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Original article
peer-reviewed

## Sepsis Cards and Facts: A Simple Way to Increase Sepsis Bundle Compliance

### Abstract

#### Objective

The objective of this study was to improve sepsis bundle compliance via an educational intervention in our emergency department (ED).

#### Methods

This was a before and after study. Historical data on sepsis bundle compliance was obtained from our quality officer. Data were collected for 30 consecutive days to compare sepsis bundle compliance rates before and after the intervention. Descriptive statistics were compiled, and the z-test for proportions was used to calculate statistical significance.

The intervention was two-fold: 1) a bright yellow card with sepsis criteria listed was posted on all ED workstation computers and 2) there was a daily email blast for one month with “sepsis facts.” These email blasts were short pearls that highlighted the importance of recognizing and treating sepsis.

#### Results

The sepsis bundle compliance rates in the month prior to the intervention was 38%. In the month during the targeted intervention, the compliance rate increased to 56%. There was a statistically significant increase in bundle compliance rates during the intervention (p=0.0399).

We also administered a survey to the ED attendings and residents following the completion of the study to assess whether they perceived that our intervention was helping them increase compliance with ordering the sepsis bundle. The response rate was 94%. To the question “Did you feel the sepsis cards placed on the workstations make you more likely to consider sepsis earlier in patients under your care in the emergency department?” 70% answered agree or strongly agree. To the question “Were you more likely to order the sepsis bundle after receiving the daily "Sepsis Facts"?” 29% were neutral while 59% answered agree or strongly agree. Finally, to the question “Did you feel the sepsis cards and "sepsis facts" help you improve the care of Septic patients in the emergency department?” 76% answered agree or strongly agree.

#### Conclusion

Sepsis criteria reminders and email blasts highlighting the importance of treating and recognizing sepsis can improve compliance with sepsis bundle ordering within the emergency department.

### Introduction

#### Data analysis

Descriptive statistics were compiled, and the z-test for proportions was used to calculate statistical significance.

### Results

The sepsis bundle compliance rate in the month prior to the intervention was 38%. In the month during the targeted intervention, the compliance rate increased to 56%. There was a statistically significant increase in bundle compliance rates during the intervention (p=0.0399). The intervention demonstrated continued improvement, with the bundle compliance rate at six months post-intervention being 79%.

We also administered a survey to the ED attendings and residents following the completion of the study to assess whether they perceived our intervention as helpful in increasing their compliance with ordering the sepsis bundle. The response rate was 94% (Figures 2-4).

To the question “Did you feel the sepsis cards placed on the workstations make you more likely to consider sepsis earlier in patients under your care in the emergency department?” 70% answered agree or strongly agree. To the question “Were you more likely to order the sepsis bundle after receiving the daily "sepsis facts’?” 29% were neutral while 59% answered agree or strongly agree. Finally, to the question “Did you feel the sepsis cards and ‘sepsis facts’ help you improve the care of septic patients in the emergency department?” 76% answered agree or strongly agree.

### Discussion

In this before and after study, we demonstrated that small interventions can have meaningful results. There is significant literature involving the importance of recognizing sepsis; however, we were unable to find any studies that created a specific intervention to increase sepsis awareness for the early implementation of the sepsis bundle.

Studies that incorporate screening methods to identify specific patients in the ED have previously been shown to produce significant results. For example, a suicide screening and detection for all patients in the ED identified nearly twice as many patients at risk for suicide [13]. Additionally, a systematic review that looked at the effectiveness of interventions aimed at increasing handwashing in healthcare workers found that interventions based on an assessment of individual and organizational barriers to behavior change were found to be more effective, and multifaceted interventions were generally more effective than single interventions [14].

Our daily emails and bright yellow cards proved to have a significant effect on the awareness and identification of septic patients, leading to the early implementation of the sepsis bundle. We recognize that any “reminder” will result in behavior change, at least temporarily. For example, daily reminders have proved to be very effective for medication compliance [15]. Similarly, our daily reminders led to an increased identification of patients who met the sepsis criteria. Seventeen ED physicians were surveyed regarding the impact of intervention: the majority agreed that they were more likely to consider sepsis earlier, improve their care of septic patients, and felt that the daily “sepsis facts” led them to utilize the sepsis bundle more often.

Our intervention led to an 18% increase in bundle compliance in just one month [16]. Our small intervention has led to an increased awareness and interest in sepsis and has slowly become part of the “culture” in our emergency department. We have noticed that not only physicians but also the nursing staff has also developed an “eye” for the identification of septic patients and are eager to alert physicians in order to begin the appropriate treatment, which, in turn, saves lives.

Finally, from an administrative standpoint, early identification and bundle compliance has been shown to decrease the length of hospitalization, rates of readmission, and overall mortality. Mortality was lower at hospitals that had high compliance with the resuscitation bundle (29.0% vs. 38.6%) and, less dramatically, at those that had high compliance with the management bundle (32.3% vs. 33.8%). For every 10% increase in compliance with the resuscitation bundle, length of stay in both the hospital and intensive care unit decreased by 4% [17].

### Conclusions

In this before-and-after study, we demonstrated that small interventions can have meaningful results. There is significant literature involving the importance of recognizing sepsis; however, we were unable to find any studies that created a specific intervention to increase sepsis awareness for the early implementation of the sepsis bundle.

### References

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### Author Information

###### Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

###### Acknowledgements

Disclaimer: This research was supported (in whole or in part) by HCA and/or an HCA-affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA or any of its affiliated entities.

Original article
peer-reviewed

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