Author(s): Katherine Fuller, MSN, RN
Director of Quality - Nuvance Health
Katherine Fuller MSN RN is the Director of Quality at Nuvance Health's Northern Dutchess Hospital in Rhinebeck, NY. Ms. Fuller collaborates with hospital leadership to drive strong health care outcomes with a CMS 5-star rating and Leapfrog B grade for the Hospital. She leads and supports various quality improvement projects throughout the hospital such as reducing sepsis mortality, improving Cesarean section rates and reducing inpatient falls. In her current role, Ms. Fuller promotes a culture of safety by leading high reliability training sessions, Team STEPPS instruction, and runs a safety coach program. Prior to joining Northern Dutchess Hospital, Ms. Fuller worked for ten years at Nuvance Health's Vassar Brothers Medical Center starting as a bedside nurse, then working as the Director of the Mother Baby Unit before moving into her current career of quality professional.

Ellen Edge, RN, CIC
Infection Control Officer - Northern Dutchess Hospital
Ellen Edge, RN CIC, a seasoned healthcare professional with over 20 years of experience, initially serving as a bedside nurse in the ICU before becoming a Certified Infection Preventionist and Sepsis Coordinator. During her tenure as the Sepsis Coordinator at Sharon Hospital, she spearheaded significant performance improvements. Over eight years, Ellen successfully led a performance improvement program for the Sep-1 Surviving Sepsis initiative, consistently achieving over 70% compliance. She coordinated yearly action plans, gathered, and presented monthly data to identify practice gaps, and developed educational tools and programs for staff and providers. I also created and delivered nursing education sessions, trained local EMS squads, and developed educational materials for newly privileged practitioners. Additionally, she now collaborates with a multidisciplinary team at Northern Dutchess Hospital to establish a comprehensive Sepsis program, aiming for compliance rates exceeding 70% within the first year. Ellen's dedication and expertise have played a pivotal role in enhancing sepsis management and patient outcomes across multiple healthcare settings.

Competency Domain: Performance & Process Improvement

Description: Sepsis contributes to over a third of hospital deaths which represents 350,000 hospital deaths or discharges to hospice annually. In addition to patient outcomes, sepsis rates influence quality scores, performance and financials with the addition of the Sepsis/Septic Shock SEP-1 bundle compliance to value-basedl purchasing in 2024. Northern Dutchess Hospital will improve SEP-1 bundle compliance by establishing a project charter and creating driver diagrams to guide development of meaningful change ideas for improvement. An interdisciplinary workgroup will guide implementation of changes through Plan-Do-Study-Act cycles. The goal is to is to increase compliance to 70% by the end of FY2024.Problem: Trying to solve problem of low compliance with Sepsis Septic Shock Bundle Measurement: Run charts for each of the SEP-1 bundle elements will be developed and identify where changes were implemented to track whether changes resulted in improvement with compliance. Analysis: Compliance with each bundle element will be analyzed to develop primary and secondary driver diagrams. ED and inpatient data will be tracked separately to prioritize focus. Baseline knowledge surveys of staff was used to establish where to focus change ideas and education. Implementation: Driver diagrams based on data led to new prioritized workplans. Elements that could be improved with quick fixes were implemented. The team conducted PDSA cycles for other change ideas. Obstacles are EMR changes and stakeholder engagement. Facilities can benefit by using project charters, interdisciplinary workgroups, and data driven change ideas. Results/Discussion Preliminary results are positive with compliance increasing from 37.5% to 78.26% in the first two months. Blood culture collection increased from 78% to 95% and antibiotic administration increased from 87.5% to 100%. It is still early but the primarily results are promising with many items still to be implemented.

Evaluation: Complete Poster Evaluation