The Surviving Sepsis Campaign and IHI have developed a suite of tools to help organizations reduce mortality due to sepsis and to guide their improvement. In addition, many organizations have developed tools in the course of their improvement efforts — successful protocols, order sets and forms, instructions and guidelines for implementing key changes — and are making them available on IHI.org for others to use or adapt in their own organizations. We invite you to submit tools you have found useful!

General Tools

Definitions
Bundles
Measures
Quality Indicators
Evaluation for Severe Sepsis Screening Tool
Individual Chart Measurement Tool
Chart Review Database
Monthly Measurement Worksheet
Interim Glucocorticoid Administration Policy
Median Plateau Pressure Calculation Tool
Median Glucose Calculation Tool

Definitions
Detailed definitions of and parameters for "sepsis" (including general and inflammatory variables) and "severe sepsis" (including organ dysfunction, tissue perfusion, and hemodynamic variables). This tool was developed to provide teams with a concise reference for some of the parameters used in the definitions of sepsis, severe sepsis, and septic shock. The parameters are derived from the guidelines developed by the Surviving Sepsis Campaign. 

Bundles
A one-page listing of the Severe Sepsis Bundles. The bundles represent a distillation of the key interventions recommended in the practice guidelines published by the Surviving Sepsis Campaign and the Institute for Healthcare Improvement.  The specific implementation of the Severe Sepsis Bundles is extensively detailed here.

Click here for the Chinese translation.

Measures
How will you know that your team is making progress in carrying out the identified changes in the Severe Sepsis Bundles? Do the changes you have made represent the science in the bundle, or do you need to re-evaluate your changes? Are changes being translated into actual practice as you intended them to be?

This tool is a listing of all the measures related to the Bundles with their associated specifications.

Quality Indicators
This document is a listing of all the quality indicators related to the Severe Sepsis Bundles with their associated specifications. 

Reviewing this document will help improvement teams to understand the measures that will be used to evaluate their progress in improving the care of severely septic patients.  The measures are defined as “quality indicators” meaning that they measure the aspects of care that are most correlated with the best outcomes found in the literature. 

Background: Measures of quality need to be both valid (i.e., based upon scientific evidence) and feasible (i.e., capable of actually being measured in a particular setting).  These indicators have been designed to fulfill both criteria.  The indicators were drawn from foundational studies in severe sepsis care and have been pilot tested at several institutions.

Click here for the Chinese translation.

Evaluation for Severe Sepsis Screening Tool
There are specific criteria for severe sepsis as distinct from non-severe sepsis. Patients ought to be evaluated for severe sepsis based on these formal criteria when making clinical decisions. This tool provides a simple method to rapidly screen patients in any clinical setting (e.g., in the emergency department, the clinical wards, or the intensive care unit) for appropriateness of enrollment in a severe sepsis treatment protocol.

Directions: Review and modify this protocol before applying it within your own organization. Specifically ensure that (1) clinicians whose patients would be appropriate for the protocol are in agreement with the steps and parameters, and (2) the orders are appropriate for the patient population.

Click here for the Chinese translation.

Individual Chart Measurement Tool

The tool captures the information described in the Severe Sepsis Bundles and translates it into a format ready for tabulation at the end of a monthly data collection effort.  This tool can be used for concurrent, prospective, or retrospective data collection.  However, individual hospitals are strongly encouraged to choose a single approach and maintain that collection over time. 

Background: Improvement efforts without standard practices are almost certainly doomed to failure.  It is essential to standardize the data collection process for your improvement effort.  The use of this abstraction tool will allow you to quickly gather the required data and put it in a format acceptable for inclusion in your monthly results. 

Paper Version of the Individual Chart Measurement Tool
Directions for Paper Version: Attach the Paper Individual Chart Measurement Tool to each chart of a patient with severe sepsis or septic shock at the time of data abstraction.  The data for collection can be found in familiar places in the chart after a few reviews have been completed.  The objective is to collect a single Sepsis Paper Individual Chart Measurement Tool for each patient with severe sepsis. 

If you have a large number of severely septic patients and collecting data on all patients is not possible, select an appropriate number of charts for inclusion each month (i.e., 20 charts).  Once all Sepsis Paper Individual Chart Measurement Tools are gathered for a single month, complete the Sepsis Monthly Measurement Worksheet to report results.

Click here for the Chinese translation.

