Early detection and treatment of severe sepsis in the emergency department: identifying barriers to implementation of a protocol-based approach

The Predictors of Perceived Barriers and Facilitators of Applying Sepsis Six Guidelines Among Critical Care Nurses

BACKGROUND

Sepsis is a life-threatening condition that demands quick and cautious interventions from nurses, as they are the frontline caregivers, so they are essential in recognizing early signs of sepsis, initiating prompt healthcare interventions, and providing comprehensive care to improve patient outcomes. This study aimed to examine the predictors of perceived barriers and facilitators of applying evidence-based sepsis guidelines among critical care nurses.

METHODS

This cross-sectional descriptive study was conducted on a convenience sample of 180 nurses working in critical care settings (ICU, critical care unit, ED, burning unit, dialysis unit) at a university hospital. A valid and reliable questionnaire was used to examine the predictors of perceived barriers and facilitators of applying evidence-based sepsis guidelines among critical care nurses.

RESULTS

This study revealed that the main barriers faced by critical care nurses are lack of sepsis recognition during observational rounds and delay in sepsis diagnosis by medical staff. For the most common facilitators of applying Sepsis Six guidelines, the participating nurses reported the presence of a written tool/protocol for sepsis identification and management.

CONCLUSIONS

The study emphasized the importance of the presence of evidence-based protocols for sepsis assessment and management and nurses' compliance with guidelines. Ongoing education training for nurses and providing step-by-step written checklists are a cornerstone to improving nurses' knowledge and the practical skills of early identification and management of sepsis.

Knowledge, attitudes and practices towards the diagnosis and management of paediatric sepsis among paediatric physicians and nurses: a cross-sectional study of 21 hospitals in Hubei Province, China

OBJECTIVES

To evaluate the knowledge, attitudes and practices towards diagnosing and managing paediatric sepsis among paediatric physicians and nurses.

DESIGN

A cross-sectional, questionnaire-based study.

SETTING

21 hospitals in Hubei Province between February 2023 and March 2023.

PARTICIPANTS

Paediatric physicians and nurses.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The questionnaire contained 35 items across four dimensions (demographic information, knowledge, attitude and practice).

RESULTS

The study included 295 participants (173 women). The average knowledge, attitude and practice scores were 10.93±2.61 points (possible range, 0-20 points), 32.22±2.65 points (possible range, 7-35 points) and 36.54±5.24 points (possible range, 9-45 points), respectively. Knowledge had a direct influence on both attitude (β=0.240, 95% CI 0.136 to 0.365, p=0.009) and practice (β=0.278, 95% CI 0.084 to 0.513, p=0.010), which also indirectly influenced practice through attitude (β=0.162, 95% CI 0.078 to 0.290, p=0.007). Attitude directly influenced practice (β=0.677, 95% CI 0.384 to 0.902, p=0.025). A higher attitude score was associated with good practice (OR=1.392; 95% CI 1.231 to 1.576; p<0.001), while not working in a tertiary hospital reduced the odds of good practice (OR=0.443; 95% CI 0.2390.821; p=0.010).

CONCLUSIONS

The knowledge regarding paediatric sepsis, especially knowledge about sepsis management, is poor among paediatric physicians and nurses in Hubei Province. The findings of this study may facilitate the development and implementation of training programmes to improve the diagnosis and management of paediatric sepsis.

Early Prediction of Mortality for Septic Patients Visiting Emergency Room Based on Explainable Machine Learning: A Real-World Multicenter Study

BACKGROUND

Worldwide, sepsis is the leading cause of death in hospitals. If mortality rates in patients with sepsis can be predicted early, medical resources can be allocated efficiently. We constructed machine learning (ML) models to predict the mortality of patients with sepsis in a hospital emergency department.

METHODS

This study prospectively collected nationwide data from an ongoing multicenter cohort of patients with sepsis identified in the emergency department. Patients were enrolled from 19 hospitals between September 2019 and December 2020. For acquired data from 3,657 survivors and 1,455 deaths, six ML models (logistic regression, support vector machine, random forest, extreme gradient boosting [XGBoost], light gradient boosting machine, and categorical boosting [CatBoost]) were constructed using fivefold cross-validation to predict mortality. Through these models, 44 clinical variables measured on the day of admission were compared with six sequential organ failure assessment (SOFA) components (PaO2/FIO2 [PF], platelets (PLT), bilirubin, cardiovascular, Glasgow Coma Scale score, and creatinine). The confidence interval (CI) was obtained by performing 10,000 repeated measurements via random sampling of the test dataset. All results were explained and interpreted using Shapley's additive explanations (SHAP).

RESULTS

Of the 5,112 participants, CatBoost exhibited the highest area under the curve (AUC) of 0.800 (95% CI, 0.756-0.840) using clinical variables. Using the SOFA components for the same patient, XGBoost exhibited the highest AUC of 0.678 (95% CI, 0.626-0.730). As interpreted by SHAP, albumin, lactate, blood urea nitrogen, and international normalization ratio were determined to significantly affect the results. Additionally, PF and PLTs in the SOFA component significantly influenced the prediction results.

