Give 3, Take 3: Improving compliance with Sepsis Six at a District General Hospital
Quality Improvement Project
Authors: Stephanie Jordan*, Samantha Kingdon*, Jennifer Ward* *equal contributors
Introduction
Sepsis is associated with a high morbidity and mortality as
well as carrying a large economic burden. In 2010, 5.1% of all
deaths in England were associated with sepsis,1 and it is
estimated that sepsis costs the NHS £2.5 billion a year. 2
The ‘Surviving Sepsis Campaign' was initiated in 2002, and
was aimed at reducing mortality from severe sepsis and
septic shock worldwide.3 From this stemmed simplified
guidelines, ‘Sepsis Six’, for junior doctors. Usage of ‘Sepsis Six’
has been shown to improve the management of patients with
sepsis and thus improve mortality.4
Supervisors: Dr Martin Al-Soof and Dr Ruari Moulding
Acknowledgments: Ann-Marie Burrows and Claire Hollingworth
Discussion:
Methods
Baseline Knowledge
Baseline Audit
Inclusion criteria: new
adult medical admissions
Exclusion criteria:
neutropenic sepsis,
surgical patients, hospital
acquired sepsis
Questionnaire given to
foundation year one
and two doctors
assessing knowledge of
sepsis six bundle
Figure 1: Nursing triage proforma for identification of sepsis.
Figure 2: Sepsis Six poster displayed in Weston General Hospital.
Fig 1
Fig 2
Plan, Do, Study, Act (PDSA ) Cycle 1
Addition of lactate assay on blood gas machine
Motivation
We felt the management of sepsis at Weston General was
sub-optimal. It was identified by the Global Trigger Tool as a
recurrent contributing factor in deaths at this hospital and
the Standardised Hospital-level Mortality Indicator (SHMI)
suggested observed deaths, attributed particularly to
pneumonia and urinary tract infection, were higher than
expected. As junior doctors we felt given the availability of
an evidence-based nationally recognised Sepsis Six bundle,
there was no excuse for sepsis not to be managed
exceptionally.
PDSA Cycle 2
Education - departmental teaching on sepsis
management
Posters - promotion of Sepsis Six bundle and SIRS
criteria
Training - usage of new lactate machines
Provision of login codes for lactate machine
Figure 3:
Percentage
knowledge of
junior
doctors of
Sepsis Six
bundle
before and
after
education.
PDSA Cycle 3
Aims and Objectives
Introduction of a nurse triage proforma for
identification of suspected sepsis
Implementation of Sepsis Six and SIRS stickers
Aim
• To improve the management of sepsis in medical
admissions by improving adherence to the nationally
recognised Sepsis Six bundle.
Objectives
• To ascertain base-line knowledge of the Sepsis Six bundle
amongst junior doctors, and implement means to
improve any deficiency in knowledge.
• To assess the compliance to the Sepsis Six bundle and
then carry out interventions to improve short-falls in
compliance.
• To use quality improvement methodology to assess the
impact of any implemented changes.
Following our interventions the most striking
improvements were seen in junior doctor
knowledge and percentage of antibiotics
being administered within an hour. This is
especially
pleasing
as
it
required
communication between multiple healthcare
professionals to complete this within the
time constraints.
Implementing a new
lactate assay machine in A&E appears to be a
major contributor in increasing lactate
measurements from 15% to 83%.
Nurse initiated actions were performed most
consistently and their longer duration in post
will be a key driver in maintaining continuity
long after the current junior doctor cohort
have moved on. A multidisciplinary and interdepartmental approach will continue to
ensure Trust-wide co-operation. We aim too
provide new junior doctors with a Sepsis Six
crib card at induction to ensure sustainability
of good practice.
Recommendations:
PDSA Cycle 4
Email reminder to clinical staff to use the
proforma and stickers
Figure 1: Flow chart outlining QI methodology used.
Initially the majority of the Sepsis Six
components were underperformed and
knowledge of sepsis management amongst
junior doctors required improvement. A lack
of Trust guidelines or resources could
account for this.
Figure 4: Percentage completed of each component of Sepsis 6 after
each intervention.
• Methodology to be applied to medical
and surgical in-patients with new onset
sepsis.
• To re-audit compliance of sepsis six
annually and to assess for aimed
improvement in SHMI data.
• Development of trust sepsis management
guidelines.
References:
1
2
3
4
McPherson D, Griffiths C, Williams M, Baker A, Klodawski E, Jacobson B, Donaldson L. Sepsis-associated mortality in England: an analysis of multiple cause of death data from 2001 to 2010. BMJ Open 2013;3:e002586.
The UK Sepsis Trust. Info for the public; what is sepsis? http: http://sepsistrust.org/info-for-the-public/ (accessed 28 June 2014).
Surviving Sepsis Campaigne. About the Surviving Sepsis Campaign. http://www.survivingsepsis.org/About-SSC/Pages/default.aspx (last accessed 28 June 2014).
Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J 2011;28:507-512.