Database Version of the Individual Chart Measurement Tool
Directions for Database Version: Attach this Sepsis Database Individual Chart Measurement Tool to each chart of a patient with severe sepsis or septic shock at the time of data abstraction.  The data for collection can be found in familiar places in the chart after a few reviews have been completed.  The objective is to collect a single Sepsis Database Individual Chart Measurement Tool for each patient with severe sepsis. 

Each Sepsis Database Individual Chart Measurement Tool should be entered into the Surviving Sepsis Campaign database.

Click here for the Chinese translation

Surviving Sepsis Campaign Chart Review Database
The Chart Review Database is a Microsoft Access-based improvement tool that screens for severe sepsis, collects and organizes data for chart abstraction, and calculates the monthly results of each of the Severe Sepsis Quality Indicators.  Enter the results of your chart abstraction and the database automatically generates graphs of your improvement and produces flow charts documenting the results of your resuscitation efforts.

Monthly Measurement Worksheet
Once each severely septic patient’s chart has an Individual Chart Measurement Tool completed, that data must be integrated with other patients’ data to report the institution’s monthly results. The Sepsis Monthly Measurement Worksheet enables the reviewer to put this data in the appropriate format for reporting. The worksheet performs simple calculations at each step to capture accurate totals for the numerators and denominators of the Severe Sepsis Quality Indicators, making exceptions for non-applicable items and adjustments for various conditions. 

Background: An improvement effort without a standard method to report results is highly likely to fail. It is essential to standardize the data collection process for your improvement effort. The use of the Sepsis Monthly Measurement Worksheet will allow you to integrate the patient data and calculate numerators and denominators for your measures accurately and like other hospitals involved in the effort.

Click here for the Chinese translation.

The associated measure for compliance with delivery of drotrecogin alfa (activated) requires documentation that such a policy exists and was followed for each patient in order to obtain credit.  Credit may be assigned for this indicator even if drotrecogin alfa (activated) is not delivered as long as a standardized ICU policy exists and was followed.

Interim Glucocorticoid Administration Policy
An interim policy for the administration of low dose glucocorticoids should has been developed by the Surviving Sepsis Campaign to help teams that presently do not have such a policy to comply with the Severe Sepsis Quality Indicators.  The policy was designed to account for the best known science regarding use of low-dose steroids and provides the user choice in whether to use glucocorticoids based upon several known contraindications and the option to declare other relative contraindications.

Directions: Download the tool for complete instructions.

This tool may be modified by individual hospitals as the ICU staff sees fit.  However, the goal of creating such a policy is that it should be applied to each patient with severe sepsis to determine whether low dose steroids should be given (see the related Sepsis Management Bundle element Administer Low-Dose Steroids by a Standard Policy). 

The associated measure for compliance with delivery of low-dose steroids requires documentation that such a policy exists and was followed for each patient in order to obtain credit. Credit may be assigned for this indicator even if steroids are not delivered as long as a standardized ICU policy exists and was followed.

Median Plateau Pressure Calculation Tool
Use this optional tool for easy calculation of the median inspiratory plateau pressure for a mecahnically ventilated patient with severe sepsis within the first 24 hours of presentation, then enter this data in the Individual Chart Measurement Tool.

Calculating a median requires a visual understanding of a set of individual values. If the number of measurements is odd, the median is the middle value of the set. If the number of measurements is even, the median is the average of the central pair. This tool allows a reviewer to place a set of values in order and determine the middle value or the average of the central pair. 

Directions: Chart all inspiratory plateau pressure values obtained using this Median Plateau Pressure Calculation Tool, smallest to largest, and determine the median value as described in the tool.  Record the final result on the Individual Chart Measurement Tool.

Click here for the Chinese translation.

Median Glucose Calculation Tool
Use this optional tool for easy calculation of a patient’s median serum glucose value over 24 hours, then enter this data in the Individual Chart Measurement Tool.

Calculating a median requires a visual understanding of a set of individual values. If the number of measurements is odd, the median is the middle value of the set. If the number of measurements is even, the median is the average of the central pair. This tool allows a reviewer to place a set of values in order and determine the middle value or the average of the central pair. 

Directions: Chart all glucose values obtained using this Median Glucose Calculation Tool, smallest to largest, and determine the median value as described in the tool.  Record the final result on the Individual Chart Measurement Tool.