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Pathway Toolkit

The Paediatric Sepsis Pathway Toolkit includes evidence-based processes and resources to help implement the Pathway in emergency departments and inpatient wards caring for children across Queensland. The Pathway Toolkit can be used by people without formal training in quality improvement or change management techniques. It is intended to support facilities in ongoing communication, education, sustainability and evaluation measures, and aligns with the introduction of the national clinical care standard.

Facilities are encouraged to adapt and expand the Pathway Toolkit to suit their local context.

The Australian Commission on Safety and Quality in Health Care has developed a Sepsis Clinical Care Standard to ensure patients presenting with signs and symptoms of sepsis receive optimal care, from symptoms onset through to discharge from hospital and survivorship care. The national standard requires implementation of a locally approved sepsis clinical pathway.

Step 1 - Quality Improvement idea generation

Quality improvement is used in healthcare settings nationally and internationally to improve safety, effectiveness and patient experiences. Quality improvement methodologies such as the Model for Improvement allows for changes to be approached in small plan, do, study, act (PDSA) cycles. These cycles help identify, define and diagnose problems in complex healthcare environments, and develop solutions and make improvements using a systemic approach.

The model includes 3 questions to guide improvement:

  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What changes can we make that will result in improvement?

Answering these questions will help you understand the problem you are trying to solve. You can then develop your ideas for change. These ideas can be tested through small PDSA cycles to determine the effectiveness of the changes.

The Clinical Excellence Queensland Project Management Framework (initiate, plan, deliver, sustain) can also support change management processes and continuous quality improvement.

Want more information on quality improvement?

National and international sepsis toolkits

Step 2 - Planning and preparation

Consider the following questions when planning your implementation:

  • Do you have organisational support including medical and nursing management and/or executive sponsorship?
  • Do you have senior clinical support and engagement?
  • Have you identified a medical and nursing lead to drive and champion this change?
  • Have you engaged other teams that may be impacted by this change such as pharmacy?

Assign 6 to 12 months to implement the sepsis pathway including PDSA cycles, educating staff, and collecting and reviewing evaluation metrics. This will help ensure the Pathway is implemented effectively and becomes a sustainable part of your department’s core business.

Use the Readiness Self-Assessment Checklist and the following resources to support the implementation.

Identify sepsis champions

Identify ‘champions’ from multiple disciplines (nursing, medical, pharmacy) and levels of seniority (senior leaders, frontline clinicians) who have a special interest in paediatric sepsis.
These staff must have an enthusiastic attitude towards driving improvements and will facilitate the successful implementation of the Pathway. This will include promoting the screening tool to facilitate early recognition of sepsis and delivery of the sepsis bundle of care, providing education at the point of care, addressing issues efficiently, and providing feedback to the wider team and stakeholders. These champions will be the faces of the implementation team in your facility/department and you could make them identifiable with a special t-shirt, lanyard or badge. Unit, department and executive support is also essential for the implementation.

The national Sepsis Clinical Care Standard also recommends all healthcare services appoint a Sepsis Care Coordinator to support quality improvement and coordination of care for sepsis at a health service level.

Resource

Paediatric Sepsis Design Files for Lanyards, ID cards, Badges, Labels (QH staff only)

Identify the need for a pathway and collect baseline data

It is important to communicate why the Pathway is needed and how this will impact your area. Start with some baseline measurements specific to your department or facility to help increase understanding, and communicate the current clinical approach to sepsis and the experience of children and families.

Use the Data Collection Tool and liaise with your Health Information Service (HIS) or Business Intelligence (BI) teams to identify cases of sepsis at your facility. Review these cases to determine:

  • How often is sepsis recognised?
  • Do patients receive best practice treatment?
  • Is care appropriately escalated, when needed?

The Paediatric Sepsis Knowledge Survey can also be used to assess how clinicians recognise, escalate and manage paediatric sepsis.

Review the results with your team and present these findings to other clinicians and hospital management to support implementation of the Pathway. Understanding this baseline will make it easier to determine where and when you see improvement.

Tip: Use the Office 365 Forms application to create an online version of the Paediatric Sepsis Knowledge Survey and share it with staff electronically and with a QR code. This will make it easier to compare results before and after implementation.

