Sepsis guideline implementation: benefits, pitfalls and possible solutions

Performance of hospital administrative data for detection of sepsis in Australia: The sepsis coding and documentation (SECOND) study

BACKGROUND

Sepsis is the world's leading cause of death and its detection from a range of data and coding sources, consistent with consensus clinical definition, is desirable.

OBJECTIVE

To evaluate the performance of three coding definitions (explicit, implicit, and newly proposed synchronous method) for sepsis derived from administrative data compared to a clinical reference standard.

METHOD

Extraction of administrative coded data from Australian metropolitan teaching hospital with 25,000 annual overnight admissions compared to clinical review of medical records; 313 (27.9%) randomly selected adult multi-day stay hospital separations from 1,123 separations with acute infection during July 2019. Estimated prevalence and performance metrics, including positive (PPV) and negative predictive values (NPV), and area under the receiver operator characteristic curve (ROC).

RESULTS

Clinical prevalence of sepsis was estimated at 10.7 (95% CI = 10.3-11.3) per 100 separations, and mortality rate of 11.6 (95% CI = 10.3-13.0) per 100 sepsis separations. Explicit method for case detection had high PPV (93.2%) but low NPV (55.8%) compared to the standard implicit method (74.1 and 66.3%, respectively) and proposed synchronous method (80.4% and 80.0%) compared to a standard clinical case definition. ROC for each method: 0.618 (95% CI = 0.538-0.654), 0.698 (95% CI = 0.648-0.748), and 0.802 (95% CI = 0.757-0.846), respectively.

CONCLUSION

In hospitalised Australian patients with community-onset sepsis, the explicit method for sepsis case detection underestimated prevalence. Implicit methods were consistent with consensus definition for sepsis, and proposed synchronous method had better performance.

How Are Clinicians Treating Children With Sepsis in Emergency Departments in Latin America?: An International Multicenter Survey

OBJECTIVE

Guidelines adherence in emergency departments (EDs) relies partly on the availability of resources to improve sepsis care and outcomes. Our objective was to assess the management of pediatric septic shock (PSS) in Latin America's EDs and to determine the impact of treatment coordinated by a pediatric emergency specialist (PEMS) versus nonpediatric emergency specialists (NPEMS) on guidelines adherence.

METHODS

Prospective, descriptive, and multicenter study using an electronic survey administered to PEMS and NPEMS who treat PSS in EDs in 14 Latin American countries.

RESULTS

We distributed 2164 surveys with a response rate of 41.5%, of which 22.5% were PEMS. Overall American College of Critical Care Medicine reported guidelines adherence was as follows: vascular access obtained in 5 minutes, 76%; fluid infusion technique, 60%; administering 40 to 60 mL/kg within 30 minutes, 32%; inotropic infusion by peripheral route, 61%; dopamine or epinephrine in cold shock, 80%; norepinephrine in warm shock, 57%; and antibiotics within 60 minutes, 82%. Between PEMS and NPEMS, the following differences were found: vascular access in 5 minutes, 87.1% versus 72.7% (P < 0.01); fluid infusion technique, 72.3% versus 55.9% (P < 0.01); administering 40 to 60 mL/kg within 30 minutes, 42% versus 29% (P < 0.01); inotropic infusion by peripheral route, 75.7% versus 56.3% (P < 0.01); dopamine or epinephrine in cold shock, 87.1% versus 77.3% (P < 0.05); norepinephrine in warm shock, 67.8% versus 54% (P < 0.01); and antibiotic administration within first 60 minutes, 90.1% versus 79.3% (P < 0.01), respectively. Good adherence criteria were followed by 24%. The main referred barrier for sepsis care was a failure in its recognition, including the lack of triage tools.

CONCLUSIONS

In some Latin American countries, there is variability in self-reported adherence to the evidence-based recommendations for the treatment of PSS during the first hour. The coordination by PEMS support greater adherence to these recommendations.

Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study

OBJECTIVE

To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals.

METHODS

Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries.

RESULTS

Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals.

CONCLUSION

In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.

