California State University Long Beach Sepsis Paper

HCA 450 – Fall 2019Assignment Guidelines: Final Project Presentation
Due Date
All the presentations should be submitted by the specified deadline (check the course schedule).
Expectations Overview
The students are expected to present their final project in the class. This is a group project, therefore, all
deliverables for this assignment will be graded based on the group’s performance. Teams must work together to
ensure that they are prepared for the presentation. All team members should participate in the presentation. This
assignment aims to demonstrate the students’ ability to present and discuss the selected problem for the final
project as well as the solutions and interventions.
It is preferred to be in professional attire for the presentation. You will be evaluated on the actual presentation,
presentation skills, and professionalism. After the presentation, teams will evaluate all members. Members will be
assessed on participation, involvement, contribution, and group dynamics (see Peer Evaluation form on
The presentation should be timed to be finished within 10 minutes. There will be a 5 minute Q&A session at the
end of the presentation.
You may use various visual aids for your oral presentations including, but not limited to, PowerPoint
presentations, handouts and videos.
Consider asking questions throughout presentation to keep the audience engaged.
Presentation flows
well. Speakers are
clear and engage
audience. All team
participate equally
in presenting.
Materials are
appropriate and
designed well.
Presentation flows
Presentation does
well. Not all
not flow well. Not
speakers are clear
all speakers are
and engage
clear and engage
audience. All team audience.
Materials have
participate equally
major flaws (font
in presenting
Materials are
spelling, etc.)
appropriate and
designed well but
have minor flaws
(font inconsistency,
spelling, etc.)
Page 1 of 2
Presentation suffers
significantly from
lack of flow and
materials are used.
There are the four core sections that should be included in your presentation:
**Do not copy what is in the paper, as the goal of this assignment is to show that you understood the work
presenting in the paper**
Background: Provide background information necessary to understand how the problem at hand
aroused. (2 points)
Problem definition: Define the problem being solve. (2 points)
Solution/Intervention: Outline the solution/interventions discussed in the paper by discussing: (12
1. Detailed description of the area chosen for study: describe the setting for the project (e.g.,
hospital, ambulatory care) and the portion of the medication use process, if medication is
involved (e.g., prescribing, dispensing, administering, monitoring) (2 points)
2. Detailed steps of the procedure and the intervention including people responsible (3 points)
3. The process and/or outcome measures necessary to determine if goal(s) were met (3 points)
4. Data collection methods, plus what data were collected and what measures existed (2 points)
5. Why the selected work is/isn’t important (2 points)
Strength and weaknesses: Express the weaknesses and strengths of the work described in the
journal paper by providing: (3 points)
1. Comments on the article, including its advantages and limitations; include personal
comments and critiques
2. A list of challenges facing the work discussed in the article
3. At least two next steps/future work for the selected article
IMPORTANT NOTE: You may need to use additional references. The intent is for you to determine
what you need to learn in order to fully understand your paper, its problem, and solution – some will
need to review many references; some may need only a few.
Page 2 of 2
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BMJ Quality Improvement Programme
A collaborative improvement project by
an NHS Emergency Department and
Scottish Ambulance Paramedics to
improve the identification and delivery
of sepsis 6.
Martin Carberry, John Harden
To cite: Carberry M,
Harden J. A collaborative
improvement project by an
NHS Emergency Department
and Scottish Ambulance
Paramedics to improve the
identification and delivery of
sepsis 6. BMJ Quality
Improvement Reports
Received 29 June 2016
Revised 18 August 2016
NHS Lanarkshire Scotland
Correspondence to
Martin Carberry martin.
Early identification of patients with sepsis is key to the
delivery of the sepsis 6 bundle including antibiotic
therapy within an hour.[1-3] Demand versus capacity
challenges in the Emergency Department (ED) led to
delays in antibiotic and sepsis 6 delivery. An alerting
tool was developed that provided criteria for Scottish
Ambulance Service (SAS) Paramedics to alert the ED
of potential sepsis patients.