CONCLUSION

Newly established ML-based models achieved good prediction of mortality in patients with sepsis. Using several clinical variables acquired at the baseline can provide more accurate results for early predictions than using SOFA components. Additionally, the impact of each variable was identified.

Sepsis assessment and management in critically Ill adults: A systematic review

Background

Early assessment and management of patients with sepsis can significantly reduce its high mortality rates and improve patient outcomes and quality of life.

Objectives

The purposes of this review are to: (1) explore nurses’ knowledge, attitude, practice, and perceived barriers and facilitators related to early recognition and management of sepsis, (2) explore different interventions directed at nurses to improve sepsis management.

Methods

A systematic review method according to the PRISMA guidelines was used. An electronic search was conducted in March 2021 on several databases using combinations of keywords. Two researchers independently selected and screened the articles according to the eligibility criteria.

Results

Nurses reported an adequate of knowledge in certain areas of sepsis assessment and management in critically ill adult patients. Also, nurses’ attitudes toward sepsis assessment and management were positive in general, but they reported some misconceptions regarding antibiotic use for patients with sepsis, and that sepsis was inevitable for critically ill adult patients. Furthermore, nurses reported they either were not well-prepared or confident enough to effectively recognize and promptly manage sepsis. Also, there are different kinds of nurses’ perceived barriers and facilitators related to sepsis assessment and management: nurse, patient, physician, and system-related. There are different interventions directed at nurses to help in improving nurses’ knowledge, attitudes, and practice of sepsis assessment and management. These interventions include education sessions, simulation, decision support or screening tools for sepsis, and evidence-based treatment protocols/guidelines.

Discussion

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis in critical care patients.

Conclusion

Nurses have poor to good knowledge, practices, and attitudes toward sepsis as well as report many barriers related to sepsis management in adult critically ill patients. Despite all education interventions, no study has collectively targeted critical care nurses’ knowledge, attitudes, and practice of sepsis management.

The Knowledge of Nursing Internship Program Students about Early Detection of Sepsis

Background: Sepsis is a life-threatening condition due to the failure of the body’s regulation of infection. Knowledge deficit is one of the barriers to early detection and initiation of sepsis care. Nursing internship program students as future nurses need to have sufficient knowledge about early detection of sepsis to support their behavior. Thus, the purpose of this study was to describe the knowledge of nursing internship program students regarding the early detection of sepsis and the demographic factor related to the knowledge.      Methods: The study design was a quantitative study. Through the proportionate stratified non-random sampling technique, the researcher involved 143 nursing internship program students of Universitas Padjadjaran. Data collection used a questionnaire based on the Sepsis-3 guidelines to measure nursing internship program students’ knowledge about early detection of sepsis. The data was carried out in July-August 2021.   Results: The average knowledge score of the respondents was 70.4 (SD=11.9). More than half of the respondents (56.6%) got a score below the average. Almost all respondents do not know the current definition of sepsis and still use the SIRS definition as clinical criteria for sepsis. However, respondents could identify clinical criteria for sepsis based on qSOFA and analyse sepsis indicators based on case scenarios. Meanwhile, based on its characteristics, the information is a factor that significantly affects the knowledge score (p < 0.05).          Conclusion: In conclusion, there is still a gap in the knowledge of the nursing internship program students regarding the update of the Sepsis-3 guidelines. Besides, information is identified as the factor that influences knowledge. Therefore, it suggested that the institution provide further effective educational methods to update students’ knowledge about the early detection of sepsis.

Sepsis knowledge, skills and attitudes among ward-based nurses

BACKGROUND

Nurses are in a prime position to identify sepsis early by screening patients for sepsis, a skill that should be embedded into their daily practice. However, compliance with the sepsis bundle remains low.

AIMS

To explore the effects of sepsis training on knowledge, skills and attitude among ward-based nurses.

METHODS

Registered nurses from 16 acute surgical and medical wards were invited to anonymously complete a questionnaire.

FINDINGS

Response rate was 39% (98/250). Nurses with sepsis training had better knowledge of the National Early Warning Score 2 for sepsis screening, and the systemic inflammatory response syndrome (SIRS) criteria, demonstrated a more positive attitude towards sepsis screening and management, were more confident in screening patients for sepsis and more likely to have screened a patient for sepsis.

CONCLUSIONS

Sepsis training improves nurses' attitudes, knowledge and confidence with regards to sepsis screening and management, resulting in adherence to evidence-based care, and should become mandatory for all clinical staff.

Visualization of three-dimensional microcirculation of rodents' retina and choroid for studies of critical illness using optical coherence tomography angiography

We developed a method to measure the relative blood flow speed using optical coherence tomography angiography (OCTA) in retina and choroid, and investigated the feasibility of this method for assessing microcirculatory function in rat models of sepsis and hemorrhagic shock. Two sepsis models, 6-h severe sepsis without treatment and 30-h moderate sepsis maintaining mean arterial pressure, and volume controlled hemorrhagic shock and fluid resuscitation model were used to see the change of microcirculation. The blood flow index (BFI), which was calculated from the OCTA images to represent the average relative blood flow, was decreasing during the 6-h severe sepsis model. Its change is in parallel with the mean arterial blood pressure (MAP) and blood lactate levels. In the 30-h moderate sepsis model, the BFI was decreased while maintaining MAP, and lactate was increased. In the hemorrhagic shock model, the change of BFI is in line with MAP and lactate levels. In all models, BFI change is more sensitive in choroid than in retina. This study presents the OCTA-based retinal and choroidal microcirculatory blood flow monitoring method and shows its utility for assessment of critical illness.

Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department

INTRODUCTION

Vital signs measurements aid in the early identification of patients at risk of clinical deterioration and determining the severity of illness. Health care providers rely on registered nurses to document vital signs and communicate abnormalities. The purpose of this project was to improve the provider notification process regarding abnormal vital signs in a pediatric emergency department.

METHOD

A best practice advisory (BPA) was piloted by the advanced practice providers in the pediatric emergency department. To evaluate the effects of the BPA, a mixed-methods study was employed.

RESULTS

Implementation of the BPA improved the provider notification process and enhanced clinical decision making. The percentage of patients discharged home with abnormal respiratory rates (10.9% vs. 5.9%, p = .31), abnormal temperatures (15.6% vs. 7.5%, p = .14), and abnormal heart rates (25% vs. 11.9%, p = .11) improved.

DISCUSSION

Creation and implementation of the BPA improved the abnormal vital sign communication process to providers at this single institution.

Clinicians' experience of providing care: a rapid review

BACKGROUND

Health care services internationally are refocussing care delivery towards patient centred, integrated care that utilises effective, efficient and innovative models of care to optimise patient outcomes and system sustainability. Whilst significant efforts have been made to examine and enhance patient experience, to date little has progressed in relation to provider experience. This review aims to explore this knowledge gap by capturing evidence of clinician experience, and how this experience is defined and measured in the context of health system change and innovation.

METHODS

A rapid review of published and grey literature review was conducted utilising a rapid evidence assessment methodology. Seventy-nine studies retrieved from the literature were included in the review. Fourteen articles were identified from the grey literature search and one article obtained via hand searching. In total, 94 articles were included in the review. This study was commissioned by and co-designed with the New South Wales, Ministry of Health.

RESULTS

Clinician experience of delivering health care is inconsistently defined in the literature, with identified articles lacking clarity regarding distinctions between experience, engagement and work-related outcomes such as job satisfaction. Clinician experience was commonly explored using qualitative research that focused on experiences of discrete health care activities or events in which a change was occurring. Such research enabled exploration of complex experiences. In these contexts, clinician experience was captured in terms of self-reported information that clinicians provided about the health care activity or event, their perceptions of its value, the lived impacts they experienced, and the specific behaviours they displayed in relation to the activity or event. Moreover, clinician's experience has been identified to have a paucity of measurement tools.

CONCLUSION

Literature to date has not examined clinician experience in a holistic sense. In order to achieve the goals identified in relation to value-based care, further work is needed to conceptualise clinician experience and understand the nature of measurement tools required to assess this. In health system application, a broader 'clinician pulse' style assessment may be valuable to understand the experience of clinical work on a continuum rather than in the context of episodes of change/care.

Emergency nurses' experiences of the implementation of early goal directed fluid resuscitation therapy in the management of sepsis: a qualitative study

BACKGROUND

Severe sepsis can lead to organ failure and death if immediate treatment, such as intravenous fluids and antibiotics, are not commenced within the first hour. Time - critical initiation of intravenous fluids which in other words is early goal directed fluid resuscitation has not always been given its clinical priority. This qualitative study aimed at exploring the experiences of emergency nurses initiating early goal directed fluid resuscitation in patients with sepsis.

METHODS

Using an exploratory approach, face - to - face semi - structured interviews were conducted with ten registered nurses working in emergency departments across New South Wales, Australia. Thematic analysis was used for data analysis.

FINDINGS

Participants described various factors that inhibited the timely initiation of early goal directed fluid resuscitation, some clinical practice challenges, and strategies to improve nursing practice. Most participants, particularly those practicing as Clinical Initiatives Nurses suggested the incorporation of nurse initiated early goal directed fluid resuscitation for patients with sepsis as part of their scope of practice.

CONCLUSION

Our findings identified several barriers that inhibit effective nurse - initiated early goal directed fluid resuscitation. It is anticipated that these findings will provide validation for the re-evaluation of the existing protocols and practice guidelines to increase the scope of practice of emergency nurses initiating early goal directed fluid resuscitation.

Barriers to implementing the Sepsis Six guidelines in an acute hospital setting

AIM

To identify the barriers to implementation of the Sepsis Six pathway.

BACKGROUND

Research has suggested that compliance with the Sepsis Six pathway remains low.

METHODS

A convenience sample of doctors and nurses from one emergency department, two medical wards and two surgical wards were asked to complete a survey questionnaire.

RESULTS

Data from 108 respondents were available for analysis. Doctors and nurses agreed that lack of sepsis recognition during observation rounds and failure to associate sepsis with deranged temperature and blood results acted as barriers to the identification of sepsis. Doctors and nurses agreed that nursing delays and knowledge deficits were the top barriers leading to delay in sepsis treatment.

