Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies

Evaluating Sepsis Bundle Compliance as a Predictor for Patient Outcomes at a Community Hospital: A Retrospective Study

BACKGROUND

Clinicians are encouraged to use the Centers for Medicare & Medicaid Services early management bundle for severe sepsis and septic shock (SEP-1); however, it is unclear whether this process measure improves patient outcomes.

PURPOSE

The purpose of this study was to evaluate whether compliance with the SEP-1 bundle is a predictor of hospital mortality, length of stay (LOS), and intensive care unit LOS at a suburban community hospital.

METHODS

A retrospective observational study was conducted.

RESULTS

A total of 577 patients were included in the analysis. Compliance with the SEP-1 bundle was not a significant predictor for patient outcomes.

CONCLUSIONS

SEP-1 compliance may not equate with quality of health care. Efforts to comply with SEP-1 may help organizations develop systems and structures that improve patient outcomes. Health care leaders should evaluate strategies beyond SEP-1 compliance to ensure continuous improvement of outcomes for patients experiencing sepsis.

[Factors that influence the use of sepsis-related competencies in health professionals and how they promote their patients' sepsis knowledge: Results of a mixed methods study with health professionals]

BACKGROUND

Sepsis is a life-threatening and relatively common emergency which is often recognized too late or not at all. Therefore, the "SepsisWissen" (SepsisKnowledge) project aimed to bring about changes in health care professionals' behavior in the area of sepsis prevention and early detection. It addressed the health care professionals themselves (e. g., their own vaccination, hygiene and early detection behavior) and their patient counseling behavior. To promote this behavior, the SepsisWissen campaign included offers such as trainings or print products. The subsequent core question is: From the health professionals' perspective, which barriers and facilitators affect their own application of sepsis competence and their promotion of their patients' sepsis competence?

METHODS

This paper was based on a cross-sectional mixed-methods study part of "SepsisWissen" withPart a) was analyzed using qualitative oriented content analysis based on Mayring, part b) was analyzed descriptively. The interviewees included physicians, nurses, pharmacists, assistants to physicians and pharmacists and, additionally, one paramedic in the quantitative sample. Some of them had attended "SepsisWissen" trainings.

RESULTS

The qualitative data analysis identified 41 conducive and hindering factors, which can be assigned to the following eight major topics: 1) syndrome sepsis; 2) predisposing factors for health professionals' own acquisition and application of sepsis competence; 3) enabling factors for health professionals themselves; 4) behavior and lifestyle of patients; 5) reinforcing factors for patients; 6) public health education; 7) political, administrative, and organizational context; 8) environmental factors. In the qualitative and quantitative surveys, the suggestion to improve the sepsis competence of the population and to reduce misinformation, respectively, through public education (e.g., via schools or the media).

DISCUSSION

Sepsis training for health professionals was considered as a facilitating factor for taking potential sepsis symptoms and patients' respective statements more seriously. Future training formats should convey more explicitly how health professionals can better communicate their own sepsis knowledge to their patients. They request instruments to support their communication, such as checklists for lay persons. According to the interviews, health workers themselves need recurring external reminders for the topic of sepsis. Organizational and political conditions should be improved. From the health professionals' point of view, it is essential to offer better reimbursement for prevention and counseling services and to allocate adequate time resources for both.

CONCLUSION

Health professionals could increase their potential to apply and promote sepsis competence if general conditions were optimized. From their perspective, it is most important to relieve them of some of their patient counselling burden by initiating more public education.

Urosepsis 30-day mortality, morbidity, and their risk factors: SERPENS study, a prospective, observational multi-center study

PURPOSE

To provide a descriptive report of mortality and morbidity in the first 30 days of diagnosis of urosepsis. Secondary aim is to identify risk factors of unfavourable outcomes.

METHODS

Prospective observational multicentre cohort study conducted from September 2014 to November 2018 in European hospitals. Adult patients (≥ 18 years) diagnosed with acute urosepsis according to Sepsis-2 criteria with confirmed microbiological infection were included. Outcomes were classified in one of four health states: death, multiple organ failure, single organ failure, and recovery at day 30 from onset of urosepsis. Descriptive statistics and ordinal logistic regression analysis was performed.

