Leading change

A nurse led project at James Paget University Hospitals has identified and implemented opportunities to improve the prompt identification and treatment of sepsis at the Trust. Their project aimed to raise staff awareness and embed best practice. The evidence based care pathway that resulted has reduced sepsis-related mortality and truly improves patient safety.

Where to look

Sepsis is a life-threatening condition and reducing episodes of sepsis is one of the top priorities for the NHS. Nurses at James Paget University Hospitals wanted to reduce unwarranted variation in treatment and outcomes observed in practice. They conducted a Trust audit which revealed that 68% of A&E patients and 58% of inpatients were receiving the right, personalised treatment for sepsis within an hour of resuscitation, as recommended by NICE and Sepsis UK. However, there was scope for improvements to the care pathway, to adhere more closely to these recommendations.

What to change

Every year in the UK, there are 150,000 cases of sepsis, resulting in 44,000 deaths. Immediate aggressive treatment is vital, with evidence showing that when intravenous antibiotics are administered to a septic patient within one hour, mortality is halved (NICE 2016).

The trust’s Transformation Nurse and his team led three months of intensive engagement with staff to evaluate sepsis performance. Alongside the audit, this involved mapping processes and protocols to identify opportunities for development and barriers preventing the Trust from achieving the highest standard.

The nurses’ evaluation demonstrated a need to improve recognition of the presence of sepsis earlier in the care pathway and to initiate treatment as quickly as possible thereafter. The aim was to create a sepsis awareness culture and to streamline the sepsis pathway. In this way, staff would more readily identify sepsis and be clearer about how to respond.

How to change

The Transformation Nurse became Clinical Project Manager for a three-year trust-wide sepsis initiative. The crucial role of nurses and healthcare assistants was recognised from the outset, with a simple call to action for front line teams: “Does your patient have an Early Warning Score of 3 or above? If so, think sepsis!”

Other measures to support the campaign included:

• Setting up a sepsis group across wards at the Trust, to encourage partnership working and to approve ideas from front line staff (such as a sticker for A&E notes as a reminder to check for sepsis);
• Supporting the Clinical Care Outreach Team and Hospital at Night Practitioners to administer antibiotics, to reduce the risk of delays;
• Developing a sepsis pack with a step-by step guide, placed in designated sepsis drawers and bags;
• Redesigning the observation chart to include a “sepsis recognition box”;
• Distributing prompt cards which fit inside staff ID card holders;
• Adapting the associated paperwork to ensure that staff can complete in less than 30 seconds;
• Running short sepsis awareness sessions to accommodate shift patterns;
• Encouraging sepsis huddles following ward rounds to ensure every patient has been assessed in line with sepsis recommendations.

Adding value

Better outcomes – There has been a direct positive impact on patient outcomes. During the first six months (June-December 2016), the trust’s mortality rate for sepsis fell from 14.5% to 12.1%. Current data shows that approximately 90% of patients are receiving antibiotics within 90 minutes which is extremely positive. The proportion of inpatients receiving antibiotics within an hour increased from 58% to 78%, and amongst A&E patients from 68% to 80%. Reported incidents of sepsis have risen due to heightened awareness and improved knowledge which is likely associated with the above fall in mortality rates.

Better experience – Patient feedback has been positive, for example:

• “James Paget Hospital was so quick in recognising severe sepsis. Thank you for saving his life and giving my son back to me.”
• “I will be forever grateful for the outstanding care and skills of all the staff”.
• “My wife and I thank you from the bottom of our hearts.”

Better use of resources – The mean length of stay for patients with sepsis fell from an average of 10.7 days to 7.4 days (compared to a national average above 10 days in the same period).

Challenges and lessons learnt for implementation

• Changing systems and pathways is not simple. It requires time and patience and needs to be done incrementally – while not losing sight of the end goal.
• Staff involvement at all stages is essential for making change stick.
• The time spent identifying barriers at the outset was crucial to effective development of the improvement strategy.
• It is important not to leave evaluation until the end. Monitoring progress helps to maintain momentum, informs further refinement, and provides opportunities to celebrate success.

Find out more

For more information, contact:

• Joan Pons Lpalana, Transformation Nurse, James Paget University Hospital, joan.ponslaplana@nhs.net