Nurses' Knowledge on Sepsis Related to Mechanical Ventilation: An Intervention Study

BACKGROUND

Sepsis is a leading cause of mortality and morbidity worldwide. South African adult public critical care units experience incidences of sepsis on an ongoing basis. Nurses caring for mechanically ventilated adult patients in intensive care units (ICUs) need to base their nursing care on "surviving sepsis campaign" (SSC) guidelines to properly manage sepsis. Adequate knowledge on sepsis guidelines remains crucially indicated for nurses as they endeavor to maintain asepsis in critically ill patients.

PURPOSE

This study was conducted to assess the effect of an educational intervention on nurses' knowledge and practices of sepsis in mechanically ventilated adult patients in public ICUs.

METHODS

An intervention study, with quasi-intervention two-group, pretest-posttest design, was used to collect data using a self-administered, structured, pretest and posttest questionnaire designed to measure nurses' knowledge and practices on sepsis related to mechanical ventilation. The study was conducted between June and October 2018. An educational intervention was developed and validated. Five purposively selected public ICUs in the Eastern Cape, South Africa, were selected and assigned to three groups: Intervention Group 1 (ICUs 1 and 2), which received the full intervention (containing a 20-minute PowerPoint presentation, printed materials based on sections of the SSC guidelines, and monitoring visits bimonthly for 3 months); Intervention Group 2 (ICUs 3 and 4; receiving the same as Intervention Group 1 but with no monitoring visits); and the control group (ICU 5; receiving no intervention).

RESULTS

One hundred seventeen nurses completed the questionnaires at pretest, and 94 completed the questionnaires at posttest, producing a response rate of 79% and 80%, respectively. The results revealed a significant knowledge score increase between pretest and posttest for both Intervention Group 2 (53.28 ± 14.39 and 62.18 ± 13.60, respectively; p = .004) and the control group (56.72 ± 13.72 and 70.05 ± 12.40, respectively; p = .001). Similarly, a recommended practice score increase was shown for Intervention Group 2 (58.8 ± 9.63 and 62.80 ± 9.52, respectively), and a significant increase was shown for the control group (56.72 ± 7.54 and 63.29 ± 5.89, respectively; p = .002). Intervention Group 1 showed a detectable but not significant decline in knowledge (57.72 ± 13.99 and 54.61 ± 12.15, respectively) and recommended practice (61.22 ± 8.66 and 60.33 ± 7.83, respectively) scores.

CONCLUSIONS

The availability of SSC guidelines was found to have increased knowledge on sepsis related to mechanical ventilation, although including monitoring visits as part of the educational intervention was not found to have a positive effect on increasing knowledge and practices. Further studies are required to explore factors contributing to improving knowledge and practices on sepsis related to mechanical ventilation and the effect that various educational interventions have in this context.

Integrating a Machine Learning System Into Clinical Workflows: Qualitative Study

Background

Machine learning models have the potential to improve diagnostic accuracy and management of acute conditions. Despite growing efforts to evaluate and validate such models, little is known about how to best translate and implement these products as part of routine clinical care.

Objective

This study aims to explore the factors influencing the integration of a machine learning sepsis early warning system (Sepsis Watch) into clinical workflows.

Methods

We conducted semistructured interviews with 15 frontline emergency department physicians and rapid response team nurses who participated in the Sepsis Watch quality improvement initiative. Interviews were audio recorded and transcribed. We used a modified grounded theory approach to identify key themes and analyze qualitative data.

Results

A total of 3 dominant themes emerged: perceived utility and trust, implementation of Sepsis Watch processes, and workforce considerations. Participants described their unfamiliarity with machine learning models. As a result, clinician trust was influenced by the perceived accuracy and utility of the model from personal program experience. Implementation of Sepsis Watch was facilitated by the easy-to-use tablet application and communication strategies that were developed by nurses to share model outputs with physicians. Barriers included the flow of information among clinicians and gaps in knowledge about the model itself and broader workflow processes.

Conclusions

This study generated insights into how frontline clinicians perceived machine learning models and the barriers to integrating them into clinical workflows. These findings can inform future efforts to implement machine learning interventions in real-world settings and maximize the adoption of these interventions.

Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?