RESULTS

Three hundred and fifty four patients were recruited, and 30-day mortality rate was 2.8%, rising to 4.6% for severe sepsis. All patients who died had a SOFA score of ≥ 2 at diagnosis. Upon initial diagnosis, 79% (n = 281) of patients presented with OF. Within 30 days, an additional 5% developed OF, resulting in a total of 84% affected. Charlson score (OR 1.14 CI 1.01-1.28), patients with respiratory failure at baseline (OR 2.35, CI 1.32-4.21), ICU admission within the past 12 months (OR 2.05, CI 1.00-4.19), obstruction causative of urosepsis (OR 1.76, CI 1.02-3.05), urosepsis with multi-drug-resistant(MDR) pathogens (OR 2.01, CI 1.15-3.53), and SOFA baseline score ≥ 2 (OR 2.74, CI 1.49-5.07) are significantly associated with day 30 outcomes (OF and death).

CONCLUSIONS

Impact of comorbidities and MDR pathogens on outcomes highlights the existence of a distinct group of patients who are prone to mortality and morbidity. These findings underscore the need for the development of pragmatic classifications to better assess the severity of UTIs and guide management strategies.

STUDY REGISTRATION

Clinicaltrials.gov registration number NCT02380170.

Sepsis screening protocol implementation: a clinician-validated rapid realist review

INTRODUCTION

The failed or partial implementation of clinical practices negatively impacts patient safety and increases systemic inefficiencies. Implementation of sepsis screening guidelines has been undertaken in many settings with mixed results. Without a theoretical understanding of what leads to successful implementation, improving implementation will continue to be ad hoc or intuitive. This study proposes a programme theory for how and why the successful implementation of sepsis screening guidelines can occur.

METHODS

A rapid realist review was conducted to develop a focused programme theory for the implementation of sepsis screening guidelines. An independent two-reviewer approach was used to iteratively extract and synthesise context and mechanism data. Theoretical context-mechanism-outcome propositions were refined and validated by clinicians using a focus group and individual realist interviews. Implementation resources and clinical reasoning were differentiated in articulating mechanisms.

RESULTS

Eighteen articles were included in the rapid review. The theoretical domains framework was identified as the salient substantive theory informing the programme theory. The theory consisted of five main middle-range propositions. Three promoting mechanisms included positive belief about the benefits of the protocol, belief in the legitimacy of using the protocol and trust within the clinical team. Two inhibiting mechanisms included pessimism about the protocol being beneficial and pessimism about the team. Successful implementation was defined as achieving fidelity and sustained use of the intervention. Two intermediate outcomes, acceptability and feasibility of the intervention, and adoption, were necessary to achieve before successful implementation.

CONCLUSION

This rapid realist review synthesised key information from the literature and clinician feedback to develop a theory-based approach to clinical implementation of sepsis screening. The programme theory presents knowledge users with an outline of how and why clinical interventions lead to successful implementation and could be applied in other clinical areas to improve quality and safety.

Effect of care bundles for acute kidney injury: A systematic review and meta-analysis

PURPOSE

Acute kidney injury (AKI) is frequent among in-hospital patients with high incidence and mortality. Implementing a series of evidence-based AKI care bundles may improve patient outcomes by reducing changeable standards of care. The aim of this meta-analysis was therefore to appraise the influences of AKI care bundles on patient outcomes.

MATERIALS AND METHODS

We explored three international databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) and two Chinese databases (Wanfang Data and China National Knowledge Infrastructure) for studies from databases inception until November 30, 2022, comparing the impact of different AKI care bundles with usual standards of care in patients with or at risk for AKI. The study quality of non-randomized controlled trials and randomized controlled trials was evaluated by the NIH Study Quality Assessment Tool and the Cochrane risk of bias tool. Heterogeneity between studies was appraised by Cochran's Q test and I2 statistics. The possible origins of heterogeneity between studies were assessed adopting Meta-regression and subgroup analyses. Funnel plot asymmetry and Egger regression and Begg correlation tests were performed to discover potential publication bias. Data analysis was completed by software (RevMan 5.3 and Stata 15.0). The primary outcome was short- or long-term mortality. The secondary outcomes involved the incidence and severity of AKI.

RESULTS

Sixteen studies containing 25,690 patients and 25,903 AKI episodes were included. In high-risk AKI patients determined by novel biomarkers, electronic alert or risk prediction score, the application of AKI care bundles significantly reduced the AKI incidence (OR, 0.71; 95% CI, 0.53-0.96; p = 0.02; I2 = 84%) and AKI severity (OR, 0.59; 95% CI, 0.39-0.89; p = 0.01; I2 = 65%). No strong evidence is available to prove that care bundles can significantly reduce mortality (OR, 1.16; 95% CI, 0.58-2.30; p = 0.68; I2 = 97%).

