Kelly Sykes1,2, Karin Thursky1,3, Tristan Vasquez1
1Melbourne Health, Royal Melbourne Hospital, Melbourne, Australia
2Safer Care Victoria, Melbourne, Australia
3Peter MacCallum Cancer Centre, Melbourne, Australia
Background:
Sepsis is a complex syndrome that is difficult to define, diagnose and treat. Left untreated, sepsis can progress to severe sepsis and septic shock, and greatly increase the risk of mortality. Early recognition and resuscitation with appropriate treatment is therefore essential to optimise survival rates. Analysis of practice at a tertiary health facility demonstrated significant variation in sepsis recognition and management as well as numerous structural and process gaps, leading to delayed recognition and resuscitation of patients with sepsis. Sepsis contributed to increased ICU utilisation, length of stay and mortality. Extensive consultation revealed medical and nursing knowledge gaps, lack of awareness of antimicrobial timeliness and fluid resuscitation, reticence to escalate to deteriorating patients, and generally inconsistent and unreliable practice.
Methods:
A multidisciplinary sepsis working party was established to carry out this 12 month quality improvement initiative across 25 wards and the emergency department. A six hour clinical pathway, based on previous work by the New South Wales Clinical Excellence Commission and later by Peter MacCallum Cancer Centre, was adapted and developed to form part of the medical record. The implementation was supported by a multidisciplinary sepsis education package was delivered to all clinical staff. A comprehensive communications strategy was utilised to ensure staff were informed of clinical changes and expectations. Additionally, electronic tools were developed to support early recognition. Process and outcome measures were collected for baseline (September – November 2016) and pathway cohorts (January – August 2017).
Outcome:
The results have demonstrated significant improvement in the pathway cohort (716 episodes) compared to the baseline cohort (126 episodes): 50.4% decrease in mortality related to sepsis, 65.4% decrease in ICU admissions, 42.9% decrease in length of stay, and 100% of services utilising a standardised sepsis pathway (all p<0.05). There was a 51.9% reduction in time to antibiotic administration. There were also significant improvements on sepsis pathway bundle components: 38.7% increase in lactate compliance and 102% increase in blood culture compliance.
Conclusion:
A standardised sepsis pathway resulted in improved outcomes on key measures: mortality, admissions to ICU, length of stay, pathway utilisation and compliance, and timely administration of antibiotics. The pathway and project is now being scaled across other Victorian health services.