Every patient, every shift, every day were the watchwords of Phase IV of the Surviving Sepsis Campaign’s (SSC) Sepsis on the Floors Quality Improvement Learning Collaborative. The actions behind those words led to the identification on hospital floors of more than 1,700 patients with severe sepsis in whom organ dysfunction was not present or had not been identified when the patient had first been admitted to the ward. The ability of the nursing staff on pilot units in 38 hospitals across the United States to screen every patient on every shift of every day during an 18-month study period resulted in less severe illness, fewer ICU admissions, reduced mortality and shorter lengths of stay for that group of patients.
Under the leadership of Mitchell M. Levy, MD, MCCM, professor of medicine at Alpert Medical School, Brown University, and Sean R. Townsend, MD, vice-president of quality and safety at California Pacific Medical Center, and with support from the Gordon and Betty Moore Foundation, the Campaign was able to meet its aim to study, test and disseminate messages and tools related to the early identification and treatment of sepsis on hospital floors through regular screening by unit nurses, who participated in four improvement collaboratives.
“When we analyzed the data from the Campaign’s original quality improvement efforts,” reported Dr. Levy, lead author of that study and member of SSC’s executive committee, “we saw the success of early identification and application of the bundles in the emergency department. We recognized that patients arriving in the ICU who developed sepsis on the floors were a vulnerable population for whom earlier identification could be greatly beneficial. We wondered if it was possible to establish a screening protocol to find and treat them earlier.”(1) With participation of leaders from the Society of Hospital Medicine, the Campaign invited hospitals to participate in tests of change on pilot units as part of the improvement collaboratives. Collaborative faculty included hospitalists, intensivists, nurses and quality improvement advisers.
Many of the participating hospitals shared success stories related to improved clinical skills, greater confidence among team members, and recognition of their clinical expertise by colleagues. Unexpected results also emerged, such as the diagnosis of a patient with a myocardial infarction and one in sickle cell crisis while completing the recommended screening on every patient during every nursing shift. Many similar rescues occurred outside the primary purpose of the collaborative interventions. These were unintended but welcome consequences of screening every patient, every shift, every day for sepsis.
Common themes among the hospitals that participated in the collaboratives confirm that hospitals benefitted from the interaction. According to Katie Choy, MS, RN-BC, CNS, NEA-BC, nursing director, patient and staff education at Washington Hospital, Fremont, California, USA, participation in the West Coast collaborative was a way to learn from others and improve their own protocols. Washington Hospital was already implementing sepsis screening on the floors, and emergency physician Kadeer Halimi, DO, was eager to spread the initiative to other floors. They knew they had accomplished their goals of awareness among the nursing staff when nurses stopped them in the hall to ask questions about sepsis care.
Stories like Choy’s are described in Spotlight on Success, a compilation of tips, experiences, challenges, and successes from among the 38 hospitals that worked with the collaborative faculty via educational sessions, webinars, coaching and face-to-face meetings to implement regular, consistent screening on the floors. The book is available from the Society of Critical Care Medicine (SCCM) Store (https://store.sccm.org/
). Search for “Spotlight on Success eBook.” Valuable Messages for Practice
As the collaboratives provided the largest study to conduct and demonstrate the feasibility of routine, every-shift screening for sepsis by floor nurses, the results provided valuable messages for practice. The nursing staff on the pilot units were able to screen patients once per shift as a trigger to evaluate them for sepsis-associated organ dysfunction as part of their regular care. This was accomplished without changing the units’ patient-to-nurse ratios. Also, there was a decrease in both mortality and rate of ICU transfer for patients diagnosed with severe sepsis on the floors over the course of the 18-month study. Compliance with the three-hour bundle increased significantly, as did administration of 30mL/kg crystalloid to patients with hypotension or lactate higher than 4 mEq/L. Continuing Campaign Activities
While the formal collaborative activities are completed, the effects continue as their work spreads to other units and other hospitals. The successes that the participants on the pilot units achieved can be disseminated to other units within the participating hospitals as well as to other hospitals and healthcare systems globally.
Required reporting to the Centers for Medicare and Medicaid Services (CMS) has generated many questions that are posted on SSC’s electronic message board. Dr. Townsend monitors the site regularly and posts clarifications and comments to assist participants in complying with CMS regulations as well as responses to improvement questions generated from dissemination of the collaborative’s work. Participants’ generous information sharing and common concerns have created a virtual community of sepsis caregivers.
SCCM and the European Society of Intensive Care Medicine continue to ensure that their SSC guidelines reflect current science. The fourth edition of the Surviving Sepsis Campaign International Guidelines is currently in development, with projected publication in late 2016.
Additional publications related to improvement data and implementation of the guidelines will be forthcoming as research is completed. SSC will continue to provide tools and educational materials to support the guidelines and their implementation by dedicated members of the multiprofessional teams who care for sepsis patients.
1. Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010 Feb;38(2):367-374.