CONCLUSION

Knowledge deficits, lack of resources and practical issues were barriers identified in this survey. This will inform the educational and process needs of both doctors and nurses in order to improve sepsis care.

A survey of sepsis knowledge among Canadian emergency department registered nurses

BACKGROUND

With the rise of patients with sepsis presenting to emergency departments, emergency nurses, as frontline healthcare workers, require current clinical knowledge of sepsis. The aim of this study was to assess emergency department registered nurses' knowledge of sepsis and their perspectives of caring for patients with sepsis.

METHODS

A descriptive cross-sectional survey was used to survey Registered Nurses from four emergency departments in a western Canadian city (N=312).

RESULTS

The majority of nurses scored poorly on questions examining knowledge of systemic inflammatory response syndrome variables associated with sepsis, and sepsis definitions, general knowledge, and treatment (mean score 51.8%). Nurses acknowledged their lack of knowledge and indicated a desire for further sepsis education. Challenges in providing sepsis-related care concerned perceived heavy workloads and clinical implications related to the patient's status.

CONCLUSIONS

Educational programs and coaching approaches that maximize nurses' abilities to enhance their decision-making with regards to early assessment and appropriate intervention for persons with sepsis are needed. Such multifaceted approaches would acknowledge nurses' existing knowledge and provide practical supports to help nurses extend and mobilize their knowledge for everyday decision-making within the complex clinical environment of the emergency department.

Exploring the Predictors of Emergency Department Triage Acuity Assignment in Patients With Sepsis

Background and purpose

Evidence suggests that septic patients, who require prompt medical attention, may be undertriaged, resulting in delayed treatment. The purpose of this study was to examine patient and contextual variables that contribute to high- versus low-acuity triage classification of patients with sepsis.

Methods

Data were abstracted from the medical records of 154 adult patients with sepsis admitted to hospital through a Canadian Emergency Department. Logistic regression was used to explore the predictors of triage classification.

Results

Language barriers or chronic cognitive impairment (odds ratio 5.7; 95% confidence interval 2.15, 15.01), acute confusion (odds ratio 3.4; confidence interval 1.3, 8.2), unwell appearance (odds ratio 3.4; 95% confidence interval 1.7, 7.0), and hypotension (odds ratio 0.98; confidence interval 0.96, 1.0) were predictive of higher acuity classification. Temperature, heart rate, respiratory rate, and contextual factors were not related to triage classification.

Conclusions

Several patient-related factors were related to triage classification. However, the finding that temperature and heart and respiratory rates were not related to triage classification was troubling. Our findings point to a need for enhanced education for triage nurses regarding the physiological indices of sepsis. The sensitivity of the Canadian Triage Assessment Scale, used in Canadian Emergency Rooms, also needs to be examined.

Three-Hour Bundle Compliance and Outcomes in Patients With Undiagnosed Severe Sepsis

BACKGROUND

The aim of this study was to compare completion of the Surviving Sepsis Campaign 3-hour treatment recommendations and patient-centered outcomes between patients with severe sepsis who received a sepsis-specific diagnosis code with those who did not.

METHODS

This was a retrospective cohort analysis of adult patients admitted through an academic medical center ED who received an antibiotic and met criteria for severe sepsis. We measured and compared the Surviving Sepsis Campaign 3-hour treatment recommendations along with patient-centered outcomes in patients who were diagnosed with severe sepsis and those who were not.

RESULTS

A total of 5,631 patients were identified (60.6 ± 17.2 years of age; 48.9% women). Less than half (32.8%) received an International Classification of Diseases, ninth revision, diagnosis code of 995.92. Completion of all four bundle components in < 3 hours was low for all patients (8.72%). Therapeutic components (a broad-spectrum antibiotic and IV fluids) were completed more often (31.3%). Those with a diagnosis code received all four bundle components (10.2% vs 7.9%; P < .005), as well as therapeutic components at a higher frequency (36.0% vs 29.0%; P < .001). Patients with a diagnosis code had higher mortality (6.3% vs 2.3%), more frequent ICU admissions (44.7% vs 22.5%), and longer hospitalizations (9.2 ± 6.9 days vs 6.9 ± 6.7 days) than did patients with severe sepsis with no diagnosis code (all P < .001).

CONCLUSIONS

Severe sepsis continues to be an underdiagnosed and undertreated condition. Patients who were diagnosed had higher treatment rates yet experienced worse outcomes. Continued investigation is needed to identify factors contributing to diagnosis, treatment, and outcomes in patients with severe sepsis.

Protocol-Based Resuscitation Bundle to Improve Outcomes in Septic Shock Patients: Evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative

OBJECTIVES

To evaluate the impact of a multi-ICU quality improvement collaborative implementing a protocol-based resuscitation bundle to treat septic shock patients.

DESIGN

A difference-in-differences analysis compared patient outcomes in hospitals participating in the Michigan Health & Hospital Association Keystone Sepsis collaborative (n = 37) with noncollaborative hospitals (n = 50) pre- (2010-2011) and postimplementation (2012-2013). Collaborative hospitals were also stratified as high (n = 19) and low (n = 18) adherence based on their overall bundle adherence.

