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Seeking Sepsis in the Emergency Department- Identifying Barriers to Delivery of the Sepsis 6

The Sepsis 6 is an internationally accepted management bundle that, when initiated within one hour of identifying sepsis, can reduce morbidity and mortality. This management bundle was advocated by the Scottish Patient Safety Programme as part of its Acute Adult campaign launched in 2008 and adopted by NHS Tayside in 2012. Despite this, the Emergency Department (ED) of Ninewells Hospital, a tertiary referral centre and major teaching hospital in Scotland, was displaying poor success in the Sepsis 6. We therefore set out to improve compliance by evaluating the application of all aspects of the NHS Tayside Sepsis 6 bundle within one hour of ED triage time, to identify what human factors may influence achieving the one hour The Sepsis 6 bundle. This allowed us to tailor a number of specific interventions including educational sessions, regular audit and personal feedback and check list Sepsis 6 sticker. These interventions promoted a steady increase in compliance from an initial rate of 51.0% to 74.3%. The project highlighted that undifferentiated patients create a challenge in initiating the Sepsis 6. Pyrexia is a key human factor-trigger for recognising sepsis with initial nursing assessment being vital in recognition and identifying the best area (resus) of the department to manage severely septic patients. EDs need to recognise these challenges and develop educational and feedback plans for staff and utilise available resources to maximise the Sepsis 6 compliance.


Problem
The Sepsis 6 has facilitated Emergency Departments (EDs) to commence timely treatment and facilitate early patient transfer to inpatient departments for ongoing monitoring and management. [1][2][3] There still, however, may be a number of factors present in the ED which delay achieving these goals.

Background
Sepsis is a medical emergency where failure to initiate and continue effective management can proceed to acute organ dysfunction with hypotension resulting in death with mortality up to 50% in certain populations. [2,[4][5][6] The Surviving Sepsis Campaign (SSC), initiated in 2002, has been performing ongoing reviews of sepsis management based on the benefit of early goal-directed therapy (EGDT) defined by Rivers et al. [7] Using the available evidence and relevant research they published advice in the form of guidelines and management bundles in 2004, 2008 and, 2013. [2] The evidence base supporting the SSC has been questioned and recent randomised controlled trials have shown no benefit to patient mortality with EGDT compared to standard care. [8][9][10][11]  emergency physicians in an optimal position to initiate quick and effective interventions. [13] Studies have suggested a positive influence on the mortality in sepsis with structured clinical management approaches adopted by EDs. [3,14,15] Consistent management, however, was lacking in our department. Compliance was defined as all aspects of the Sepsis 6 completed within one hour of triage. The use of indwelling urinary catheters in septic patients is not routine in Tayside but only when oliguria has occurred despite fluid resuscitation, a patient is displaying severe sepsis or septic shock or there is another factor preventing the patient from easily passing urine. Prompt transfer to admitting wards often occurs locally before the patient has needed to pass urine and so the lack of urine output can be misleading. For this reason 'initiating a fluid bolus' and 'measure accurate hourly urine output' were combined as a single output measure. The time to completion of each individual element was recorded for analysis.

Baseline measurement
Compliance was then analysed against factors stated previously.
Arrival time was categorised as 'In-hours' (08:00hrs-18:00hrs Monday-Friday) and 'out-of-hours' (18:01-07:59hrs Monday-Friday and all weekend) and the area of the ED in which the patient was managed as: treatment bay; resus; treatment bay patients who were transferred to resus (treatment bay to resus).

STATISTICAL METHODS
SPSS version 21 (SPSS Inc., Chicago IL) was used to analyse data. Chi-squared test was used to compare the percentages between groups and the Mann-Whitney test used to compare the non-normally distributed data. Binary multivariate regression was used to determine the most influential factors on compliance.

RESULTS
A total of 155 patients were included in the survey with demographic data shown in Table 1 (Results Supplement). The main factors associated with compliance along with the mean and median times for medical assessment and SEWS scores are summarised in Table 2 (Results Supplement). There was no significant difference in overall compliance with the Sepsis 6. The bundle was achieved for 79 (51.0%) participants and in the remaining 76 (49.0%) patients at least one element was not delivered within one hour or at all (non-compliant). There was no difference in the compliance in-hours compared with out-of-hours.
The area of the department in which the patient was managed, the presence of pyrexia and the time to first medical and senior assessment had significant influences on compliance. Regression analysis suggested that the time to 1st medical and senior doctor assessment and the presence of pyrexia had the greatest influence on compliance.

