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Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs
  1. Karin Thursky1,2,
  2. Senthil Lingaratnam3,
  3. Jasveer Jayarajan4,
  4. Gabrielle M Haeusler1,5,
  5. Benjamin Teh1,5,
  6. Michelle Tew1,6,7,
  7. Georgina Venn5,
  8. Alison Hiong5,
  9. Christine Brown5,
  10. Vivian Leung5,
  11. Leon J Worth1,5,
  12. Kim Dalziel6,7,
  13. Monica A Slavin1,8
  1. 1 National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
  2. 2 National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  3. 3 Department of Pharmacy, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
  4. 4 Department of General Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  5. 5 Department of Infectious Diseases, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
  6. 6 Center for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  7. 7 University of Melbourne, Center for Health Policy, Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
  8. 8 Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Professor Karin Thursky; karin.thursky{at}mh.org.au

Abstract

Infection and sepsis are common problems in cancer management affecting up to 45% of patients and are associated with significant morbidity, mortality and healthcare utilisation.

Objective To develop and implement a whole of hospital clinical pathway for the management of sepsis (SP) in a specialised cancer hospital and to measure the impact on patient outcomes and healthcare utilisation.

Methods A multidisciplinary sepsis working party was established. Process mapping of practices for recognition and management of sepsis was undertaken across all clinical areas. A clinical pathway document that supported nurse-initiated sepsis care, prompt antibiotic and fluid resuscitation was implemented. Process and outcome measures for patients with sepsis were collected preimplementation (April–December 2012), postimplementation cohorts (April–December 2013), and from January to December 2014.

Results 323 patients were evaluated (111 preimplementation, 212 postimplementation). More patients with sepsis had lactate measured (75.0% vs 17.2%) and appropriate first dose antibiotic (90.1% vs 76.1%) (all p<0.05). Time to antibiotics was halved (55 vs 110 min, p<0.05). Patients with sepsis had lower rates of intensive care unit admission (17.1% vs 35.5%), postsepsis length of stay (7.5 vs 9.9 days), and sepsis-related mortality (5.0% vs 16.2%) (all p<0.05). Mean total hospital admission costs were lower in the SP cohort, with a significant difference in admission costs between historical and SP non-surgical groups of $A8363 (95% CI 81.02 to 16645.32, p=0.048) per patient on the pathway. A second cohort of 449 patients with sepsis from January to December 2014 demonstrated sustained improvement.

Conclusions The SP was associated with significant improvement in patient outcomes and reduced costs. The SP has been sustained since 2013, and has been successfully implemented in another hospital with further implementations underway in Victoria.

  • nurses
  • quality improvement
  • process mapping
  • health services research
  • antibiotic management

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Footnotes

  • Contributors KAT was the clinician lead for the SP since 2012, designed the data collection, contributed to the analysis and was the main author of this paper. SL was the AMS pharmacist and project officer during 2012/2013 and contributed to the study design data collection and authorship. JJ and GMH contributed to the data collection and implementation of the pathway, and review of the manuscript. BT contributed to SP sustainability and to authorship. MT undertook the cost analysis and contributed to authorship. KD supervised cost analysis. GV and AH collected 2014 data. VL contributed to database development and antimicrobial data. CB was the WCMICS project officer who assisted with the hospital implementation at both hospitals. LJW and MAS contributed to study design and authorship.

  • Funding This study was funded by Western and Central Melbourne Integrated Cancer Centre.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Peter MacCallum Cancer Centre Human Research Ethics Committee approved this study (Project No: 13/189  L).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Requests for access to data should be addressed to the corresponding author.

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