Timeline of sepsis bundle component completion and its association with septic shock outcomes

Challenges and Advances in Biomarker Detection for Rapid and Accurate Sepsis Diagnosis: An Electrochemical Approach

Sepsis is a life-threatening condition with high mortality rates due to delayed treatment of patients. The conventional methodology for blood diagnosis takes several hours, which suspends treatment, limits early drug administration, and affects the patient's recovery. Thus, rapid, accurate, bedside (onsite), economical, and reliable sepsis biomarker reading of the clinical sample is an emergent need for patient lifesaving. Electrochemical label-free biosensors are specific and rapid devices that are able to perform analysis at the patient's bedside; thus, they are considered an attractive methodology in a clinical setting. To reveal their full diagnostic potential, electrode architecture strategies of fabrication are highly desirable, particularly those able to preserve specific antibody-antigen attraction, restrict non-specific adsorption, and exhibit high sensitivity with a low detection limit for a target biomarker. The aim of this review is to provide state-of-the-art methodologies allowing the fabrication of ultrasensitive and highly selective electrochemical sensors for sepsis biomarkers. This review focuses on different methods of label-free biomarker sensors and discusses their advantages and disadvantages. Then, it highlights effective ways of avoiding false results and the role of molecular labels and functionalization. Recent literature on electrode materials and antibody grafting strategies is discussed, and the most efficient methodology for overcoming the non-specific attraction issues is listed. Finally, we discuss the existing electrode architecture for specific biomarker readers and promising tactics for achieving quick and low detection limits for sepsis biomarkers.

The Role and Initiatives Led by the Sepsis Coordinator to Improve Sepsis Bundle Compliance and Care Across the Continuum

A dedicated sepsis coordinator role at Penn Medicine Lancaster General Hospital led initiatives to improve sepsis core measure compliance by 40% during the course of 4 years with submission of all sepsis cases. Chart abstraction and analysis of noncompliant cases identified areas for improvement: early recognition education, order set revisions, documentation support, and the implementation of a nurse-driven 24/7 sepsis monitoring process. The cooperative work with Penn Medicine affiliates, sharing best practices, improves overall sepsis bundle compliance and transitions of care. Ongoing achievements acknowledge the value of building relationships and leading improvements through the collaborative efforts of interprofessional teams.

Impact of a sepsis tracking sheet and emergency department pharmacists on sepsis compliance measures: a prospective emergency department analysis

INTRODUCTION

Compliance with core sepsis measures in Emergency Departments (ED) remains low, with a limited number of prospective trials highlighting strategies for improvement.

METHODS

A prospective historically case-controlled observational analysis assessing the pre- and post -intervention impact of a sepsis tracking sheet (STS) and the involvement of ED pharmacists. PrimaryThe primary outcome was the improvement in compliance with core sepsis measures. SecondaryThe secondary outcome was to assess the frequency of respiratory interventions and mortality with pre-defined strata of fluid resuscitation (≤ 10, 10-20, 20-30, 30, ≥ 30 cc/kg of ideal body weight).

RESULTS

194 patients were enrolled over a six -month period with a 9.3% all-cause mortality and a 10.3% rate of new respiratory interventions after fluid boluses. Post-STS implementation compliance of repeat lactate measurement was 88% (vs. 33% pre-STS), broad-spectrum antibiotic administration within 3 h of presentation improved to 96% (vs. 20% pre-STS), blood cultures were drawn on 98% of patients (vs. 9% pre-STS), and 30 cc/kg fluid boluses were administered to 39% of patients (vs. 25% pre-STS). Of the 18 deaths and 21 respiratory interventions, only two patients fell into both categories. Mortality was highest in those patients that received greater than 30 cc/kg of fluid resuscitation (50%). Respiratory interventions were greatest in the strata receiving 10-20 cc/kg of fluids (47.6%). Patients receiving the lowest fluid aliquots of < 10 cc/kg had the highest clinical severity scores but did not have higher rates of historical diagnoses of volume overload.

CONCLUSION

The ED -based implementation of a sepsis tracking sheet and the involvement of dedicated ED pharmacists was effective in improving core measures of sepsis compliance. Patients receiving higher fluid aliquots did not experience higher rates of respiratory interventions, though had higher all-cause mortality. No relationship could be identified between patients getting lower aliquots of fluid and prior diagnoses of volume overload.

The reverse shock index multiplied by the Glasgow Coma Scale score can predict the need for initial resuscitation in patients suspected of sepsis

For patients suspected of sepsis, early recognition of the need for initial resuscitation is key in management. This study evaluated the ability of a modified shock index - the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) - to predict the need for initial resuscitation in patients with sepsis. This retrospective study involved adults with infection who were admitted to a Japanese tertiary care hospital from an emergency department between January and November 2020. The rSIG, modified Early Warning Score (MEWS), quick Sequential Organ Failure Assessment (qSOFA), and original shock index (SI) values were recorded using initial vital signs. The primary outcome was the area under the receiver-operating characteristic curve (AUROC) for the composite outcome consisting of vasopressor use, mechanical ventilation, and 72-h mortality. Secondary outcomes were the AUROCs for each component of the primary outcome and 28-day mortality. As a result, the primary outcome was met by 67 of the 724 patients (9%). The AUROC was significantly higher for the rSIG than for the other tools (rSIG 0.84 [0.78 - 0.88]; MEWS 0.78 [0.71 - 0.84]; qSOFA 0.72 [0.65 - 0.79]; SI 0.80 [0.74 - 0.85]). Compared with MEWS and qSOFA, the rSIG also had a higher AUROC for vasopressor use and mechanical ventilation, but not for 72-h mortality or in-hospital mortality. The rSIG could be a simple and reliable predictor of the need for initial resuscitation in patients suspected of sepsis.