Resources

Data Collection Tool
Paediatric Sepsis Knowledge Survey

Establish governance and reporting lines

It is important to establish governance channels and reporting lines before implementation. This will help ensure the Pathway is implemented successfully.
Governance for the Paediatric Sepsis Pathway should include:

  • executive buy-in and support for the project. It is recommended the reporting end point be the Director of Medical Services and the Director of Nursing Services.
  • reporting to the Executive Director Medical Services and Executive Director Nursing Services, usually through the Directors and Nurse Unit Managers of the services involved in the change
  • collaboration with all units involved in the implementation including adult services (medicine, surgery, intensive care unit), emergency departments and paediatric services as well as local patient safety and quality teams.

This will help ensure sepsis remains a key focus for hospital executive and collaboration occurs across relevant departments.

Operational governance for the Pathway should also be considered. This will allow you to state the policies and procedures related to improving paediatric sepsis screening, care and treatment and ensure these are supported and followed. The structure and support of these groups will enable your facility to achieve best practice in sepsis care.

Recommendations for operational governance:

  • Involve a breadth of affected stakeholders (including consumers)
  • Identify paediatric medical and nursing champions for every area that will use the Pathway
  • Involve accreditation committees such as the Standard 8 Committee Recognising and Responding to Acute Deterioration. Most hospitals have an active Standard 8 Committee which includes stakeholders affected by sepsis pathways: medical emergency teams, intensive care units, inpatient teams, emergency departments, Antimicrobial Stewardship (AMS) and infectious diseases. These committees are well placed to review cases, collect and review data, and escalate safety concerns if they arise. This committee often reports to a patient safety director, directors of involved services and the executive. A paediatric subcommittee could also be considered.
  • Establish a Sepsis Pathway Committee or Working Group involving the previously mentioned stakeholders, patient safety and infectious diseases. This committee could review adult and/or paediatric cases, collect data, escalate concerns if they arise, and share learnings and feedback with clinicians. A paediatric subcommittee could be considered.
  • Attend the Close Observation and Mortality and Morbidity (M&M) meetings – these groups may discuss sepsis cases and review data, share learnings and provide recommendations
  • Ask for sepsis to be added as a standing agenda item for these committees and groups.
  • Close Observation and Mortality and Morbidity (M&M) meetings – these groups may discuss sepsis cases and review data, share learnings and provide recommendations
  • Search, review, update and share any local policies related to sepsis including training and education materials
  • Review your facility’s audit strategy for sepsis. How are audits conducted for sepsis, who is responsible for completing these audits and is it part of patient safety and quality audit schedules?

Statewide networking structures will evolve as the pathways are introduced more widely. These may include Clinical Excellence Queensland Clinical Networks and Patient Safety and Quality Improvement Service.

Engage and communicate with stakeholders

You have now identified the need for a Paediatric Sepsis Pathway in your service and established governance structures to support implementation and sustainability. Use the baseline data you have sourced as well as learnings from other facilities to identify and discuss the benefits, barriers or risks associated with implementation. Use Sepsis Key Communication Messages (QH staff only), Plan for Engaging Stakeholders to help you communicate the need for a pathway to relevant stakeholders.

It is critical to effectively engage and communicate with all stakeholders early to motivate and support the change. This can be achieved through meetings, in-services, face-to-face conversations, sepsis champion representation at safety and quality meetings, regular reports or presentations, and education sessions. Be creative – provide incentives for attendance at key meetings (e.g. cater for events, hold a project launch morning or afternoon tea).

Resources

Plan for Engaging Stakeholders
Sepsis Key Communication Messages (QH staff only)

Step 3 - Responsibilities and practicalities

Don’t try and go it alone! Form a project team to help ensure success and sustain your change efforts. Your team should be multidisciplinary and include people with different skill sets, knowledge areas and perspectives. Team members will differ depending on the size of your facility. Don’t forget to identify and recruit a project sponsor who has executive authority and can provide approval for changes, facilitate access to resources and help overcome any barriers. Work with your team to agree on meeting schedules, communication, timelines, actions and responsibilities.

Responsibilities

The table below provides guidance about who should be included in your project team.