SETTING

Eighty-seven Michigan hospitals with ICUs.

PATIENTS

We compared 22,319 septic shock patients in collaborative hospitals compared to 26,055 patients in noncollaborative hospitals using the Michigan Inpatient Database.

INTERVENTIONS

Multidisciplinary ICU teams received informational toolkits, standardized screening tools, and continuous quality improvement, aided by cultural improvement.

MEASUREMENTS AND MAIN RESULTS

In-hospital mortality and hospital length of stay significantly improved between pre- and postimplementation periods for both collaborative and noncollaborative hospitals. Comparing collaborative and noncollaborative hospitals, we found no additional reductions in mortality (odds ratio, 0.94; 95% CI, 0.87-1.01; p = 0.106) or length of stay (-0.3 d; 95% CI, -0.7 to 0.1 d; p = 0.174). Compared to noncollaborative hospitals, high adherence hospitals had significant reductions in mortality (odds ratio, 0.84; 95% CI, 0.79-0.93; p < 0.001) and length of stay (-0.7 d; 95% CI, -1.1 to -0.2; p < 0.001), whereas low adherence hospitals did not (odds ratio, 1.07; 95% CI, 0.97-1.19; p = 0.197; 0.2 d; 95% CI, -0.3 to 0.8; p = 0.367).

CONCLUSIONS

Participation in the Keystone Sepsis collaborative was unable to improve patient outcomes beyond concurrent trends. High bundle adherence hospitals had significantly greater improvements in outcomes, but further work is needed to understand these findings.

A survey of critical care nurses' practices and perceptions surrounding early intravenous antibiotic initiation during septic shock

BACKGROUND

Delays in antibiotic administration after severe sepsis recognition increases mortality. While physician and pharmacy-related barriers to early antibiotic initiation have been well evaluated, those factors that affect the speed by which critical care nurses working in either the emergency department or the intensive care unit setting initiate antibiotic therapy remains poorly characterized.

AIM

To evaluate the knowledge, practices and perceptions of critical care nurses regarding antibiotic initiation in patients with newly recognised septic shock.

METHODS

A validated survey was distributed to 122 critical care nurses at one 320-bed academic institution with a sepsis protocol advocating intravenous(IV) antibiotic initiation within 1hour of shock recognition.

RESULTS

Among 100 (82%) critical care nurses responding, nearly all (98%) knew of the existence of the sepsis protocol. However, many critical care nurses stated they would optimise blood pressure [with either fluid (38%) or both fluid and a vasopressor (23%)] before antibiotic initiation. Communicated barriers to rapid antibiotic initiation included: excessive patient workload (74%), lack of awareness IV antibiotic(s) ordered (57%) or delivered (69%), need for administration of multiple non-antibiotic IV medications (54%) and no IV access (51%).

CONCLUSIONS

Multiple nurse-related factors influence IV antibiotic(s) initiation speed and should be incorporated into sepsis quality improvement efforts.

Assessment and management of the septic patient: part 2

Sepsis has gained increasing publicity in recent years, and there is now a strong focus of clinical education and training following the Surviving Sepsis Campaign. The assessment and management of a septic patients is far from simple and requires a systematic approach in both identifying and managing the condition. This second part explores sepsis care bundles and the research that underpins each of the interventions. These discussions will enable nurses to understand why each component of the sepsis care bundle is important and thus enable them to rapidly prioritise care, as early effective interventions have been shown to optimise patient outcomes.

Assessment and management of the septic patient: part 1

Sepsis has gained increasing publicity in recent years, and is now a strong focus of clinical education and training following the launch of the 'Surviving Sepsis' campaign. The assessment and management of a septic patient are far from simple and requires a systematic approach in both identifying and managing the condition. This two-part series explores the assessment and management of a septic patient, with this article emphasising the need to identify the signs and symptoms of sepsis at the early stages if positive patient outcomes are to be realised. The ABCDE approach to patient assessment is explored in the context of sepsis, as this approach can ensure the nurse will identify sepsis as opposed to the basic method of only performing vital observations.

Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival

BACKGROUND

Systemic inflammatory response syndrome (SIRS) and sepsis are now frequently identified by observations of vital signs and detection of organ failure during triage in the emergency room. However, there is less focus on the effect on patient outcome with better observation and treatment at the ward level.

METHODS

This was a before-and-after intervention study in one emergency and community hospital within the Mid-Norway Sepsis Study catchment area. All patients with confirmed bloodstream infection have been prospectively registered continuously since 1994. Severity of sepsis, observation frequency of vital signs, treatment data, length of stay (LOS) in high dependency and intensive care units, and mortality were retrospectively registered from the patients' medical journals.

RESULTS

The post-intervention group (n = 409) were observed better and had higher odds of surviving 30 days (OR 2.7, 95 % CI 1.6, 4.6), lower probability of developing severe organ failure (0.7, 95 % CI 0.4, 0.9), and on average, 3.7 days (95 % CI 1.5, 5.9 days) shorter LOS than the pre-intervention group (n = 472).