Hour-1 bundle adherence was associated with reduction of in-hospital mortality among patients with sepsis in Japan

BACKGROUND

The updated Surviving Sepsis Campaign guidelines recommend a 1-hour window for completion of a sepsis care bundle; however, the effectiveness of the hour-1 bundle has not been fully evaluated. The present study aimed to evaluate the impact of hour-1 bundle completion on clinical outcomes in sepsis patients.

METHODS

This was a multicenter, prospective, observational study conducted in 17 intensive care units in tertiary hospitals in Japan. We included all adult patients who were diagnosed as having sepsis by Sepsis-3 and admitted to intensive care units from July 2019 to August 2020. Impacts of hour-1 bundle adherence and delay of adherence on risk-adjusted in-hospital mortality were estimated by multivariable logistic regression analyses.

RESULTS

The final study cohort included 178 patients with sepsis. Among them, 89 received bundle-adherent care. Completion rates of each component (measure lactate level, obtain blood cultures, administer broad-spectrum antibiotics, administer crystalloid, apply vasopressors) within 1 hour were 98.9%, 86.2%, 51.1%, 94.9%, and 69.1%, respectively. Completion rate of all components within 1 hour was 50%. In-hospital mortality was 18.0% in the patients with and 30.3% in the patients without bundle-adherent care (p = 0.054). The adjusted odds ratio of non-bundle-adherent versus bundle-adherent care for in-hospital mortality was 2.32 (95% CI 1.09-4.95) using propensity scoring. Non-adherence to obtaining blood cultures and administering broad-spectrum antibiotics within 1 hour was related to in-hospital mortality (2.65 [95% CI 1.25-5.62] and 4.81 [95% CI 1.38-16.72], respectively). The adjusted odds ratio for 1-hour delay in achieving hour-1 bundle components for in-hospital mortality was 1.28 (95% CI 1.04-1.57) by logistic regression analysis.

CONCLUSION

Completion of the hour-1 bundle was associated with lower in-hospital mortality. Obtaining blood cultures and administering antibiotics within 1 hour may have been the components most contributing to decreased in-hospital mortality.

The 28-Day Mortality Outcome of the Complete Hour-1 Sepsis Bundle in the Emergency Department

INTRODUCTION

The Surviving Sepsis Campaign published the Hour-1 Sepsis Bundle in 2018. The first-hour management of patients with sepsis in the emergency department (ED) is important, as suggested in the Hour-1 Sepsis Bundle. The objectives of the present study were to evaluate 28-day mortality and delayed septic shock with use of a complete and incomplete Hour-1 Sepsis Bundle in the ED.

METHODS

This prospective cohort study included adult patients with sepsis from March to July 2019. We followed the sepsis protocol used in the ED of a tertiary care hospital.

RESULTS

We enrolled 593 patients, with 55.9% in the complete Hour-1 Sepsis Bundle group. The 28-day mortality was 3.9% overall and no significant difference between the complete and incomplete Hour-1 Sepsis Bundle groups (3.6% vs. 4.2%, P = 0.707). Complete Hour-1 Sepsis Bundle treatment was not associated with 28-day mortality (adjusted OR = 2.04, 95% confidence interval [CI] = 0.72-5.74, P = 0.176) or delayed septic shock (adjusted OR = 0.74, 95% CI = 0.30-1.78, P = 0.499). Completion of each bundle did not affect outcomes of 28-day mortality and delayed septic shock.

CONCLUSIONS

The complete Hour-1 Sepsis Bundle treatment in the ED was not significantly associated with 28-day mortality and delayed septic shock.

TRIAL REGISTRATION

The trial was registered in the Thai Clinical Trial Registry, TCTR 20200526013.

Improving Antibiotic Administration Rate for Patients With Sepsis in the Emergency Department

BACKGROUND

Previous studies have demonstrated that delayed antibiotic administration increases the risk of mortality in patients with sepsis.

LOCAL PROBLEM

In the emergency department, the antibiotic administration rate within 1 and 3 hours for patients with suspected sepsis was low.

METHODS/INTERVENTIONS

We implemented an educational intervention with the nursing staff, which included training sessions and feedback, to ensure early detection and management of patients with suspected sepsis. Antibiotic administration rates were compared before and after education.

RESULTS

A total of 503 patients were included. The antibiotic administration rate improved as the phases continued (1 hour: from 5.2% to 15.6%, P = .004; 3 hours: from 35.6% to 49.7%, P = .04; 6 hours: from 74.1% to 89.1%, P = .002). The time to initial antibiotic administration also improved from 229 to 185 minutes (P < .001).

CONCLUSIONS

Nurse-initiated quality improvement improved the early administration of antibiotics for patients with suspected sepsis.