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Recommended Citation
Rosenberger A, Bores S. Optimizing Sepsis Management: A Journey from Audit to EHR Solutions. Quality Improvement poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Presentation Notes
Quality Improvement poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Abstract
Background:
Sepsis is a leading cause of mortality across the enterprise. While Sepsis and Septic Shock Early Management Bundle (SEP-1) treatment reduces sepsis mortality, the NC/GA Division lacks comprehensive SEP-1 performance reports to identify care gaps and improve outcomes.
Local Problem:
The NC/GA Division SEP-1 data, based on minimum patient sample size, is insufficient, with Pineville averaging only 9.5 abstracted patients per month. The Centers for Medicare and Medicaid Servies (CMS) abstraction process is lengthy, excluding significant patient populations (i.e. COVID, freestanding emergency departments), and is a composite metric leading to inconclusive performance insights.
Method:
We developed an internal audit tool to review all sepsis cases presenting to the Emergency Department, aligning with updated sepsis definitions. By eliminating systemic inflammatory response syndrome criteria and automatically calculating arrival times to crucial bundle elements, we significantly reduced abstraction time. This tool provided detailed insights into SEP-1 performance, facilitated timely feedback to clinicians, allowed chart revisions before CMS review, identified educational needs and barriers that would prevent future success. Physician partnership and front-end clinician engagement were vital components.
Results/Conclusions:
In 2024, our internal tool abstracted 938 patient charts, compared to 114 by CMS, with a 74% CMS abstraction congruency rate. Pineville accomplished a 50% improvement in SEP-1 bundle compliance, from 34% to 51%. The average chart abstraction time was 10 minutes, compared to the lengthy CMS process. Sepsis mortality targets were exceeded, with an O/E of 0.88, saving approximately 40 lives in 2024.
Implications for Practice:
Developing a tool that delivers comprehensive insights with minimal abstraction time is essential for performance improvement. Recognized across the NC/GA Division, this nurse-led initiative enabled Pineville to pioneer EHR-integrated solutions that enhance sepsis care and provide real-time performance insights, achieving widespread adoption across 27 hospitals, serving 1.4 million patients annually.
Document Type
Poster
Publication Date
11-12-2025
Optimizing Sepsis Management: A Journey from Audit to EHR Solutions
Background:
Sepsis is a leading cause of mortality across the enterprise. While Sepsis and Septic Shock Early Management Bundle (SEP-1) treatment reduces sepsis mortality, the NC/GA Division lacks comprehensive SEP-1 performance reports to identify care gaps and improve outcomes.
Local Problem:
The NC/GA Division SEP-1 data, based on minimum patient sample size, is insufficient, with Pineville averaging only 9.5 abstracted patients per month. The Centers for Medicare and Medicaid Servies (CMS) abstraction process is lengthy, excluding significant patient populations (i.e. COVID, freestanding emergency departments), and is a composite metric leading to inconclusive performance insights.
Method:
We developed an internal audit tool to review all sepsis cases presenting to the Emergency Department, aligning with updated sepsis definitions. By eliminating systemic inflammatory response syndrome criteria and automatically calculating arrival times to crucial bundle elements, we significantly reduced abstraction time. This tool provided detailed insights into SEP-1 performance, facilitated timely feedback to clinicians, allowed chart revisions before CMS review, identified educational needs and barriers that would prevent future success. Physician partnership and front-end clinician engagement were vital components.
Results/Conclusions:
In 2024, our internal tool abstracted 938 patient charts, compared to 114 by CMS, with a 74% CMS abstraction congruency rate. Pineville accomplished a 50% improvement in SEP-1 bundle compliance, from 34% to 51%. The average chart abstraction time was 10 minutes, compared to the lengthy CMS process. Sepsis mortality targets were exceeded, with an O/E of 0.88, saving approximately 40 lives in 2024.
Implications for Practice:
Developing a tool that delivers comprehensive insights with minimal abstraction time is essential for performance improvement. Recognized across the NC/GA Division, this nurse-led initiative enabled Pineville to pioneer EHR-integrated solutions that enhance sepsis care and provide real-time performance insights, achieving widespread adoption across 27 hospitals, serving 1.4 million patients annually.
Affiliations
Atrium Health Pineville