1
|
Visser M, Rossi D, Bouma HR, ter Maaten JC. Exploiting the Features of Clinical Judgment to Improve Assessment of Disease Severity in the Emergency Department: An Acutelines Study. J Clin Med 2024; 13:1359. [PMID: 38592702 PMCID: PMC10931686 DOI: 10.3390/jcm13051359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/18/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Clinical judgment, also known as gestalt or gut feeling, can predict deterioration and can be easily and rapidly obtained. To date, it is unknown what clinical judgement precisely entails. The aim of this study was to elucidate which features define the clinical impression of health care professionals in the ED. METHOD A nominal group technique (NGT) was used to develop a consensus-based instrument to measure the clinical impression score (CIS, scale 1-10) and to identify features associated with either a more severe or less severe estimated disease severity. This single-center observational cohort study included 517 medical patients visiting the ED. The instrument was prospectively validated.. The predictive value of each feature for the clinical impression was assessed using multivariate linear regression analyses to adjust for potential confounders and validated in the infection group. RESULTS The CIS at the ED was associated with ICU admission (OR 1.67 [1.37-2.03], p < 0.001), in-hospital mortality (OR 2.25 [1.33-3.81], p < 0.001), and 28-day mortality (OR 1.33 [1.07-1.65], <0.001). Dry mucous membranes, eye glance, red flags during physical examination, results of arterial blood gas analysis, heart and respiratory rate, oxygen modality, triage urgency, and increased age were associated with a higher estimated disease severity (CIS). On the other hand, behavior of family, self-estimation of the patient, systolic blood pressure, and Glascow Coma Scale were associated with a lower estimated disease severity (CIS). CONCLUSION We identified several features that were associated with the clinical impression of health care professionals in the ED. Translating the subjective features and objective measurements into quantifiable parameters may aid the development of a novel triage tool to identify patients at risk of deterioration in the ED.
Collapse
Affiliation(s)
- Martje Visser
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
| | - Daniel Rossi
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
| | - Hjalmar R. Bouma
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Jan C. ter Maaten
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (M.V.); .; (J.C.t.M.)
- Department of Aute Care, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| |
Collapse
|
2
|
Gustad LT, Bangstad IL, Torsvik M, Rise MB. Nurses' and Physicians' Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals. J Multidiscip Healthc 2024; 17:29-41. [PMID: 38192738 PMCID: PMC10773249 DOI: 10.2147/jmdh.s439017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024] Open
Abstract
Purpose Previous research has explored nurses´ experience with the implementation of early detection alert systems, and nurses and physicians' perceptions of sepsis management and use of sepsis triage. As one of the first, this study aims to investigate the perceived usefulness of an interdisciplinary quality improvement project including standardized sepsis patient pathway to improve the early identification and treatment of sepsis patients. Participants and Methods This study was a qualitative study that employed semi-structured interviews with thirteen ward nurses and five ward physicians recruited by convenience and respondent-driven sampling, respectively. The interviews explored the perceived usefulness of mutual training in sepsis care in medical hospital wards. We applied Systematic Text Condensation to analyze the experiences and knowledge of professional identification and cooperation in early identification of sepsis patients. Results The results revealed three main themes: Awareness of sepsis, collaboration between nurses and physicians, and clinical assessment and judgement. The findings highlighted the positive impact of the project in terms of raising awareness, improving communication, and enhancing the ability to detect and treat sepsis. The study also identified the importance of repetition and reminders to maintain awareness, the need for ongoing training for new healthcare professionals, and the challenges of collaboration and decision-making processes. Conclusion The sepsis intervention seemed successful in improving awareness of sepsis and enhancing interprofessional collaboration between nurses and physicians. Health professionals continued to rely on their clinical judgment but increased the use of objective measurements and communication of vital signs. Continuous repetition and education for new colleagues were identified as important factors for the sustainability of the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in healthcare settings.
