Design of a national patient-centred clinical pathway for sepsis in Sweden

Figures & data

Figure 1. Graphic presentation of current common experiences of healthcare for people with sepsis and challenges and needs for sepsis care.

Figure 2. Flow chart of the patient-centred clinical pathway for sepsis. The focus areas of the clinical pathway are indicated in red. Abbreviations: ICU: intensive care unit; ICF: intermediate care facility.

Table 1. Detailed description of the boxes presented in the flow-chart (Figure 2).

(Box of the flow-chart) description
(A) Assessment of suspected infection and triage with RETTS/NEWS2/other triage system (in the emergency department; ED) Discussion with patient/family/residential care facility about medical history and symptoms Report from ambulance Examination Assessment using RETTS, NEWS2 or other triage system
(B) Criteria for sepsis alert? If infection is suspected and RETTS red or NEWS2 ≥ 7 or equivalent level with other triage system, upon arrival to the ED, proceed to (D) Other patients: proceed to (C)
(C) Routine care in the ED, including assessment with RETTS, NEWS2, other triage system Care and monitoring with RETTS, NEWS2, other triage system according to clinical routine If worsening of vital parameters or new suspicion of infection, proceed to (A)
(D) Sepsis alert is activated [16,19,27,28] Patient is assigned high priority, direct medical contact Continue to (E)
(E) Medical assessment, management Diagnosis, treatment, level of care, monitoring Sample collection with plasma lactate, blood culture, targeted cultures Decision on antibiotics based on the recommendations of the Swedish Society of Infectious Diseases [8] Decision on intravenous fluids and other measures to stabilise failing vital functions Lumbar puncture if meningitis is suspected Consider imaging for identification of focus of infection Consider therapeutic intervention for the focus of infection Decide on continued level of care and possible withdrawal of life-sustaining treatment. This assessment includes consultation with the patient and/or family Make an individual plan for monitoring with treatment goals, e.g. based on the recommendations of the Swedish Society of Infectious Diseases [8] Consultation with infectious diseases on-call physician [19,20] If needed, consultation with intensive care unit (ICU) or intermediate care facility (ICF)
(F) Is sepsis suspected? Yes: continue to (G)
(G) Monitoring of vital functions, e.g. NEWS2 Monitoring with NEWS2 following action thresholds [13]; follow up individual treatment goals from (E)
(H) In case of deterioration/no improvement, consultation with ICU/ICF (if applicable), e.g. in case of: Deteriorating vital signs identified e.g. by increasing NEWS2 score [13] Increasing plasma lactate levels despite administration of intravenous crystalloid fluids Unmet treatment goals as set in (E) Deterioration in general condition, concern of the healthcare staff regarding the development of the patient’s condition
(I) Discharge: was there sepsis? Yes – if infection-induced SOFA increases by ≥ 2 points* [2,3]: continue to (J) * Automatic calculation of SOFA is a prerequisite for broad implementation of correct diagnosis
(J) Coding for sepsis If sepsis was present during the period of care, diagnosis code R65.1 (sepsis) or R57.2 (septic shock) should be set as a secondary code after the code of infection [1,3,8,29]
(K) Is the patient discharged alive? Yes: continue to (L)
(L) Information and dialogue with patient/family/municipal representative Information about: What happened during the hospitalisation period? What the patient can expect in the immediate future Warning signs, who the patients can contact if they have questions or if their condition deteriorates Written information to patients who have been hospitalised for sepsis can be downloaded from Sepsisfonden.se [22]. A translated version is presented in Supplementary Materials (information to patients at discharge after care for sepsis) Planning and booking a follow-up contact
(M) Patient follow-up after two to six weeks A structured telephone follow-up regarding the current condition of the patient, including questions about persistent or new symptoms and referral to an appropriate healthcare unit if needed [1,14,15] A translated instruction for the telephone follow-up is presented in Supplementary Materials (instructions for telephone follow-up two to six weeks after in-patient care for sepsis)

Table 2. Performance quality indicators.

Indicator	Target value
Proportion of patients alive 30 days after arrival at hospital	Unclear^a
Proportion of patients alive 90 days after arrival at hospital	Unclear^a Survival of patients with sepsis with RETTS red identified by sepsis alert was 85% at 28 days and 77% at 90 days in a recent Swedish study [16]
Number of days alive outside of hospital (including rehab/geriatrics) from arrival (day 0) to day 90	Unclear^a

^aThe plan is to set the level after one year of observation.

Table 3. Process quality indicators.

Indicator	Target value
Proportion of patients with blood culture taken before antibiotic treatment initiated	100% [18]
Proportion of patients with a plasma lactate sample obtained within 1 h of arrival	100% [18]
Proportion of patients with antibiotic treatment initiated within 1 h of arrival	Unclear^a
Proportion of patients for whom an infectious disease physician was consulted in the emergency department	Unclear^a
Proportion of discharged patients with follow-up carried out	Unclear^a
Proportion of patients with ICD-10 code R65.1 or R57.2 registered as a secondary code	100% of patients with sepsis (of patients with sepsis and RETTS red, < 20% receive an ICD-10 code for sepsis in Sweden [16])
Proportion of patients with any treatment restriction set within 36 h of arrival	Descriptive measure
Admission to intensive care unit within 36 h of hospital arrival	Descriptive measure
Vasopressor treatment initiated within 36 h of hospital arrival	Descriptive measure

^aThe plan is to set the level after one year of observation.

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