Table 1

Barriers to appropriate sepsis management and corresponding interventions

Intervention
Issue focus 1: improve recognition and referral of sepsis across clinical areas
1.1 Target areas
Ambulatory areas:
Staff rely on experience and training to identify sepsis; variability in referral practices, often have bank/junior staff.
Outpatient clinics: 300–400 visits per day, but 1 in 5 unplanned admissions due to sepsis. Strong support for a standardised approach.
Radiotherapy: perceived as infrequent: estimated as 1 every 2 months.
Apheresis: many other reasons for haemodynamic instability (eg, transfusion reactions).
Inpatients areas:
Different sepsis screening procedures across wards.
Many high-acuity patients (requiring emergency department level care) are admitted after-hours directly to wards.
Identification of sepsis without fever in patients is difficult; treatment guided by senior nurse/haematologists. Doctors often rationalise that fever is due to other causes (eg, cancer related).
Sepsis pathway to be implemented across all ambulatory and inpatient areas.
Decision aids for sepsis identification and workup (posters) in all clinical areas.
six bed acute assessment area opened in December 2012. Used for all unintended admissions where possible. On same floor as the intensive care unit and able to monitor patients.
1.2 Observations
Current chart uses clinical review (Between the Flags) parameters that differ from the systemic inflammatory response syndrome criteria. The basic observation charts in the ambulatory areas are not using the Between the Flags criteria. In radiotherapy, only a single set of observation done.
No process to identify unwell patients.
Variation in compliance with RR measurement and documentation.
Observation charts standardised across all inpatient areas.
Observation chart adapted for single day to ambulatory areas including radiotherapy.
Nursing education and audits of observations.
1.3 Knowledge gaps among junior resident medical offices (RMO) and nursing staff about definitions, indicators and management of sepsis.Whole of hospital education strategy involving junior, senior medical staff and nursing. Sepsis launch; posters and in-services
Issue focus 2: improve time to medical review
2.1 Poor communication/handover:
Doctors find it difficult to prioritise clinical review when vital clinical information is not available from the referring nurse.
Phones in wards/clinical areas left unattended or not answered.
Difficulty in troubleshooting with on-call doctors if not they are not familiar with complex haematology patients.
Many divisional junior staff do not have a formal morning handover process. Overnight events are usually picked up by reading clinical notes by the day teams.
Institute Identify, Situation, Background, Assessment and Recommendation for nurses to page, communicate efficiently to doctors.
Mobile phones provided to nurse unit managers and patient services. ManagersInstitute formal handover process for overnight staff.
Institute handover between nursing shifts about patients with sepsis.
2.2 Absent or unclear escalation process
Radiotherapy: notably more difficult to contact Radiation Oncology Registrars (as usually off-site for education).
Poor clarity about escalation process if multiple teams are involved (med oncology vs radiation oncology vs surgery).
Poor ownership of the medically unwell patient who is not a planned day admission; confusion about who to call (multiple teams). As above for inpatient areas.
Established an accepted escalation process.
Once implemented—wards to audit and feedback.
2.3 Medical emergency team (MET) calls
Most MET calls (60%) are after-hours when only skeleton junior medical staff are available.
No formal escalation process if RMO does not attend for clinical review in time. Nurses may revert to MET call if desperate.
Many inpatients that develop sepsis immediately postoperative have not been to a preadmission clinic; surgical RMOs unfamiliar and cases can be complex.
Many high-acuity patients are admitted after-hours to the hospital.
Change in RMO roster to that more staff onsite till 21:00 hours and to assist with late surgical admissions.
After-hours admissions sent to Acute Assessment Area   ward.
Issue focus 3: improve timeliness for correct treatment of sepsis
3.1 Advanced care directives or not-for-resuscitation status
Not readily available for many patients (especially in ambulatory setting).
Implemented hospital-wide policy for timely documentation.
3.2 Fluid resuscitation
Not concordant with Australian/international guidelines—smaller volumes (than to 20 mL/kg) are commonly prescribed.
Fluid is not being administered as rapid fluid bolus (eg, increased maintenance fluids or using the intravenous pump on 999 mL/hour).
Basic fluid resuscitation does not commence until after medical review or MET called.
Many staff not familiar with the use of rapid infusers.
Education of all clinical staff and ensured adequate stock ofrapid infusors.
Performance measures:
Time to commencement of fluid bolus.
3.3 Difficult intravenous cannulation and other equipment issues
Lack of sufficient nurse intravenous cannulators—leading to major delays in instituting fluids/antibiotics (worse after-hours)
No intravenous trolley on haematology and radiation oncology ward (RMOs have to get equipment from other sites), no resuscitation trolley in apheresis.
Standard disposable tourniquets are inadequate, especially for obese/difficult cannulations.
Addressed equipment shortages.
Non-disposable tourniquets, Hartmann’s placed on resuscitation trolley and checked daily.
Urgent credentialing of new cannulators.
Intravenous trolleys all wards.
3.4 Access to intravenous antibiotics in clinical areas
Some areas already take phone orders for antibiotics.
Apheresis/radiotherapy: does not have on imprest antibiotics for penicillin-allergic patients—can be a long wait from pharmacy.
No antibiotics currently on resuscitation trolley.
Stocked all clinical areas with sepsis antibiotics.
In selected high-risk patients pre-emptive charting of antibiotics permitted.