CONCLUSIONS

The introduction of AKI care bundles in routine clinical practice can effectively improve the outcomes of patients with or at-risk of AKI. However, the accumulated evidence is limited and not strong enough to make definite conclusions.

Sepsis incidence, suspicion, prediction and mortality in emergency medical services: a cohort study related to the current international sepsis guideline

PURPOSE

Sepsis suspicion by Emergency Medical Services (EMS) is associated with improved patient outcomes. This study assessed sepsis incidence and recognition by EMS and analyzed which of the screening tools recommended by the Surviving Sepsis Campaign best facilitates sepsis prediction.

METHODS

Retrospective cohort study of claims data from health insurances (n = 221,429 EMS cases), and paramedics' and emergency physicians' EMS documentation (n = 110,419); analyzed outcomes were: sepsis incidence and case fatality compared to stroke and myocardial infarction, the extent of documentation for screening-relevant variables and sepsis suspicion, tools' intersections for screening positive in identical EMS cases and their predictive ability for an inpatient sepsis diagnosis.

RESULTS

Incidence of sepsis (1.6%) was similar to myocardial infarction (2.6%) and stroke (2.7%); however, 30-day case fatality rate was almost threefold higher (31.7% vs. 13.4%; 11.8%). Complete vital sign documentation was achieved in 8.2% of all cases. Paramedics never, emergency physicians rarely (0.1%) documented a sepsis suspicion, respectively septic shock. NEWS2 had the highest sensitivity (73.1%; Specificity:81.6%) compared to qSOFA (23.1%; Sp:96.6%), SIRS (28.2%; Sp:94.3%) and MEWS (48.7%; Sp:88.1%). Depending on the tool, 3.7% to 19.4% of all cases screened positive; only 0.8% in all tools simultaneously.

CONCLUSION

Incidence and mortality underline the need for better sepsis awareness, documentation of vital signs and use of screening tools. Guidelines may omit MEWS and SIRS as recommendations for prehospital providers since they were inferior in all accuracy measures. Though no tool performed ideally, NEWS2 qualifies as the best tool to predict the highest proportion of septic patients and to rule out cases that are likely non-septic.

Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol

INTRODUCTION

Early sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood culture, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L and vasopressors for hypotension during/after fluid resuscitation within 1 hour of sepsis recognition) is low across healthcare settings. Delays in sepsis recognition and a lack of high-quality evidence hinder its implementation. We propose a novel sepsis care model (National Early Warning Score, NEWS-1 care), in which the SSC Hour-1 Bundle is triggered objectively by a high NEWS-2 (≥5). This study aims to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial on the NEWS-1 care in multiple EDs.

METHODS AND ANALYSIS

We will conduct a pilot type 1 hybrid trial and prospectively recruit 200 patients from 4 public EDs in Hong Kong cluster randomised in a stepped wedge design over 10 months. All study sites will start with an initial period of standard care and switch in random order at 2-month intervals to the NEWS-1 care unidirectionally. The implementation evaluation will employ mixed methods guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, which includes qualitative and quantitative data from focus group interviews, staff survey and clinical record reviews. We will analyse the 14 feasibility outcomes as progression criteria to a full-scale trial, including trial acceptability to patients and staff, patient and staff recruitment rates, accuracy of sepsis screening, protocol adherence, accessibility to follow-up data, safety and preliminary clinical impacts of the NEWS1 care, using descriptive statistics.

ETHICS AND DISSEMINATION

The institutional review boards of all study sites approved this study. This study will establish the feasibility of a full-scale hybrid trial. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities.

TRIAL REGISTRATION NUMBER

NCT05731349.

Patient mobilization in the intensive care unit: Assessing practice behavior - A multi-center point prevalence study

OBJECTIVES

To describe intensive care unit mobility clinical practice behaviors and the factors associated with these behaviors that could explain the theory-practice gap.

METHODOLOGY

A multi-center, descriptive, retrospective, one-day point prevalence study.

SETTING

intensive care patients hospitalized for a minimum of 24 hours, in 20 Israeli Adult Intensive Care Units, from six medical centers.