Collapse
Affiliation(s)
- Lise Tuset Gustad
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
- Nord-Trøndelag Hospital Trust, Department of Medicine, Levanger Hospital, Levanger, Norway
| | | | - Malvin Torsvik
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
| | - Marit By Rise
- Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU Central Norway), Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| |
Collapse
|
3
|
Lan L, Zhou M, Chen X, Dai M, Wang L, Li H. Prognostic accuracy of SOFA, MEWS, and SIRS criteria in predicting the mortality rate of patients with sepsis: A meta-analysis. Nurs Crit Care 2023. [PMID: 38129945 DOI: 10.1111/nicc.13016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND In recent years, some studies classified patients with sepsis and predicted their mortality by using some evaluation scales. Several studies reported significant differences in the predictive values of several tools, and the non-uniformity of the cut-off value. OBJECTIVE To determine and compare the prognostic accuracy of Sequential Organ Failure Assessment (SOFA) score, Modified Early Warning Score (MEWS), and Systemic Inflammatory Response Syndrome (SIRS) criteria in predicting the mortality of patients with sepsis. METHODS This study comprised of systematic literature review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched PubMed, Embase, Web of Science and Cochrane Library databases from their establishment to July 31, 2022. The research articles published in the index journals provide sufficient data (true positive, false positive, true negative, and false negative results) for patients with sepsis. The combined sensitivity and specificity of the 95% confidence interval (CI) were calculated using the bivariate random effect model (BRM). The hierarchical overall subject working characteristics (HSROC) curve was drawn to evaluate the accuracy of the overall prognosis. RESULTS Data of 55 088 patients from 32 studies were included in this meta-analysis. SOFA had an intermediate sensitivity of 0.73 (95% CI: 0.67-0.78) and a specificity of 0.70 (0.63-0.76). SIRS criteria had the highest sensitivity of 0.75 (0.66-0.82) and the lowest specificity of 0.40 (0.29-0.52). MEWS had the lowest sensitivity of 0.49 (0.40-0.59) and the highest specificity of 0.82 (0.78-0.86). CONCLUSIONS Among SOFA, MEWS, and SIRS criteria, SOFA showed moderate sensitivity and specificity for predicting mortality in patients with sepsis, the highest sensitivity of SIRS and the strongest specificity of MEWS for predicting mortality in patients with sepsis. The future research direction is to combine the relevant indicators of MEWS and SIRS to develop a measurement tool with high reliability and validity. RELEVANCE TO CLINICAL PRACTICE The review provides useful insights into the prognostic accuracy of different assessment tools in predicting mortality in sepsis patients, which will help clinicians choose the most appropriate tool for early identification and treatment of sepsis. The findings may also contribute to the development of more accurate and reliable prognostic models for sepsis.
Collapse
Affiliation(s)
- Lin Lan
- Department of Emergency Medicine,West China Hospital, Sichuan University/West China School of Nursing,Sichuan University, Chengdu, China
- Institute of Disaster Medicine, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Meichi Zhou
- Nephrology and Urology Ward, West China Hospital,Sichuan University/ West China School of Nursing, Sichuan University Chengdu, Chengdu, China
| | - Xiaoli Chen
- Department of Emergency Medicine,West China Hospital, Sichuan University/West China School of Nursing,Sichuan University, Chengdu, China
- Institute of Disaster Medicine, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Min Dai
- Department of Emergency Medicine,West China Hospital, Sichuan University/West China School of Nursing,Sichuan University, Chengdu, China
- Institute of Disaster Medicine, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Ling Wang
- Department of Emergency Medicine,West China Hospital, Sichuan University/West China School of Nursing,Sichuan University, Chengdu, China
- Institute of Disaster Medicine, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Hong Li
- Department of Emergency Medicine,West China Hospital, Sichuan University/West China School of Nursing,Sichuan University, Chengdu, China
- Institute of Disaster Medicine, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| |
Collapse
|
4
|
Pan D, Peng P, Fang Y, Lu J, Fang M. Distribution and Drug Resistance of Pathogenic Bacteria and Prognosis in Patients with Septicemia Bloodstream Infection with Renal Insufficiency. Infect Drug Resist 2022; 15:4109-4116. [PMID: 35924018 PMCID: PMC9342692 DOI: 10.2147/idr.s373665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/20/2022] [Indexed: 12/13/2022] Open
Abstract
