Table 6 System improvement intervention informed by SEIPS 2.0 model [60]

Person

1. Increase administrative staff knowledge on sepsis.

2. Increase clinical staff knowledge on the identification and management of sepsis in the community.

1. Development of sepsis case analysis tool for use within practices.

2. Education session for receptionist staff, production of learning pack deliverable in practices.

3. Clinical educational sessions and production of accessible educational material (e.g. webinar, online module, dissemination of learning pack) Containing summary of guidelines, systems approach, recommendations and their rationale for standardising communication to increase recording of physiological parameters.

4. Training for adult community nurses on sepsis management and measuring and interpreting physiological values.

1. Reception staff aware of how sepsis will present and possible red flags—prompting them to arrange sooner clinical review.

2. Increased knowledge of guidelines, available tools (IT templates and NEWS), appreciation by clinical staff of reasons for recording and communicating values and how this can be achieved.

3. Earlier recognition by community adult nurses of septic patients and more effective communication of concern resulting in sooner clinical review by GP.

1. Evaluate satisfaction with training and other educational materials.

2. Evaluate change in attitude and knowledge following training.

Tools and Technology

1. Provide adult community nurses with required resources—thermometers and saturation monitors.

2. Facilitate recording of physiological values.

1. Resources provided through health board funding.

2. Improved IT systems that are a useful resource, available when needed that may help positively constrain behaviour.

3. Dissemination of existing in-hours IT templates to practice managers with instructions on how to use short cuts to open—work with frontline staff to improve out-of-hours IT systems

1. All necessary equipment available.

2. Easier to record physiological values.

3. Awareness of guideline that supports everyday work (positive control). Patients who are potentially septic are identified earlier.

1. Assess via survey—satisfaction with created protocols and templates.

2. Survey staff to determine if protocols and templates are a beneficial control and represent work-as-done.

3. Measure use of templates.

Tasks

1. Increase recording and communication of physiological parameters

2. Improve the ability of practice administrative staff to identify patients who may have sepsis.

3. Improve completion of Key Information Summary to include—the recording of risk factors for sepsis and normal physiological parameters

1. Development of sepsis case analysis tool for use within practices.

2. Through educational events that describe importance of recording values in other parts of the system.

3. Co-design guidance with community nurses following education on sepsis—potentially positive control.

4. Co-design protocol for communication between primary/secondary care.

5. Co-design guidance with practice administrative staff following educational sessions—potentially positive control.

6. Improvement in KIS completion will be achieved through existing programme of work—sepsis work will feed into this.

1. Increase recording and communication of physiological parameters.

2. More accurate and useful information contained in KIS—allows interpretation of physiology to facilitate accurate diagnosis in out-of-hours and secondary care.

1. Measure use of protocols and templates to determine if they represent work-as-done.

2. Evaluate information contained in KIS—through existing GP cluster and locality work.

3. Evaluate patients admitted with sepsis to determine if all parameters recorded—results to be used for reflection and not as a performance indicator.

Internal Environment

1. Develop practice culture where receptionists can interrupt clinicians if needed.

2. Improve culture within out-of-hours to reduce concern regarding auditing of data.

1. Development of sepsis case analysis tool for use within practices.

2. Co-design of protocols with clinical and administrative staff in practices following reception and GP training.

3. Regular reinforcement of use of data and incident investigation for learning—recording of observations or early warning scores should not be used as a performance indicator without appreciation of the context within which the patient was assessed.

1. Receptionists know when to adapt behaviour—when to seek early review and have confidence to implement—supports staff wellbeing and improves performance.

2. Feedback from incident investigation and data used for learning—supports staff wellbeing.

1. Survey of perceptions of culture.

Organisation

1. KIS available when SPOC used—resource provision.

2. Improve communication when out-of-hours community healthcare staff use the single point of contact.

3. Improve communication between primary/secondary care

1. Change system to ensure KIS available—arranged with out-of-hours leaders.

2. Following education sessions with adult community nurses and out-of-hours administrative staff—co-design guidance for communication including communication of physiological values. Potentially positive behaviour control.

3. The sepsis work would feed into existing cross interface programme boards—co-design protocol for communication between primary/secondary care.

1. Normal values available for out-of-hours and secondary care clinicians to facilitate early diagnosis and treatment.

2. Awareness of guideline that helps work (positive control). Patients who are potentially septic are identified earlier.

1. Evaluation as above.

External Influences

1. Sepsis management prioritised by Health board.

2. Nice Guidelines widely distributed

3. Reflection on management of sepsis patients with other GP practices

1. Report sent to health board for discussion and approval at Primary Care Leadership committee.

2. Dissemination guidelines and sepsis app as part of educational intervention-—potentially positive behaviour control.

1. Resources available to implement and evaluate changes.

2. More patients managed following guidance.

1. Use of guidance can be evaluated following educational events using a survey.

Processes

1. Increased rates of provision of relevant physiological values when admission arranged by primary care clinicians.

2. Increased rates of provision of relevant physiological values when community healthcare staff contacts out-of-hours services.

1. Work with secondary care sepsis leads—for all admissions receiving team will request all physiological parameters—GP expected to provide values when relevant—educational sessions detail when it is relevant. This will include all admissions with infective, cardiac or respiratory cause. Efficiency thoroughness trade-offs may lead to performance variability and this should be recognised.

2. SPOC will use a template and ask for all physiological parameters.

1. Improved communication of physiological values so secondary care aware of admissions and have values from community for comparison. Results in quicker assessment and initiation of appropriate treatment.

2. Out-of-hours staff will be aware of severity of illness of patient and, if necessary see sooner and ensure treatment initiated sooner, resulting in improved healthcare outcomes.

1. Measure rates of communication of relevant values when SPOC used and at admission.

2. Survey—perceptions of clinical staff in acute care hub to new system for adult community nurses.

Outcomes

1. Reduce time from contacting health services to receiving antibiotics for ten patients with a confirmed admission diagnosis of sepsis per month.

1. Long term outcome of all above measures

1. Improved mortality and morbidity outcomes for patients presenting to primary care with sepsis.

1. Measure for ten patients per month and feedback to all GPs and ANPs. Once baseline measure obtained specific target will be set.