This Sepsis Awareness Month learn how SickKids works hard 365 days a year to prevent sepsis

While September is Sepsis Awareness Month, rest assured the sepsis steering committee at SickKids thinks about sepsis 365 days a year.

Sepsis is a systemic inflammatory response to any infection, and can lead to widespread tissue damage, multi-organ failure, and death. Treatment for sepsis is time-sensitive and needs to be delivered as soon as a diagnosis is reached.

"Like heart attack and stroke, where the care received in the first minutes to hour can change the outcome for the patient, sepsis is another medical emergency we need to recognize immediately," says Julie Watson, NP, 8A, and Clinical Lead on the sepsis steering committee. 

In 2015, the team implemented an effective screening tool in the Emergency Department (ED) that required clinicians to screen for sepsis during triage. In 2016, as part of a hospital-wide group, the team developed an inpatient sepsis pathway that outlines a management workflow with order sets aligned with international best practice guidelines for sepsis in the paediatric population. SickKids met the sepsis targets outlined in the Quality Improvement Plan (QIP): last year, 99.6 per cent of patients who came through the ED were screened for sepsis (exceeding the targeted 80 per cent) and this spring, staff met the target of 80 per cent of inpatient nurses completing the sepsis education bundle.

"There hasn't been a serious safety event (SSE) for lack of recognition or late recognition of sepsis in the inpatient units since the education bundle and the sepsis pathway have been launched across the entire organization," says Mary McAllister, Associate Chief of Nursing.

The Caring Safely initiative has laid the groundwork in setting behavioural expectations for and building our culture of safety and reducing preventable harm. It's well known in health care that when prevention techniques and monitoring tools are reliably implemented and used, preventable harm can be reduced significantly. But, we still have an opportunity to further the adoption of technology to enhance team performance, and that is where Epic comes in.

Over the past year, the team has worked diligently with physicians, nurses, IT specialists, and the Epic team to roll out a computerized version of the already-used best practice alert (BPA) tool for sepsis in the Epic module in the ED. The majority of sepsis cases (approximately 85 per cent) will actually be seen in the ED, with the remainder presenting on inpatient units. The sepsis BPA rapidly identifies patients who may have sepsis, and quickly escalates to further RN and physician review.

How will Epic change how we screen for sepsis?

It automates the process, thinking of sepsis as a possibility when the clinician may not.

Epic uses a smart algorithm to recognise abnormal vital signs in patients with a known or suspected infection, and other high-risk features. It offers a forced function to consider the possibility of sepsis.

"The rules laid in the background of the sepsis BPA are always looking for indicators of sepsis," says Linda Marques, RN, Project Manager, Epic Project. "The screening is more embedded in the workflow with Epic."

While clinicians have a sepsis pathway card to follow, there are many things to keep in mind when assessing a patient, and sepsis can be easy to miss. "One of the big challenges is that sepsis can look like a lot of things, and many things can look like sepsis," says Watson. "Especially in children, sepsis can look very different. Think of how differently it would present in a six-month-old and a 10-year-old. The alert prompts clinicians to put the pieces together."

Dr. Deborah Schonfeld, physician champion for Epic in the ED, concurs. "The Epic BPA alerts our clinicians to something they might otherwise miss in a busy and hectic ED."

The BPA provides reminders for clinicians to check their patients at regular intervals.

If an initial set of vital signs triggers a sepsis alert but physicians decide that the patient is stable and not in need of immediate treatment, the clinician will still receive reminders to check on the status of the patient at regular intervals thereafter.

"Sepsis can evolve over time – clinical conditions can and do change quickly," says Schonfeld. "The new system is designed to alert clinicians of abnormal vital signs at any point during the ED course, not just at triage. Furthermore, the alert will continue to fire every two hours if the heart rate remains critically elevated. This guarantees that a high risk patient is continually reassessed for sepsis."

The data collected on Epic will give us more information on our sepsis patients.

Using the data collected will provide a better understanding of our patient population with sepsis, and this, in turn, can further inform the algorithm to capture more patients in the screening stage. "The ability to get meaningful data and information out of Epic is far superior to our old systems," says McAllister.

Schonfeld elaborates: "At SickKids we see sepsis in children of all ages and medical backgrounds. Analyzing the data provided by Epic will allow us to better understand our population's risk factors and outcomes. It will also allow us to determine how well we are doing when it comes to delivering life-saving medications and fluids in the recommended timeframes. All of this will inform further sepsis-related quality improvement projects."

What's next?

The ED staff and Epic team are working to fine tune the sepsis BPA. "We want the alerts to fire as appropriately as possible on the right patient at the right time," says McAllister. The inpatient sepsis BPA is under development, and will be launched to inpatient areas in 2019.