Implementation of an Emergency Department Sepsis Bundle and System Redesign: A Process Improvement Initiative

Abstract

Background: In 2008-2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality. Methods: This before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use. Results: We included a total of 167 and 185 patients in the pre-and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8-17.0; p = 0.006). There was also a higher rate of sepsis protocol use in the postintervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1-65.3; p < 0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission. Interpretation: The implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.

Early Machine-human Interface around Sepsis Severity Identification: From Diagnosis to Improved Management?

“…Additionally, we also implemented simulation training for ED nurses related to sepsis identification, care algorithms, standardized treatment protocols, and clinician roles and responsibilities. This QI supported the results of other studies incorporating a standardized process via education, interdisciplinary patient management, and visual tools, resulting in clinically significant results (14,15,41). Although numerous successful reports on the multidisciplinary approach have been published, limited publications on the human decision to activate sepsis response teams were found.…”

“…Sepsis order sets implemented using the Six-Source Influencer Model to create an atmosphere of teamwork to help counteract resistance to change, improved the process of care (14). A more recent study published in 2016 evaluated the effect of a QI sepsis management bundle on mortality and sepsis protocol compliance, determining that interdisciplinary ED sepsis bundles composed of triage flagging, registered nurse (RN) medical directives, education campaigns, and modified sepsis protocols improved early diagnosis and protocolized medical care resulting in improve care (15).…”

Identifying factors associated with intravenous fluid administration in patients with sepsis presenting to the emergency department: a retrospective cohort study

“…The proportion of patients who received fluids in this study is similar to previous retrospective studies [ 9 , 17 ]. The average time to first fluid administration was also similar compared to other studies [ 18 – 21 ] conducted in settings that use local protocols adapted from the Surviving Sepsis Campaign guidelines [ 22 ] similar to the Sepsis Pathway [ 11 ] used in the participating hospitals in this study.…”

Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

“…Unlike the negative results from recently published RCTs, most observational studies demonstrated that SSC bundle adherence was associated with a reduced mortality rate (9,(59)(60)(61)(62)(63)(64)(65)(66)(67)(68)(69)(70)(71)(72)(73)(74), but without significantly increasing medical cost (75). Over a 7.5-year period running from 2005 till 2012, Levy et al found that compliance to the SSC bundle resulted in a 25% relative mortality risk reduction (76).…”