Assessment 2 Policy Proposal – Policy Proposal for Improving Sepsis Care at Eagle Creek Hospital

Assessment 2 Policy Proposal – Policy Proposal for Improving Sepsis Care at Eagle Creek Hospital

Eagle Creek Hospital is facing significant challenges in meeting prescribed benchmarks for sepsis care performance. The hospital’s sepsis dashboards revealed worrisome gaps in different areas relevant to sepsis management, for instance, performing blood cultures before administering antibiotic therapy and providing appropriate vasopressors for septic shock treatment. They bring about unsafe outcomes related to increased inpatient mortality, which is appallingly very far above the National Benchmarks. It is imperative from an ethical perspective to prevent any apparent risk to patients’ safety and to meet the financial ends of the bargain by avoiding penalties and keeping the reputation of the hospital holy among the people around the community deserted.

Effective strategies for impactful progress to sepsis outcomes need to be developed. Then, an operational policy and complete practice guidelines concordant with evidence-based standards and existing healthcare codes and laws must be created. These policy proposals incorporate the requirements of these components, descriptions of the particular policy and practice guidelines suggested, environmental factors, and the key individuals to be engaged in to enhance the successful implementation.

Need for Policy and Practice Guidelines

The greatest concerning evidence gap at Eagle Creek Hospital is the fifty 70% compliance rate for drawing a blood culture sample before antibiotics are given, far below the 80% national mandate set by the CMS SEP-1 Sepsis Quality Measure (Barbash et al., 2019; Gesten & Evans, 2021). With regards to the large number of sepsis cases at the facility, this widespread failure to document 1st line of patient care markedly increased poor patient outcomes, evidenced by the 40% inpatient fatality rate, which is way higher than the national toll and ranges from 14.7% to 29.9%.

Disregarding the detection and identification of pathogens using sample culture so impedes the productive service delivery to patients since the effective causal agent’s treatment is hindered. Moreover, shortcomings in these areas represent a huge risk to the hospital, potentially getting penalties from regulatory bodies like CMS and being deprived of reimbursements. Contrarily, community trust deterioration and the hospital’s challenge in recruiting and maintaining skilled staff are long-term outcomes of poor quality and unsafe outcomes. Creating an organization policy and evidence performance guidelines will help to overcome sepsis care shortcomings and minimize the dangers and effects of the occurrence of sepsis on a patient as they are severe.

Proposed Organizational Policy and Practice Guidelines

Policy Statement

Sepsis, an immediate health hazard, carries a high mortality risk and has to be responded to with an evidence-based treatment approach to increase the patient’s survival chances. This code of policy puts into effect standardized protocols and guidelines for the execution of the process of acute sepsis and care, which is of superior quality and attains or exceeds performance benchmarks. It is its prerogative as an ethical duty of that community to which Eagle Creek Hospital–serving–is accountable.

Scope

This policy covers all clinicians and the hospital’s support team, including the physicians, nurses, laboratory personnel, and IT staff engaged in detecting, validating, and treating sepsis at Creek Eagle Hospital.

Practice Guidelines

Sepsis Care Pathway and Clinical Protocols

Comprehensive, proven, and validated protocols will be developed and incorporated for the triaging, diagnosis, and management (therapeutic) of sepsis in the emergency department. These protocols will be based on the Surviving Sepsis Campaign guidelines and will address key interventions such as rapid identification of suspected sepsis cases through standardized screening tools, prompt collection of blood cultures prior to antibiotic administration, timely initiation of broad-spectrum antibiotic therapy and early goal-directed fluid resuscitation and vasopressor therapy for septic shock.

Staffing and Training

The hospital will ensure appropriate staffing levels in the sepsis care unit, targeting a nurse-to-patient ratio of 1:2. One of the impacts drones have on the environment is the emissions produced by their operations. All the clinical personnel will undergo a periodically re-scheduled demand course on sepsis protocols, e.g., proper techniques, which entail blood culture collection, antibiotic administration, and vasopressor therapy.

Technology Integration

The healthcare setting will be using technology to maintain standardization and efficacy in delivering sepsis care. Among other measures, it will feature seamless electronic screening for sepsis placement in an electronic health record, automatic alerts concerning late blood cultures or medication administration, and the introduction of barcode-assisted medication administration to ensure the “seven rights” of medication safety.

Patient Safety and Quality Improvement

The hospital will develop a multi-disciplinary sepsis quality improvement committee that involves clinicians from the different aspects of direct patient care. The committee will meet regularly to review performance data, identify specific areas that require improvement, and design and implement intervention strategies. The committee, in addition, will assist in conducting timely studies on all sepsis-related incidents, which will help the organization retain the lessons and further develop the care mechanism.

Environmental Factors and Considerations

The successful implementation of these practice guidelines will require careful consideration of several environmental factors that could enable or impede progress.

Regulatory Considerations

As the proposed policies and guidelines are designed to address deficiencies in meeting CMS SEP-1 Sepsis Quality Measure benchmarks, the hospital must be sensitive to all applicable regulations from the federal, state, and other levels (Barbash et al., 2019; Gesten & Evans, 2021). Regular updates with regulatory changes should be on the agenda to eliminate any compliance issues that could lead to costly losses in the form of penalties.

Resource Availability

Sufficient staffing, financial means, and the provision of adequate services will be a sine qua non for the successful launch and sustenance of the suggested adjustments. The hospital’s capacity should be correctly evaluated, and resource deficiencies should be identified and projected for future development and planning of investments in human capital, technology, and infrastructure for quality improvement.

