Table 1

Learning Cycle (PDSA) to improve the management process of septic patients

	PDSA group 1	PDSA group 2	PDSA group 3	PDSA group 4	PDSA group 5
Cycles (n)	17	4	25	28	10
Plan	To map sepsis management in the hospital (before study intervention), and to identify and propose alternatives to improve sepsis care in the ICU	To develop an early warning system for sepsis	Identify opportunities to improve sepsis treatment at the ICU and implement them	To define standard flows for early recognition and treatment of patients who developed sepsis in the wards	Improve early identification and early referral of patients with sepsis from the neighbouring emergency unit
Do	Observational track of real cases of patients with sepsis (followed by debriefing with attending nurses and physicians)	Discussions about components of the hospital early warning system	Brainstorming with ICU team/subgroups that were defined to build proposals based on the most accepted ideas	Spread and share successful experiences developed in the ICU. Brainstorming to propose and implement specific changes/improvements	MSP document sharing; four waves of educational activities were developed, compliance with the protocol was measured and feedback to teams was provided
Study	Evaluation of staff perceptions, and brainstorming on alternatives for earlier identification of patients with sepsis	Tests with patients (real cases). Consensus about early warning system components	Tests with staff included individual perception of gain, usefulness and time saving	Impact assessment of the ICU tools (stamp) and new tools (new vital signs record form) on staff perception	Time intervals assessed (from admission to diagnosis, from diagnosis to blood samples, from diagnosis to treatment)
Act	Development of new tools: Nurse empowerment (suspected sepsis stamp) Lab stamp (to reduce time to lab results) Sepsis training programme for nurses (simulation and role-playing techniques)	Validation and implementation of: Sepsis standard order set Clinical decision support algorithm Sepsis test kit (for lab samples)	Validation and implementation of: Sepsis standard order set Clinical decision support algorithm Sepsis test kit (for lab samples)	Spread suspected sepsis stamp Sepsis champions Education of high-risk patients and their families (video) New vital signs record form	Physicians and nurses educational programme on sepsis Sepsis kits (to blood samples) and lab results are provided MSP and sepsis standard order sets are shared Performance indicators are created (based on electronic medical record and sepsis standard order set audits)

ICU, intensive care unit; MSP, managed sepsis protocol; PDSA, Plan-Do-Study-Action.