MAIN OUTCOME MEASURES

Maximum patient mobility level during the 24 hours prior to the prevalence study collection day and 48 hours from patient admission; mobility clinical practice behaviors and their inhibiting factors.

RESULTS

The study included 210 patients from a relatively even distribution of admission diagnoses. About half (46%) were intubated and 31% were hemodynamically unstable. Position change was most frequently reported as the maximum mobility level. The use of intubation, ventilation, tracheostomy, and inotropes was positively correlated with the level of mobility. Charlson Comorbidity Index and body mass index were not related to the level of mobility. A multiple regression model including these variables found that only intubation was a significant predictor of mobility level (R2 = 0.52, p < 0.001).

CONCLUSION

There is a gap between clinical practice guidelines and actual intensive care mobility practice behaviors. The association between mobility level and common therapies suggests subjective norms or common practices that could serve as a barrier to guideline implementation and partially explain the gap between clinical practice guidelines and clinical practice behavior.

IMPLICATIONS FOR CLINICAL PRACTICE

Behaviors and their subjective norms can be barriers to the implementation of clinical practice guidelines. Promoting increased provider awareness and policies of proactive mobilization could potentially improve patient outcomes.

Decrease in Mortality after the Implementation of a Hospital Model to Improve Performance in Sepsis Care: Princess Sepsis Code

Sepsis is a time-dependent disease whose prognosis is influenced by early diagnosis and therapeutic measures. Mortality from sepsis remains high, and for this reason, the guidelines of the Surviving Sepsis Campaign recommend establishing specific care programs aimed at patients with sepsis. We present the results of the application of a hospital model to improve performance in sepsis care, called Princess Sepsis Code, with the aim of reducing mortality. A retrospective study was conducted using clinical, epidemiological, and outcome variables in patients diagnosed with sepsis from 2015 to 2022. A total of 2676 patients were included, 32% of whom required admission to the intensive care unit, with the most frequent focus of the sepsis being abdominal. Mortality in 2015, at the beginning of the sepsis code program, was 24%, with a declining rate noted over the study period, with mortality reaching 17% in 2022. In the multivariate analysis, age > 70 years, respiratory rate > 22 rpm, deterioration in the level of consciousness, serum lactate > 2 mmol/L, creatinine > 1.6 mg/dL, and the focus of the sepsis were identified as variables independently related to mortality. The implementation of the Princess Sepsis Code care model reduces the mortality of patients exhibiting sepsis and septic shock.

Sepsis Stewardship: The Puzzle of Antibiotic Therapy in the Context of Individualization of Decision Making

The main recent change observed in the field of critical patient infection has been universal awareness of the need to make better use of antimicrobials, especially for the most serious cases, beyond the application of simple and effective formulas or rigid protocols. The increase in resistant microorganisms, the quantitative increase in major surgeries and interventional procedures in the highest risk patients, and the appearance of a significant number of new antibiotics in recent years (some very specifically directed against certain mechanisms of resistance and others with a broader spectrum of applications) have led us to shift our questions from "what to deal with" to "how to treat". There has been controversy about how best to approach antibiotic treatment of complex cases of sepsis. The individualized and adjusted dosage, the moment of its administration, the objective, and the selection of the regimen are pointed out as factors of special relevance in a critically ill patient where the frequency of resistant microorganisms, especially among the Enterobacterales group, and the emergence of multiple and diverse antibiotic treatment alternatives have made the appropriate choice of antibiotic treatment more complex, requiring a constant updating of knowledge and the creation of multidisciplinary teams to confront new infections that are difficult to treat. In this article, we have reviewed the phenomenon of the emergence of resistance to antibacterials and we have tried to share some of the ideas, such as stewardship, sparing carbapenems, and organizational, microbiological, pharmacological, and knowledge tools, that we have considered most useful and effective for individualized decision making that takes into account the current context of multidrug resistance. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment.

Effect of a quality improvement program on compliance to the sepsis bundle in non-ICU patients: a multicenter prospective before and after cohort study

Objective

Sepsis and septic shock are major challenges and economic burdens to healthcare, impacting millions of people globally and representing significant causes of mortality. Recently, a large number of quality improvement programs focused on sepsis resuscitation bundles have been instituted worldwide. These educational initiatives have been shown to be associated with improvements in clinical outcomes. We aimed to evaluate the impact of a multi-faceted quality implementing program (QIP) on the compliance of a "simplified 1-h bundle" (Sepsis 6) and hospital mortality of severe sepsis and septic shock patients out of the intensive care unit (ICU).

