Hi

Ours would be initially changed by Sepsis nurse and consultant, then reviewed with deteriorating patient group (MDT which encompassed the previous sepsis steering group, CCOT and Resus), once ratified any changes to practice would be implemented by the sepsis nurse (or other appropriate clinicians)

Amy

Hi Sian
Initial changes to policy made by Sepsis nurses and consultant - in process of going through deteriorating patient group which has resus & CCOT/ICU rep chaired by Medical Director (this group absorbed the Sepsis Steering Group). Would be the same for screening tool.
anne

Oh yes the ratification / governance process is robust.

The sepsis team would raise concern with governance board. It would be worked upon and then sent to the sepsis working action group (multi professional group) for comment, then also to drugs and therapeutics committee. The changes would then go through the nursing midwifery advisory panel and if all happy sent for finalisation at the quality governance operating group and finally disseminated and embedded by sepsis team.

A

Any changes to our sepsis programme/tool have to initially go through our Sepsis Steering Group (SSG) (made up of various MDT members). This would then have to be shown to our Clinical Quality Assurance Committee to keep them aware of any changes and the potential this may have on/in the trust.
Once they have agreed then the sepsis nurse would re-do the policy which would be reviewed the SSG and then passed to the care pathways policies and guidance manager for review at their board meeting.
If everyone agrees then its a quick process. If there are concerns it takes a lot longer