Implement and Improve

​​The Surviving Sepsis Campaign (SSC) partnered with the Institute for Healthcare Improvement to incorporate its “bundle concept” into the diagnosis and treatment of ​​The Surviving Sepsis Campaign (SSC) partnered with the Institute for Healthcare Improvement to incorporate its “bundle concept” into the diagnosis and treatment of patients with severe sepsis and septic shock. We believe that improvement in the delivery of care should be measured one patient at a time through a series of incremental steps that will eventually lead to systemic change within institutions and larger healthcare systems. Local SSC implementation is the key to mortality reduction for patients with severe sepsis and septic shock. Successful SSC adoption requires a hospital champion who can coordinate the LEADER steps outlined below.

L: Learn about sepsis and quality improvement by attending local and national sepsis meetings.

Establish a baseline to convince others that improvement is necessary and to make your measurements relevant. Do this before conducting formal improvement efforts. Start by collecting data on all sepsis patients in your intensive care unit (ICU); you may see only one or two patients per day.

Ask for buy-in from institutional leadership and seek initial support from the emergency department (ED) and ICU staff and directors, quality improvement personnel, nursing staff, and others. You may want to watch the webcast Administrative Buy-In: Key to Sepsis Care Improvement.
Form a sepsis team and bring all stakeholders to the table for input. Tell people what you are doing and why. You may not receive initial support across the board, but opinions often change when data start to become available. Publicize the SSC with a formal kickoff event. Highlight several physicians to speak about the effort and invite representatives from administration, medicine, nursing, respiratory therapy, and pharmacology. This commitment will provide early momentum and drive improvement efforts forward.

Develop an institution-specific SSC protocol comprising all bundle elements. Seek feedback and refine your protocol to the satisfaction of your team. Assign a “protocol owner” with the task of refining the protocol and patiently obtaining feedback from all stakeholders. Invite comments and suggestions at regular team meetings. Publish refinements by scheduled deadlines and label each version with a date to ensure uniformity of use.

Educate stakeholders in the ED, ICU, and units according to shift schedules. Post the hospital sepsis protocol in several prominent locations. Familiarize staff with the bundle and your protocol. Explain the importance of the bundle tools. Tolerate failure but revise teaching as needed.

Remediate errors and anticipate obstacles along the way. Recount successes and failures every month. Remediate errors and anticipate obstacles along the way. Recount successes and failures every month. Everybody involved needs to see what is happening to drive the SSC effort forward. Identify critical failure modes as a team and redesign processes as needed while simultaneously measuring your results.​


 Process and Outcome Measures

​Process Measures
These measures tell you about how the process of change is unfolding as your improvement and clinical teams work to comply with the bundles. Are changes being translated into actual practice as you intended them to be?  

Process measures will allow you to identify whether you have created a reliable system that follows the timing, sequence, and goals mandated in the Sepsis Bundles.

Outcomes Measures
These measures tell you whether changes are actually leading to the improvement you intended.
Faithful implementation of the Severe Sepsis Bundles, combined with an unwavering focus on the above process measures, will help you to achieve this goal at your institution

Data Collection
A hospital’s improvement team is likely to use one of two methods to collect data for the measures described above. Whichever method is selected, that approach should be maintained from month-to-month in order to assess the degree of improvement over time accurately. 

Concurrent Data Collection
Concurrent data collection is best suited to new improvement teams. That is, once a patient is placed on the hospital’s sepsis protocol, data can be abstracted from the patient chart in real-time or, as most teams have found, at some point during the first 24 hours of admission so that data collection is semi-concurrent with the patient's admission.  One convenient location for this effort is in the ICU where most patients will presumptively be admitted. There are two important advantages to this approach: 

Concurrent collection of data serves as a prompt to execute the next phase of the bundle. Therefore, some teams may choose to begin the collection in the ED to encourage compliance.  

Concurrent collection of data allows teams to segment their population carefully so that they focus their initial efforts on patients for whom they are most likely to succeed. For example, an improvement team may wish initially to segment their patient population to only those patients on a hospitalist-driven service to overcome resistance from multiple private practitioners. Over time as the institutional culture has matured to understand and accept the protocol, the sphere of care can be expanded.
Retrospective Chart Review
Retrospective Chart Review is suitable for advanced improvement teams, or teams that have demonstrated success with concurrent data collection. Using this strategy, teams identify charts for monthly review with the assistance of the health information services department based upon discharge diagnoses. As the clinical protocol is introduced and established, the success or deficiency of the improvement effort should be reflected in the results of the retrospective chart review. Advantages to this approach include:
  • Obtaining a more accurate reflection of the state of sepsis care at the institutional level by reviewing charts coded by reviewers unaware of the protocol. 
  • The ability to use sampling to analyze only a portion of the charts coded as above. If there are a large number of charts, teams can select a reasonable sample to analyze, e.g.., 20 charts per month.