Methods

Emergency departments (EDs) and medical wards (MWs) of 12 academic and non-academic hospitals in the Lombardy region (Northern Italy) were involved in a multi-faceted QIP, which included educational and organizational interventions. Patients with a clinical diagnosis of severe sepsis or septic shock according to the Sepsis-2 criteria were enrolled in two different periods: from May 2011 to November 2011 (before-QIP cohort) and from August 2012 to June 2013 (after-QIP cohort).

Measurements and main results

The effect of QIP on bundle compliance and hospital mortality was evaluated in a before-after analysis. We enrolled 467 patients in the before-QIP group and 656 in the after-QIP group. At the time of enrollment, septic shock was diagnosed in 50% of patients, similarly between the two periods. In the after-QIP group, we observed increased compliance to the "simplified rapid (1 h) intervention bundle" (the Sepsis 6 bundle - S6) at three time-points evaluated (1 h, 13.7 to 18.7%, p = 0.018, 3 h, 37.1 to 48.0%, p = 0.013, overall study period, 46.2 to 57.9%, p < 0.001). We then analyzed compliance with S6 and hospital mortality in the before- and after-QIP periods, stratifying the two patients' cohorts by admission characteristics. Adherence to the S6 bundle was increased in patients with severe sepsis in the absence of shock, in patients with serum lactate <4.0 mmol/L, and in patients with hypotension at the time of enrollment, regardless of the type of admission (from EDs or MWs). Subsequently, in an observational analysis, we also investigated the relation between bundle compliance and hospital mortality by logistic regression. In the after-QIP cohort, we observed a lower in-hospital mortality than that observed in the before-QIP cohort. This finding was reported in subgroups where a higher adherence to the S6 bundle in the after-QIP period was found. After adjustment for confounders, the QIP appeared to be independently associated with a significant improvement in hospital mortality. Among the single S6 procedures applied within the first hour of sepsis diagnosis, compliance with blood culture and antibiotic therapy appeared significantly associated with reduced in-hospital mortality.

Conclusion

A multi-faceted QIP aimed at promoting an early simplified bundle of care for the management of septic patients out of the ICU was associated with improved compliance with sepsis bundles and lower in-hospital mortality.

Sepsis and Clinical Simulation: What Is New? (and Old)

BACKGROUND

Sepsis is a critical and potentially fatal condition affecting millions worldwide, necessitating early intervention for improved patient outcomes. In recent years, clinical simulation has emerged as a valuable tool for healthcare professionals to learn sepsis management skills and enhance them.

METHODS

This review aims to explore the use of clinical simulation in sepsis education and training, as well as its impact on how healthcare professionals acquire knowledge and skills. We conducted a thorough literature review to identify relevant studies, analyzing them to assess the effectiveness of simulation-based training, types of simulation methods employed, and their influence on patient outcomes.

RESULTS

Simulation-based training has proven effective in enhancing sepsis knowledge, skills, and confidence. Simulation modalities vary from low-fidelity exercises to high-fidelity patient simulations, conducted in diverse settings, including simulation centers, hospitals, and field environments. Importantly, simulation-based training has shown to improve patient outcomes, reducing mortality rates and hospital stays.

CONCLUSION

In summary, clinical simulation is a powerful tool used for improving sepsis education and training, significantly impacting patient outcomes. This article emphasizes the importance of ongoing research in this field to further enhance patient care. The shift toward simulation-based training in healthcare provides a safe, controlled environment for professionals to acquire critical skills, fostering confidence and proficiency when caring for real sepsis patients.

[The current sepsis guidelines-What do you need to know?]

The current international sepsis guidelines from 2021 are based on the work of a panel of 60 international experts from various fields. They include a total of 93 recommendations, some of which include new aspects compared to the 2016 version of the guidelines. This article provides a subjective compilation by two internal medicine intensivists who highlight some aspects, especially of changes within the guidelines compared to the previous version. The focus is on the fields of screening, sepsis bundles, fluid and vasopressor treatment and adjuvant treatment. In addition, for the first time these guidelines address the important issue of long-term sequelae for sepsis survivors and their environment.

Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades?

Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.

Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis

Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).