Data from patients presenting to the ED prior to the
alerting process commencing (n=50) and during
alerting (n=50) were analysed, a questionnaire was
used to ascertain feedback from all staff groups;
nurses doctors, and paramedics (n=38). Mean Time to
triage improved by 82% from 17 minutes to 3 minutes
( p=0.01), time to first antibiotic improved by 39%
from 49 minutes to 30 minutes. Overall 78% of
patients received antibiotics within an hour of leaving
their home; no significant increase in workload was
reported by staff.
In conclusion alerting by paramedics of potential
sepsis patients reduced the time taken to deliver the
Sepsis 6 Bundle. Process reliability has been sustained
over several months. This process has been spread to
seven regional ambulance stations in Lanarkshire
Wishaw General Hospital is a district general
hospital in Lanarkshire, Scotland. The
Emergency Department (ED) sees 70,000
patients per year. Wishaw hospital is served
by the West of Scotland SAS.
A problem was highlighted with the early
identification and treatment of septic
patients. This was felt to be due to increased
activity and demand versus capacity in the
busy ED. The cause of the problem was supported by data from the multidisciplinary ED
sepsis team; the mean time to Triage for
sepsis patients was 17 minutes, time to antibiotics was 49 minutes, and reliability of the
sepsis 6 bundle was 78% (aim was 95% reliability). The mean time to triage of 17
minutes was therefore consuming nearly a
third of the 60 minute timeframe for the
delivery of the sepsis 6 care bundle.
Collaborative identified early recognition of
sepsis as essential for the timely delivery of
the sepsis 6 bundle, an issue also supported
by the literature.1 2 The issue was shared with
the ED staff and discussed at length. SAS
were subsequently contacted to discuss the
project. A small improvement team including
consultant nurse, consultant ED physician,
SAS paramedic, and SAS management team
was established. The project team liaised and
provided feedback to the multidisciplinary
site team at the weekly ED sepsis meet.
The aim of this project was to demonstrate
a 20% improvement in the time taken to
identify potentially septic patients (as measured by the time to triage) and treat them
(as measured by the time to antibiotics)
within 12 months, through SAS Paramedics
pre-alerting the ED of potentially septic
patients. The time of arrival in the ED is
taken as the start time for measurement of
time to antibiotics.
NHS Lanarkshire committed to the Scottish
Patient Safety Programme (SPSP) sepsis work
stream in 2012. In the two years that followed, NHS Lanarkshire developed multidisciplinary sepsis pilot teams in three EDs
across three district general hospitals.3 The
model for improvement was used to test
improvements with Plan Do Study Act
(PDSA) cycles aimed at implementing and
improving the delivery of the sepsis 6 care
Carberry M, Harden J. BMJ Quality Improvement Reports 2016;5:u212670.w5049. doi:10.1136/bmjquality.u212670.w5049
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Open Access
Sepsis causes significant morbidity and mortality as
much as 35% in severe sepsis.4 Financial costs were estimated in the US at $16 billion per annum in 2001 and
reported to be rising in 2007.5 6 Data from a multicentre
European prospective observation study (SOAP Study)
was used to estimate the cost of each case of sepsis at
€25,000.7 Taking into account the UK sepsis prevalence
this has been reported as equating to about £2 billion
annually for the UK.8
The epidemiology of sepsis was more recently estimated in a review in 2012 and suggested the incidence
of sepsis is significant with severe sepsis estimated to be
as much as 300 cases per 100 000, with mortality estimated at 30% for sepsis, 50% for severe sepsis, and as
much as 80% for septic shock.9 However, the data as
reported was from developed countries.
The mortality rate of severe sepsis and septic shock is
also significantly higher than other time-sensitive diseases. This has been reported as sepsis patients having a
level of risk of mortality 6–10 times greater than if admitted with an acute myocardial infarction and 4–5 times
greater than an acute stroke.10
There is compelling evidence that the implementation
of the sepsis treatment bundle (sepsis 6) within the first
hour of the recognition of severe sepsis (organ dysfunction) can markedly reduce mortality, in some studies by
as much as 50%, with the number needed to treat
reported at 4.6. The sepsis 6 is a care bundle that is
based on the recommendations from the surviving
sepsis campaign (SSC) but it simplifies the pathways in
order to improve reliable delivery and subsequently
patient outcome.11 12 The SSC bundle includes the
administration of high flow oxygen, rapid intravenous
fluid administration, and antibiotic administration
together with blood cultures, lactate and haemoglobin,
and urinary output assessment.12
The importance of early administration of antibiotics
was highlighted by a study by Kumar and colleagues in
2006, who demonstrated that for every one hour delay
in the administration of antibiotics in severe sepsis, the
risk of death increases by 7.6%.13 The reduction in mortality from sepsis has been the focus of worldwide and
national campaigns, namely the SSC and now SPSP.3 12
However, a recent systematic review and meta-analysis
of literature looked at the timing of antibiotic administration and outcome in severe sepsis and sepsis shock.
