Running head: USING A CLINICAL GUIDELINE COUPLED WITH EDUCATION

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Using a Clinical Guideline Coupled with Education to Improve Healthcare Providers'
Knowledge of Early Sepsis Recognition in the Post-Acute Care Setting: A Quality Improvement
Project
Erin Krzywicki, BSN
Arizona State University

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Abstract
Aims: The goals of this project were (1) develop a sepsis clinical guideline, (2) enhance direct
patient care staff knowledge of sepsis and (3) survey staff comfort level with identifying sepsis
post intervention.
Background: Sepsis remains a significant healthcare problem associated with high treatment
costs and high mortality rates. Older adults are at an increased risk for developing sepsis,
especially when age is combined with any type of compromising factor, such as chronic illness,
recent hospitalizations, wounds, or invasive devices. Current evidence demonstrates that sepsis
screening is effective for early identification of sepsis. Early identification of sepsis improves
time to treatment initiation, which improves outcomes.
Methods: An evidence-based, provider approved clinical guideline was developed for a postacute care facility after an extensive review of the literature. Upon implementation, brief
educational sessions were provided to direct patient care staff. Participants completed pre- and
post-tests as well as a demographic survey. A satisfaction survey was administered 30 days post
intervention. A paired samples t-test was used to analyze the difference in test scores. Pearson's
correlation was used to analyze the relationship between staff comfort levels and the clinical
guideline.
Results: The samples included 25 participants in the educational intervention and 18 in the
satisfaction survey. There was a significant difference in the scores between pre-test (M = 72.3,
SD = 12.43) and post-test scores (M = 86.6, SD = 10.2); t(24) = -5.578, p < 0.001. There was a
significant correlation between staff who felt comfortable in identifying sepsis with ease of
screening (r = .831, p < .01) and high comfort levels with the policy (r = .889, p < .01).

USING A CLINICAL GUIDELINE COUPLED WITH EDUCATION
Conclusion: Utilizing a clinical guideline, coupled with education, improves staff knowledge
and comfort identifying sepsis in the post-acute care setting, which may improve early
recognition and treatment initiation. This outcome is clinically significant as patients in this
setting represent a vulnerable population.
Keywords: Clinical guideline, early recognition, post-acute care, screening, sepsis

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Using a Clinical Guideline Coupled with Education to Improve Healthcare Providers'
Knowledge of Early Sepsis Recognition in the Post-Acute Care Setting: A Quality Improvement
Project
Septicemia, more commonly referred to as sepsis, is a serious illness, which may lead to
shock, organ failure or death (Sutton & Friedman, 2013). Sepsis is a significant healthcare
problem in the United States (U. S). It was the sixth most common reason for hospitalization in
2009 (Sutton & Friedman, 2013). Since that time, the incidence of sepsis has continued to
increase, especially among vulnerable populations. Sepsis is associated with high healthcare
costs and mortality rates (Elixhauser, Friedman, & Stranges, 2011; Hall, Williams, DeFrances, &
Golosinskiy, 2011; Sutton & Friedman, 2013). These impacts make sepsis a serious concern for
patients, providers and policy makers (Sutton & Friedman, 2013). The Surviving Sepsis
Campaign (SSC) was created in 2002 with the challenging goals of changing the perception of
sepsis, influencing policy, creating guidelines and ultimately, improving management (Schorr &
Dellinger, 2014).
Problem Statement
Sepsis is a clinical syndrome, defined as the presence of infection, either potential or
actual, coupled with signs of a systemic inflammatory response (Dellinger et al., 2013; Levy et
al., 2003). There are a myriad of clinical inflammatory markers used to diagnose sepsis
(Dellinger et al., 2013; Levy et al., 2003). Severe sepsis is the progression of sepsis to include
signs of organ dysfunction or tissue hypoperfusion (Dellinger et al., 2013; Levy et al., 2003;
Umberger, Callen, & Brown, 2015). Not all variables are required to diagnose sepsis or severe
sepsis, which can prove problematic for clinicians, especially in the early stages of onset as these
signs and symptoms are often subtle and mimic other disease processes (Lopez-Bushness,