Core team
Project sponsor Has executive authority and can provide approval for changes, facilitate access to resources and help overcome barriers.
Project lead Coordinates the project timeline and team, and has an interest in sepsis or experience with quality improvement initiatives or research. The project lead is the primary contact for the project and reports on progress to executive sponsors.
Sepsis champion (nursing) Ensures the clinical requirements (including policies) meet standards. Acts as a clinical champion for the change among the nursing cohort.
The nursing sepsis champion facilitates the successful implementation of the paediatric sepsis bundle of care, promotes the use of the Pathway, provides education at the point of care, addresses issues and gives feedback to the project lead.
Sepsis champion (medical) Provides medical expertise and leadership particularly during the initial planning phases. This role influences the medical teams in accepting the use of the Paediatric Sepsis Pathway. This position is vital to ensuring the medical team is educated about current best practice for paediatric sepsis treatment.
The medical sepsis champion will address issues and provide feedback to the project lead.
Sepsis champion (pharmacy) Ensures clinical requirements (including policies) meet standards. Acts as a clinical champion for the change among the pharmacy cohort and champions optimal AMS practice and engagement.
Consider including other positions in your team such as:
Nurses Educators, clinical practice facilitator
Clinical nurse consultant, nurse practitioner, Nurse navigator Medical officer, paediatrician, emergency department physician
Social worker or psychosocial teams, important for post-sepsis support Infectious disease physician or AMS team
Consumer representative Administration officer
Patient safety officer, quality and safety manager or clinical governance representative Digital clinician, ieMR representative, data analyst.

Engagement with an established AMS service at, or external to, your facility will ensure the continued appropriateness of antimicrobial choices within the Pathway. Linking with infectious diseases physicians, antimicrobial pharmacists and microbiologists will ensure the most effective antimicrobials are used to treat confirmed infections, and prompt antimicrobial reviews are conducted for patients who do not have sepsis.

It can be challenging to undertake project work when you have a clinical caseload. Consider including clinical and non-clinical staff in your team to share the tasks and ensure the project can be delivered successfully.

Each team member should have defined roles and responsibilities.

Resources

Responsibilities and practicalities
NHS Sustainability Guide, Figure 3: Involvement table Pg13 (PDF) National Health Service, 2010

Practicalities

  • Printed Sepsis Pathway Forms (for non-digital sites)
    • Who is responsible for ordering more when stock is low?
    • Who will manage version control?
  • Location, location, location
    • Do you have a dedicated place for your Sepsis Pathway Forms?
    • Do all relevant nursing and medical staff know where to locate the form?
    • Do you have a dedicated place for family resources including postcards and family support network flyers? You can request these resources from paediatricsepsis@health.qld.gov.au
  • Capturing data and measuring improvement
    • Do you have a process to track patients who are screened or treated using the Pathway? Use the tracking sheet to manage this information.
    • All paper pathways (complete or incomplete) should be scanned into the electronic medical record. Who is responsible for this in your area? How frequently are these sent to medical records for scanning?
    • How will you measure any improvements?
    • Who will be responsible for measuring any improvements?

Download the Responsibilities and practicalities template and complete this for your team.

Resources

Responsibilities and practicalities
Tracking sheet
How to order the paper pathway form

Step 4 - Deliver education and launch

Education

Education is essential to successfully implement the Pathway and initiate changes in clinical practice. It is also vital to help sustain the change over time. The Queensland Paediatric Sepsis Program (QPSP) has developed a range of educational materials about paediatric sepsis and the Pathway including case studies, videos, animations, presentations, fact sheets, online learning modules and formal training packages. These can be viewed and downloaded at the Sepsis Education website.
Help your staff prepare for the change by delivering education before your launch date. Awareness training (key sepsis messages and orientation to the Pathway) is essential for the nursing and medical staff who will be in direct contact with patients.
The education strategy will vary at each facility and among professions however, the QPSP recommends at least two to six weeks of education sessions before implementation. Use your local sepsis champions and multidisciplinary teams (including educators and clinical practice facilitator groups) to deliver these sessions. At least 80 per cent of staff should complete training before launch.
Use the following resources for these sessions.