The reviewers found no benefit in mortality based on
administration of antibiotics within three hours of ED
triage or within one hour of shock recognition in severe
sepsis and septic shock. They concluded that time to
antibiotics should not be used as a measure of quality of
care. The reviewers did however “recognize that failure
to administer effective antimicrobial therapy will at some
time point be detrimental to patient outcomes, the
exact time frame when this shift begins to occur remains
Sepsis has very recently been “redefined” by the third
international consensus group, “As a life-threatening
organ dysfunction caused by a dysregulated host
response to infection” with the recommendation to
implement Sequential (Sepsis related) Organ Failure
Assessment (SOFA) for assessment causing significant
With the support of the SPSP programme, NHS
Lanarkshire sepsis pilot teams had defined severe sepsis as
a Systemic inflammatory Response Syndrome (SIRS) score
of 2 or more, with evidence of probable infection and a
Modified Early Warning Score (MEWS) of 4 or greater.16
The MEWS trigger of 4 was derived from Daniels and colleagues study who reported patients median MEWS at time
zero of 6.0 (range 0-15), with n=467 (81.2%) of patients
meeting the trigger threshold of 4.11
The activation of SIRS is a physiological response in
the presence of inflammation, often accompanied by
infection, but not exclusively so. SIRS criteria alone lacks
sensitivity of detecting sepsis and should be used in conjunction with a severity score, in our case MEWS.11
The SIRS criteria tested were respirations >20, pulse
>90, temp >38.5 or 12 or 7.7 in absence of diabetes and reduced conscious
level with the removal of WBC criteria due to potential
time delay in obtaining results in the ED. These criteria
were key to the development and testing of the paramedic pre alerting tool for suspected sepsis patients.
The UK Sepsis Trust pre hospital recommendation and
pre hospital screening tool were also taken into consideration prior to testing.17
An increased incidence of severe sepsis presentations
to ED has been reported internationally, in comparison
with acute myocardial infarction and stroke.2 Moreover
the study highlights the pre-hospital interval as an
important opportunity for recognition of sepsis due to
its time sensitive nature.2 In relation to Scotland, one
study reported that approximated 88% of patients with
severe sepsis present to Scottish ED’s by ambulance.1
There is a lack of publications on the design, testing,
and efficacy of pre hospital sepsis alert tools used to
alert EDs of suspected sepsis patients. With this in mind
and with evidence to support the time sensitivity of treating severe sepsis the pre alerting of suspected cases was
the focus for this improvement project.
The ED is a busy environment for staff with not only
increasing acuity and an aging patient population, but
also national and regional targets including triage time,
waiting time, and patient flow identified as areas for
Review of reliability of the delivery of the sepsis 6
bundle within the ED based on 50 patients, led the team
to identify time to triage (mean 17 minutes), time to
antibiotic (mean 49 minutes) and sepsis 6 reliability of
78% as an opportunity for improvement. Time zero
(time when clock started for sepsis delivery within 1
hour) was operationally defined as the time sepsis was
Carberry M, Harden J. BMJ Quality Improvement Reports 2016;5:u212670.w5049. doi:10.1136/bmjquality.u212670.w5049
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Open Access
identified. In all cases this equated to the time the
patient “booked into” the ED, for SAS patients.
Triage time was highlighted as the primary target area
for improvement. The team hypothesised that if suspected sepsis patients were pre alerted then this would
subsequently reduce/eliminate triage and reduce the
time to antibiotics and sepsis 6 delivery. The aim was to
improve these measurements by 20% in a 12 month
The data below were included in the project measurement plan. The team analysed data from SAS septic
patients prior to the implementation of the Alerting
process (n=50) and during the alerting process (n=50).
