Leading change

The Lead Nurse for Deteriorating Patient and Sepsis at Weston Area Health Trust identified unwarranted variation in the rates of early detection and prompt treatment of sepsis at Weston Area Health Area Trust and addressed this through awareness raising campaigns, training and introduction of best practice sepsis alert practices. This has significantly improved patient outcomes and safety.

Where to look

Sepsis is a leading cause of death in the United Kingdom (UK) with a reported 44,000 cases every year (NICE, 2017). Sepsis causes more deaths every year than breast, prostate and bowel cancer combined (UK Sepsis Trust, 2016). Forty percent of cases relating to sepsis are severe and 50% of cases are related to septic shock (NICE, 2014). Sepsis is the biggest cause of maternal death in the UK (World Health Organisation, 2016) and costs the National Health Service (NHS) over an estimated £2.5 billion per year (Health Care Ombudsman, 2014). Successful management of sepsis requires prompt recognition, appropriate interventions to identify and control the micro-organisms and restore oxygen delivery to tissues, and appropriate escalation and decisive medical management within the first hour of red flag sepsis.

What to change

The Trust was making progress in providing sepsis care but identified an opportunity to strengthen the sepsis care pathway, to not only save lives but to sustain improvements by using quality improvement methodology and integrating clinical governance. This unwarranted variation was identified through an audit in 2017 identifying the need and opportunity for improvement in the compliance in the use of the sepsis screening and delivery of the Sepsis Six within one hour of red flag sepsis. The Sepsis Six consists of three diagnostic and three therapeutic steps – all to be delivered within one hour of the initial diagnosis of sepsis.

The Lead Nurse for Deteriorating Patient and Sepsis conducted a baseline survey to try to understand why the sepsis screening tool wasn’t being used; 91 out of 100 of the survey results that were returned identified an opportunity to train staff so that they were aware of sepsis, its signs and symptoms and treatments so that they could provide best practice within their clinical areas.

How to change

The Lead Nurse for Deteriorating Patient and Sepsis addressed the unwarranted variation through the following focused actions:

• Multidisciplinary staff training, developing and empowering staff to support the clinical recognition of sepsis and the requirements of prompt action at the signs of sepsis.
• Improving sepsis identification through national guidelines (NICE NG51)
• The creation of a sepsis multidisciplinary team (MDT) providing a more integrated approach across medical disciplines to sepsis care.
• An integrated nursing leadership programme empowering nurses to escalate patients through the sepsis pathway more effectively.
• The introduction of NEWS (National Early Warning Scoring) enabling staff to utilise a validated medical assessment tool which supports staff to identify any patient who may have sepsis and trigger the appropriate sepsis pathway which includes the ‘Sepsis Six’ stepped treatment model.
• The introducing of a standard operating procedure (SOP) utilising sepsis alert cards for immunocompromised patients.
• On-going sepsis awareness campaigns. For example, all lift doors now display full-height posters encouraging patients and visitors to ask themselves, and to question hospital staff, ‘Could it be sepsis?’ Sepsis awareness is also now part of the Trust staff induction.

Adding value

Better outcomes – There was a large increase in the use of the sepsis screening tool from 17% in September 2017 to 96% across the Trust by January 2018. In the emergency department screening for sepsis is over 90% and administration of IV antibiotics within 1 hour is at 89%. Sepsis screening and treatment for inpatients has reached 100%. The sepsis related incidents reduced from 4 in October 2017 to an average of 0 or 1 by May 2018.  Sepsis length of stay at Weston General Hospital reduced from an average of 8 days in October 2017 to 4 in May 2018, which is below the national average length of stay average of 12 days in May 2018.

Better experience – Staff experience has been positive with 100% of staff saying they would recommend the sepsis training to colleagues and they feel confident to use the training in practice. Between September 2017 and March 2018 458 members of staff had attended the sepsis training. The educational sessions gave nurses the knowledge to identify and pre-empt interventions and encouraged them to prompt doctors in decision-making. One member of staff set up study days on their ward for their specialty, which includes sepsis care.

• I enjoyed “all of it – felt my knowledge has improved hugely with regards to sepsis and feel that can confidently complete sepsis 6 pathway”.
• The ‘sepsis stars’ initiative has been introduced, where staff are praised for recognising, escalating and treating patients with sepsis within one hour. Staff and teams are presented with certificates and included within internal communications or on social media.
• Anecdotal evidence from patients and families has also been positive and where there was learning, this has been shared. Sepsis support groups have now been set up for patients post discharge.

Better use of resources – The initiatives used throughout the Trust have been low in cost, using simple solutions that provide a standardised measurable response to sepsis and increase the compliance with the delivery of the Sepsis Six by using NEWS and the sepsis screening tool. By recognising and treating sepsis early, intensive care admissions, treatment and length of stay costs are reduced.

Challenges and lessons learnt for implementation

• Solutions that are known to work were implemented without inventing anything new and a 90 day implementation plan broke the work down into 90 day segments, making it more manageable.
• There was some challenge around staff engagement but educating, supporting and guiding colleagues addressed this.
• A culture of reporting and learning within the hospital is promoted – so if errors occur staff feel supported, cared for and valued.

Improvements are continuing to be made with sepsis care and looking at sustainability across the hospital and the maternal sepsis screening tool is being reviewed.

Find out more

For more information contact:

• James Merrell, Lead Nurse Deteriorating Patient and Sepsis, james.merrell2@nhs.net