Employing quality improvement methodology in sepsis: an electronic sepsis order set further improves compliance with the Surviving Sepsis Campaign 3-hour bundle

Introduction

The Surviving Sepsis Campaign (SSC) has developed guidelines to promote evidence-based management for patients with severe sepsis [1]. Improvements in bundle compliance have been demonstrated over time, but compliance remains below 40%. Sepsis has been studied in acute and critical care environments, but little research has focused on the management in level 1 wards. An initial audit of patients with sepsis who were referred to the GSTT critical care outreach team revealed very low overall compliance to the SSC 3-hour bundle. A novel quality improvement campaign was instituted with the aim of improving bundle compliance.

Methods

A retrospective cohort study in a university hospital was performed. Patients on level 1 wards with severe sepsis registered in the adult critical care response team (CCRT) database in November 2012 were identified (Cohort A). Physiological observation, track and trigger scores, compliance with the 3-hour bundle elements (measured lactate, blood cultures before antibiotics, fluid challenge, early antibiotics), antimicrobial stewardship and 28-day mortality were recorded. Following this, a quality improvement project was initiated: central to this was an electronic 'SEPSIS' order set, containing appropriate investigations and a step-by-step management guide for use on level 1 wards. A 'viral' print and social media campaign were also undertaken. Compliance to the SSC early care bundle was re-examined in two cohorts of patients in July 2013; patients that were referred to the CCRT as before (Cohort B) and also patients who had the electronic order set activated (Cohort C).

Results

The mean age of all patients studied (n = 79) was 66.5 years. Fifty-three per cent of the patients were male. Thirty-one per cent were in septic shock at the time of sepsis identification. Overall SSC bundle compliance was 6.60% (Cohort A), 24% (Cohort B) and 45.5% (Cohort C). Improvements in other bundle parameters were also seen, including blood culture (54%, 72%, 91%), antibiotic administration (50%, 69%,76%) and fluid administration in septic shock (50%, 42%, 75%) in Cohort A, Cohort B and Cohort C respectively.

Conclusion

Baseline compliance with the SSC 3-hour bundle on level 1 wards was very low. An electronic sepsis order set was associated with marked improvement. Novel quality improvement methodology may be important to achieve optimal compliance with evidence-based guidelines and an electronic sepsis order set is recommended.