SEPSIS UNIT IN THE EMERGENCY DEPARTMENT: IMPACT ON MANAGEMENT AND OUTCOME OF SEPTIC PATIENTS

ABSTRACT

Study hypothesis : Implementation of a new pathway dedicated to septic patients within the emergency department (ED) would improve early management, organ dysfunction, and outcome. Methods: During phase 1, all consecutive adult patients with infection and qualifying quick Sequential Organ Failure Assessment (qSOFA) score upon ED admission were managed according to standards of care. A multifaceted intervention was then performed (implementation phase): educational program, creation of a sepsis alert upon ED admission incorporated in the professional software, together with severity scores and Surviving Sepsis Campaign (SSC) bundle reminders, and dedication of two rooms to the management of septic patients (sepsis unit). During phase 2, patients were managed according to this new organization. Results: Of the 89,040 patients admitted to the ED over the two phases, 2,643 patients (3.2%) had sepsis including 277 with a qualifying qSOFA score on admission (phase 1, 141 patients; phase 2, 136 patients). Recommendations of SSC 3-h bundle significantly improved between the two periods regarding lactate measurement (87% vs. 96%, P = 0.006), initiation of fluid resuscitation (36% vs. 65%, P < 0.001), blood cultures sampling (83% vs. 93%, P = 0.014), and administration of antibiotics (18% vs. 46%, P < 0.001). The Sequential Organ Failure Assessment score between H0 and H12 varied significantly more during phase 2 (1.9 ± 1.9 vs. 0.8 ± 2.6, P < 0.001). Mortality significantly decreased during the second phase, on day 3 (28% vs. 15%, P = 0.008) and on day 28 (40% vs. 28%, P = 0.013). Conclusion: Systematic detection, education, and per protocol organization with a sepsis unit dedicated to the early management of septic patients appear to improve compliance with SSC bundles, organ dysfunction, and short-term mortality. These results warrant to be confirmed by prospective studies.

HLA-DR Expression on Monocytes and Sepsis Index Are Useful in Predicting Sepsis

The reduction of mortality in patients with sepsis depends on the early identification and treatment of at-risk patients. The aim was to evaluate the HLA-DR expression on the surface of monocytes (_MHLA-DR ratio), the sepsis index (CD64 expression on neutrophils/_MHLA-DR ratio), and C-reactive protein (CRP) with the development of sepsis. We prospectively enrolled 77 critically ill patients, 59 with stroke and 18 with traumatic brain injuries. The biomarkers were tested at the baseline and 3, 6, 9, 12, and 15 days later. Most patients (71%) developed sepsis (4.2 ± 1.3 days after admission). On day 3, those subsequently developing sepsis had lower levels of _MHLA-DR+ (81.7 ± 16.2% vs. 88.5 ± 12.1%, p < 0.05) and higher sepsis indexes (0.19 ± 0.19 vs. 0.08 ± 0.08, p < 0.01) than those not developing sepsis. The _MHLA-DR ratio slowly recovered before day 6, while the sepsis index remained raised in septic patients up to day 9 (p < 0.05). To predict the development of sepsis, optimal cut-offs were CRP levels > 106.90 mg/mL (74.19% sensitivity, 69.49 specificity) and _MHLA-DR expression rate < 72.80% (45.31% sensitivity, 89.47% specificity). The periodic monitoring of the _MHLA-DR expression together with CRP and sepsis index may help to identify patients in the ICU at increased risk of developing sepsis.

Association of a sepsis initiative on broad spectrum antibiotic use and outcomes in an ED population: A retrospective cohort study

INTRODUCTION

Sepsis identification and treatment is a priority for emergency department (ED) providers and payors alike. However, aggressive metrics aimed at improving sepsis care could have unintended consequences for patients who do not have sepsis.

METHODS

All ED patient visits for a one month period before and after a quality initiative to increase early antibiotic use in septic patients were included. Overall broad spectrum (BS) antibiotic use, admission rates, and mortality were compared in the 2 time periods. A more detailed chart review was performed on those who received BS antibiotics in the before and after cohorts. Patient were excluded for pregnancy, age < 18, COVID-19 infection, hospice patients, left ED against medical advice, and if antibiotics were given for prophylaxis. In BS antibiotic treated patients, we sought to determine mortality, rates of subsequent multidrug resistant (MDR) or Clostridium Difficile (CDiff) infections and rates of non-infected patients receiving BS antibiotics.