Non-digital sites Digital sites
How to use the paediatric sepsis pathway (10-minute video) How to use the ieMR Paediatric Sepsis Care Pathway (coming soon)
Pathway education with case studies ieMR Pathway education with case studies

Use site-specific, pre- and post-education evaluation processes to assess the effectiveness of the education sessions.

The QPSP is committed to supporting your service to adopt the Pathway and improve outcomes for children and families. If you require support for education sessions or further guidance to implement or relaunch the Pathway within your service, register your interest via the Request for QPSP Support.

Resources

Paediatric Sepsis Pathway
Frequently Asked Questions
Paediatric Sepsis Clinical Guidelines

Launch

Ensure you promote awareness in the lead up to the launch date. Promote the key messages including Just ask: Could this be sepsis? and use a variety of methods to raise awareness such as:

  • create a visual board in a central location with education, information and data
  • hang posters in tea rooms and hallways
  • use local case studies to share lessons and retrofit the Pathway, and demonstrate applicability and advocate for improved patient outcomes
  • communicate through your hospital newsletter and social media channels
  • establish a standing agenda item at regular meetings
  • use staff huddles to provide short, regular updates
  • hold a Pathway Launch (morning or afternoon tea).
Tip: Aim to have a local champion on each shift for the first few weeks of implementation, where possible. The champion can encourage use of the Pathway, provide education as needed, manage issues and obtain feedback.

Resources

Poster – Paediatric Sepsis Pathway explained
Poster – Do you know the signs of Sepsis in children (A3)
Media tools and infographics
Sepsis Key Communication Messages

Step 5 - Ongoing awareness and sustainability

After implementation, the team will need to ensure ongoing awareness and sustainability. Common barriers may include staff turnover, project fatigue and competing priorities.

Sustainability means building on the hard work that has already been completed and continuously improving. It is a collective responsibility and the greatest impact for children will come from using the Pathway to screen, recognise and treat sepsis.

To ensure sustainability, start to answer these questions now:

  • What is your plan to ensure improvements are not lost?
  • What is your plan to continue with measurement and evaluation processes?
  • Have you tested the new processes during evening and night shifts, and where staffing levels and patient acuity may vary?
  • What is your plan to ensure all new staff are trained and understand your local processes?

Resources

Use the NHS Sustainability Guide and the following strategies to improve the recognition and management of paediatric sepsis at your facility.

Embed into standard processes

  • Create a sepsis kit that sits on the resus trolley in your area. It could include a copy of the Pathway and blood culture bottles to assist in prompt management of sepsis.
  • Create a sepsis code to initiate a huddle for children where sepsis is suspected. Research has demonstrated early recognition and escalation of care to the multidisciplinary team improves outcomes. Involving the right team early in the process will improve time metrics and streamline care.
  • Ask for the Paediatric Sepsis Pathway to be added as ongoing agenda item to regular meetings such as the Paediatric Working Group, Close Obs meetings, M&M, Standard 8.
  • Print out sepsis labels and stick these on charts or patient boards behind beds to facilitate discussions at handover.

Resources

Could this be sepsis labels
I am on sepsis pathway labels

Conduct regular training and education

Conduct regular educational activities to increase knowledge and sustain awareness of paediatric sepsis.

Consider mandatory training at orientation or within 12 weeks of commencement using existing courses and platforms such as Recognising and Responding to Acute Deterioration, Optimus CORE, Clinical Review Meeting education, other clinical training or required training for your HHS matrix.

Integrating this information into existing education frameworks for your department or facility will ensure sustainability.

Other education strategies

  • Include sepsis resources and links in medical and nursing orientation materials for junior doctors, interns, registrars, clinical nurses, and registered and enrolled nurses
  • run monthly, simulation-based sessions using the Optimus BONUS sepsis simulation package
  • Request all clinicians complete the Optimus PRIME Sepsis module eLearning course
  • Co-ordinate regular sepsis awareness sessions and include local cases and learnings to create realistic scenarios and enhance understanding
  • Attend Retrieval Services Queensland (RSQ) sepsis education sessions
  • Access and share free CPD/CME accredited lectures from the Australian Sepsis Network library and listen to leading sepsis experts from around the world
  • Share and watch webinars and skills station videos from the Sepsis Education website (updated regularly)
  • Run in-service or grand rounds sessions with focused updates
  • Undertake formalised training programs (e.g. Prompt, ALS, aPLS, Triage)
  • Register your interest in a QPSP-facilitated education session or workshop or liaise with our statewide Sepsis Clinical Nurse Consultant for advice or support with initiatives and presentations.

