title: A quality improvement project to improve early sepsis care in the emergency department.
abstract: BACKGROUND
  Sepsis causes substantial morbidity and mortality in hospitalised patients. Although many studies describe the use of protocols in the management of patients with severe sepsis and septic shock, few have addressed emergency department (ED) screening and management for patients initially presenting with uncomplicated sepsis (ie, patients without organ failure or hypotension).
  
  
  OBJECTIVE
  A quality improvement task force at a large, quaternary care referral hospital sought to develop a protocol focusing on early identification of patients with uncomplicated sepsis, in addition to severe sepsis and septic shock.
  
  
  METHODS
  The three-tiered intervention consisted of (1) a nurse-driven screening tool and management protocol to identify and initiate early treatment of patients with sepsis, (2) a computer-assisted screening algorithm that generated a 'Sepsis Alert' pop-up screen in the electronic medical record for treating clinical healthcare providers and (3) automated suggested sepsis-specific order sets for initial workup and resuscitation, antibiotic selection and goal-directed therapy.
  
  
  METHODS
  A before and after retrospective cohort study was undertaken to determine the intervention's impact on compliance with recommended sepsis management, including serum lactate measured in the ED, 2 L of intravenous fluid administered within 2 h of triage, antibiotics administered within 3 h of triage and blood cultures drawn before antibiotic administration. Mortality rates for patients in the ED with a sepsis-designated ICD-9 code present on admission were also analysed.
  
  
  RESULTS
  Overall bundle compliance increased by 154%, from 28% at baseline to 71% in the last quarter of the study (p<0.001). Bundle, antibiotic and intravenous fluid compliance all increased significantly after launch of the sepsis initiative (eg, bundle and intravenous fluid compliance increased by 74% and 54%, respectively; p<0.001). Bundle and antibiotic compliance both showed further significant increases after implementation of suggested order sets (31% and 25% increases, respectively; p<0.001). The mortality rate for patients in the ED admitted with sepsis was 13.3% before implementation and fell to 11.1% after (p=0.230); mortality in the last two quarters of the study was 9.3% (p=0.107).
  
  
  CONCLUSIONS
  The new protocol demonstrates that early screening interventions can lead to expedited delivery of care to patients with sepsis in the ED and could serve as a model for other facilities. Mortality was not significantly improved by our intervention, which included patients with uncomplicated sepsis.
authors.affiliation: Division of Emergency Medicine, University of Washington Medical Center, Seattle, Washington, USA.
authors.forename: Medley O'Keefe
authors.initials: MO
authors.lastname: Gatewood
authors.affiliation: Division of Pulmonary & Critical Care Medicine, VA Puget Sound Health Care System, Seattle, Washington, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Wemple
authors.affiliation: Divisions of Critical Care and Cardiology, Patient Care Services, University of Washington Medical Center, Seattle, Washington, USA.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Greco
authors.affiliation: Division of Pulmonary & Critical Care Medicine, University of Washington Medical Center, Seattle, Washington, USA.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Kritek
authors.affiliation: Division of Nephrology, University of Washington Medical Center, Seattle, Washington, USA.
authors.forename: Raghu
authors.initials: R
authors.lastname: Durvasula
mesh_terms: D000465:Algorithms; D002985:Clinical Protocols; D003936:Diagnosis, Computer-Assisted / Q000379:methods; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D019983:Guideline Adherence; D006801:Humans; D008403:Mass Screening / Q000458:organization & administration; D064872:Patient Care Bundles / Q000379:methods; D017410:Practice Guidelines as Topic; D058996:Quality Improvement / Q000458:organization & administration*; D012151:Resuscitation / Q000379:methods; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D012772:Shock, Septic / Q000175:diagnosis / Q000628:therapy
keywords: Critical care; Emergency department; Information technology; Performance measures; Quality improvement