Twenty percent of all intensive care admissions are attributed to severe sepsis. Sepsis is the leading cause of death in non-cardiac intensive care units (Angus et al., 2001). The Surviving Sepsis Campaign provides evidence-based guidelines for the management of severe sepsis and septic shock. Key recommendations include early, within the first six hours of recognition, goal-directed resuscitation including blood cultures before antibiotic therapy initiation, fluid resuscitation, administration of broad-spectrum antibiotics within one hour of diagnosis of septic shock, vasopressor preference for norepinephrine or dopamine to maintain a mean arterial pressure of at least 65 mm Hg (Dellinger et al., 2008). Implementation of these evidence-based practice measures has been shown to decrease hospital mortality in patients diagnosed with severe sepsis and septic shock (Levy et al., 2010).
P.B., the CNS for the Pulmonary (intensivist) service at a local hospital, recognized that we were often not meeting time-sensitive goals in the treatment of sepsis. Issues included long wait times for antibiotic delivery from pharmacy, inadequate central venous access, and difficulty locating necessary equipment. A “sepsis cart” was created to address these issues. The carts are located in the ICU’s that have the highest volume of septic patients and are also available for delivery from materials management. Located within the cart are is the necessary equipment for central venous line placement, blood, urine, and sputum culture supplies, four commonly prescribed vasopressor drip kits, and the first dose of broad spectrum antibiotic coverage for penicillin and non-penicillin tolerant patients.
Outcomes of change
Initial informal data review after implementation of the carts indicates success. Cultures are being performed before antibiotic administration more consistently and time to first antibiotic administration has decreased. Nurses who have had experience with the carts have had positive experiences. Nurses appear to be more comfortable assessing patients to determine early signs of sepsis and initiating resuscitation. No data collection is planned regarding sepsis morbidity and mortality before and after implementation although it would be interesting to examine outcomes.
This change occurred at the microsystem level. The critically ill patient is at the center of this microsystem surrounded by the patient’s family and the healthcare team. The intervention was targeted with the needs of the patient at the forefront.
The Change Leader
The change was led by a CNS working in conjunction with the Pulmonary service. P.B. is both a formal and informal leader in the unit where the change took place and has been a key figure in the intensive care area for many years.
Reasons for Success
Nurses were prepared for the change in practice by the CNS which aided in their acceptance of the change. Yukl (2010) posits that even motivated agents of change can be overwhelmed by the difficulties of implementing and maintaining change. During this episode of change support was provided by the CNS when issues arose.
Nurses were invited to attend educational seminars on the management of septic patients increasing their knowledge of the subject and preparing them to recognize early signs of sepsis and begin resuscitation. Classes were provided by an interdisciplinary team consisting of the CNS, staff development, and pharmacy. Receiving training and education concerning the project increased the self-confidence of the nurses in their clinical skills.
A sense of urgency was created to motivate change (Yukl) during the conference as nurses were educated concerning the incidence of sepsis and the associated mortality rates. Nurses were given tools to address the issue empowering them to make changes that would improve patient outcomes.
According to Yukl, the most effective leaders rely on position and personal power to influence change. P.B. has been an important resource to nurses at the local hospital for many years. She is an expert clinician who continues to provide direct patient care at the bedside at the side of the staff nurse. Due to her position as a CNS and her reputation as an expert she has a great deal of power with which to influence change.
Proactive influence tactics were utilized to shape the change increasing the likelihood of success. Rational persuasion was utilized via the provision of educational conferences which educated nurses regarding sepsis, the management of shock, and the nurses’ role in recognition and resuscitation in sepsis. Coalition tactics were employed as the CNS found champions for the project in physicians and ancillary service members. Collaboration between physicians, nurses, pharmacy, and materials management during the development and implementation of the program also helped to make the change successful (Yukl).
Features identified by Nelson et al. (2007) to be indicative of successful microsystems including leadership, patient focus, staff focus, and process improvement were present. The CNS leading the project provided clear, consistent goals for the project. Positive patient outcomes were the focus of the intervention. Education was provided for the staff and informal leaders were identified and recruited to increase support for the project. Process evaluation and improvement began during the developmental phase of the project and continues in the present.
Areas for Improvement
There is high staff turnover in the critical care area making further and continuing education regarding the cart necessary. The hospital rotates resident physicians, who provide the majority of physician care, every month. As new physicians enter the unit they require education concerning the cart and its function. At this time no further educational sessions have been announced.
Some less experienced nurses appear to be having difficulty identifying early signs of sepsis which would allow timely resuscitation to begin. Further education, perhaps utilizing case studies, would increase their knowledge and confidence in identifying and managing severe sepsis and septic shock.
According to Yukl, when implementation does not require many visible changes people will question whether the change effort remains ongoing. In the instance of the sepsis cart, utilization of the cart has been erratic and is determined by fluctuations in the patient population and its acuity. In order to communicate a sense of the progress of the project and keep it at the forefront of the healthcare team’s attention scheduled updates concerning project goals their evaluation should be sent to staff from the CNS.
I believe that this has been a successful change implementation. It was well planned and well received by staff. The program is still in its early stages, but outcomes including reduction in time to first antibiotic administration and collection of blood cultures before antibiotic administration appear to support its implementation.
Angus, D.C., Linde-Zwirble, W.T., Lidicker, J., Clermont, G., Carcillo, J., & Pinsky, M.R. (2001). Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Critical Care Medicine 29(7), 1303-1310.
Dellinger, R.P., et al. (2008). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine, 36(1), 296-327.
Levy, M.M., et al. (2010). The surviving sepsis campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine 38(2), 367-74.
Nelson, E.C., Batalden, P.B., & Godfrey, M.M. (2007). Quality by design: A clinical Microsystems approach. San Francisco, CA: Jossey-Bass.
Yukl, G.A. (2010). Leadership in organizations. (7th edition). Upper Saddle River, New Jersey: Pearson Education.