Objective The aim of this study was to investigate the distribution and drug resistance of pathogenic bacteria and the prognosis of patients with sepsis bloodstream infection with renal insufficiency. Methods One hundred and twelve patients with septicemic bloodstream infection with renal insufficiency and 112 patients with septic bloodstream infection without renal insufficiency were selected as study group and control group, respectively. We compare the distribution of pathogenic bacteria, analyze the drug resistance of major bacteria, and compare the efficacy, the incidence of septic shock, duration of mechanical ventilation, hospitalization time, and duration of antimicrobial drug administration between the two groups. Results A total of 140 pathogenic strains were isolated from blood cultures in the study group, and 136 strains were isolated from blood cultures in the control group. The sepsis bloodstream infection was mainly caused by Gram-negative bacteria, accounting for 59.42% (164/276). Among the gram-negative bacteria, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter baumannii had higher resistance rates to levofloxacin, ceftazidime, piperacillin sodium tazobactam, and amikacin. Among the gram-positive bacteria, Streptococcus pneumoniae, Enterococcus, and Staphylococcus aureus had high resistance rates to clindamycin, cefazolin, penicillin G, gentamicin, azithromycin, and levofloxacin. The rate of extended spectrum β-lactamase (ESBLs)-producing enterobacteria and multi-drug resistant Pseudomonas aeruginosa (MDR-PA) infection was significantly higher in the study group than in the control group; there was no difference in multi-drug resistant Acinetobacter baumannii (MDR-AB), vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA) between the two groups. The duration of hospitalization and the duration of antimicrobial drug administration were longer in the study group than in the control group. Conclusion The pathogenic bacteria in patients with sepsis bloodstream infection with renal insufficiency are mainly Gram-negative bacteria, are more difficult to be cured, have a longer course of treatment, and need to use antibacterial drugs for a long time.
Collapse
Affiliation(s)
- Deng Pan
- Department of Infectious Disease, Xianning Central Hospital, The First Affiliated Hospital of Hubei University of Science and Technology, Xianning, Hubei, People’s Republic of China
| | - Pin Peng
- Intensive Care Unit, Wuhan Asia General Hospital, Wuhan, Hubei, People’s Republic of China
| | - Yu Fang
- Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Jun Lu
- Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Minghao Fang
- Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
- Correspondence: Minghao Fang, Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, Hubei, 430030, People’s Republic of China, Tel +86-15071157405, Email
| |
Collapse
|
5
|
Öztürk Birge A, Karabag Aydin A, Köroğlu Çamdeviren E. Intensive care nurses' awareness of identification of early sepsis findings. J Clin Nurs 2021; 31:2886-2899. [PMID: 34729839 DOI: 10.1111/jocn.16116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 12/29/2022]
Abstract
AIM To determine intensive care nurses' awareness of identification of early sepsis findings. BACKGROUND The incidence of sepsis is increasing in intensive care units, and if not identified early, it increases morbidity, mortality and cost of care. Intervention within one hour after the diagnosis of sepsis increases survival. Nurses' ability to identify early findings of sepsis affects the time of diagnosis of sepsis. DESIGN The study used a cross-sectional design. METHODS The sample of the study consisted of 544 nurses working in adult intensive care units of hospitals in Turkey. The study data were collected online between 11 January-8 April 2021 using the snowball method. Data were statically analysed. All procedures of the study adhered to the STROBE guidelines. RESULTS The nurses who had been working for 11 years or more, had worked with a patient diagnosed with sepsis in the last month and used a measurement tool in the diagnosis thought that it was significantly easier to determine the early warning findings of sepsis. In the study, the majority of nurses correctly identified the early findings of sepsis, but the rates of the correct responses to the variables of lactate >2 mM, leucopenia and hypothermia were low. Female gender, having a graduate degree, unit type, total work experience, having received training on sepsis and working with a patient diagnosed with sepsis in the last month made a significant difference in determining the early warning findings of sepsis accurately. CONCLUSIONS Nurses had a good rate of identifying early sepsis findings. Yet, they could not distinguish between early sepsis and late sepsis findings. RELEVANCE TO CLINICAL PRACTICE The results of the study can support nursing practices in the diagnostic process by considering the factors affecting nurses' ability to distinguish early sepsis findings from late sepsis findings and to identify them correctly.
