Improving early management of bloodstream infection: a quality improvement project

Problem Bloodstream infection is a common but serious illness with high mortality and morbidity, which is seen in many clinical specialties. Errors such as delay in diagnosis and lack of effective treatment often occur. Design Initial observational study followed by prospective study before and after intervention in a high risk clinical area. Setting 1400 bed teaching hospital in the United Kingdom where the initial management of all inpatients with bloodstream infections was surveyed over six weeks. This showed 55 major errors in 46 (30%) of 157 episodes of bloodstream infection. Most (44) were in general areas of the hospital without a specific protocol for managing sepsis. 29 of the 55 errors were caused by delay in giving effective antibiotics to critically ill patients. In 19 cases, effective antibiotics were still not given despite advice from infection services based on blood culture results. A diagnosis of bloodstream infection had not been considered in 7 patients already in hospital despite clear signs of sepsis for more than 48 hours. Strategy for improvement Development of guidelines for recognition and initial management of patients with severe sepsis and bloodstream infection, implementation of an education programme on clinical standards for managing sepsis, and introduction of a bacteraemia service that included feedback. Key measure of improvement Reduction in incidence of major errors in early management of bloodstream infection. Effects of change In the second part of the study, major errors were found in 11 of 37 episodes (30%) immediately before the intervention in the main high risk area (medical wards), whereas such errors were found in 6 of 79 episodes (8%) after the intervention. Lessons learnt The early management of patients with bloodstream infection was often suboptimal. The underlying factors included failure to recognise patients with serious infection; delays in giving antibiotics as a result of poor communication between medical, nursing, and pharmacy teams; and lack of understanding of empirical antimicrobial selection. Introduction of improvement measures was associated with considerable improvement in the early management of severe sepsis caused by bloodstream infection.