Data were extracted retrospectively from case note
review, recorded by hand and later transcribed onto
excel for analysis. All data were checked for accuracy
and then quality assured by the consultant ED physician.
The improvement project measurements were; the time
from the SAS alert call to the arrival at the ED; the time
of triage; the time to first antibiotic dose; the time to
sepsis 6 completion (all components of the bundle delivered) and the percentage of patients who had Sepsis 6
completed within 60 min. Furthermore, the number of
“false” sepsis alerts (alerted patients who were diagnosed
as not sepsis by the ED) was also noted.
Staff concerns regarding a potential increase in workload were noted. To assess this, a questionnaire was constructed to gauge staff feedback (See Supplementary
File SAS Tool and Questionaire). This was identified as a
possible balancing measure (increased workload).
The questions were developed from themes noted
during staff discussions. The themes were then refined following results from a test of the questionnaire. ED nurses,
senior doctors, and paramedics not directly involved in the
alerting process were asked how appropriate they felt the
responses were.18 The questionnaire was in written format;
participation was voluntary and responses anonymised.
The questionnaire was circulated to all staff groups during
the alerting phase of the project.
Statistical analysis was conducted by using a t test to
test for differences in mean time to triage for both
groups i.e. prior introduction of the alerting process
and during the alerting process.
With evidence to suggest that 88% of septic patients
arrive by ambulance, pre alerting of septic patients was
highlighted as a key area for improvement in time to
deliver the sepsis 6.1
The first step in the improvement design was to
engage key stakeholders, namely ED staff, who were
already involved in hospital testing and SAS leaders with
a view to forming a small improvement team. This was
done by presenting the ED baseline data together with
the background on sepsis, sepsis mortality, and the
sepsis 6 treatment pathway to key SAS leaders. A series
of meetings were used to highlight the potential impact
of a proposed pre alerting process for suspected sepsis
patients and the impact on patient outcome. A local SAS
station was carefully chosen to design and test a draft
alerting process.
The next step was to work with the paramedics in the
field as they treated patients in order to observe their
processes and systems. The consultant nurse worked
with one paramedic at one station in order to learn
their ways of working.
The final step was to commence the design of a
simple tool that would take into account the paramedics
and ED current processes. A simple tool was then
designed by the team. (See Supplementary File SAS
Tool and Questionaire) The tool was then tested and
refined through multiple PDSAs, the tool for testing
included source of infection, vital signs, and patient
allergies. Paramedics called the ED with this information. By pre-alerting the department of potentially septic
patients, the department would prioritise these patients,
seeing them as soon as they arrived. The ED staff prepared for the patients arrival with the belief that this
would reduce time to triage and instigation of the sepsis
6 treatment bundle.
Using the Model for Improvement, training for this
tool was undertaken with a Paramedic on a 1-1 basis.
Further PDSAs refined the alerting process over the
next two months. Paramedics and the ED team were
fully involved in providing feedback at weekly ED sepsis
meetings in an effort to further improve the process.
Additional PDSA cycles were completed to spread the
process over a testing period of four months and
included all paramedics at one testing SAS station.
Educational support included 1:1 sepsis sessions that
provided a brief overview of pathophysiology, incidence,
mortality, and treatment, with particular emphasis
placed upon the time sensitive aspects of the sepsis 6
care bundle.
The Model for Improvement with multiple PDSA cycles
were used to observe practice, design, and then test the
paramedic sepsis alerting tool. (Details of the PDSA
cycles are shown in the Supplementary File PDSA)
Tested if the pre alerting process could be used by paramedics for suspected sepsis patients.
Tested a call to the ED stand by phone using the refined
Alerting tool.
Tested a statement of “Sepsis pre alert call” test instead
of “Stand by” call.
Initial plans were to deliver intravenous antibiotics to
patients by the paramedics at the scene with radio communication providing professional to professional
support. This was rejected for testing as it was felt to be
Carberry M, Harden J. BMJ Quality Improvement Reports 2016;5:u212670.w5049. doi:10.1136/bmjquality.u212670.w5049
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Open Access
overly complex, impractical, and unnecessary for the
majority of the geographical locations of sepsis calls
received by the testing SAS station.
