After disappointing results in delivering timely treatment for sepsis, the Emergency Department (ED) at Royal Cornwall Hospital (RCH) in Truro turned to systematically addressing the barriers to success in their treatment. Working with the South West Academic Health Science Network (SW AHSN), the department is using Model for Improvement methodology.
The learning from this Quality Improvement (QI) process is ongoing – but the team are seeing significant insights just part way through the project. In this blog, SW AHSN deteriorating patient lead Harriet Matthews, together with RCH ED consultant Dr Mark Jadav and ED matron Jane Michell, share what they know in the hope it will help colleagues in the sector who are also grappling with change across areas of hospital treatment.
At RCH, a combination of QI interventions has led to a sustained increase in patients receiving antibiotics within one hour of arriving at the ED – contributing to a reduction in observed and expected deaths from septicaemia throughout the hospital.
What’s more, on this journey seven ED staff (nursing and medical) have actively participated in the Patient Safety Kernow Quality Improvement Collaborative (PSKQI), a collaborative helping to improve the way health and social care partners are delivering care in Cornwall (learn more here). In doing so they have increased their knowledge of QI methodology, culture, and human factors, and their understanding of the barriers and drivers for improvement. Several staff have gone on to set up their own QI projects for other conditions, augmenting the impact of this empowerment and skills development across the trust’s care services.
What was happening in RCH’s ED before this change in approach?
Despite persistent efforts by the ED over the last four years to increase the number of patients with severe sepsis receiving Sepsis-6 treatment within one hour of presentation [I], data from various sources has shown variable success and limited sustainable improvement [II].
In recent years, the ED has faced many challenges including periods of over-crowding, the incorporation of new definitions of sepsis as recommended by NICE and the UK Sepsis Trust, the restructuring of the workplace, a regularly changing workforce and the use of new electronic systems.
In response to these challenges, in June 2018 RCH ED and the SW AHSN joined PSKQI. Under the guidance of QI specialists from the health and social care system, PSKQI uses the Model for Improvement, a framework developed by Associates in Process Improvement to encourage teams to look at problems in a different way.
The ED team wanted to make changes to systems and working methods to enable staff to recognise, exclude or treat Red Flag (severe) Sepsis within one hour of patients presenting to the emergency department. In the face of numerous potential obstacles and a need for numerous changes, a dedicated team was formed to identify the pathways and barriers to this timely treatment of patients.
By looking at each barrier in turn, the team has been facilitating key changes needed to pursue this aim.
What are these changes?
Improving knowledge, communication, use of resources
- Focused staff training on sepsis, including a toolbox talk to all nursing staff, in-situ simulations to test pathways, and sepsis inductions for new doctors.
- Feedback on staff performance, including monthly audits and personalised emails to doctors encouraging them to reflect on cases of sepsis they have seen to identify factors which helped or hindered delivery of timely treatment.
- Pre-alert and triage documentation available at critical points. The ED telephone alert information form and the triage document both now contain specific questions relating to the recognition of sepsis.
- 24/7 resourcing of the Rapid Assessment and Treatment Models (RATS) team. The team is allocated on rotas to ensure the right skill mix at any time.
- Improved communication between triage nurses and senior doctors/RATS team, including face-to-face sharing of information about patients with suspected sepsis instead of reliance on computer systems.
- A bundle of documentation on standard treatment in one form, instead of numerous forms, to encourage speed and accuracy.
Staff and equipment resource and space available
- A designated sepsis nurse in the RATS team responsible for immediate treatment of septic patients until the ‘Sepsis Six’ care bundle is delivered.
- Fully-stocked grab boxes and a sepsis trolley in the rapid assessment area.
- Designated cubicles or resus kept free for sepsis assessment.
Working with Quality Improvement Partner Panels (QuIPPs)
- Public panel members wanted to ensure that domestic staff would be able to raise the alarm if they noticed a deteriorating patient, so the team put posters in waiting rooms publicising the Sepsis Trust’s campaign Just ask: Could it be sepsis?, and ensured that domestic staff knew of escalation channels.
Working with the wider health-care system
- The RCH ED team are working with St Austell Health Hub to ensure they are able to take blood cultures and deliver a first dose of antibiotic to patients diagnosed with Red Flag Sepsis. This is now being rolled out at other surgeries in the county.
The interventions and change facilitated at the RCH ED intersect numerous aspects of emergency department care, but collectively are part of the team’s ongoing and collective efforts. The impact of this work in relation to a timely response to sepsis will of course be closely monitored and will also be critical to identifying other indirect benefits of this QI methodology, or how it enables further projects focused on improvements to patient care.
Are you thinking of undertaking a deteriorating patient or sepsis QI project at your trust? Consider our top tips.
- When the old approaches don’t work, use QI methodology.
- Find an expert to guide you. The RCH ED worked with the expertise of the SW AHSN for several months.
- Collect a comprehensive team and meet regularly, even for short catch-ups.
- Bring data collection as close to the time and people involved as you can.
- Finally, always remember why you are making changes: to improve care and save lives.
For more information on this project please contact firstname.lastname@example.org.
[i] Achieving full sepsis-6 treatment within 1 hour of presentation is associated with a reduced mortality. Daniels, et al. The Sepsis Six and the Severe Sepsis Resuscitation Bundle: A Prospective Observational Cohort Study. Emergency Medicine Journal. 2011;(28):507–512.
[ii] From Royal College of Emergency Medicine audits, Commissioning for Quality and Innovation frameworks, and monthly audit data.