Sepsis Champions Develop ‘Code Sepsis’ to Improve Patient Care

At least 1.7 million adults in the United States develop sepsis each year, and one in three patients who die in a hospital have sepsis, according to the Centers for Disease Control and Prevention. Starting antibiotics as soon as possible is key to combatting the potentially life-threatening condition. Beginning in 2018, the ICU at Cleveland Clinic Hillcrest Hospital implemented several interventions, including a nurse-led “Code Sepsis” project, to reduce the time from antibiotic order to administration.

A series of interventions to improve antibiotic delivery time

During a case review at the end of 2018, Namita Gupta, MD, critical care intensivist, noted a delay in antibiotic treatment for a patient. She collaborated with Melissa Raich, PharmD, BCCCP, the ICU pharmacist, who audited antibiotic orders and suggested ways to decrease the time from antibiotic order to administration. These included stocking Zosyn® in the automated medication dispensing system and delivering vancomycin in person to the ICU.

After these interventions were put in place, a subsequent random audit of all patients showed continued delays in antibiotic treatment. “We were still averaging greater than 120 minutes,” says Samantha Connelly, MSN, RN, nurse manager of the ICU. “We thought this was something that nurses could improve on.”

In April 2019, the nursing team on the ICU set an OKR goal of improving antibiotic administration to 90 minutes or less for sepsis patients. (OKR stands for objectives and key results; these professional development goals outline a clear objective to improve a process.) During daily huddles, nursing leaders reminded clinical nurses of the importance of antibiotic delivery and educated staff on Cleveland Clinic’s sepsis care path and the unit’s sepsis handoff sheets. That month, the ICU averaged 94 minutes for antibiotic delivery time – an improvement, but the nursing team still wanted to do better so the unit’s sepsis champions stepped in to tackle the issue.

Algorithm stresses communication and role assignments

Four sepsis champions on the ICU led the charge: Colleen Hurley, BSN, RN, assistant nurse manager, and three clinical nurses, Kellie Grant, BSN, RN; Jennifer Sopko, MSN, RN, CCRN; and Joann Ward, BSN, RN. They developed a Sepsis Alert and Code Sepsis algorithm to improve overall care of patients with sepsis.

When the ICU gets a report from the Emergency Department that it will receive a patient who has been diagnosed with sepsis or might be septic, a broadcast sepsis alert is sent to all caregivers on the unit via the wireless voice communication system including the room number where the patient will be admitted. “This broadcast gives the staff a heads up that a septic patient will be arriving on the unit, allowing the primary RN to assign roles to other nurses who are available to help,” says Connelly.

A Code Sepsis message is then broadcast to ICU staff when the patient arrives on the unit, indicating the patient’s bed number. “The expectation is that the response is the same as a Code Blue or stroke code,” says Connelly. The algorithm created by the sepsis champions delineates specific nursing roles:

• The first RN to arrive notifies the ICU team of patient arrival, ensures the patient is placed in the computer, reviews fluid orders, administers remaining/ordered fluids and obtains the ordered lactate after bolus.
• The primary RN hooks the patient up to the monitor and obtains vital signs, assesses the patient, and records time of admission, fluid bolus and antibiotics initiated.
• The second RN to arrive establishes IV access, reviews antibiotic orders, ensures blood cultures have been collected before antibiotics are administered, reviews and collects all other STAT labs and blood cultures, and administers the antibiotic as ordered.

Initiative benefits patients and empowers nurses

Nurse education on Code Sepsis was conducted in May 2019 using another innovation on the ICU – the Pay It Forward education process, which was developed by Connelly and Jeanne Henry, MEd, BSN, RN, a nursing education manager with Cleveland Clinic. The sepsis champions educated two nurses on Code Sepsis, who in turn each educated two other individuals and so on until the entire team learned about the new process.

In June 2019, the first full month after education was complete, the ICU averaged 41 minutes from the time antibiotics were ordered for patients with sepsis to administration. From June through December 2019, the average time was 24 minutes.

“I am so proud of my team,” says Connelly. “To see them collaborate to solve a problem, use innovation and technology, and see that they could make a difference in patient care was such a huge win.” The team earned the 2020 Nursing Team Excellence Award at Hillcrest Hospital, recognizing the work they put into the project and the success of Code Sepsis.

Connelly says the project has made a broader impact beyond improved patient care. “It showcased that frontline nurses do have a voice and can make a change for the better,” she says. “As nurse leaders, that’s the message we try to send to the team, but sometimes they don’t always see it.”

ICU nurses at Hillcrest Hospital now have first-hand knowledge that they can make a difference, and they feel empowered to continue improving patient care.