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Demaray, & Jaco, 2014). The SSC first created guidelines for sepsis management in 2004.
Since that time, the guidelines have been updated and revised in 2008 and 2012 (Schorr &
Dellinger, 2014). The sepsis management guidelines represent best practice, which the SSC
considers the aim of clinical practice (Dellinger et al., 2013).
The incidence of sepsis continues to rise. Sepsis was the sixth most common diagnosis
for hospitalization in 2009. However, it was the most expensive treated condition, with costs
totaling almost $15.4 billion (Elixhauser et al., 2011). The rate of sepsis as a primary diagnosis
increased 148% between 2000 and 2009. During that time, the rate of sepsis as a secondary
diagnosis increased 66% (Elixhauser et al., 2011). The rate of hospitalization for sepsis is higher
for those 65 and older at 122.2 per 10,000 population. For those 85 and older, the sepsis
hospitalization rate is 30 times higher than for those under 65, at 271.2 per 10,000 population
and 9.5 per 10,000 population respectively (Hall et al., 2011). Patients hospitalized for sepsis
experience greater illness severity and longer hospital stays. The average length of stay for
sepsis is 75% longer than other conditions. Patients 65 and older who are hospitalized with
sepsis have an average stay that is 43% longer than other patients with the same condition (Hall
et al., 2011).
A diagnosis of sepsis is associated with significant morbidity and mortality. Despite
improvements in management, mortality rates remain high, ranging from 14% to 43% (Angelelli,
2016; Lopez-Bushnell et al., 2014; Umberger et al., 2015). Patients hospitalized from a skilled
nursing facility (SNF) for sepsis are more likely to die. In 2010, 28% of SNF patients admitted
with sepsis died (Sutton & Friedman, 2013). Conversely, survivors of sepsis are more likely to
be discharged to a SNF (Hall et al., 2011; Kumar et al., 2011; Lagu et al., 2012). In addition,

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sepsis survivors are more likely to experience readmissions. Thirty-day readmission was 62.3%
in 2010 for sepsis survivors (Sutton & Friedman, 2013).
Risk Factors
Sepsis has several associated risk factors. These risk factors include age (elderly and
very young), compromised immune system, currently sick or hospitalized, wounds or injuries,
and invasive devices (i.e. urinary or intravenous catheters) (Mayo Clinic, n.d.). Healthcare
advancements have contributed to the increase in life expectancy. However, as the population
ages people are living with multiple chronic conditions (Englert & Ross, 2015). Chronic illness
coupled with the polypharmacy necessary for management increases the risk of sepsis (Englert &
Ross, 2015). Older patients are at a higher risk of delayed detection of sepsis due to the subtlety
of signs and symptoms and the often atypical presentation of infection (Umberger et al., 2015).
Practice Guide and Early Identification
The SSC clinical practice guideline for sepsis management is evidence based. The SSC
partnered with Institute for Healthcare Improvement (IHI) to develop sepsis treatment bundles
based on the guideline in order to facilitate clinicians in best practice. Two bundles have been
developed, the three-hour resuscitation bundle for severe sepsis and the six-hour bundle for
septic shock. The National Quality Forum (NQF) has approved these bundles (Institute of
Healthcare Improvement [IHI], 2013). The three-hour resuscitation bundle includes measuring
serum lactate, obtaining blood cultures prior to antibiotic treatment, broad-spectrum antibiotic
administration and fluid resuscitation (IHI, 2013). Greater compliance has been achieved with
the three-hour bundle.
Paramount to the SSC guideline is routine screening to allow early identification and
initiation of treatment (Dellinger et al., 2013). Early identification of sepsis enables prompt

