We received sepsis certification in July 2016.
Our initial measures submitted were all clinical.
Now we measure
Clinical-
Antibiotics within one hour of time of presentation.
Fluid resuscitation based on 30ml/kg and lactate level
Administrative- Patient Satisfaction
Readmissions
They focused heavily on education of the patient and family r/t: hygiene and
knowledge of disease.
They also focused on inter-rater reliability of the data. We had to have a
policy and have a sample of our charts reviewed by a second reviewer for
reliability on an on-going basis.
Information contained in this document is confidential. It is intended for use
in the course of internal quality control or medical study for the purposes of
reducing morbidity, mortality, improving patient evaluation and improving
quality of care pursuant to the Medical Studies Act, 735 ILCS 5/8-2101
Gerri Buss, MS, RN
Performance Excellence Consultant
Blessing Hospital
Quincy,Il. 62305
217-223-8400 Ext 6894
[email protected]
-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On
Behalf Of [email protected]
Sent: Tuesday, March 07, 2017 1:41 PM
To: [email protected]
Subject: Sepsisgroups Digest, Vol 237, Issue 2
Send Sepsisgroups mailing list submissions to
[email protected]
To subscribe or unsubscribe via the World Wide Web, visit
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You can reach the person managing the list at
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When replying, please edit your Subject line so it is more specific than "Re:
Contents of Sepsisgroups digest..."
Today's Topics:
1. Severe Sepsis/Septic Shock order sets (Osburn, Jennifer R. RN)
2. Re: Sepsisgroups Digest, Vol 236, Issue 1 (Pierce1, Marie)
3. Antibiotics >24 prior to presentation of Sepsis (Pender.Linda)
----------------------------------------------------------------------
Message: 1
Date: Fri, 3 Mar 2017 15:52:59 +0000
From: "Osburn, Jennifer R. RN" <[email protected]>
To: "[email protected]"
<[email protected]>
Subject: [Sepsis Groups] Severe Sepsis/Septic Shock order sets
Message-ID:
<61eb11df76bc404baa706e7a14a9dbc5dca32...@smmc-ex10mb03.st-marys.org>
Content-Type: text/plain; charset="utf-8"
Our facility is working on revising our severe sepsis/septic shock order set
used in ICU setting. Would anyone be willing to share the order set(s) their
facility currently uses?
Thanks
Jennifer Osburn, RN, BSN
Performance Improvement
St. Mary's Medical Center
304-526-1506
[email protected]<mailto:mailt:[email protected]>
Confidential & Privileged Peer Review/Quality Improvement Activity Pursuant to
West Virginia Code 30-3C-1, et seq. and Ohio Revised Code 2305.25, et seq.
Important Notice: This e-mail message and any attachments are from the above
sender at St. Mary's Medical Center and are intended solely for the individual
or entity to which it is addressed and may contain information that is
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Message: 2
Date: Fri, 3 Mar 2017 20:16:00 +0000
From: "Pierce1, Marie" <[email protected]>
To: "[email protected]"
<[email protected]>
Subject: Re: [Sepsis Groups] Sepsisgroups Digest, Vol 236, Issue 1
Message-ID:
<mwhpr08mb28624f22838d86210d349b14b1...@mwhpr08mb2862.namprd08.prod.outlook.com>
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We abstract everything. We share at the Sepsis committee meeting or with other
departments that may impact that part of the measure. We also use it to help
with communications with physicians, both individually and as departments to
inform them of where the failures are occurring, how it fits in the core
measure and also, most importantly... what they can do to positively impact it.
Marie Pierce MSN, RN, CCDS
Quality?Specialist
Quality and Resource Management
McLaren Bay Region
email:[email protected]
office phone: (989) 894-3881
-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On
Behalf Of [email protected]
Sent: Wednesday, March 01, 2017 9:09 AM
To: [email protected]
Subject: Sepsisgroups Digest, Vol 236, Issue 1
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[email protected]
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or, via email, send a message with subject or body 'help' to
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You can reach the person managing the list at
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When replying, please edit your Subject line so it is more specific than "Re:
Contents of Sepsisgroups digest..."
Today's Topics:
1. Re: Abstract to failure (Pesek, Elizabeth)
2. Re: Abstract to failure or further? (Patricia Posa)
3. TJC certification in sepsis (Posani, Theresa)
----------------------------------------------------------------------
Message: 1
Date: Mon, 27 Feb 2017 16:35:05 +0000
From: "Pesek, Elizabeth" <[email protected]>
To: "'[email protected]'"
<[email protected]>
Subject: Re: [Sepsis Groups] Abstract to failure
Message-ID:
<[email protected]>
Content-Type: text/plain; charset="us-ascii"
We abstract all elements of the bundle and track them for improvement, to serve
performance improvement initiatives.
Betsy Pesek MN, BSN, RN, CCRN, CPHQ |
Clinical Outcomes Specialist| Clinical Effectiveness Overlake Hospital Medical
Center |1231 116th Ave NE - 6th floor| Bellevue WA 98004|
fax: 425-467-3950|direct: 425.688.5935 | [email protected]|
-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On
Behalf Of [email protected]
Sent: Friday, February 24, 2017 3:23 PM
To: [email protected]
Subject: Sepsisgroups Digest, Vol 235, Issue 13
Send Sepsisgroups mailing list submissions to
[email protected]
To subscribe or unsubscribe via the World Wide Web, visit
https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.sepsisgroups.org%2Flistinfo.cgi%2Fsepsisgroups-sepsisgroups.org&data=01%7C01%7Cmarie.pierce1%40mclaren.org%7C14be17f5dc8149cfa80308d460ac9cb8%7C82021bda879141b4807aff5b548750e6%7C0&sdata=IYSwFRGZs6J0qpSO0fUApckVvIE5HW8QYN3zGUQgZ2o%3D&reserved=0
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You can reach the person managing the list at
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When replying, please edit your Subject line so it is more specific than "Re:
Contents of Sepsisgroups digest..."