Design
The following aim was created in order to address the problem: basis of this an initial target of 75% compliance with the complete Sepsis 6 bundle was set.
When considering how to address the problem, there appeared to be two main aspects to address: correct placement of the patient in the department and commencing early interventions to maximise the first hour after triage. The two main groups who could affect these were the initial assessment nurse who triages the patient to the most appropriate area of the department and the junior doctors who, most commonly, make the first medical assessment and initiate management under the guidance of the senior clinicians.
Raising awareness of the clinical need for rapid assessment and completion of the Sepsis 6, in particular administering antibiotics and IV fluid, was essential to improve compliance. The most obvious system was through departmental education and targetdriven clinical care. This was supported with ongoing audit of compliance with regular feedback to the clinical team.
The QI team comprised of a ST3 doctor, a Clinical Audit Facilitator, and two Emergency Medicine Consultants.

Strategy
In order to improve compliance with the Sepsis 6 bundle a series of

Results
Audit data were evaluated from 1st June to 31st December 2014 after interventions were put in place to assess any change to the Sepsis 6 compliance. A total of 140 patients were recruited to the follow-up survey through the same methods as the initial survey. Compliance improved across all factors measured in the primary survey. As with the initial survey earlier, 1st medical and senior doctor involvement were associated with increased compliance.

Demographic data shown in
The mean and median time to senior involvement, however, did not reduce post-intervention.

Lessons and limitations
Our initial survey showed that there was room for improvement with We also learned that this approach needed to be partnered with improvement methods that give continuous feedback to staff and identify knowledge gaps and system issues that might threaten compliance. This also allowed us to reinforce good clinical management.
In both surveys oxygen administration was well performed compared to other elements (Table 3, Results Supplement). This is a simple intervention which we found all members of the clinical team comfortable to perform. Also a large proportion of patients arrived already receiving oxygen administered by the ambulance service. Blood sampling and peripheral cannulation are performed by medical staff in our department so any delay in doctors' involvement would reduce the length of time available to comply with this element. Fluid and antibiotic administration is dependent on venous access and so it is understandable that more people did not receive timely fluids and antibiotics than blood sampling. One way to address this issue would be to train nurses in venepuncture and cannulation. This is the case in other EDs. Doing this would have involved a large change in local policy and training for nursing staff. We believe it is important to have medical assessment and input early in these potentially critically unwell patients in order to provide other timely decision making and so we used education to ensure septic patients, who needed timely management, were managed in the appropriate area of the department. It is important to emphasise the need for a quick initial assessment by clinical staff that identifies deranged physiology and presence of infection and SIRS criteria. Undifferentiated patients and those with multiple co-morbidities present significant challenges with the absence of pyrexia being an important factor in our failure to identify sepsis at this early stage. Data showed a strong association between compliance with the sepsis protocol and being managed entirely in resus and so early triage by nursing staff to place the patient in the relevant area of the department is paramount. Early senior doctor involvement increased our compliance rate and is a key part of the management of sepsis as this increased experience allows more timely decision making maximising time to instigate management. The experience of senior clinicians is invaluable when assessing such patients in order to avoid pitfalls that hinder our ability to provide the sepsis bundle in an appropriate time frame.
A rolling departmental educational programme focussing on pathophysiology, bundle awareness and the need for early senior clinician involvement supplemented by regular monthly audit on sepsis compliance has helped identify and reinforce these points. A Sepsis 6 check-list sticker aids data collection and acts as a prompt for clinicians. All these initiatives along with ongoing surveillance for areas of improvement have allowed us to improve sepsis management in our department.
Locally we have the challenge to continue to improve sepsis compliance and since the addition of the Sepsis 6 check-list sticker an element of competition within the department has developed with medical and nursing teams showing a desire to have a high personal compliance. Ongoing surveillance will continue to facilitate further interventions which may benefit compliance with the Sepsis 6. This project has also acted as a stepping stone to another QI project into blood culture contamination, where improving contamination rates will not only benefit patient care but also help support the overall importance of the appropriate, timely and highquality management of septic patients.
Although there has been recent controversy in the benefit of EGDT, in the form suggested by the SSC (on which the Sepsis 6 is based) this is still the management advocated by the RCEM with GDT being of overall benefit. [9][10][11][12]16] This means most UK EDs are likely to be targeting and managing sepsis in a similar way with these factors likely to be apparent. As most will have similar a set-up with clinical area division, triage system and regular rotation of medical staff our simple, replicable interventions could be rolled out to other UK EDs and potentially improve compliance with the Sepsis 6 and decrease sepsis mortality.

Declaration of interests
Nothing to declare.