Criterion 26: #176662


The Infection Control Committee’s review of electronic health record (EHR) data indicated a high rate of patients contracting sepsis in the ICU. A task force was formed with representatives from the CME department, medical staff, nursing, pharmacy, and information technology to determine how to incorporate an alert into the EHR system when a patient’s condition put them at high risk for sepsis. A new protocol was developed to help prevent infection in high-risk patients. The provider produced a training video to educate all healthcare providers on the ICU team, and facilitated a monthly team meeting to review compliance with the alert system and protection protocol.