Objective

The aim of this study was to compare the stratification of sepsis patients in the emergency department (ED) for ICU admission and mortality using the Predisposition, Infection, Response and Organ dysfunction (PIRO) and quick Sequential Organ Failure Assessment (qSOFA) scores with clinical judgement assessed by the ED staff.

Patients and methods

This was a prospective observational study in the ED of a tertiary care teaching hospital. Adult nontrauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome criteria were included. The primary outcome was direct ED to ICU admission. The secondary outcomes were in-hospital, 28-day and 6-month mortality, indirect ICU admission and length of stay. Clinical judgement was recorded using the Clinical Impression Scores (CIS), appraised by a nurse and the attending physician. The PIRO and qSOFA scores were calculated from medical records.

Results

We included 193 patients: 103 presented with sepsis, 81 with severe sepsis and nine with septic shock. Fifteen patients required direct ICU admission. The CIS scores of nurse [area under the curve (AUC)=0.896] and the attending physician (AUC=0.861), in conjunction with PIRO (AUC=0.876) and qSOFA scores (AUC=0.849), predicted direct ICU admission. The CIS scores did not predict any of the mortality endpoints. The PIRO score predicted in-hospital (AUC=0.764), 28-day (AUC=0.784) and 6-month mortality (AUC=0.695). The qSOFA score also predicted in-hospital (AUC=0.823), 28-day (AUC=0.848) and 6-month mortality (AUC=0.620).

Conclusion

Clinical judgement is a fast and reliable method to stratify between ICU and general ward admission in ED patients with sepsis. The PIRO and qSOFA scores do not add value to this stratification, but perform better on the prediction of mortality. In sepsis patients, therefore, the principle of ‘treat first what kills first’ can be supplemented with ‘judge first and calculate later’.

Epidemiology of Pediatric Septic Shock

Sepsis, or dysregulated host response to infection, is considered a worldwide public health problem. It is a major childhood disease both in terms of frequency and severity, and severe sepsis is still considered the main cause of death from infection in childhood. This review provides an overview of the epidemiology of pediatric septic shock. The prevalence of severe sepsis and septic shock among hospitalized children ranges from 1 to 26%. Mortality is high, ranging from 5% in developed countries to up to 35% in developing countries. However, 10 years after the publication of pediatric sepsis definitions, a global perspective on the burden of this disease in childhood is still missing. Major obstacles to a better knowledge of sepsis epidemiology in children are the absence of an adequate disease definition and not having sepsis as a cause of death in the World Health Organization Global Burden of Disease Report, which is one of the most important sources of information for health policies decision-making in the world. Several studies performed in both developed and developing countries have shown that mortality from septic shock is high and is associated with delayed diagnosis, late treatment, and nonadherence to the treatment guidelines. Reducing mortality from sepsis in childhood is a worldwide challenge, especially in developing countries, where the highest number of cases and deaths are recorded and where financial resources are scarce. Many specialists consider that prevention, education, and organization are key to achieve a reduction in the burden of sepsis.

Barriers and facilitators towards implementing the Sepsis Six care bundle (BLISS-1): a mixed methods investigation using the theoretical domains framework

Background

The ‘Sepsis 6’, a care bundle of basic, but vital, measures (e.g. intravenous fluid, antibiotics) has been implemented to improve sepsis treatment. However, uptake has been variable. Tools from behavioral sciences, such as the Theoretical Domains Framework (TDF) may be used to understand and address such implementation issues. This study used a behavioral science approach to identify barriers and facilitators towards Sepsis Six implementation at a case study hospital.

Methods

Semi-structured interviews based on the TDF were conducted with a sample group of consultants, junior doctors and nurses from Emergency Department, Medical and Surgical Admissions, to explore barriers/facilitators to Sepsis Six performance. Transcripts were analyzed following the combined principles of content and framework analysis. Emerging themes informed a questionnaire to explore generalizability and importance across a sample of 261 stakeholders. Median importance and agreement ratings for each theme were calculated overall and for each role and clinical area. These were used to identify important barriers and important facilitators as targets for performance improvement.