Today's Topics:
1. Abstract to failure or further? (Aceves, Christine)
----------------------------------------------------------------------
Message: 1
Date: Thu, 23 Feb 2017 21:06:40 +0000
From: "Aceves, Christine" <[email protected]>
To: "[email protected]"
<[email protected]>
Subject: [Sepsis Groups] Abstract to failure or further?
Message-ID:
<bn6pr01mb2769150c802a5d433745587ed4...@bn6pr01mb2769.prod.exchangelabs.com>
Content-Type: text/plain; charset="us-ascii"
For SEP-1:
We would like to know if centers are abstracting only to failure as required by
CMS? Or, abstracting for all elements of the measure? If abstracting for all
elements, how do you utilize the data?
Thank you!
Christine Aceves, MSN, RN, CNL, CEN
Sepsis Program Manager
Nursing Quality
Stanford Health Care
300 Pasteur Dr., HG021A MC 5221 Stanford, CA 94305
O: 650.498.0971 C: 650.483.2248 P: 650.723.8222 ID# 26611
[email protected]<mailto:[email protected]>
[cid:[email protected]]
Confidential Information: This communication and any attachments may contain
confidential or privileged information for the use by the designated
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notified that you have received this communication in error and that any
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Subject: Digest Footer
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End of Sepsisgroups Digest, Vol 235, Issue 13
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This message is confidential, intended only for the named recipient(s) and may
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Message: 2
Date: Fri, 24 Feb 2017 19:54:32 -0500
From: Patricia Posa <[email protected]>
To: "Aceves, Christine" <[email protected]>
Cc: "[email protected]"
<[email protected]>
Subject: Re: [Sepsis Groups] Abstract to failure or further?
Message-ID: <[email protected]>
Content-Type: text/plain; charset="us-ascii"
We abstract all elements and then share with the providers who cared for the
patient and also with the sepsis collaborative team
Pat Posa RN, BSN, MSA, FAAN
Quality Excellence Leader
St joseph Mercy Hospital
Sent from my iPhon
> On Feb 23, 2017, at 4:06 PM, Aceves, Christine
> <[email protected]> wrote:
>
> For SEP-1:
> We would like to know if centers are abstracting only to failure as required
> by CMS? Or, abstracting for all elements of the measure? If abstracting for
> all elements, how do you utilize the data?
>
> Thank you!
>
> Christine Aceves, MSN, RN, CNL, CEN
> Sepsis Program Manager
> Nursing Quality
> Stanford Health Care
> 300 Pasteur Dr., HG021A MC 5221 Stanford, CA 94305
> O: 650.498.0971 C: 650.483.2248 P: 650.723.8222 ID# 26611
> [email protected]
>
> <image001.png>
> Confidential Information: This communication and any attachments may contain
> confidential or privileged information for the use by the designated
> recipient(s) named above. If you are not the intended recipient, you are
> hereby notified that you have received this communication in error and that
> any review, disclosure, dissemination, distribution or copying of it or the
> attachments is strictly prohibited. If you have received this communication
> in error, please contact me and destroy all copies of the communication and
> attachments. Thank you.
>
> _______________________________________________
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Message: 3
Date: Tue, 28 Feb 2017 15:14:13 +0000
From: "Posani, Theresa" <[email protected]>
To: "[email protected]"
<[email protected]>
Subject: [Sepsis Groups] TJC certification in sepsis
Message-ID:
<mwhpr02mb260571c056719e1d87a4ad59bf...@mwhpr02mb2605.namprd02.prod.outlook.com>
Content-Type: text/plain; charset="us-ascii"
For those of you certified in sepsis by TJC would you answer a couple of
questions?
1) What are your clinical indicators?
2) What are your administrative indicators?
3) Any helpful hints on going through the process?
Thank you
Theresa
Theresa Posani, MS, RN, ACNS-BC | Med/Surg CNS/Sepsis Coordinator T
817.250-3907 | M 972.838-7954
[email protected]<mailto:[email protected]>
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Message: 3
Date: Fri, 3 Mar 2017 17:11:44 +0000
From: Pender.Linda <[email protected]>
To: "[email protected]"
<[email protected]>
Subject: [Sepsis Groups] Antibiotics >24 prior to presentation of
Sepsis
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If a patient is on IV antibiotics for >24 hours prior severe sepsis
presentation shouldn't they be excluded from the Sep-1 Core Measure? We use
Comparion to abstract our data. The abstracting tool requires entry of the
initial collection of the lactic acid before the antibiotics, if the patient
did not have a lactic acid collected 6 hrs before of 3 hrs after the severe
sepsis presentation, the pt fails the measure instead of being excluded.
Please let me know what you all think of this. It is truly affecting our
numbers.
Linda G. Pender RRT-NPS
Sepsis Coordinator
Patient Care Services Administration
phone: 478-633-6806 pager: 4444
KNOW Sepsis: Inside & Out
[MCCG...World Class Care! See our website...]<http://www.navicenthealth.org/>
Confidential Quality Improvement: Not for Disclosure
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