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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
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