 Setting Aims

The first step in improving the care of patients with sepsis and septic shock is making a solid commitment to improving that care. This commitment includes a strong and well-worded aim statement that sets an aggressive global aim. It is critical that the overall aim has a measurable objective and a specified time frame.

The original aim of the Surviving Sepsis Campaign was "a 25 percent reduction in sepsis mortality within the next 5 years (2009)" [Dellinger RP, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32(3):858-873].

In addition to the global aim, the sepsis work is divided into segments, each having its own specific aim, all of which contribute to achieving the global aim.

Each institution committed to this aim should have senior leaders involved in setting the specific aims, to ensure that these aims are aligned with the organization's strategic goals. When senior leaders approve the aims, they should also make a commitment to giving the team whatever support is needed to achieve them.

The following are specific aims, adopted from the Surviving Sepsis Campaign guidelines, that support the global aim of improving septic patient mortality. These aims break the work into smaller, measurable, achievable chunks for teams to tackle. Several teams may be working on specific aims simultaneously, with all reporting to the leadership team.

Examples of Effective Aim Statements:
  • Time from sepsis recognition to presumptive diagnosis of sepsis is 1 hour
  • Time from sepsis recognition to all patients’ meeting sepsis criteria having an elevated serum lactate level (> 2 mmol/L) is 1 hour
  • Time from sepsis recognition to appropriate antibiotics given is 1 hour
  • If the patient is hypotensive or if their lactate > 4.0 mmol/L, staff will begin rapid fluid administration (30 mL/kg crystalloid)
  • If the patient is hypotensive during or after fluid resuscitation, apply vasopressors to maintain a mean arterial pressure of > 65 mm Hg 

 Forming the Team

To achieve the improvement goals, everyone involved with the care of septic and septic shock patients needs to be well educated and included in setting aims. To achieve the improvement goals, work processes must be carefully scripted and standardized, and awareness and commitment to this effort must be elevated. This must be a team effort that crosses disciplines and departments; it requires leadership and support from the entire organization and buy-in from all stakeholders.

There are three different levels of participation in creating successful change:

Active working team responsible for daily planning, documenting, communication, education, monitoring, and evaluation of activities.

The working team must be multidisciplinary, with representation from all departments involved in the change processes — doctors, nurses, pharmacists, respiratory therapists and other staff with roles in the specific change process, such as clerks and technicians. Team members should be knowledgeable about the specific aims, the current local work processes, the associated literature, and any environmental issues that will be affected by these changes.

The leadership group or person who helps remove barriers, provides resources, monitors global progress, and gives suggestions from an institutional perspective is essential.

The working team needs someone with authority in the organization to overcome barriers that arise, and to allocate time and resources the team needs to achieve its aim. Leadership needs to understand both the implications of the proposed changes for various parts of the system and the remote, unintended consequences such a change might trigger.

Providers, including all stakeholders who have an interest in the change, must be engaged.
Procedures are needed to keep providers and other stakeholders informed, provide a hassle-free mechanism to receive their feedback, and assure them that their responses are respected and will influence the changes. This helps give them some ownership and facilitates implementation and utilization of the new processes. 

 Effective Teams

Example 1: Effective Work Team

Aim: Diagnose patients with sepsis or septic shock in the emergency department (ED) urgently as sepsis is a medical emergency
Core Working Team: The overall core team must be interdisciplinary and must include, at a minimum:
  • ED physician
  • Triage nurse
  • Staff nurse
  • Laboratory technician
  • Laboratory supervisor
  • Pharmacist
  • Admissions clerk
  • Additional team members may include:
  • Critical care medicine (CCM) physician
  • House officer
  • ICU charge nurse
  • Infectious disease physician

Example 2: Effective Work Team

Aim: Ventilated septic patients will have tidal volumes near 6 ml/kg ideal body weight and plateau pressures less than 30 cm H2O
Core Working Team: The overall core team must be interdisciplinary and must include, at a minimum:
  • CCM physician
  • Respiratory therapist
  • Staff nurse
  • Pharmacist
  • Additional team members may include advanced practice nurses or physician assistants, fellows and residents

Private attending physician

  • Surgeon
  • ED physician
  • Laboratory personnel

Example 3: An Effective Leadership Team 
Aim: ED and CCM will join to implement best possible care for septic patients, using the known evidence that fits their institution.

Core Leadership Team: The overall leadership team must be interdisciplinary and must include, at a minimum: 

  • Administrator over ED and CCM
  • Critical care medicine physician
  • ED physician
  • CCM nurse manager
  • ED nurse manager
  • ED charge/triage nurse
  • CCM charge nurse

Additional team members may include:

  • Pharmacist
  • Respiratory therapy supervisor
  • Process improvement facilitator
  • Laboratory supervisor
  • Technicians from ED