something like diagnostic accuracy, a refresher course is a great place to start. Thankfully, ARHQ’s TeamSTEPPS Diagnostic Improvement Course is developed to improve diagnostic accuracy for individuals or large groups. For more information on the course, please go here.

At Cynosure, we have many team members that are certified TeamSTEPPS trainers and know the ins and outs of the TeamSTEPPS Diagnostic Improvement Course. If your organization is wanting to implement this vital training, but isn’t sure how to get started, please reach out to us today.

Care Transitions: Improving Discharge Phone Call Outcomes

When it comes to discharge phone calls, we often encounter the "my patient didn't answer" obstacle. Such a vital piece of the care puzzle should get bypassed because our team was sent to voicemail. This article outlines a few ways to increase the chances of patients answering this important phone call.

Tactics to Increase Answering of Discharge Phone Call

1) Tell the patient in advance that you will call and share the purpose of the call or details you might discuss
2) Schedule a convenient time for the call
2) Ask if a significant family member or caregiver can be present and make sure the scheduled call works for them
3) Create reminder magnets with the date and phone number you'll be calling from
4) Put a post it note with the date and phone number on the top of the discharge papers

Bonus: Telling the patient and/or caregiver the phone number you'll be calling from ensures they have a callback number in case they miss your call or they need help prior to the follow up

Example: What can I do to Improve Care Transitions in 1 Week?

Let's walk through an example involving explaining the discharge phone call, scheduling a day and time for the call, and what number they will receive the call from.

Monday: Review the QI Project Planning Worksheet that will guide you through the steps of planning for a Small Test Of Change (STOC).

Tuesday: Huddle with your hospital team that will be involved in testing something new and explain the expectations.

Wednesday: Test one change idea with one or several discharges that day. Huddle with your team after. How did it go? What would make it easier? What challenges did you encounter? What will you do differently with the next patient, tomorrow?

Thursday: Try the test again with modifications based upon Wednesday’s experience.

Friday: Call the patient or family caregiver that you tested advance notification intervention with. Did they pick up the call?  If yes, what made them answer?  If no, reflect on your STOC conducted on Wednesday. Will you adapt or abandon the change idea?  Will you try adding a post it note with the date, time and phone number you will be calling from?

All this to say, discharge phone calls may be low-hanging fruit to capitalize on that can do a great deal to help decrease your readmissions and continually better serve your patient population. If you’re looking for more ways to improve your Care Transitions, reach out and we’d be happy to talk strategy with you.

For the New Quality Manager in Health Care: Determining Where to Start

Stepping into any new role is scary, but stepping in as a new Quality Manager in health care can be particularly challenging. You may be so familiar with being on the floor or in a clinical setting and dealing with the hustle that brings, that switching to this role may feel completely overwhelming. And that’s okay.  

As a quality manager in health care, you’ll take on new acronyms, reports, leadership strategies, improvement planning, and more. Just when you thought you’d made the right career decision, you probably started to second-guess it. Yearning for the familiar is normal and expected, so we assure you that you aren’t alone in this.  

Now we aren’t saying this to imply there’s nothing you can do about it. In fact, we have a handy guide to help you navigate those first few months to help ease the transition. 


Find Other Leaders in the Organization 

Getting to know your new colleagues and their roles in the organization is a huge first step in building the foundation of your new role. As a quality manager in health care, knowing who else will be on your team to build and implement new quality measures can help you identify where to go when you run into any sticking points. 

It’s also important not only to build allies but to have a good face-to-face relationship with everyone. With that, you have more leverage – building rapport helps to make for smoother policy changes or testing suggestions.  


Identify your Champions of Change  

Your Champions of Change aren’t always leadership. These individuals that will actually help implement or test a new procedure are often your most stellar staff member. They must be highly liked and highly respected by their colleagues. If they start to change their routine for the new procedure you’re testing, often their colleagues will follow suit.  

You can find your Champions by observing the department. See how team members interact. Take note of who is speaking when everyone else is listening. Find who is already leading. If it’s hard to identify, talk to a few of the staff members or leadership team members to see what their thoughts are. Finding your champions will help make your new policies run a lot smoother.  


Small Steps, Big Rewards  

Speaking of new policies, when you jump into your new role, you might want to start by making a huge splash and improvement. However, we don’t recommend this approach. Thinking too big actually can backfire sometimes.  

We suggest you start small – start in one department, with one team, on one shift with whatever policy you’d like to test. Often we can’t see potential negative outcomes of even the best-intended new policies, and starting small can mitigate any large negative effect.  


Know When to Seek Outside Help  

Getting outside training doesn’t mean you’re a failure at your job; it means you care about your new role and organization enough to want to succeed. You recognize you may not have all the answers, but you’d like them. Finding a guiding light during this transition time is a huge asset, but not everyone is so lucky to have a colleague who’s been in their shoes.   

Thankfully, at Cynosure we’ve recognized this and created an on-demand course designed for new quality managers in health care that have been in their role for 6 months or less. New Quality Director Orientation: What I Wish Someone Had Told Me on my First 30 Days on the Job is taught by Dan Lanari, who has been exactly where you’re sitting before. He felt lost, frustrated, and like a failure at his new job. But he’s broken down everything he wishes he knew, so you don’t have to keep wondering.  


If you’re new to your role and ready to get some proper training, you can learn more about the New Quality Director Orientation: What I Wish Someone Had Told Me on my First 30 Days on the Job and sign up for the course here!