1. Using Your EMR for More than Just Documenting
Stacey Ryan MSN RN, Manager Infection Prevention
Barbara Malacaria MS RN CCRN, Nursing Director

2. Journey to Zero Harm and High Reliability
Leadership Commitment
Safety Culture which allows staff to speak up
Robust Process Improvement

3. Our answer is SURVEILLANCE
Process Improvement
Use of the EMR to support consistency with processes, help provide pertinent data to aid clinical decision making and to be able to highlight clinical data to drive early diagnosis.
Our answer is SURVEILLANCE

4. …more that just for documenting
The EMR is:
A complex collection of templates
Integrated algorithms that guide practice
A safety net for patients
Able to identify current and future trends
A tool that can be used to drive clinicians toward clinical diagnosis

5. SURVEILLANCE Tool that works in the background of EMR
Helps with analysis and interpretation of data
Takes predetermined data elements and links them together for real-time actionable items
Updated in real time as new data is available
Uses tracking boards, status boards and surveillance boards.

6. Ways to Use Surveillance
Guide clinicians to add items to problem list
Link clinicians to best practice guidelines and order sets
Take discrete data elements to trend patient status
Link nursing interventions to surveillance metrics
Translate safety information to patient tracker boards

7. Oversight of Surveillance Project
Interdisciplinary Team
Application Process
Project Owner
Approval process by Team members
Monthly update on all projects

8. Projects Malnutrition Indicator Legal Guardian Indicator
Adult Early Warning System: vital signs monitor
Sepsis Indicator
Antibiotic Stewardship
PEWS: pediatric early warning

9. Sepsis – What is it?
Sepsis is the body’s extreme response to an infection.
It is a life-threatening medical emergency.
Sepsis happens when an infection you have triggers a chain reaction throughout your body.
Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.

10. Sepsis Stats According to the Centers for Disease Control:
More than 1.7 million adults in America develop sepsis each year
Nearly 270,000 die as a result
1 in 3 patients who die in a hospital have sepsis

11. Sepsis – Reducing Mortality
Goal-directed therapy for the early resuscitation of patients with sepsis significantly reduces overall mortality in patients with sepsis, if initiated within the first 6 hours of diagnosis,
Critical Care Medicine, 2014 Oct 20;18(5):570.

12. Sepsis –Goal Directed Therapy
SHBH built 4 Sepsis Order Sets to drive clinicians to take specific actions for patients on the Sepsis Continuum:
SIRS [Systemic Inflammatory Response Syndrome]
Sepsis
Severe Sepsis
Septic Shock
These order sets are based on best practice standards and include diagnostic tests, antibiotics, fluid resuscitation guidelines, the use of vasopressors, and triggers for changing the patient’s level of care.

13. Sepsis –Goal Directed Therapy
Challenges Identified:
Missed opportunities for ordering the sets early
Inconsistent utilization of the order sets

14. Sepsis Surveillance
Build a Sepsis Surveillance Module within the Electronic Medical Record [EMR]
Flag patients that sepsis is suspected based on vital signs and labs
Drive clinicians to take specific actions including use of order sets

15. Multidisciplinary! Sepsis Surveillance Creating the Team:
Information Technology
Physicians
Nursing Leadership
Pharmacy
Infection Prevention/ID
Laboratory
Staff Education
Front-line staff
Quality Specialist
Multidisciplinary!

16. Sepsis Surveillance Unique to SHBH:
“Widen the net” of patients captured – expand criteria for inclusion
Added Procalcitonin levels to the algorithm
Attached antibiotic guidelines based on infection source, best practice guidelines, and local Antibiogram
Hardwire a re-evaluation period

17. Sepsis Surveillance How it works: Patient “flagged” Sepsis in EMR
Nurse takes action(s)
- Recheck vital signs, and notify provider
Provider takes action(s)
- Place Sepsis Order Set
- Enter an event note (documents on the problem list)
- Re-evaluate
(2 hours, 4 hours, or 24 hours if sepsis is ruled out)

18. Sepsis – Measuring Success
Mortality trends
Order set usage
Length of Stay
Discharge disposition

19. Sepsis – Next Steps
Identify severe sepsis earlier
Attempt to manipulate positive microbiology results into discreet data to include in surveillance
Explore the rapid turn around organism testing with blood cultures

20. Future Projects Obesity flagging for BMI>30
Link Obesity flag to OSA assessment
Narcotic Usage
Monitoring of High Risk for OSA
Post operative surveillance system

21. Thank You!
We would like to thanks Chris Mitchell who is the Senior Systems Analyst and coordinator of the surveillance system in Meditech.