Create a vision. Where would you like to be?
Once the current workflow is understood and areas for improvement have been identified, the team must decide where to focus their initial efforts. The team must have a clear vision about what to improve first which is simple, easily understood, and inspiring to all staff (see Appendix B). Ensure all stakeholders, especially clinicians are excited, as it is unlikely that they will support improvement efforts if they are not involved at this stage. For example, if you want to focus
in the ED, then the vision can be “To improve the recognition of patients with sepsis and initial treatment in the ED."
Be systematic in your approach to quality improvement
Making sustained changes that improve care in health care settings, is best done using quality improvement methodology. Changes in health care do not happen overnight. Expectations must be set at the beginning regarding the process of change and how it will be monitored. This will take time, but be encouraging, because small tests of change over time can have great, sustained impact.
The Plan-Do-Study-Act (PDSA) cycle of change is a well-established method to create sustainable change in healthcare settings. There are four phases:
- Planning phase.
- Doing phase.
- Study phase.
- Acting phase.
Planning phase: What intervention or change do you want to test first?
The team will have many ideas about how to make improvements but must decide what to do first. Select an intervention that is most likely to have an impact. Simply educating staff will not make a change. To make changes that are significant and sustainable, the culture and systems of care must also be changed.
In general, conduct one intervention at a time and keep the intervention simple, practical, and focused:
- For example, an intervention could be the development of a screening protocol for sepsis or implementing a sepsis treatment bundle/pathway (see Appendix C for an example).
Use international guidelines and learn from experiences of others when deciding on what intervention to implement. Most interventions do not require many additional resources. However, some may require the mobilization of resources such as extra staffing or funding to improve systems such as making broad-spectrum antibiotics or intravenous fluids readily available in the Emergency Department (ED).
Planning phase: How will you know you are improving?
Before implementation, consider how you will study the impact of the intervention. This is an aspect which is often forgotten and is arguably the most important. Without measuring you will not know if you have made an impact. Make a plan as to how you will collect data. If there is an electronic health record, then leverage this to collect data for your project. If not, then use clinical data already collected in patient information systems. Try not to add extra work to staff if they are already overextended.
Make sure the objectives you set are specific, measurable, achievable, reliable and time-bound (SMART).
Do-Study-Act phase: Implement the change
Implement one change at a time, start simple and then build on successes.
The initial “quick wins” should help motivate your team so make sure you celebrate successes.
Also learn from your failures. Examples of inadequate care (incidents) as well as examples of good care are necessary to bring about change. Use patient stories to describe the impact of improvements in care or inadequate care. Staff often relate to patient stories rather than only using quantitative data.
Run your improvement project like a campaign with senior managers and clinicians supporting the work to win hearts and minds. Make sure you have support from executives and influential staff to help remove barriers to change when they occur.
Embarking on developing programmatic changes in your health system to improve patient care with sepsis is no small feat. Obvious challenges faced with limited access to structural and human resources can seem overwhelming.
You may find the WHO 6 building blocks of systems useful in determining what you need to do:
- Improving financing or funding for certain areas of care such as the emergency department.
- Improving health workforce such as recruiting more nurses or doctors.
- Improving use of health information systems to improve data about sepsis management.
- Improving service delivery such as improving triage in the emergency department or response to deteriorating patients.
- Improving leadership and governance in your hospital or specific departments.
- Improving access to essential medicines such as antibiotics and intravenous fluids.
Patient Engagement
Patient education and involvement is crucial to sepsis improvement. Significant improvements in sepsis care have been made in other parts of the world by involving patients and relatives in improvement activities and by advocacy. Clinical staff are also more likely to change behavior when they listen to real life patient stories. Low levels of public awareness about sepsis hinders early recognition and management of sepsis.
The public in LMICs desperately needs resources to provide information and support to improve screening, prevention, recognition, diagnosis and treatment. Patients and their loved ones need assistance in coping during the immediate recovery period and in knowing what to expect during the oftentimes protracted post-sepsis healing process.
You will need information for patients as well as information for public awareness campaigns. This is a list of potential resources for the public, however you should develop your own local resources.
Sepsis Resources for the Public
Where you can find further useful information
- Surviving Sepsis Campaign guidelines – Recommendations for Sepsis Management in resource limited settings (Reference) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307996/
- New definition of sepsis and implications for quality improvement from the Quality Improvement Committee of the Global Sepsis Alliance
- WHO IMAI and IMCI guidelines ETAT guidelines for RLS
- Examples of successful projects in low and middle income countries
- ESICM Global Health working group adapted guidelines for RLS
Examples of sepsis screening and management tool for LMIC
Screening
- Assess opportunities to identify sepsis and to improve outcomes for those patients that acquire and are at risk for sepsis—emergency department, wards, ICU.
- Formalize a process/workflow to screen patients for signs of sepsis throughout the entire institution
- What is a screening tool?
- Who does the screen?
- When is the screen done?
- What is done once the screen is positive?
- Who responds to a positive screen?
- How is the sepsis 3-hour bundle activated?
- Implement a sepsis response team or incorporate early detection of sepsis into existing medical emergency teams (e.g. rapid response teams, if available)
Treatment/Intervention:
- Adhere to the Surviving Sepsis Campaign 2016 and other international guidelines for LMIC (WHO Emergency Triage Assessment and Treatment (ETAT), etc).
- Formalize processes/workflows for clinicians to adhere to after a sepsis screen is positive in order to activate bundles.
- Activation of the 3-hour sepsis bundle leads to the following actions:
- Obtain IV access and obtain blood cultures (if possible).
- Give oxygen if SpO2 < 90% on room air or < 94% if patient is in shock. If pulse oximeter is not available, use clinical indicators to initiate oxygen therapy.
- Administer appropriate broad spectrum antibiotics according to clinical suspicion and local antibiograms (when available) and preferably within one hour.
- If patient is hypotensive or has other signs of hypoperfusion, give initial fluid bolus of 30 ml/kg over 30 minutes in adults.
- Monitor clinical signs of perfusion after bolus:
- blood pressure (BP),
- skin exam,
- capillary refill (CR),
- urine output,
- alert, voice, pain, unresponsive (AVPU),
- in addition to vital signs.
- If hypotension resolved, then resume maintenance fluid and monitoring every 1-2 hours.
- If hypotension persists, then activate 6-hour sepsis bundle.
- Sepsis 6-hour bundle for patients with septic shock includes the following actions:
- Give 2nd bolus of crystalloid fluid and monitor markers of perfusion. Repeat as clinically indicated as long as volume responsive.
- Start vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg.
- If vasopressors are needed, insert central venous catheter (CVC) under sterile conditions (when possible), though vasopressors can be delivered via peripheral IV with caution.
- Monitor in the ICU, preferably continuous monitoring of HR, SpO2 BP check at least every 30 minutes.
Appendix A: Driver Diagram