CONCLUSIONS

In a cohort with stable mortality rates, early sepsis recognition by ward nurses may have reduced progression of disease and improved survival for patients in hospital with sepsis.

Knowledge about systemic inflammatory response syndrome and sepsis: a survey among Dutch emergency department nurses

Background

Sepsis has a high mortality. Early recognition and timely treatment are essential for patient survival. The aim of this study is to examine the factors that influence the knowledge and recognition of systemic inflammatory response syndrome (SIRS) criteria and sepsis by emergency department (ED) nurses.

Methods

A prospective, multi-center study including 216 ED nurses from 11 hospitals and academic medical centers in The Netherlands was conducted in 2013. A validated questionnaire was used to evaluate ED nurses’ knowledge about SIRS and sepsis. Questions about demographic characteristics were also included, to investigate factors that may contribute to the knowledge about SIRS and sepsis.

Results

The mean total score was 15.9 points, with a maximum possible score of 29 points. ED nurses employed at hospitals with a level 3 intensive care unit (ICU) scored significantly higher than their colleagues employed at hospitals with a level 1 or 2 ICU. Recently completed education in sepsis was associated with a higher score. The employees in low ICU level hospitals who reported recent education did not score significantly lower than their ICU level 3 colleagues. ED nurses over the age of 50 scored significantly lower than their younger colleagues.

Conclusions

The knowledge of ED nurses concerning SIRS and sepsis rises proportionally with the level of ICU in hospitals. Recent education in sepsis raises knowledge level as well. We recommend that when there is a low exposure rate to SIRS and sepsis, more emphasis should be placed on regular education.

Crossing the handover chasm: Clinicians' perceptions of barriers to the early detection and timely management of severe sepsis and septic shock

PURPOSE

The purpose was to identify barriers to the early detection and timely management of severe sepsis throughout the emergency department (ED), general ward (GW), intermediate care unit (IMC), and the intensive care unit (ICU).

MATERIALS AND METHODS

Five multicenter focus group discussions with 29 clinicians were conducted. Discussions were based on a moderation guide were recorded and transcribed. Qualitative analysis was performed according to the principles of the concept mapping method and the framework approach.

RESULTS

The major causes of the delayed detection and treatment could be summarized in a framework of communication errors and handover difficulties throughout patients' course of treatment, which can be divided into 5 core areas: inadequate histories before hospital admission; poorly coordinated handovers between the ambulance service and the ED; delayed patient transfer between the ED and the GW as well as delays in patient transfers between the GW and the ICU by, for example, a lack of bed capacity and a shortage of staff. Generally, participants from all wards mentioned that the urgency with which septic patients needed to be treated was not communicated.

CONCLUSIONS

Our study shows the need to improve intra- and interunit handover processes in hospital care, which would ensure a holistic treatment concept, thereby improving patient care.

"Beat the Shock Clock": An Interprofessional Team Improves Pediatric Septic Shock Care

Ideal care for septic shock (SS) is difficult. This interprofessional quality improvement intervention in a mid-volume pediatric emergency department aimed to reduce time to vascular access, fluid resuscitation, and antibiotics for SS. Intensive education, a care pathway, and an order set were applied. Outcome measures for patients with criteria for SS before and after intervention were compared. There were 43 patients pre-intervention (January 2009 to June 2011) and 63 post-intervention (June 2012 to June 2013). Median time to vascular access decreased from 37 minutes pre-intervention to 24 minutes post-intervention (p = 0.05). Median time to first fluid bolus decreased from 35 to 26 minutes (p = 0.08). Percentage of boluses delivered rapidly by pressure method increased from 21% to 74% (p < 0.0001). Median time to antibiotics decreased from 92 to 55 minutes (p = 0.02). In conclusion, a multimodal, interprofessional quality improvement intervention in a mid-sized pediatric emergency department improved the time to critical interventions for SS.

Nurses' perceptions of using an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury: A qualitative study

Evidence to guide initial emergency nursing care of patients with severe traumatic brain injury (TBI) in Thailand is currently not available in a useable form. A care bundle was used to summarise an evidence-based approach to the initial emergency nursing management of patients with severe TBI and was implemented in one Thai emergency department. The aim of this study was to describe Thai emergency nurses' perceptions of care bundle use. A descriptive qualitative study was used to describe emergency nurses' perceptions of care bundle use during the implementation phase (Phase-One) and then post-implementation (Phase-Two). Ten emergency nurses participated in Phase-One, while 12 nurses participated in Phase-Two. In Phase-One, there were five important factors identified in relation to use of the care bundle including quality of care, competing priorities, inadequate equipment, agitated patients, and teamwork. In Phase Two, participants perceived that using the care bundle helped them to improve quality of care, increased nurses' knowledge, skills, and confidence. Care bundles are one strategy to increase integration of research evidence into clinical practice and facilitate healthcare providers to deliver optimal patient care in busy environments with limited resources.