PDSA cycle 1 tested the concept that a pre alerting
process could be used by paramedics for sepsis patients.
We learned that vital signs were recorded reliably but,
due to nature of pre-hospital working methods and time
constraints the National Early Warning Scores (NEWS)
was usually calculated retrospectively. Observational sessions provided invaluable insight, facilitated the development of the teams to improve the process and helped
with essential team building. We concluded we could
test SIRS, vital signs, and source of infection in a pre
alert tool with the only additional workload being the
radio call to the ED.
The paramedic, nurse consultant, and ED consultant
then progressed to design a draft alerting tool that
focused on the above patient information. The process
was then tested by a single paramedic. Initial feedback
from ED staff and the paramedic was positive, but the
radio call was highlighted as an issue.
PDSA cycle 2 tested a call to the ED stand by phone
using the refined Alerting tool. Following suggestion
from ED consultant the PDSA added “Patient Allergies”
to the tool. Feedback was positive but noted potential
for misunderstanding i.e. was this a “stand by” call.
PDSA cycle 3 included a statement of “Sepsis pre alert
call” test instead of “Stand by” call this was clearly understood by staff. Feedback was positive and prompted staff
to think about good antimicrobial stewardship.
The alerting process was then spread gradually by providing 1:1 teaching sessions to 3, then 5, then all 10
paramedics at one station.
Of those alerted patients, n=43 (86%) had a MEWS of 4
or more, and met the inclusion criteria for our definition of severe sepsis. Sources of infection for alerted
patients were chest sepsis n=36 (72%), urinary sepsis
n=9(18%), chest and urine sepsis n=1 (2%),
neutropenia 1 (2%), and unknown origin n=3 (6%).
Non septic patients or those with significant data
missing were excluded as where patients alerted by
“inadvertent spread” to non testing stations.
Triage times for non-alerted (n=50) and alerted
(n=50) sepsis patients are illustrated in Figure 1. Time to
Triage is used as a surrogate for the time taken to identify potentially septic patients and was reduced by 82%
(17 minutes to 3 minutes) with a reduction in process
variation noted. The reduction in the variation is indicative of the introduction of the alerting tool and subsequent standardisation of the process afterwards. A t test
showed statistical difference between alerted and non
alerted mean times to triage, p=0.01.
Time to antibiotic improved by 39% (49 minutes to 30
minutes) which indicates a reduction in the time to
treatment. Overall, the sepsis 6 process reliability ( percentage of patients successfully receiving the complete
bundle within 60 minutes) improved from 78% to 98%.
Importantly it was noted that 78% of pre alerted patients
received the sepsis 6 bundle within an hour of leaving
Balancing measures included results from a staff questionnaire. The questionnaire focused most notably on
the degree of workload as perceived from the multidisciplinary team (n=38), doctors (n=14), and nurses (n= 18)
in the ED and SAS paramedics (n=6). No significant
increase in workload was reported by any staff group with
89% (n=34) reporting that the alerting process improved
care for sepsis patients.
Further balancing measures were evaluated via the
number of “False positives”; the alerting of non-sepsis
patients. These were minimal and decreased over time
with ED staff reporting simple step down for these
A number of important lessons were learned during this
project. Firstly the importance of multidisciplinary team
work. One key example of this was the valuable learning
Figure 1 Time to Triage in
minutes per patient
Carberry M, Harden J. BMJ Quality Improvement Reports 2016;5:u212670.w5049. doi:10.1136/bmjquality.u212670.w5049
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Open Access
gained from observing SAS colleagues in the field in
order to understand their way of working. This informed
the design of the alerting process. The decision to build
the tool around the actual process of the SAS paramedics routine working pattern was essential.
Secondly the decisions to keep the tool very simple
and resist the temptation to add to it or overcomplicate
it. This decision was informed again by the early learning in the project from the paramedics.
Thirdly the value of real time feedback and open discussion and debate, at weekly meetings of the NHS
Lanarkshire’s reducing harm collaborative. This regional
approach allowed the team to share experiences, data,
and learning as well as facilitating education for colleagues in other neighbouring ED’s.