Measure and evaluate

You will need to collect data before and after implementation to measure changes in practice and evaluate the outcomes.

Quarterly audits after implementation are recommended to confirm your improvements have been sustained. Audits and reports could:

  • compare the process, outcome and/or balancing measures before and after implementation (e.g. percentage of sepsis cases that used the Pathway, cases with timely blood culture collection, cases where antimicrobial was delivered within the specified timeframe). You can use the Data Collection Tool and liaise with your HIS or BI teams to assist with this process.
  • Measure and evaluate your performance against ACHS and the Sepsis Clinical Care standards. Refer to the National Sepsis Clinical Care Standard Appendix B: Indicators to support local monitoring for details on sepsis indicators and how to collect and calculate to support local quality improvement activities.
  • compare Paediatric Sepsis Knowledge Survey results before and after implementation.
  • review all level 1 and 2 RISKMAN reports.
  • establish incident notifications with patient safety.

Resources

Data Collection Tool
Paediatric Sepsis Knowledge Survey

Report progress and share learnings

  • Share the audit results with your team to provide opportunities for positive feedback, reflection and learning.
  • Evaluate the outcomes and impacts of implementing the Pathway with your stakeholders – use data to tell the story (e.g. There was a X% increase in staff confidence in managing sepsis, there was a Y% decrease in length of stay before and after the implementation).
  • Continue regular reporting through local committees and governance channels such as Standard 8 committees.
  • Celebrate success stories with your teams.
  • Present your results at a conference or in a poster.
  • Share your progress and learning with QPSP to support continual improvement of the Pathway. Email: paediatricsepsis@health.qld.gov.au

Additional resources

Implementation framework (A4) Highlights the key steps and processes for Pathway implementation and sustainability.
Sepsis Information for Health Professionals (website) Includes educational resources, clinical tools and information to support clinicians and healthcare professionals to screen and recognise sepsis early and initiate treatment in line with international best-practice guidelines.
Paediatric Sepsis Pathway explained poster (A4) Provides guidance to clinicians on how to complete page 1 of the Paediatric Sepsis Pathway. It can be displayed in common areas to prompt clinicians to ask, “Could this be sepsis?”
Postcards Outlines the signs and symptoms of sepsis in babies and children.

This resource is for display or distribution to families. It is designed to increase awareness of the signs and symptoms of sepsis. With the help of the Refugee Council of Australia, this postcard has been translated into 10 languages.

Animation Video Helps raise awareness among families about the signs and symptoms of sepsis.

Available in 10 languages.

Family Support Flyer (DL: 99x210mm colour) For clinicians to distribute to parents/carers of children affected by sepsis.

The flyer highlights the resources and support available for families including the Family Support Network and Peer Mentor Program.

Sepsis Information for Families (website) Provides families with education on sepsis and information on the support available including, but not limited to, the Family Support Network, Peer Mentor Program and Journeying Through Sepsis videos
Referral to QPSP (coming soon) (A4) To help families to engage the expertise and specialist services of the QPSP.

Within the QPSP team, we have an Aboriginal and Torres Strait Islander Lead to provide advice and guidance regarding the unique needs of Aboriginal and Torres Strait Islander children, families and communities. An Advanced Social Worker is also available to provide information, resources and support for families with children who have been diagnosed with sepsis.

Sepsis research (website) Includes information on world-leading research projects to reduce sepsis.
Sepsis useful resources (website) Includes media tools, graphics and screensavers as well as links to partner websites and international sepsis alliances.

The QPSP would like to acknowledge the ongoing support of the Clinical Excellence Queensland, Children’s Health Queensland and the unwavering commitment of the Clinical Advisory Group, clinicians and consumers.

The Queensland Paediatric Sepsis Program (QPSP) team is committed to supporting your service to adopt the Paediatric Sepsis Pathway and improve outcomes for families and children.

Please register your interest if you would like QPSP education, guidance or support on paediatric sepsis and implementing the Pathway at your site.