Quality improvement in pediatric sepsis

PURPOSE OF REVIEW

Although there is abundant literature detailing the impact of quality improvement in adult sepsis, the pediatric literature is lacking. Despite consensus definitions for sepsis, which patients along the sepsis spectrum should receive aggressive management and the exact onset of sepsis ('time zero') are not clearly established. In the adult emergency department (ED), sepsis onset is defined as the time of entry into the ED; however, this definition cannot be applied to hospitalized patients or patients who evolve during their ED course. Since the time of sepsis onset will dictate the timeliness of subsequent process measures, the variable definitions in the literature make it difficult to generalize findings among prior studies.

RECENT FINDINGS

Despite the variation in defining time zero, aggressive fluid administration, timely antibiotics, and compliance with sepsis bundles have been shown to improve mortality and to reduce hospital and intensive care length of stay. In addition, early identification tools show promise in beginning to define sepsis onset and retrospective search tools may allow improved case finding of those children of concern for sepsis.

SUMMARY

Quality improvement in pediatric sepsis is evolving. As we continue to define quality measures, we must standardize the definition of sepsis onset. This definition should be applicable to any treatment venue to ensure measures can be evaluated across all settings. In addition, we must delineate which patients along the sepsis spectrum should be candidates for timely interventions and standardize other outcome measures beyond mortality.

Barriers to referral for elevated blood pressure in the emergency department and differences between provider type

A multidisciplinary sample of emergency department providers across the United States (n=450) were surveyed to identify barriers to referral for elevated blood pressure (BP) in the emergency department and differences between provider type. Registered nurses reported less knowledge of stage I hypertension (P=.043) and prehypertension (P<.01); were less aware of definitions for hypertension (P<.001); reported more difficulty in caring for patients who are asymptomatic (P=.007); required financial compensation to refer (P=.048); and perceived that BP referrals are influenced by the medical director (P<.001). Medical doctors reported more skills to refer (P=.008) and time as a barrier (P=.038). Physician assistants were more likely to report patients are not aware of health benefits (P=.035), doubted their concern for their BP (P=.023), and felt emotionally uncomfortable when referring (P=.025). Despite these differences, there was no significant difference between provider type and referral rates.

Impact of nurse-initiated ED sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality

INTRODUCTION

Emergency nurses play a key role in the initial triage and care of patients with potentially life-threatening illnesses. The aims of this study were to (1) evaluate the impact of a nurse-initiated ED sepsis protocol on time to initial antibiotic administration, (2) ascertain compliance with 3-hour Surviving Sepsis Campaign (SSC) targets, and (3) identify predictors of in-hospital sepsis mortality.

METHODS

A retrospective chart review investigated all adult patients-admitted through either of 2 academic tertiary medical center emergency departments-who were discharged with a diagnosis of severe sepsis or septic shock (N = 195). Pre- and post-protocol implementation data examined both compliance with 3-hour SSC bundle targets and patient outcomes. Multivariate logistic regression analysis identified predictors of in-hospital mortality.

RESULTS

Serum lactate measurement (83.9% vs 98.7%, P = .003) and median time to initial antibiotic administration (135 minutes vs 108 minutes, P = .021) improved significantly after protocol implementation. However, one quarter of antibiotic administration times still exceeded the 3-hour target. Significant predictors of in-hospital mortality were respiratory dysfunction, central nervous system dysfunction, urinary tract infection, vasopressor administration, and patient body weight (P < .05). There were no in-hospital mortality rate differences between the pre- and post-protocol implementation groups.

DISCUSSION

Compliance with serum lactate measurement and blood culture collection goals approached 100% in the post-protocol group. However, compliance with medical interventions requiring multiple health care-provider involvement (ie, antibiotic and fluid administration) remained suboptimal. Efforts focused on multidisciplinary bundle elements are necessary to achieve full compliance with SSC targets.

Emergency physician perspectives on central venous catheterization in the emergency department: a survey-based study

OBJECTIVES

The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients.

METHODS

The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goal-directed therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in real-time ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, time-related, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes.

RESULTS

The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater self-reported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing US-guided internal jugular catheters.

CONCLUSIONS

In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in US and/or by disseminating existing evidence about the low risk of complications associated with the procedure.

Validation of sepsis screening tool using StO2 in emergency department patients

BACKGROUND

Sepsis is a deleterious systemic response to an infection with a high incidence of morbidity and mortality, affecting more than a million patients a year in the US. The purpose of this study was to develop a screening tool for the early identification of sepsis in emergency department patients using readily available information at triage.

MATERIALS AND METHODS

This prospective, observational study took place at an academic tertiary referral hospital. Over a period of 10 wk, all patients who were seen at triage were screened for study enrollment. Inclusion criteria were adult (age≥18 y) nontrauma patients and exclusion criteria were prisoners and pregnant women. Using a Spot Check StO2 device to measure StO2 value, heart rate, respiratory rate, and temperature, these values were used to generate a cumulative screening score indicating whether a patient may have sepsis.

RESULTS

A total of 500 patients were screened. The incidence of sepsis in the present study population was 8.4%. The screening tool yielded a sensitivity of 85.7%, a specificity of 78.4%, a positive predictive value of 26.7%, and a negative predictive value of 98.4%.

