Improving the ‘wicked complex problem’ of sepsis through co-design and collaboration

In mid-December of 2010 Mark took his wife to the emergency department at the QEII’s Halifax Infirmary site. His wife was undergoing chemotherapy, had developed a fever and became septic. Within a few hours, she went into septic shock and multi-organ failure. 

By her side for 60 days, Mark went through the whole experience with her, from emergency admission to a stay in the intensive care unit and rehabilitation.

After chasing cancer for many years, his wife passed away at Christmas of 2016.

Mark is now a patient family advisor at Nova Scotia Health, offering feedback from his lived experience with the healthcare system. 

Mark plays an important role in the Central Zone Action Improvement Team (AIT) focused on the early detection and treatment of sepsis. This team is using Quality Improvement (QI) methods to brainstorm and test evidence-based solutions at Cobequid Community Health Centre in Sackville, Hants Community Hospital in Windsor and Twin Oaks Memorial Hospital in Musquodoboit Harbour. If successful, these initiatives will be spread across the province.

“I've been involved [with this team] from the get-go by sharing the story about my late-wife’s experience with sepsis,” said Mark. “Not many people who work in the emergency department (ED) or intensive care unit (ICU) get to see what happens after patients leave. They just see a small part of the journey.”

Mark has also been providing input on what kind of communications should be used to help people understand the signs of sepsis and that sepsis is a medical emergency.

“Early identification and treatment are key to surviving sepsis,” said Dr. Jan Sommers, Northern Zone ED head, located in Colchester East Hants Health Centre in Truro. “We are implementing strategies to keep sepsis top of mind, and to pick the best antibiotic for each patient based on their problem and medical history.”

These strategies include following a sepsis protocol and ensuring patients’ histories are reviewed for past infection and medication.

Tracey Tooke, clinical nurse educator for the ED at Valley Regional Hospital in Kentville, said the identification and treatment of sepsis is woven into many of their education tools, from simulation training using mannequins to discussions at safety huddles.

“We've done a lot of education around early recognition of sepsis right at triage in the ED,” said Tooke. “Staff uptake has been positive. Staff and physicians act quickly when they identify potential sepsis cases and get things initiated.” 

Meanwhile, in the Eastern Zone, several initiatives are underway to improve sepsis detection and treatment, led by a sepsis coordinator. These include new methods for documenting positive screenings in electronic and manual triage charts, as well as enhanced collaboration with various departments. 

“In addition to early identification and timely interventions, we also work collaboratively with labs and pharmacies around blood culture reports and in-patient clinical nurse leaders to ensure effective communication and care,” explained Sharon MacLeod, sepsis coordinator for Eastern Zone. “We’ve made significant progress in sepsis awareness, thanks to ongoing education and dedicated staff efforts.”

Jami Gillis is a clinical nurse educator at Cobequid Community Health Centre. She is also part of the AIT with Mark. Prior to her joining the AIT, Gillis and the ED staff and physicians developed quick reference triage cards to wear in the back of their name badges. These cards help frontline staff respond quickly and effectively to sepsis cases.

“Oftentimes frontline staff have ideas for a solution to a problem, which is what we saw with our project,” said Gillis referring to the quick reference cards. “We have great frontline champions and when we’re able to bring an idea to a leadership team to move the idea forward and see it through, it’s really rewarding.” 

Gillis hopes that these cards will be helpful beyond her unit – and potentially across the organization.

In addition to Gillis and Mark, the AIT is made up of a number of staff and physicians. Co-led by Erin Leith, director, Quality Improvement & Patient Safety, and Dr. Vanessa Sweet, senior medical director Quality Improvement & Patient Safety, they recognized the need to approach sepsis improvement efforts differently—and that’s how the AIT was formed.

“The challenge with sepsis is that it's a wicked complex problem and at the same time, it’s everybody's problem and nobody's problem because it shows up in so many forms,” said Dr. Sweet. “That's where the idea of the action improvement team came from. We brought different teams and people together in a new way to collaboratively co-design the solution with the people who are actually doing the work.”

In addition to learning from one another through the co-design process, Dr. Sweet and Leith have taken time to learn from other jurisdictions that are making headway in sepsis management. They have learned from colleagues in British Colombia and even as far away as Scotland.

“Sepsis is not a new problem. We're not the only health system that is struggling with the management of sepsis because it is a persistently complex issue,” said Leith. “Scotland has a very similar demographic population as Nova Scotia and shares the same challenges. We’re learning from other health systems—like Scotland—who have been there, done that and have made great gains in recognition and treatment of sepsis.”

Dr. Sweet and Leith have been part of the Scottish Quality and Safety (SQS) Fellowship Programme aimed at clinical leaders who are improving the quality and safety of health and healthcare for the patients.

The AIT approach to sepsis improvement was inspired from the fellowship program. Thus far it is showing encouraging initial results and has been a positive experience for all.

“The thing I enjoy the most about the team is that there doesn’t seem to be any hierarchy. Everybody’s completely committed to the idea of let's stop people from becoming septic,” said Mark. “This is from doctors and nurses to clinical educators and quality directors, as well as researchers, statisticians and communications. We’re seeing real solutions that the hospitals are starting to test and that is incredible!”