Collapse
|
6
|
Intensive care patients receiving vasoactive medications: A retrospective cohort study. Aust Crit Care 2021; 35:499-505. [PMID: 34503915 DOI: 10.1016/j.aucc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Vasoactive medications are high-risk drugs commonly used in intensive care units (ICUs), which have wide variations in clinical management. OBJECTIVES The aim of this study was to describe the patient population, treatment, and clinical characteristics of patients who did and did not receive vasoactive medications while in the ICU and to develop a predictive tool to identify patients needing vasoactive medications. METHODS A retrospective cohort study of patients admitted to a level three tertiary referral ICU over a 12-month period from October 2018 to September 2019 was undertaken. Data from electronic medical records were analysed to describe patient characteristics in an adult ICU. Chi square and Mann-Whitney U tests were used to analyse data relating to patients who did and did not receive vasoactive medications. Univariate analysis and Pearson's r2 were used to determine inclusion in multivariable logistic regression. RESULTS Of 1276 patients in the cohort, 40% (512/1276) received a vasoactive medication for haemodynamic support, with 84% (428/512) receiving noradrenaline. Older patients (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.01-1.02; p < 0.001) with higher Acute Physiology and Chronic Health Evaluation (APACHE) III scores (OR = 1.04; 95% CI = 1.03-1.04; p < 0.001) were more likely to receive vasoactive medications than those not treated with vasoactive medications during an intensive care admission. A model developed using multivariable analysis predicted that patients admitted with sepsis (OR = 2.43; 95% CI = 1.43-4.12; p = 0.001) or shock (OR = 4.05; 95% CI = 2.68-6.10; p < 0.001) and managed on mechanical ventilation (OR = 3.76; 95% CI = 2.81-5.02; p < 0.001) were more likely to receive vasoactive medications. CONCLUSIONS Mechanically ventilated patients admitted to intensive care for sepsis and shock with higher APACHE III scores were more likely to receive vasoactive medications. Predictors identified in the multivariable model can be used to direct resources to patients most at risk of receiving vasoactive medications.
Collapse
|
7
|
Hon KL, Leung KKY, Oberender F, Leung AK. Paediatrics: how to manage septic shock. Drugs Context 2021; 10:dic-2021-1-5. [PMID: 34122587 PMCID: PMC8177956 DOI: 10.7573/dic.2021-1-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/22/2021] [Indexed: 02/07/2023] Open
Abstract
Background Septic shock is a common critical illness associated with high morbidity and mortality in children. This article provides an updated narrative review on the management of septic shock in paediatric practice. Methods A PubMed search was performed using the following Medical Subject Headings: "sepsis", "septic shock" and "systemic inflammatory response syndrome". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies and reviews. The search was limited to the English literature and specific to children. Results Septic shock is associated with high mortality and morbidity. The outcome can be improved if the diagnosis is made promptly and treatment initiated without delay. Early treatment with antimicrobial therapy, fluid therapy and vasoactive medications, and rapid recognition of the source of sepsis and control are the key recommendations from paediatric sepsis management guidelines. Conclusion Most of the current paediatric sepsis guideline recommendations are based on the adult population; therefore, the research gaps in paediatric sepsis management should be addressed.
Collapse
Affiliation(s)
- Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia.,Monash University, School of Clinical Sciences, Department of Paediatrics, Melbourne, Australia
| | - Alexander Kc Leung
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| |
Collapse
|
8
|
Abstract
OBJECTIVES This article aims to update nurses on the incidence, diagnosis, and treatment of neutropenic sepsis and septic shock. DATA SOURCES A search of electronic databases, including PubMed and CINAHL, and e-books was performed, as was a search of clinically focused and point-of-care resources from the National Cancer Institute and UpToDate until December 2020. CONCLUSION Neutropenic sepsis and septic shock are oncological emergencies and can be fatal for patients undergoing anticancer treatment. Prompt and targeted treatment based on clinical signs is necessary to minimize further sequela, including morbidity and mortality. IMPLICATIONS FOR NURSING PRACTICE The oncology nurse must possess an understanding of the risk factors, presenting signs, and initial management of a neutropenic fever, sepsis, and septic shock. Early identification and initiation of treatments in patients in sepsis and septic shock will allow the oncology nurse to intervene with speed, skill, and confidence while working within the multidisciplinary team to provide the best outcome based on current evidence.
Collapse
Affiliation(s)
- Aran Tavakoli
- Oncology Clinical Nurse Specialist, University of California San Diego Health, San Diego, California.
| | - Alia Carannante
- Clinical Nurse and Educator, Blood and Marrow Transplant, University of California San Diego Health, San Diego, California
| |
Collapse
|