Additionally, the decision to form a small improvement team was also crucial. This allowed quick and
simple decision making that was based on real time data
from testing. These data were then used to feedback to
the wider ED staff and SAS colleagues in order to build
will and improve team rapport. Overall this helped with
the embedding and the subsequent ownership of the
process as well as longer term process reliability and sustainability. Building on from this we have spread to
include seven SAS stations whilst maintaining > 95% reliability of sepsis 6 process.
Finally the decisions to resist accelerated spread early
in the project allowed the improvement team time to
build will with a few colleagues who feared over alerting
and alert fatigue. We managed to overcome this challenge as more supporting data and patient stories
became available.
Challenges included potential alert fatigue, namely
potential to underestimate incoming sepsis alerts due to
the volume of calls for all ED alerts, such as myocardial
infarction and stroke, or desensitisation of the process.
This was addressed by weekly review of all SAS alerted
cases, feedback and discussion and sharing of process
reliability data with the ED and SAS staff.
This study was not designed to change the time taken
to assess the patients. This remained constant throughout the study period. During this ~25 minute period, the
patient received initial medical and nursing assessments,
monitoring, IV access and the other components of the
Sepsis 6 bundle required before safely delivering antibiotic therapy.
Limitations of the project included inadvertent spread
by SAS paramedics into SAS stations that were not formally testing the process. This may have resulted in
some bias. Although they were effective in alerting some
patients, the process was not underpinned by teaching
or supported by the improvement methodology. To minimise the potential for bias from this source, these data
were removed from the project analysis. This inadvertent
spread may have been reduced by more effective and
consistent communication by the improvement team.
Other potential limitations to the generalisability of
this study’s findings may be that the geographical
location of the SAS stations was in relative close proximity to the test ED. The recorded SAS travel time to hospital was for most patients less than 15 minutes, but a
few patients took up to 25 minutes. The process
described for pre-alerting of patients with a greater travelling time to the ED would still be applicable, however
possible on site treatment for severe sepsis with antibiotic delivery should be tested.
The introduction and sustained use of the alerting tool
by paramedics has improved the time to triage and thus
time to antibiotic and time to sepsis 6 for patients presenting with sepsis by ambulance. Reducing time to
triage coupled with pre identification of suspected sepsis
patients has provided valuable minutes required to meet
the sepsis 6 delivery within 60 minutes.
To our knowledge, there have been no high quality
studies specifically looking at the benefits from pre-hospital
identification or alerting processes. It has been suggested
that work needs to be done to look at this area.19
The team approach facilitated by the sepsis collaborative has helped embed ownership of the process with
regular review and feedback helping to refine the
The reliability of the alerting process has been sustained. The alerting process has now been spread to
seven SAS stations. The spread plan to these and other
SAS stations has been subject to careful but deliberate
debate and based data and staff feedback specifically in
relation to workload.
We continue to monitor its use and the efficacy of the
process. We are working with colleagues to share our
learning from this project and the integration of this
work into the national agenda for SAS and pre hospital
Acknowledgements Ann Rodger SAS, Andy Graham SAS, SCN Tracy Dodd
ED, Wishaw Hospital ED staff and Hospital Emergency Care Team, Connie
Sharrock, Joe Hands, Raymond Hamill, Ann Hair.
Declaration of interests None declared.
Ethical approval This project was exempt from ethics approval as it was
deemed an improvement project as part of NHS Lanarkshire reducing harms
Open Access This is an open-access article distributed under the terms of
the Creative Commons Attribution Non-commercial License, which permits
use, distribution, and reproduction in any medium, provided the original work
is properly cited, the use is non commercial and is otherwise in compliance
with the license. See:
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Carberry M, Harden J. BMJ Quality Improvement Reports 2016;5:u212670.w5049. doi:10.1136/bmjquality.u212670.w5049
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A collaborative improvement project by an
NHS Emergency Department and Scottish
Ambulance Paramedics to improve the
identification and delivery of sepsis 6.
Martin Carberry and John Harden
BMJ Open Quality: 2016 5:
doi: 10.1136/bmjquality.u212670.w5049
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