Implementing clinical practice change in the Emergency Department for sepsis and fractured neck of femur; the good, the bad and the ugly of trying to change clinicians practice

Ms Julie Gawthorne1

1St Vincents Hospital, Sydney, Australia

Aim: Implementing clinical practice changes in Emergency Departments (ED’s) can be challenging. This paper aims to discuss how one ED implemented changes to improve the management of sepsis and fracture neck of femurs (NOF’s). It will discuss the fundamental drivers that lead to sustainable clinical improvements and improved patient outcomes

Background: The mortality rate for severe sepsis is 25%. Fractured NOF is the leading cause of morbidity and mortality in elderly patients.

Despite evidence, it is acknowledged that translating evidence into clinical practice is slow and the gap between what we know and what we do remains. Clinical practice guidelines take up to three years to  implemente and require time, skill, and resources.

Implementation: The ED joined Clinical Excellence Commission (CEC) ‘sepsis kills’ program that aimed to improve sepsis recognition and reduce time to antibiotics for septic patients .

The fracture NOF project aimed to developed evidence based pain management guidelines that included nurse initiated FIB’s .

Multidisciplinary working parties focused on delivering patient centred care through developing evidenced based guidelines, education packages, auditing tools and implementation plans.

Results: Sepsis recognition improved from 67% to 90% Time to antibiotics decreased from 103 to 43 minutes. Patients receiving antibiotic within 60 minutes increased from 28% to 80% These improvements have been maintained for over three years.

FIBs insertion increased from 2% to 80%. Up to 50% of all FIB’s were inserted by nursing staff. Delirium rates decreased from 44% to 33%. Hospital length of stay decreased from 13 to 10 days.

Conclusion: Despite evidence, changing clinical practice in the ED is challenging. Engaging clinicians, time constraints, clinical priorities, and limited resources all contribute significantly on the ability of ED’s to successfully implement change. The ED has shown that strong clinical lead leadership focusing on patient centred care ultimately improves patient outcomes.


Julie is the Clinical Nurse Consultant in Emergency at St Vincent’s Hospital, Sydney.  She started her emergency nursing career at St Vincent’s Hospital in 1995. Since then Julie has worked in London and a number of Sydney ED’s before returning to St Vincent’s as the CNC in 2004.

She has also worked in Tanzania and Sudan with Medicines San Frontier

Julie has a Master’s in Nursing in Critical Care, is a Clinical Fellow at the Australian Catholic University, and is a member of the St Vincent’s Hospital Nursing Leadership Team.