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initiation of appropriate treatment, which may have the greatest effect on outcomes (Dellinger et
al., 2013). Process changes, such as screening, and education serve to enhance the identification
of sepsis in patients (Buck, 2014). To date, much of the research on sepsis has been conducted
in the intensive care unit (ICU) setting. However, evidence suggests that a significant number of
patients are diagnosed and treated in the non-ICU setting (Gyang, Shieh, Forsey, & Maggio,
2014; Mearelli et al., 2015). Routine screening of patients outside the ICU setting is necessary
as these patients represent a vulnerable population and may suffer significant morbidity and
mortality if sepsis develops. This leads to the clinical inquiry: In adults (>18 years old) in the
post-acute care setting, how does the use of an evidence-based clinical guideline for sepsis
screening compared with not using a guideline affect early detection of sepsis and treatment
initiation?
Search Strategy
In light of the proposed clinical question, a comprehensive search was conducted in order
to examine best practice for sepsis screening in the non-ICU setting. Evidence was obtained by
searching the following databases: Cumulative Index of Nursing and Allied Health Literature
(CINAHL), Cochrane Database and PubMed. Keywords for the search included: sepsis, early
identification, early warning signs, screening tools, and clinical guideline. The Boolean operator
'AND' was used to combine sepsis with the intervention and descriptive search terms. Initial
yield results are as follows: CINAHL 231 references, Cochrane 59 references and PubMed 300
references. Searches were limited to publications between January 2010 and January 2016,
adults only, written in the English language and studies conducted in the non-ICU setting. After
review of the references, a final yield of 10 studies was obtained for analysis.
Evidence Synthesis

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In reviewing the evidence, 10 studies were appraised; half of the studies were conducted
in the non-ICU setting and the other half were conducted in the ED. All studies utilized
screening parameters and treatment initiatives outlined in the SSC guideline. The evidence
demonstrates that sepsis screening is effective for early identification of sepsis and improving
treatment initiation. Positive benefits demonstrated throughout the studies include: improved
time intervals to antibiotic administration, improved time intervals to intravenous fluid (IVF)
bolus administration, and improved adherence to blood culture and lactate measurement. These
clinical actions are important because they have been shown to improve outcomes. The evidence
also reveals a positive trend to decreased mortality. Additionally, the evidence demonstrates that
screening outside of the ICU setting is not only possible, but also necessary, especially when
vulnerable populations are concerned, such as those in the post-acute care setting. In summary,
sepsis screening improves early identification and treatment initiation, which positively affects
outcomes.
Framework and Purpose
The Physiologic Model served as the driving conceptual framework in the majority of
studies, and is the model underpinning this project. This theory provides an explanatory
mediator to the degree of biophysical markers and potential for sepsis. The evidence review
demonstrates the need for screening based on common biophysical markers to enhance early
identification and treatment initiation.
The ACE Star Model of Knowledge Transformation provided the framework to facilitate
the proposed change. This framework was developed as an interdisciplinary strategy to guide
the implementation of evidence based practice to accomplish the goal of quality improvement
(Schaffer, Sandau, & Diedrick, 2013). The ACE Star Model has five key steps, which are

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discovery, evidence summary, translation, integration, and evaluation (Schaffer et al., 2013).
Major emphasis of this model is on knowledge transformation including not only the
summarized evidence, but also the integration of the organizational and patient preferences
(Melnyk & Fineout-Overholt, 2015). This model laid the groundwork to facilitate a
multidisciplinary practice change.
The goals of the project were threefold, including: (1) development of a clinical guideline
for sepsis screening and treatment initiation, (2) provide education to direct patient care staff on
sepsis and the new guideline, and (3) survey staff comfort level with guideline and screening
post intervention.
Methods
Project Design, Setting and Population
The project served as a quality improvement project for a 155 bed skilled nursing facility
in the southwestern United States. Direct patient care staff were invited to participate in the
intervention. Ethical approval was obtained from the Institutional Review Board at Arizona
State University.
Project Protocol and Measurement
An evidence-based clinical guideline was written for the facility. The guideline outlined
sepsis screening parameters and treatment initiation for positive screens. Staff roles and
responsibilities were defined in the guideline. The sepsis guideline received provider approval
from key stakeholders including physicians and nurse practitioners within the facility. After
final approval was obtained from the medical director, an educational intervention was provided
to staff. The educational sessions consisted of general sepsis information, the importance of
screening, and the new clinical guideline being implemented. Educational sessions were

