Scottie’s Sepsis September:

A Review

• We had…

• documented delays in recognition & treatment of sepsis

contributing to patient harm

• tried this once before and failed (2008)

• We knew implementing the sepsis bundle was the right thing to do

because…

• early recognition and intervention leads to better patient

outcomes

• improvement bundles work

• it is important for our patients, our agency and to PHSA

(Included in the 11/12 Strategic Action Plan).

Background

Problem Statement

Lack of standardized recognition, communication of findings and response to sepsis have lead to long lead-times from recognition to response and have caused patient harm

Primary Objective & Key Measure

• Primary objective:

– To implement an internationally-recognized sepsis screening tool

and treatment protocol.

• Key measure:

– Documented timely screening of appropriate patient population

and where required, timeliness of medical intervention.

Kaizen Strategy

Kaizen Strategy

Areas of Focus:

Recognition PDSA Cycles

• Problem:

– No standard work

• Idea:

– Standardize screening process throughout the BCCH• When to screen

• Who to screen

• How to screen

• PDSA cycles

– 14 (& counting)

– Testing of screening tool for value added• Relevance to patient population balanced with:

– time to complete

– frequency of use = time vs benefit

– Readability

– Standard work instructions within screening tool

– Alignment of screening with existing processes/tools

Recognize - Respond - Refer

Aligned with ED Triage and Initial

Assessment

• Andon for screening on electronic patient tracking board (to be

developed)

• Combined sepsis screening tool with RN assess form (to be

developed)

Recognize - Respond - Refer

Aligned EoPC with Sepsis Screen in

Inpatient Areas

Recognize - Respond - Refer

Aligned with Fever & Neutropenia

Guidelines

• Bloodwork standardized

• Inclusion of fever & neutropenia

antibiotic protocol into sepsis bundle

• Adaptation of screening tool to

reflect oncology patient & referral

process

Recognize - Respond - Refer

Aligned with PICU “Purple Sheet”

• Highlight WBC trends

as indicator for sepsis

screening

Recognize - Respond - Refer

Result Recognize PDSA Cycles

• Standard work for screening

(Including who, when & how)

Recognize - Respond - Refer

New Admission to Unit

Monitor and Assess

Increase in EoPC Score

Follow escalation of

patient care protocol

Screen for Sepsis

YES

NO

Screen for Sepsis

New Patients

Existing Patients

Screened Positive (+)

for Acute Organ

Dysfunction

YES

NO

PDSA Cycles with Response

• Problem:

– No standard escalation process

or response upon suspicion of

sepsis.

• Idea:

– Standardize response process

and treatment

• PDSA

– Aligned with EoPC process for

monitoring and accessing

supports

Recognize - Respond - Refer

PDSA Cycles with Response

• PDSA (con’t)

– “Suspected Sepsis” order set &

Algorithm (Final testing)

– Incorporated audit components

(Order time, receipt time,

delivery time)

– “Critical Care Sepsis” order set

& Algorithm

Recognize - Respond - Refer

PDSA Cycles with Refer

• Problem:– No standard work for

referring patients

• Idea: – Aligned with EoPC process

• PDSA:– Reinforcement of existing

escalation processes.

– Highlight supports and screening prompts with First Responders, CTU residents and PICU team

Recognize - Respond - Refer

Results of Kaizen Events

Patient Condition

Worsens

Recognition of

deterioration by

“someone”

Assistance sought

Medical

Intervention

Management by

most appropriate

resources

Relocation to

appropriate care

area if required

DELAY

INCONSISTENT

INCONSISTENT

DELAY

DELAY

INCONSISTENT

DELAY

X

XX

XX

XX

Follow On

• All areas:

– Ongoing measurement

– Update communication plan

– Living PDSA cycle collectively (8 month timeframe)

– Physician order sets have been approved and are available for use

• ED:

– Update documentation • Incorporate sepsis screening

– Further defined measurement process

– Implement Status Board andon

• PICU:

– Test critical care algorithm and order set

• Oncology:– Updated Fever & Neutropenia order sets.

Six units developed detailed Action Plans. Some examples:

Accomplishments

• Recognize:

– Screening tool as part of standard work

– Highlighted usefulness of existing processes and tools in screening process

– Strengthened existing processes/tools

• Respond:

– Initial resuscitation order set & algorithm redesigned & in use

– Critical care order set & algorithm designed & are available for use

• Refer:

– Clarification with PICU re: role in screening

• Surprises

– 75% of areas liked “it”

– Value of standardization

– Linkages between other processes

– EoPC documentation patterns

– Number of changes hitting staff at once

• Highlighted for next time

– Communication (more & targeted)

– Assessment of organizational readiness

(e.g., upcoming changes and resources

available to be successful)

Lessons Learned

Audit Plan

• Question: Screening for sepsis at appropriate times

• Question: Timeliness of response upon (+) screen

References

• Brierley J, Carcillo JA, Choong K et al. (2009). Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Critical Care Medicine. 37, 666-688.

• Cruz AT et al. (2011). Implementation of goal-directed therapy for children with suspected sepsis in the emergency department. Pediatrics; 127: 3 e758-766.

• Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R et al. (2008). Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine. 36, 296-327.

• Goldstein B, Giroir B, Randolph A. (2005). International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr. Critical Care Medicine. 6(1):2-8.

Contact Information

Deb Scott RN BScN

Professional Practice Leader

BC Children’s Hospital

dscott6@cw.bc.ca

604-875-3059

Jamie Lepard

Facilitator, imPROVE

Provincial Health Services Authority

jlepard@cw.bc.ca

604-916-5795