Organizational Culture

Building up specific safety, openness, and learning culture will be basic in the disability-free introduction of the sepsis care protocols. Enabling clinicians to report their errors without concerns of repercussions and ensuring the provision of a communicative environment for interdisciplinary problem-solving will be two major factors that guarantee these changes will be sustained over time.

Stakeholder Engagement and Implementation Strategies

Successful implementation of the proposed sepsis policy and practice guidelines will require the active engagement and collaboration of key stakeholder groups, including:

Executive Leadership

The hospital’s executive team, which incorporates the CEO, COO, and CNO, must take the place of the managers of the sepsis performance improvement team. The management’s behavior, such as funds allocation, regular communication, and clear implications, will help tackle the organization’s wide acceptance and initiative.

Physicians and Nursing Staff

Frontline clinicians taking essential diagnostic steps, including recognition and treatment, must produce an introduction protocol for sepsis care that involves them to a considerable extent (Akwanalo et al., 2019; Potthoff et al., 2023). Through their academic training, experiences, and presence as the final owners of the guidelines, they will be irreplaceable for clinical relevance and adherence.

Laboratory and Information Technology Teams

Similarly, the staff members from the laboratory and IT sections are crucial for ensuring smooth workflow incorporation of the new technology containing, e.g., electronic sepsis screening, automatic alerts, and barcode medication administration. Such people will assist in the functionalization of the planned devices through their participation.

Strategies for Collaborating with the Stakeholder Group

To facilitate effective collaboration with these stakeholder groups, the hospital should consider the following strategies:

Multidisciplinary Steering Committee

Develop a fine-tuned standing steering committee comprising people responsible for checking the progress and quality of the guideline development, implementation, and continuous evaluation of the sepsis policy and practice guidelines (Akwanalo et al., 2019; Potthoff et al., 2023). These representatives should be involved in two committees: first, one for each major stakeholder group that will be expected to provide insights and work collectively; second, the other will have the essential function of being a collaborative problem-solving structure.

Pilot Testing and Adjustments

The proposed guidelines will be tested in a pilot program in a unit/department before being electronically disseminated to the hospital. The feedback of the frontline staff will be utilized, the performance statistics examined, and the protocols operationally refined again and again through the experience of the real world to ensure that the recommendations will be practical, effective, and sustainable.

Continuous Education and Communication

Create the expected staff education that will be recurring and will be focused on the described protocols, their roles, and responsibilities (Bhati et al., 2023; Montori et al., 2022). Provide complementary channels of clear and frequently communicated information to update the stakeholders regularly on progress, celebrate successes, and stress the need for handling how to solve emerging challenges.

Monitoring Performance and Feedback loops

Put efficient data collection mechanisms in place and provide metrics reports to monitor key sepsis care metrics and areas for improvement and get timely feedback to the stakeholders. Lend frontline workers the autonomy to directly contribute to an ongoing quality improvement process, which, in this way, will end up bringing them closer to the quality initiative and ownership.

Conclusion

Improving sepsis care performance at Eagle Creek Hospital is an ethical imperative and a strategic necessity. By developing and implementing the proposed organizational policy and evidence-based practice guidelines, the hospital can drive sustainable improvements in patient outcomes, comply with applicable healthcare regulations, and protect its reputation as a trusted provider within the community. Engaging key stakeholders throughout the process and addressing critical environmental factors will be essential to ensuring the successful adoption and long-term impact of these changes.

References

Akwanalo, C., Njuguna, B., Mercer, T., Pastakia, S. D., Mwangi, A., Dick, J., Dickhaus, J., Andes, J., Bloomfield, G. S., Valente, T., Kibachio, J., Pillsbury, M., Pathak, S., Thakkar, A., Vedanthan, R., Kamano, J., & Naanyu, V. (2019). Strategies for Effective Stakeholder Engagement in Strengthening Referral Networks for Management of Hypertension Across Health Systems in Kenya. Global Heart, 14(2), 173. https://doi.org/10.1016/j.gheart.2019.06.003

Barbash, I. J., Davis, B., & Kahn, J. M. (2019). National Performance on the Medicare SEP-1 Sepsis Quality Measure. Critical Care Medicine, 47(8), 1026–1032. https://doi.org/10.1097/ccm.0000000000003613

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving Patient Outcomes Through Effective Hospital Administration: A Comprehensive Review. Cureus, 15(10). https://doi.org/10.7759/cureus.47731

Gesten, F., & Evans, L. (2021). SEP-1—Taking the Measure of a Measure. JAMA Network Open, 4(12), e2138823. https://doi.org/10.1001/jamanetworkopen.2021.38823

Montori, V. M., Ruissen, M. M., Hargraves, I. G., Brito, J. P., & Kunneman, M. (2022). Shared decision-making as a method of care. BMJ Evidence-Based Medicine, 28(4), bmjebm-2022-112068. https://doi.org/10.1136/bmjebm-2022-112068

Potthoff, S., Finch, T., Bührmann, L., Etzelmueller, A., Claire van Genugten, Girling, M., May, C., Perkins, N. J., Vis, C., & Rapley, T. (2023). Towards an Implementation‐STakeholder Engagement Model (I‐STEM) for improving health and social care services. Health Expectations, 26(5). https://doi.org/10.1111/hex.13808

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Assessment 2: Health Policy Positions and Collaboration.
Review your Assessment 2 Problem Identification and Policy Development activity, which enables you to practice identifying problems within healthcare systems and the types of policies and stakeholders who could help drive improvements.