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approximately 10 minutes in length. Sessions were held over a period of four weeks on various
days and at various times in order to facilitate optimal staff participation. Sessions were open to
all direct patient care staff. Participants completed a demographic questionnaire, pre-test and
post-test. No identifiable information was obtained. Demographic information collected
includes age, race, gender, highest level of education, highest level of nursing education, years of
experience, current position title, years of experience in current position, and hours worked per
week Thirty days post intervention staff were asked to complete an anonymous satisfaction
survey to assess their comfort level with sepsis identification and use of the clinical guideline.
The demographic questionnaire, pre-test, post-test and satisfaction survey were all developed by
the project investigator.
Data Analysis
Descriptive statistics were used to analyze demographic data. Pre-test and post-test raw
scores and percentages were calculated for each participant. The paired samples t-test examined
the difference between pre-test and post-test scores. Pearson's correlation coefficient examined
the relationship between staff comfort level of identifying sepsis with the use of the clinical
guideline and screening parameters. Correlation analysis was conducted independently of
demographics, pre-test and post-test. Statistical analysis was performed using SPSS for
Windows version 24 (SPSS Version 24, 2016).
Results
Twenty-five direct patient care staff members participated in the educational intervention
(Table 1). The sample ranged in age from 22 to 64 with a mean age of 37.8 (SD=12.2) years.
Eighty percent of the sample was female. Nearly half of the participants were white (40%), with
the remaining 60% ethnically diverse (Table 1). The highest educational level of the sample was

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USING A CLINICAL GUIDELINE COUPLED WITH EDUCATION
a bachelor's degree (40%), followed by an associate's degree (32%) and certificate (28%).
Participants had a mean of 9.2(SD=11.1) years of total experience and a mean of 4.9(SD=8.2)
years of experience in their current position. Most of the participants were nurses, 15 (60%)

were licensed practical nurses (LPN) and 8 (32%) were registered nurses (RN). One participant
was a respiratory therapist (RT) and one was a nursing student. The highest level of nursing
education for the sample was a bachelor's of science in nursing (BSN) (32%), associates degree
in nursing (ADN) (12%) and a diploma in nursing (36%). Participants worked a range of 32 to
60 hours per week with a mean of 42.04(SD=7.04).
Table 1
Demographic Information for Educational Intervention Participants (n=25)
Age
Gender
Female
Male
Race
White
Asian
Black or African American
Hispanic or Latino
Other
Highest Educational Level
Certificate
Associates Degree
Bachelor's Degree
Years of Experience
Total
Years of Experience
Current Position
Current Position Title
RN
LPN
Other
Highest Level of Nursing Education
BSN
ADN
Diploma

M (SD)
37.8 (12.2)

Percent (%)

80
20
40
24
20
12
4
28
32
40
9.2 (11.1)
4.9 (8.2)
32
60
8
32
12
36

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USING A CLINICAL GUIDELINE COUPLED WITH EDUCATION
N/A
Hours Worked per Week

20
42.04 (7.04)

A paired t-test was conducted to compare pretest and post test results. There was a
statistically significant difference in the scores between pretest (M = 72.3, SD = 12.43) and post
test scores (M = 86.6, SD = 10.2); t(24) = -5.578, p < 0.001, as shown in Table 2. These results
are clinically significant because staff that is better educated serve to improve early identification
of sepsis, which improves outcomes for patients.
Table 2
Paired Samples t-Test of Pre-test and Post-test Scores

M (SD)
Pair
Pre-test Score &
Post-test Score

-14.3(12.8)

95% Confidence
Interval
LL
UL
-19.6

-9.02

t

df

Significance (2-tailed)

