A multifaceted intervention to improve sepsis

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QUALITY IMPROVEMENT REPORT

A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series Charis A Marwick,1 Bruce Guthrie,1 Jan E C Pringle,2 Josie M M Evans,3 Dilip Nathwani,4 Peter T Donnan,1 Peter G Davey1

▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/bmjqs2013-002176). For numbered affiliations see end of article. Correspondence to Dr Charis A Marwick, Population Health Sciences Division, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK; [email protected] Received 24 May 2013 Revised 24 September 2013 Accepted 3 November 2013 Published Online First 20 November 2013

▸ http://dx.doi.org/10.1136/ bmjqs-2012-001726

To cite: Marwick CA, Guthrie B, Pringle JEC, et al. BMJ Qual Saf 2014;23:e2.

ABSTRACT Problem Antibiotic administration to inpatients developing sepsis in general hospital wards was frequently delayed. We aimed to reproduce improvements in sepsis management reported in other settings. Context Ninewells Hospital, an 860-bed teaching hospital with quality improvement (QI) experience, in Scotland, UK. The intervention wards were 22 medical, surgical and orthopaedic inpatient wards. Design A multifaceted intervention, informed by baseline process data and questionnaires and interviews with junior doctors, evaluated using segmented regression analysis of interrupted time series (ITS) data. Measures for improvement Primary outcome measure: antibiotic administration within 4 hours of sepsis onset. Secondary measures: antibiotics within 8 hours; mean and median time to antibiotics; medical review within 30 min for patients with a standardised early warning system score ≥4; blood cultures taken before antibiotic administration; blood lactate level measured. Strategies for change The intervention included printed and electronic clinical guidance, educational clinical team meetings including baseline performance data, audit and monthly feedback on performance. Effects of change Performance against all study outcome measures improved postintervention but differences were small and ITS analysis did not attribute the observed changes to the intervention. Lessons learnt Rigorous analysis of this carefully designed improvement intervention

could not confirm significant effects. Statistical analysis of many such studies is inadequate, and there is insufficient reporting of negative studies. In light of recent evidence, involving senior clinical team members in verbal feedback and action planning may have made the intervention more effective. Our focus on rigorous intervention design and evaluation was at the expense of iterative refinement, which likely reduced the effect. This highlights the necessary, but challenging, requirement to invest in all three components for effective QI.

BACKGROUND Outline of problem

Sepsis is associated with significant morbidity, mortality and healthcare costs. Timely effective therapy can improve outcomes for patients with severe sepsis on admission to hospital and in the intensive care unit (ICU),1 2 and the evidence has been summarised in guidelines for severe sepsis management3 with key elements condensed into two care bundles.4 Implementing the bundles has been associated with improved clinical outcomes for patients admitted to hospital with severe sepsis.5 It is not clear whether similar improvements are achievable for patients who develop sepsis while in general wards. In pilot work, we found that only 20/ 35 (57%) of patients with sepsis received antibiotics within 4 h of onset.6 The questions for our improvement project were:

Marwick CA, et al. BMJ Qual Saf 2014;23:e2. doi:10.1136/bmjqs-2013-002176

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Quality improvement report ▸ What are the deficiencies in the management of patients who develop sepsis while inpatients in general wards in our hospital? ▸ What barriers and facilitators exist that may impact on good sepsis management and on implementation of an intervention to improve care? ▸ Will a multifaceted intervention lead to measureable improvements in the care of these patients? Context

Ninewells Hospital is an 860-bedded, teaching hospital serving a population of about 400 000, with most acute services, including accident and emergency, acute medical and surgical admissions units, intensive care, renal dialysis and cardiac catheterisation, available on one site. The intervention wards were the 22 general medical, general surgical and orthopaedic wards, excluding acute admissions units. There is an established history of quality improvement (QI) activity in Ninewells Hospital as part of the Scottish Patient Safety Programme.7 There is a mature antimicrobial stewardship programme, and an Infectious Diseases service. There are large numbers of doctors in training, rotating through multiple clinical units and contributing to on-call rotas and out-of-hours cover. A Hospital at Night team led by senior nurse practitioners coordinates and aids the delivery of care overnight to hospital inpatients. There is no rapid response or medical outreach team, but there is a cardiac arrest team and a doctor on call for each specialty (within normal working hours only for some smaller or subspecialties). ASSESSMENT OF PROBLEMS Case identification

The study case definition was a patient with sepsis occurring ≥24 h after admission to hospital, either as a first episode or following a period of ≥24 h without meeting the systemic inflammatory response syndrome (SIRS) criteria (ie, having two or more of the following: heart rate ≥90 beats/minute; respiratory rate ≥20 breaths/minute; temperature