Multicomponent sepsis interventions Identifying sepsis as quickly as possible is of critical importance to improving outcomes, but there are other areas of sepsis care and management that can improve outcomes, such as test ordering and results delivery, and initiation of treatment following a sepsis diagnosis. In response to this complexity, some institutions have implemented multicomponent quality improvement (QI) programs aimed at improving the full spectrum of sepsis recognition and care. Several studies found in the search results for the PSPs Patient Monitoring Systems and Screening Tools concern such multifaceted QI initiatives. Many of the barriers and facilitators to the implementation of a multicomponent intervention are similar to those for implementing a screening tool or PMS, including the importance of clinician education to identify signs of sepsis onset and consistent protocols across hospital units. Additional facilitators mentioned in these five studies included strong teamwork among providers, pharmacy staff ensuring initiation of antibiotics. One study found that additional nursing staff and space for triage were needed to overcome delays in diagnosis and treatment of sepsis. BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 3.
Conclusions The two PSPs reviewed in this section aim to reduce the time to recognition of sepsis so that treatment can be initiated quickly, with improvement in important patient outcomes. The review of evidence shows that manual screening tools can improve time to treatment, but the effect on mortality and other outcome measures is uncertain. Such tools may be most useful in non-hospital settings such as EMS and nursing homes, but many more studies are needed to test their effects in these settings. Evidence for PMSs in the hospital setting showed some improvement in both process and outcome measures, especially in non-ICU units. However, many studies were observational in design, limiting their strength and increasing the risk of bias. More rigorous studies are needed to test the effects of these systems. Implementing a screening tool or PMS for sepsis requires dedicated resources and effective staff training, and it can be costly. Either type of tool can be effective if it demonstrates acceptable and sustained sensitivity and specificity, which requires pre-validation and regular monitoring. A manual screening tool is more time intensive for clinicians, but an electronic PMS may be more costly to implement and more difficult for staff to use. The customizability of a PMS’s features (e.g., “snooze” button) can add flexibility to the
complexities of sepsis care, but this comes with a higher cost to implement than a manual screening tool. The decision to implement a sepsis recognition PSP, and whether it should be manual or automated, should be based on the needs and constraints of the particular setting rather than a “one-size-fits- all” approach. Clostridioides difficile infection Preventing Clostridioides difficile infection (CDI) in healthcare settings is an important U.S. public health priority and has led to new research, guidelines, and reporting requirements. [Note: the Clinical and Laboratory Standards Institute and the CDC transitioned from use of the name Clostridium difficile to Clostridioides difficile . For the purposes of this activity, the names are synonymous.] While many of the patient safety practices that help prevent a range of healthcare-associated infections (HAIs) also help to prevent the transmission of CDI (e.g., contact precautions), several CDI-specific practices address the unique risk factors, pathology, and transmission of CDI.
Instructions: Spend 10 minutes reviewing the case below and considering the questions that follow. Case Study 3: Identifying sepsis in the ED In 2014 clinicians at the University of Washington Medical Center undertook a quality improvement project to improve the early identification of patients with uncomplicated sepsis, severe sepsis, and septic shock presenting to the emergency department (ED). 43 The three-tiered intervention consisted of: 1. A nurse-driven screening tool and management protocol to identify and initiate early treatment of patients with sepsis. 2. A computer-assisted screening algorithm that generated a ‘Sepsis Alert’ pop-up screen in the electronic medical record for treating clinical healthcare providers. 3. Automated suggested sepsis-specific order sets for initial workup and resuscitation, antibiotic selection and goal-directed therapy. A before and after retrospective cohort study was undertaken to determine the intervention’s impact on compliance with recommended sepsis management, including serum lactate measured in the ED, intravenous fluid administered within 2 hours of triage, antibiotics administered within 3 hours of triage and blood cultures drawn before antibiotic administration. Mortality rates for patients in the ED with a sepsis-designated ICD-9 code present on admission were also analyzed. Overall bundle compliance increased from 28% at baseline to 71% in the last quarter of the study. Bundle, antibiotic and intravenous fluid compliance all increased significantly after launch of the sepsis initiative (eg, bundle and intravenous fluid compliance increased by 74% and 54%, respectively. Bundle and antibiotic compliance both showed further significant increases after implementation of suggested order sets (31% and 25% increases, respectively). The mortality rate for patients in the ED admitted with sepsis was 13.3% before implementation and fell to 11.1% after (p=0.230). The authors concluded that “the new protocol demonstrates that early screening interventions can lead to expedited delivery of care to patients with sepsis in the ED and could serve as a model for other facilities.”
1. Thinking about your own institution how effective do you think efforts are to identify and manage patients with sepsis or suspected sepsis? In what ways could that effort be improved?
2. Do you think the three steps used in this quality improvement project could be realistically replicated in other hospitals? Why or why not?
3. Which of the outcomes assessed in the study of this intervention do you think is most clinically important, and why?
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