-5.6

24

.000

Eighteen direct patient care staff members participated in the satisfaction survey. All
participants indicated the screening parameters located in the guideline were helpful. A
significant correlation was found between staff comfort level in identifying sepsis and the ease of
using screening parameters (r=.831, p < .01). In addition, a significant correlation was found
between staff comfort level in identifying sepsis and comfort with using the clinical guideline
(r=.889, p < .01), as shown in Table 3. These results demonstrate that staff members who felt
comfortable with identifying sepsis found the clinical guideline and screening parameters within
the guideline easy to use. Clinically this is significant because it is important for staff to have
clinical tools that are utilized correctly to improve early recognition of sepsis.
Table 3

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Pearson's Correlations of Satisfaction Survey
Comfort level in
identifying sepsis
Comfort level in
identifying sepsis
Screening tool easy to
use

Pearson Correlation
Sig. (1-tailed)
N
Pearson Correlation
Sig. (1-tailed)
N

1
18
.831
.000
18
Comfort level in
identifying sepsis

Comfort level in
identifying sepsis
Comfort level with
policy

Pearson Correlation
Sig. (1-tailed)
N
Pearson Correlation
Sig. (1-tailed)
N

1
18
.889
.000
18

Screening tool easy to
use
.831
.000
18
1
18

Comfort level with
policy
.889
.000
18
1
18

Discussion
Healthcare has shifted to evidence-based care. Organizations need to embrace this
change to promote best practice and improve patient outcomes. The use of evidence-based
clinical practice guidelines can facilitate this process change within an organization. The
development of an evidence-based provider approved clinical guideline on sepsis was the
primary goal of this quality improvement project. Implementation of this guideline took place in
a SNF and provided staff with the necessary tools to screen patients for sepsis and initiate
treatment if warranted. Research demonstrates that early sepsis identification and prompt
treatment has the greatest effect on outcomes (Dellinger et al., 2013). In addition, more patients
are being identified with sepsis outside of the ICU setting (Gyang, 2015; Mearelli 2015).
Patients in a SNF represent a high-risk population with regard to sepsis. These patients often

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demonstrate more than one risk factor for the development of sepsis. Therefore, it is an
important setting to improve early identification.
According to Buck (2014), screening and education are part of the process changes
needed to enhance sepsis identification. Results demonstrate that the education was effective at
improving staff knowledge of sepsis as evidenced by significantly improved post-test scores.
Staff who felt comfortable with identifying sepsis found the clinical guideline and screening
parameters easy to use. The use of a clinical guideline coupled with education enhanced staff
knowledge and comfort level with identification of sepsis. This may improve early identification
of sepsis and treatment initiation, which improves patient outcomes.
This project has several limitations. First, the samples are small and distinct. Data
collection and analysis of those who participated in the educational intervention is completely
separate from those who completed satisfaction surveys. There is no way to compare test scores
with comfort level. Second, is the design of the educational intervention. Educational sessions
were held over a period of four weeks in order to encourage greater participation. It is unknown
whether participants communicated test materials to one another, which may threaten internal
validity. Finally, organizational readiness may have impacted project implementation. Although
the organization had identified a need for the implemented process change, it may not be fully
engaged with the process of evidence-based change. This may affect staff motivation to embrace
change.
The present project did not evaluate the effect of the intervention on patient outcomes.
Future research should focus on the effect of sepsis screening in the post-acute care setting on
patient outcomes, such as morbidity, mortality and costs. Due to the high-risk of sepsis in this
patient setting, similar organizations may benefit from similar practice changes.

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Conclusion
Sepsis is associated with high mortality and treatment costs. Patients in the post-acute
care setting represent a high-risk population for the development of sepsis. Sepsis screening is
effective for improving early identification, which improves patient outcomes. The purposes of
this project were to develop a clinical guideline for sepsis screening, provide education to
enhance staff knowledge of sepsis, and evaluate staff comfort level with guideline use and
recognition of sepsis. Results demonstrate that education significantly improved staff knowledge
of sepsis. Staff who felt comfortable at identifying sepsis found the guideline and screening
parameters easy to use. The use of a clinical guideline coupled with education may improve the
early identification of sepsis and treatment initiation, which may improve patient outcomes.

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