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Overcoming Barriers to Sepsis Bundle Implementation

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The sepsis bundle is designed to take a complex process and select elements of care that, when implemented as a group, have an effect on outcomes beyond the individual elements alone. Over the years, sepsis bundle utilization, as part of a formal hospital performance improvement program, was welcomed by many, modified by some, and resisted by others. Yet we find ourselves in a position where all U.S. hospitals are being held to a similar standard by the Centers for Medicare and Medicaid Services (CMS) by way of the Severe Sepsis/ Septic Shock Management Bundles (SEP-1).1 As clinicians, we need to align our thoughts and actions to strive for early identification and increase sepsis bundle compliance as a means to improve patient outcomes.

Echoes of the Past Leading Up to Current Practice 
In 2010, the Surviving Sepsis Campaign (SSC) Phase III results showed that sepsis bundle compliance was associated with improved outcomes.2 Despite low bundle compliance in this study, collaborative efforts continued lengthening to a 7.5-year period in 218 community, academic and tertiary-care hospitals. Over that period, volunteer sites entered sepsis bundle indicator data into the SSC database for 29,470 severe sepsis patients.3 In 2014, data were published showing that hospitals with higher (6 hour) resuscitation bundle compliance (> 15%) had lower mortality when compared to lower-compliance hospitals (29.0% vs. 38.6%).3 Additionally, for every 10% increase in compliance, ICU and hospital lengths of stay were reduced by 4%.3These results pose several questions: Did improved compliance with the bundles directly lead to improvement in survival or do guideline-compliant hospitals reflect better care in general or was there a yet unidentified component present that improved outcomes?

Similar to the International SSC Phase III program, small and large groups independently collaborated to improve sepsis care. The Michigan Health and Hospital Association Keystone Sepsis Collaborative found that hospitals with high bundle adherence and collaborative participation had significantly lower in-hospital mortality and decreased lengths of stay.4 Results from a multisite, single-health system showed that increased compliance with a three-hour sepsis bundle was associated with improved survival and cost savings.5 Advantages of participating in a system, state, regional, or national collaborative improvement model include peer-to-peer learning; sharing data, tools and protocols; and striving as a noncompeting member of a group to overcome barriers through lessons learned. Like Michigan, other states developed sepsis collaborative programs. New Jersey hospitals aligned to tackle sepsis mortality, reducing the rate by 11% in one year.6

Sepsis Indicators, Challenges and Results 
In the 2012 Surviving Sepsis Campaign Guidelines, the sepsis bundles were reduced from 6- and 24-hour to 3- and 6-hour bundles.7 The total number of indicators decreased from 10 to seven. However, time to complete several indicators (initial lactate and fluid resuscitation) was moved from 6 to 3 hours. In order to achieve goals in such a short time window, hospitals integrated tools and technology to increase efficiency and effectiveness.

The individual sepsis indicators have anticipated barriers and associated potential solutions. Some solutions are more complex than others. A primary focus in all programs is early identification, giving the clinician the best opportunity to initiate treatment when it will most make a difference. Common barriers to sepsis bundle achievement and potential solutions are provided in Table 1. With any performance improvement activity, executive leadership and staff engagement are essential, as are project leaders, including physician and nurse champions. 

Advancing Toward Best Outcomes
Achieving 100% compliance with sepsis bundle indicators in patients with severe sepsis is unlikely due to a combination of patient pathophysiology not amendable to intervention, the large number of health care providers that must be trained, and surges in patient volume. However, improvement is possible and starts with the power of one—you. One committed individual with an optimistic mindset can inspire a team to success. Although the hope is to engage everyone in this improvement effort, some will be resistant to change. In order to engage these individuals, data, data and more data will help combat the negativity. Knowing when to pass the baton or a piece of the baton to a new optimistic leader brings fresh ideas to the team.

Success occurs behind the scenes in preparation of protocols, order sets, screening tools, best practice alerts and educational rollout planning. Important in this process is engaging the end user in all steps of the build and accepting and modifying based on feedback. Adequate preparation will result in ease of execution. A process to evaluate effectiveness and use of the tools developed is essential. The tools only work when used. If met with resistance, one-on-one instruction can be useful. Feedback close to the occurrence of “misses” increases effectiveness. 

High compliance with sepsis bundles need to be linked to early identification and facilitated by sepsis screening education and tools. Empowering nursing staff to actively screen and identify sepsis can lead to early treatment and prevention of devastating sequelae. The primary value of sepsis screening is early identification leading to early intervention.8 Second, ongoing screening (once per shift) can identify organ dysfunction and potentially prevent progressing or worsening organ failure. 

The addition of a sepsis nurse coordinator can bring expertise to the multidisciplinary team to bridge gaps among clinicians, patients and family members.9 Other responsibilities may include programs to develop and monitor adherence to protocols and treatments. The coordinator also recognizes staff and patient learning needs with corresponding educational plans. Recall that increased sepsis bundle compliance is associated with decreased mortality, hospital length of stay and cost. The value of the coordinator will likely exceed the cost that he/she brings to the program.

Annual education, ideally in September during International Sepsis Awareness Week, can serve to energize the hospital’s sepsis program. Daily huddles may include feedback on sepsis bundle success or failures within the past 24 hours. It is important to highlight accomplishments to maintain staff engagement. Negative feedback, although important, may be deflating if not balanced with positive feedback. 

Early activities of the international SSC sepsis performance program spawned both regional and national hospital collaboratives as well as individual hospital efforts associated with improved sepsis outcomes. Barriers to sepsis bundle achievement include factors associated with process, people, communication and documentation. Solutions to overcome these challenges consist of standardization of processes for continuous screening surveillance, implementation of order sets and protocols and documentation.

1. Centers for Medicare and Medicaid Services, Joint Commission. SEP-1 Early Management Bundle. Severe Sepsis/Septic Shock. Centers for Medicare and Medicaid Services and Joint Commission; 2017. Accessed March, 27, 2017.
2. Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med. 2010 Feb;36(2):222-231.
3. Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-1633.
4. Thompson MP, Reeves MJ, Bogan BL, DiGiovine B, Posa PJ, Watson SR. Protocol-based resuscitation bundle to improve outcomes in septic shock patients: evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative. Crit Care Med. 2016 Dec;44(12):2123-2130.
5. Leisman D, Bianculli A, Doerfler ME, et al. Survival benefit and cost savings from emergency department compliance with a basic 3-hour sepsis bundle in a multisite, prospective, observational study. Acad Emerg Med. 2016;23:S18.
6. Stainton LH. NJ hospitals join forces to reduce deaths caused by sepsis. NJ Spotlight. September 13, 2016. Accessed March 23, 2017.
7. Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637.
8. Schorr C, Odden A, Evans L, et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11 Suppl 1:S32-S39.
9. Schorr C. Nurses can help improve outcomes in severe sepsis. Am Nurse Today. 2016;11(3):20-25.
10. Dellinger RP, Schorr CA, Levy MM. A users’ guide to the 2016 Surviving Sepsis Guidelines. Intensive Care Med. 2017 Mar;43(3):299-303.