CONCLUSIONS

Heart rate, respiratory rate, and temperature have good diagnostic potential for the early identification of sepsis among emergency department triage personnel. Additionally, early evidence suggests StO2 may play a complementary and synergistic role in the early identification of sepsis by triage personnel.

Predictors of unattempted central venous catheterization in septic patients eligible for early goal-directed therapy

INTRODUCTION

Central venous catheterization (CVC) can be an important component of the management of patients with severe sepsis and septic shock. CVC, however, is a time- and resource-intensive procedure associated with serious complications. The effects of the absence of shock or the presence of relative contraindications on undertaking central line placement in septic emergency department (ED) patients eligible for early goal-directed therapy (EGDT) have not been well described. We sought to determine the association of relative normotension (sustained systolic blood pressure >90 mmHg independent of or in response to an initial crystalloid resuscitation of 20 mL/kg), obesity (body mass index [BMI] ≥30), moderate thrombocytopenia (platelet count <50,000 per μL), and coagulopathy (international normalized ratio ≥2.0) with unattempted CVC in EGDT-eligible patients.

METHODS

This was a retrospective cohort study of 421 adults who met EGDT criteria in 5 community EDs over a period of 13 months. We compared patients with attempted thoracic (internal jugular or subclavian) CVC with those who did not undergo an attempted thoracic line. We also compared patients with any attempted CVC (either thoracic or femoral) with those who did not undergo any attempted central line. We used multivariate logistic regression analysis to calculate adjusted odd ratios (AORs).

RESULTS

In our study, 364 (86.5%) patients underwent attempted thoracic CVC and 57 (13.5%) did not. Relative normotension was significantly associated with unattempted thoracic CVC (AOR 2.6 95% confidence interval [CI], 1.6-4.3), as were moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5-10.1) and coagulopathy (AOR 2.7; 95% CI, 1.3-5.6). When assessing for attempted catheterization of any central venous site (thoracic or femoral), 382 (90.7%) patients underwent attempted catheterization and 39 (9.3%) patients did not. Relative normotension (AOR 2.3; 95% CI, 1.2-4.5) and moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5-10.3) were significantly associated with unattempted CVC, whereas coagulopathy was not (AOR 0.6; 95% CI, 0.2-1.8). Obesity was not significantly associated with unattempted CVC, either thoracic in location or at any site.

CONCLUSION

Septic patients eligible for EGDT with relative normotension and those with moderate thrombocytopenia were less likely to undergo attempted CVC at any site. Those with coagulopathy were also less likely to undergo attempted thoracic central line placement. Knowledge of the decision-making calculus at play for physicians considering central venous catheterization in this population can help inform physician education and performance improvement programs.

Emergency department boarding times for patients admitted to intensive care unit: Patient and organizational influences

INTRODUCTION

Critically ill patients can be subject to prolonged stays in the emergency department following receipt of an order to admit to an intensive care unit. The purpose of this study was to explore patient and organizational influences on the duration of boarding times for intensive care bound patients.

METHODS

This exploratory descriptive study was situated in a Canadian hospital in northern Ontario. Through a six-month retrospective review of three data sources, information was collected pertaining to 16 patient and organizational variables detailing the emergency department boarding time of adults awaiting transfer to the intensive care unit. Data analysis involved descriptive and non-parametric methods.

RESULTS

The majority of the 122 critically ill patients boarded in the ED were male, 55 years of age or older, arriving by ground ambulance on a weekday, and had an admitting diagnosis of trauma. The median boarding time was 34 min, with a range of 0-1549 min. Patients designated as most acute, intubated, and undergoing multiple diagnostic procedures had statistically significantly shorter boarding times.

DISCUSSION

The study results provide a profile that may assist clinicians in understanding the complex and site-specific interplay of variables contributing to boarding of critically ill patients.

Plethysmographic variation index predicts fluid responsiveness in ventilated patients in the early phase of septic shock in the emergency department: a pilot study

PURPOSE

Feasibility study examining whether plethysmographic variability index (PVI) can predict fluid responsiveness in mechanically ventilated patients in the early phase of septic shock in the emergency department.

MATERIALS AND METHODS

Monocentric, prospective, observational study that included 31 mechanically ventilated and sedated patients with septic shock in whom volume expansion was planned. The patients were equipped with a pulse oximeter that automatically calculated and displayed PVI. The intervention consisted in infusing 8 mL/kg of hydroxylethyl starch over a 20-minute period. Before and after intervention, we recorded PVI and measured the aortic velocity-time integral (VTIao) using transthoracic echocardiography. Responders were defined as patients who increased their VTIao by 15% or higher after fluid infusion.

RESULTS

Sixteen patients were classified as responders, and 15 as nonresponders. Mean PVI values before intervention were significantly higher in responders vs nonresponders (30%±9% vs 8%±5%, P<.001). Plethysmographic variability index values before intervention were correlated with percent changes in VTIao induced by intervention (R2=0.67; P<.001). A PVI threshold value of 19% discriminates responders from nonresponders with a sensitivity of 94% and a specificity of 87% (area under the curve, 0.97; P<.001).

CONCLUSION

Our study suggests that PVI is a feasible and interesting method to predict fluid responsiveness in early phase septic shock patients in the emergency department.