Enterprise Population Health Care Transitions Health

Presentation Notes

Quality Improvement poster presented at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Background: Sepsis is a life-threatening infection with a mortality rate estimated between 25-50%. Majority of efforts to reduce mortality are focused on early identification and treatment. Many sepsis survivors experience cognitive impairment and functional disability that persist after discharge. Advocate Aurora Population Health Care Transitions Bundle Program telephonically coordinates care after discharge for 90 days with the intent to improve health outcomes measured by prevention of readmissions and ED utilization.

Local Problem:Care Transition readmission data was reviewed over a 3-month period in the spring of 2021, identifying sepsis as the initial diagnosis in 218 patients with a readmission rate of 22%. Discussion at a nursing staff meeting revealed varying practices related to patient education based on a nurse’s knowledge of sepsis. Nurses also identified an opportunity to tailor patient education to the specific source of sepsis.

Method:A smart phrase, a preformatted statement, was developed to standardize patient education in both prevention and identification of infection. Patient education was divided into sections for general review of sepsis and then specific to either pneumonia, urinary tract infections, or wound infections. Care Transition nurses reviewed and approved the smart phrase. The Care Transitions team was instructed to use the smart phrase on all patients discharged with a sepsis diagnosis beginning in early August 2021.

Results/conclusions:41 out of 180 patients were readmitted within 90 days after an initial hospitalization for sepsis in the fall of 2021. The 23% readmission rate does not reveal an immediate impact on readmissions. Nurses identified the smart phrase as being a helpful tool in guiding patient education conversations. Barriers to using the smart phrase include changes in nursing personnel. Plans to survey nurses to evaluate consistency of use, modification of phrase, and timing of the education are in process. Readmission rates will be monitored.

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