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Illinois Statutes Chapter 210. Health Facilities and Regulation § 85/6.23a. Sepsis screening protocols

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§ 6.23a. Sepsis screening protocols.

(a) Each hospital shall adopt, implement, and periodically update evidence-based protocols for the early recognition and treatment of patients with sepsis, severe sepsis, or septic shock (sepsis protocols) that are based on generally accepted standards of care. Sepsis protocols must include components specific to the identification, care, and treatment of adults and of children, and must clearly identify where and when components will differ for adults and for children seeking treatment in the emergency department or as an inpatient. These protocols must also include the following components:

(1) a process for the screening and early recognition of patients with sepsis, severe sepsis, or septic shock;

(2) a process to identify and document individuals appropriate for treatment through sepsis protocols, including explicit criteria defining those patients who should be excluded from the protocols, such as patients with certain clinical conditions or who have elected palliative care;

(3) guidelines for hemodynamic support with explicit physiologic and treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and timeframe goals;

(4) for infants and children, guidelines for fluid resuscitation consistent with current, evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children;

(5) identification of the infectious source and delivery of early broad spectrum antibiotics with timely re-evaluation to adjust to narrow spectrum antibiotics targeted to identified infectious sources; and

(6) criteria for use, based on accepted evidence of vasoactive agents.

(b) Each hospital shall ensure that professional staff with direct patient care responsibilities and, as appropriate, staff with indirect patient care responsibilities, including, but not limited to, laboratory and pharmacy staff, are periodically trained to implement the sepsis protocols required under subsection (a). The hospital shall ensure updated training of staff if the hospital initiates substantive changes to the sepsis protocols.

(c) Each hospital shall be responsible for the collection and utilization of quality measures related to the recognition and treatment of severe sepsis for purposes of internal quality improvement.

(d) The evidence-based protocols adopted under this Section shall be provided to the Department upon the Department's request.

(e) Hospitals submitting sepsis data as required by the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting program as of fiscal year 2016 are presumed to meet the sepsis protocol requirements outlined in this Section.

(f) Subject to appropriation, the Department shall:

(1) recommend evidence-based sepsis definitions and metrics that incorporate evidence-based findings, including appropriate antibiotic stewardship, and that align with the National Quality Forum, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, and the Joint Commission;

(2) establish and use a methodology for collecting, analyzing, and disclosing the information collected under this Section, including collection methods, formatting, and methods and means for aggregate data release and dissemination;

(3) complete a digest of efforts and recommendations no later than 12 months after the effective date of this amendatory Act of the 99th General Assembly; the digest may include Illinois-specific data, trends, conditions, or other clinical factors; a summary shall be provided to the Governor and General Assembly and shall be publicly available on the Department's website; and

(4) consult and seek input and feedback prior to the proposal, publication, or issuance of any guidance, methodologies, metrics, rulemaking, or any other information authorized under this Section from statewide organizations representing hospitals, physicians, advanced practice registered nurses, pharmacists, and long-term care facilities. Public and private hospitals, epidemiologists, infection prevention professionals, health care informatics and health care data professionals, and academic researchers may be consulted.

If the Department receives an appropriation and carries out the requirements of paragraphs (1), (2), (3), and (4), then the Department may adopt rules concerning the collection of data from hospitals regarding sepsis and requiring that each hospital shall be responsible for reporting to the Department.

Any publicly released hospital-specific information under this Section is subject to data provisions specified in Section 25 of the Hospital Report Card Act.

Cite this article: - Illinois Statutes Chapter 210. Health Facilities and Regulation § 85/6.23a. Sepsis screening protocols - last updated January 01, 2019 |

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