Results

No new belief statements were discovered and data saturation was deemed achieved after 10 interviews. 1699 utterances were coded into 64 belief statements, then collated into a 51-item questionnaire. 113 questionnaire responses were obtained (44.3% response rate). Important barriers included insufficient audit and feedback, poor teamwork and communication, concerns about using the Sepsis Six in certain patients, insufficient training, and resource concerns. Facilitators included confidence in knowledge and skills, beliefs in overall benefits of the bundle, beliefs that identification and management of septic patients fell within everyone’s role, and that regular use of the bundle made it easier to remember. Some beliefs were applicable for the entire group, others were specific to particular staff groups.

Discussion and Conclusions

A range of barriers and facilitators towards Sepsis Six performance across different staff groups were systematically identified using a theoretically-informed approach. This can inform development of targeted performance improvement interventions.

Electronic supplementary material

The online version of this article (10.1186/s13049-017-0437-2) contains supplementary material, which is available to authorized users.

The Epidemiology of Sepsis in Childhood

BACKGROUND

Sepsis, or systemic inflammatory response to infection, is a major childhood disease and a common cause of death in children. Despite its importance, a global perspective on the epidemiology and mortality of pediatric sepsis across the world is still lacking.

METHODS

A non-systematic review of the medical articles published in Medline from 2005 to 2015.

RESULTS

Studies suggest that there has been a rise in the number of pediatric sepsis cases along the last two decades, which may relate to the increased survival of preterm and low birth-weight infants and children with severe chronic conditions. Children living in low-income countries represent a vulnerable population for sepsis. Despite several initiatives to improve the diagnosis and early treatment of pediatric sepsis, the mortality resulting from pediatric sepsis remains high, ranging from 5% to 40%. Poor outcomes, however, do not seem to be related to the limitation of resources but to the delay in the recognition and early treatment of sepsis.

CONCLUSIONS

Educational efforts aiming to increase the awareness on sepsis by the general public and the adherence to the treatment guidelines by healthcare providers may result in significant improvements in sepsis survival. The global attention to pediatric sepsis, however, can only be achieved with the standardization of the definitions and the use of simple and sensitive diagnostic criteria that incorporate the differences in the necessities among different settings and the availability of local resources.

Mortality trends in U.S. adults with septic shock, 2005-2011: a serial cross-sectional analysis of nationally-representative data

Background

We aimed to investigate mortality trends in hospitalized patients with septic shock in the US. To achieve this objective, we tested hypothesis that mortality decreased in patients identified by the code of septic shock while mortality did not change in those with septic shock identified by vasopressor use.

Methods

We conducted a serial cross-sectional analysis using Nationwide Inpatient Sample database from 2005 through 2011. First, we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria: 1) primary ICD-9 diagnosis of infection plus procedure code for vasopressor use, 2) primary ICD-9 diagnosis of infection plus septic shock in non-primary field, and 3) primary ICD-9 diagnosis of septic shock. Second, we stratified all identified patients by record of vasopressor use. The outcome of interest was year-to-year changes in the in-hospital all-cause mortality.

Results

From 2005 to 2011, we identified 109,812 weighted hospitalizations with septic shock. Overall, there was a significant downward trend in in-hospital mortality (from 46 % in 2005 to 42 % in 2011; P_trend = 0.003); the adjusted mortality also decreased significantly (OR for comparison of 2005 with 2011, 0.98; 95 % CI, 0.96–1.00; P < 0.001). In stratified analysis, the mortality trend was not significant in the subgroup with vasopressor use (from 42 % in 2005 to 40 % in 2011; P_trend =0.57); similarly, the adjusted mortality did not change significantly (OR, 1.01; 95 % CI, 0.97–1.05; P =0.62). By contrast, there was a downward trend in mortality in the subgroup without vasopressor use (from 47 % in 2005 to 43 % in 2011; P_trend =0.002); likewise, the adjusted mortality decreased significantly (OR, 0.97; 95 % CI, 0.95–0.99; P =0.002)

Conclusions

From 2005 to 2011, we found a modest decrease in in-hospital mortality among patients identified with septic shock. However, in the subgroup with vasopressor use, we found no significant change in mortality. Our data challenge the conventional wisdom that mortality in this population has improved during the last decade.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1620-1) contains supplementary material, which is available to authorized users.