Reducing Unnecessary Variation in Care – Sepsis QI Project

The World Health Organization has designated sepsis as a global priority – one that Island Health shares.

The Sepsis Quality Improvement Initiative began in 2019, updating Island Health’s sepsis protocols and standardizing tools and processes with the aim of reducing variation in practice and improving early recognition and management of sepsis in adults at all Island Health facilities.

New clinical tools aligning with the Provincial the BC Sepsis Network guidelines and the Surviving Sepsis Campaign are available on the Sepsis Resource Centre*Island Health login required*.

Quality Improvement in Action

The Sepsis Quality Improvement Oversight Committee leveraged the program quality council structures, bringing together Emergency Department Medicine, In-patient Medicine, Critical Care, Laboratory Medicine, Infection Management, Pharmacy, and Medication Safety. Through the leadership of these standard setting quality structures, an updated evidence-based sepsis algorithm and accompanying order sets for emergency and in-patient medicine was developed and approved, ensuring that the same standards could be applied to patients across all acute care services wherever they presented within Island Health.

While standards apply to everyone everywhere, local needs for implementation vary. The new tools have been shared through the geographical and site-based quality councils responsible for operationalizing of high quality care in their local environments along with site-based data of blood culture time and lactate measures.  With the Island-wide vision of standard-setting program quality and local uptake of the standards, the Sepsis QI initiative demonstrates clinical governance in action – the interaction between high setting high standards of care, local delivery of care, and measurement for improvement. 

Setting a New Standard

Updated standards and tools are only one component of quality and the delivery of excellent care through application of knowledge and skills is in the hands of care providers. So how is your team doing? At Island Health 95% of patients admitted with sepsis have blood cultures drawn and 77% of these blood culture draws are within 6 hours of presentation to an acute care facility or urgent primary care centre. 85% of patients have a lactate drawn. Check out our Sepsis QI site level measures documents for 2020/21 and 2021/22 by visiting the Report PORTAL to see these measures for your facility. *Island Health login required.*


**Island Health login is required**

The Sepsis QI Initiative: Preliminary site level measures 2021/22 document is located
on the ‘Quality Improvement’ section of the Report PORTAL under the heading
‘Medical Quality’.
(Updated September 2022)

What do I need to know about the new clinical tools and resources as a physician? 

Any physician or medical staff member who is providing care to a single adult patient or a group of adult patients with a suspected or confirmed sepsis diagnosis will be required to use the tools developed as part of the Sepsis Quality Improvement Initiative.

A resource has been developed for physicians which can be viewed here. (Updated March 2022)

An infographic has been developed to highlight ‘What’s New, What’s Changed, and Why?'. This one-pager shares details of what is new and what has changed for Emergency Department Clinical Order Sets and Protocol for those familiar with previous tools for sepsis recognition or management. (Updated March 2022)

Please visit the Sepsis Resource Centre on the Island Health Intranet to learn more about the clinical tools and educational resources developed to support sepsis care. *Island Health login is required*

Clickhere Sepsis Resource Centre
**Island Health login is required**
Intranet resource hosting clinical tools and educational materials.

Sepsis Physician Package
Developed for Emergency Department and Inpatient physicians involved
in early recognition and management of sepsis.

What’s New, What’s Changed, and Why? Infographic
Document to highlight changes and additions to emergency department
clinical order sets.

(Updated March 2022)

September is Sepsis Awareness Month 

Island Health is committed to continued sepsis awareness and invites medical staff and our multidisciplinary team members to participate in Sepsis Awareness month each September!

Want to learn more about Sepsis? Explore a curated list of sepsis resource videos, brought to you by the Island Health Sepsis Quality Improvement Initiative Oversight Committee.

Visit the Sepsis Resource Centre on the Island Health Intranet *Island Health login required* to view the tools, including the new algorithm, antibiotic module, and new and updated order sets.

Clickhere SEPSIS: Learn More PDF

Recognizing World Sepsis Day with two new challenges in 2022

In Recognition of World Sepsis Day on September 13 Island Health is launching two new challenges!

Join your peers on World Sepsis Day in showing your support of sepsis awareness by participating the Island Health Sepsis Photo Challenge in three easy steps!

We encourage you to get creative and promote sepsis awareness in your area.

You are also invited to take part in the Return of the Great Sepsis Challenge and put your current knowledge of sepsis recognition and treatment to the test. Share the quiz with your colleagues and help us reach our goal of 1,000 participants in recognition of Sepsis Awareness Month!

We have two downloadable resources that you can print and post or email to colleagues in your area:


World Sepsis Day Photo Challenge 2022

The Great Sepsis Challenge Quiz 2022