Table 2 Detailed description of sepsis protocol intervention and implementation strategy

Rationale/goals

Intervention designed to address a recognized gap in sepsis care and through this improve patient outcomes. Specifically, the intervention was designed to support early identification of patients with suspected or confirmed sepsis and to provide a step-by-step guide to evidence-based clinical care of sepsis patients, tailored to the TASH-ED context

Materials and procedures

Intervention components included the following: knowledge adapted to local context, implementation strategies tailored to barriers to and facilitators of implementation, educational meetings, hard copy reminder tools, and local opinion leaders

The protocol was developed based on existing evidence-based guidelines, with adaptation to the TASH-ED context based on local data regarding pathogens and antibiotic sensitivities and consideration of resource availability

Implementation strategies were tailored to barriers to and facilitators of implementation, identified in our prior work and discussions with stakeholders regarding barriers/facilitators unique to or of specific importance to sepsis care in the TASH-ED. Examples of tailoring included the following: selection of hard copy reminders due to limited Internet access in the TASH-ED, inclusion of both ED leadership and a local opinion leader in educational and ad hoc meetings, and inclusion of alternative therapeutic options to address medication availability

Educational meetings were conducted with TASH-ED clinical staff during the 4-week implementation phase. Sessions occurred during regularly scheduled physician and nursing meetings and began with a didactic session introducing the project, followed by an opportunity for questions and discussion. The didactic portion included presentation of goals and objectives of the project, TASH-ED sepsis mortality data and findings of the barriers/facilitator study that informed the implementation plan, description of the process for development of the sepsis protocol including tailoring to the local context, and step-by-step approach to care of patients with suspected or proven sepsis beginning with trigger for urgent assessment at triage. In addition, due to the high turnover of physician trainees rotating through the emergency department, a short power-point presentation was developed and presented at trainee orientation sessions.

Hard copy reminder tools: three hard copy reminder tools were employed to support implementation. The first was a large poster, placed on the wall in the triage area. The poster included criteria to trigger a request by triage nursing staff for an urgent physician assessment for suspected sepsis. The second were large posters of the sepsis protocol, placed for easy reference in the resuscitation and acute care areas of the department. The third were laminated pocket cards, with the sepsis protocol on one side, and antibiotic recommendations and special considerations for tuberculosis and/or malaria, on the reverse side

Intervention provider

The TASH-ED is staffed by EM and off-service residents supervised by 6 EM faculty. The majority of nursing staff have bachelor’s degree training, with a small number of emergency medicine and critical care master’s degree nursing staff providing clinical care, coordinating activities in the ED, and teaching, coaching, and supervising students and junior nurses working the ED. Educational meetings were provided to both physician and nursing staff during the implementation period and through regular orientation sessions with new trainees rotating through the department. Sessions outlined the process for triggering an urgent physician assessment for suspected sepsis during time periods without a physician based on a triage. Sessions also highlighted the need for more frequent monitoring as part of the protocol sepsis, including the requirement for a senior resident to conduct the ultrasound assessment. EM residents receive training in and are highly skilled in ultrasound assessment, and the protocol used the volume assessment approach commonly employed in this setting, and therefore, no additional ultrasound training was provided

Method of delivery

Face to face

Location/context

TASH-ED is the largest publicly funded academic referral hospital in Addis Ababa and is the site of the first EM residency program in Ethiopia and the Masters Nursing Program in Critical Care and EM. A total of 20–25% of the estimated 20,000 patients treated annually in the TASH-ED are critically ill or injured, requiring emergent care. Given the small number of EM faculty, direct care is provided principally by EM and off-service residents, with supervision and support from EM faculty. A physician is based at triage weekdays during the day; at all other times, triage is staffed by 2 senior nurses. Lack of both human and material resources, and delays in accessing necessary resources, are common

Dose

Educational meetings were held at the start of the implementation period and during orientation sessions with new physician trainees rotating through the department on a biweekly/monthly basis. Posters remained posted throughout the implementation period. Pocket cards were distributed to new trainees rotating through the department during orientation

Tailoring

The protocol and implementation strategy were tailored to the TASH-ED context with no additional tailoring during implementation

Modifications

Initially, charts of suspected sepsis patients were to be flagged by placing a marker on the triage note and a physician informed of the need for an urgent assessment. However, as flagging was inconsistently done, nurses were asked to bring the triage note to the physician and inform them of the need for assessment. This adaptation was made during the first month post-implementation

Fidelity

Fidelity information was collected informally via study team meetings, intermittent attendance at nursing and physician meetings, site visits in the first and last quarter of the post-implementation period by the PI and Toronto-based research coordinator, and interviews in the first and last quarters of the post-implementation period

Several challenges to intervention fidelity were encountered

(1) Pocket card distribution and education of new trainees to the department were not consistently implemented, in part due to absences of individuals responsible for this task (2) Triage notification to physicians of suspected sepsis cases was infrequent

(3) Several specific and uncommon resource challenges, such as shortage of oxygen delivery equipment, were encountered and limited strict adherence to the sepsis treatment protocol

Several additional meetings were held with clinical staff during regularly scheduled meetings in an effort to address these challenges, as well as inadequate charting (noted throughout the post-implementation period) of time of assessment, blood culture, and first antibiotic. Meetings were led by the study PI during site visits, a local opinion leader, and/or the local study team leads and included both an educational component and time for discussion of the issues encountered and strategies for improvement