Box 1 An example from the emergency department: creating a sepsis performance improvement program in a large university medical center. The different phases of implementing a sepsis performance improvement program in the Amsterdam University Medical Center

Pre-implementation phase:

• Retrospective and prospective evaluation of the current situation to identify opportunities for improvement. We noted:

 - Sequential ED consultations by various specialists, which delayed appropriate care.

 - Non-urgent triage codes in (elderly) patients with suspected sepsis.

• Involvement of patient representatives.

 Interventions:

• Screening tool selected: MEWS (already in use and thus easy to incorporate).

• Process changes: Initiation of a sepsis response team, standardized notes and EHR order sets, daily audit and weekly feedback.

• Education: Launch of a dedicated website, pocket cards, talks at morning hand-over.

 Lessons learned so far:

• Early challenges include behavior change and trust among all stakeholders that the new workflow will be efficient and may improve outcomes.

• The engagement of only a few clinical leaders per department seems insufficient for successful implementation, especially in the dynamic environment of an ED.

ED emergency department, ICU intensive care unit, MEWS Modified Early Warning Score, EHR electronic health record