Quality statement 4 – Multidisciplinary coordination of care in hospital

Sepsis is a complex, multisystem disease requiring a multidisciplinary approach to treatment. A patient with sepsis has their treatment in hospital coordinated by a clinician with expertise in managing patients with sepsis.

Purpose

To improve patient outcomes by ensuring planned and coordinated care for all patients with sepsis, including in the inpatient and rehabilitation setting.

For patients

Treatment for sepsis can involve many different clinicians, at different times and in different settings. You, and your family or carer, are a vital part of your healthcare team. While in hospital, a lead doctor or nurse with expertise in managing sepsis will organise the care that is provided. Other members of your healthcare team may include surgeons, different specialist doctors, nurses, pharmacists, physiotherapists, psychologists, social workers, occupational therapists and dietitians.

For clinicians

Care of the patient with sepsis in acute settings requires multidisciplinary input. A clinician who is experienced in sepsis management should coordinate care, with the patient and family at the centre of the multidisciplinary team. Team members may include a range of clinicians, including medical, nursing and allied health professionals. The coordinating clinician should ensure that the patient, carer or family participate in decision-making whenever possible, and that the patient voice is being respected, heard and responded to. The coordinating clinician should attend regular multidisciplinary meetings to discuss and optimise the care of patients with sepsis.

The coordinating clinician may be different depending on the healthcare setting, and may change at different stages of treatment. The coordinating clinician needs to access and review accurate and timely information on the patient’s clinical status and care requirements. Some patients may have complex care needs and already have care coordination in place, such as those with chronic health conditions. In such cases, consult with the patient’s general practitioner where appropriate to avoid duplication of care. Ensure that person-centred care remains the focus.

When planning a hospital discharge, communication and coordination between the acute service and the patient’s community healthcare team is required. The patient’s general practitioner will usually be the coordinator of care following discharge (see Quality statement 6 – Transitions of care and clinical communication and Quality statement 7 – Care after hospital and survivorship).

For healthcare services

Provide a policy and system framework that nominates and enables a central clinician to coordinate multidisciplinary care in collaboration with the patient with sepsis, or their family or carer, in line with the National Safety and Quality in Health Service Comprehensive Care Standard Action 5.05. Define the roles and responsibilities of each clinician working in the team.

Optimise communication between services, and ensure that there are processes in place to enable routine, structured collaboration between all clinicians. Support multidisciplinary meetings where there is an opportunity for all stakeholders to discuss care, as this provides a basis for shared care. This may mean providing logistical support for meetings or communication systems that allow multiple clinicians to communicate in a timely and effective way.

A different coordinator may be nominated for long-term management in the community; this is usually the patient’s general practitioner. Ensure that adequate communication processes are in place (see Quality statement 6 – Transitions of care and clinical communication and Quality statement 7 – Care after hospital and survivorship).

For patients

Treatment for sepsis can involve many different clinicians, at different times and in different settings. You, and your family or carer, are a vital part of your healthcare team. While in hospital, a lead doctor or nurse with expertise in managing sepsis will organise the care that is provided. Other members of your healthcare team may include surgeons, different specialist doctors, nurses, pharmacists, physiotherapists, psychologists, social workers, occupational therapists and dietitians.

For clinicians

Care of the patient with sepsis in acute settings requires multidisciplinary input. A clinician who is experienced in sepsis management should coordinate care, with the patient and family at the centre of the multidisciplinary team. Team members may include a range of clinicians, including medical, nursing and allied health professionals. The coordinating clinician should ensure that the patient, carer or family participate in decision-making whenever possible, and that the patient voice is being respected, heard and responded to. The coordinating clinician should attend regular multidisciplinary meetings to discuss and optimise the care of patients with sepsis.

The coordinating clinician may be different depending on the healthcare setting, and may change at different stages of treatment. The coordinating clinician needs to access and review accurate and timely information on the patient’s clinical status and care requirements. Some patients may have complex care needs and already have care coordination in place, such as those with chronic health conditions. In such cases, consult with the patient’s general practitioner where appropriate to avoid duplication of care. Ensure that person-centred care remains the focus.

When planning a hospital discharge, communication and coordination between the acute service and the patient’s community healthcare team is required. The patient’s general practitioner will usually be the coordinator of care following discharge (see Quality statement 6 – Transitions of care and clinical communication and Quality statement 7 – Care after hospital and survivorship).

For healthcare services

Provide a policy and system framework that nominates and enables a central clinician to coordinate multidisciplinary care in collaboration with the patient with sepsis, or their family or carer, in line with the National Safety and Quality in Health Service Comprehensive Care Standard Action 5.05. Define the roles and responsibilities of each clinician working in the team.

Optimise communication between services, and ensure that there are processes in place to enable routine, structured collaboration between all clinicians. Support multidisciplinary meetings where there is an opportunity for all stakeholders to discuss care, as this provides a basis for shared care. This may mean providing logistical support for meetings or communication systems that allow multiple clinicians to communicate in a timely and effective way.

A different coordinator may be nominated for long-term management in the community; this is usually the patient’s general practitioner. Ensure that adequate communication processes are in place (see Quality statement 6 – Transitions of care and clinical communication and Quality statement 7 – Care after hospital and survivorship).

Equity and cultural safety for healthcare services

Ensure that clinicians have received cultural safety training, and that Aboriginal and Torres Strait Islander health workers and liaison officers, translators, social workers and others who can assist in the social aspects of care are involved whenever cultural differences may be a barrier to the patient’s experience of care. 

Resources

Related resources have been identified which are relevant to the quality statements, including:

  • Decision support tools and sepsis pathways and other guidance about sepsis - including state and territory resources
  • Guidelines and tools for recognising and responding to acute deterioration, including patient escalation pathways for each state and territory
  • Resources to support management of antimicrobial therapy
  • Education and information for patients and carers during hospitalisation for sepsis, on discharge and through survivorship.

A range of implementation resources have also been developed by the Commission including guidance, factsheets and tools for healthcare services and clinicians ,and resources for consumers.