RESULTS

There were 7967 and 7407 ED visits in the pre- and post-implementation periods, respectively. Of those, BS antibiotics were administered in a total of 3.9% pre-implementation and 6.2% post-implementation (p ≤ 0.00001). Admission was more common in the post-implementation period, but overall mortality was unchanged (0.9% pre-implementation and 0.8% post-implementation, p = 0.41). After exclusions, 654 patients treated with BS antibiotics were included in the secondary analyses. Baseline characteristics were similar between the pre-implementation and post-implementation cohorts. There was no difference in the rate of CDiff infection or the proportion of patients receiving BS antibiotics who were not infected, but there was an increase in the post-implementation period in MDR infections after ED BS antibiotics, 0.72% vs. 0.35% of the entire ED cohorts, p = 0.0009.

CONCLUSIONS

We found that a QI sepsis initiative was associated with an increase in the proportion of patients who received BS antibiotics in the ED, and a small absolute increase in associated subsequent MDR infections, with no apparent effect on mortality in all ED patients or the subset treated with BS antibiotics. Further research is needed to assess the impact on all patients affected by aggressive sepsis protocols and initiatives, rather than only those with sepsis.

Deployment of machine learning algorithms to predict sepsis: systematic review and application of the SALIENT clinical AI implementation framework

OBJECTIVE

To retrieve and appraise studies of deployed artificial intelligence (AI)-based sepsis prediction algorithms using systematic methods, identify implementation barriers, enablers, and key decisions and then map these to a novel end-to-end clinical AI implementation framework.

MATERIALS AND METHODS

Systematically review studies of clinically applied AI-based sepsis prediction algorithms in regard to methodological quality, deployment and evaluation methods, and outcomes. Identify contextual factors that influence implementation and map these factors to the SALIENT implementation framework.

RESULTS

The review identified 30 articles of algorithms applied in adult hospital settings, with 5 studies reporting significantly decreased mortality post-implementation. Eight groups of algorithms were identified, each sharing a common algorithm. We identified 14 barriers, 26 enablers, and 22 decision points which were able to be mapped to the 5 stages of the SALIENT implementation framework.

DISCUSSION

Empirical studies of deployed sepsis prediction algorithms demonstrate their potential for improving care and reducing mortality but reveal persisting gaps in existing implementation guidance. In the examined publications, key decision points reflecting real-word implementation experience could be mapped to the SALIENT framework and, as these decision points appear to be AI-task agnostic, this framework may also be applicable to non-sepsis algorithms. The mapping clarified where and when barriers, enablers, and key decisions arise within the end-to-end AI implementation process.

CONCLUSIONS

A systematic review of real-world implementation studies of sepsis prediction algorithms was used to validate an end-to-end staged implementation framework that has the ability to account for key factors that warrant attention in ensuring successful deployment, and which extends on previous AI implementation frameworks.

Hyperoxia in critically ill patients with sepsis and septic shock: a systematic review

BACKGROUND

In septic patients, hyperoxia may help with its bactericidal effects, but it may cause systemic impairments. The role of hyperoxia and the appropriate oxygen target in these patients is unknown. The aim of this systematic review was to summarize the available literature.

METHODS

We conducted a systematic search screening PubMed and Cochrane Library. Studies on adult patients with sepsis or septic shock and admitted to ICU addressing the topic of hyperoxia were included and described.

RESULTS

We included 12 studies, for a total of 15.782 included patients. Five studies were randomized controlled trials (RCTs) or analyses from RCTs, three were prospective observational studies, and four were retrospective observational studies. The definition of hyperoxia was heterogeneous across the included studies. Mortality was the most frequent outcome: six studies showed an increased rate or risk of mortality with hyperoxia, three found no differences, and one a protective effect of hyperoxia. At the critical appraisal assessment stage, no major methodological flaws were detected, except for a single-center, pilot study, with a lack of adjustment for confounders and imbalance between the groups.

CONCLUSION

The optimum range of oxygen level able to minimize risks and provide benefits in patients with sepsis or septic shock seems still unknown. Clinical equipoise between hyperoxia and normoxia is uncertain as conflicting evidence exists. Further studies should aim at identifying the best range of oxygenation and its optimal duration, investigating how effects of different levels of oxygen may vary according to identified pathogens, source of infection, and prescribed antibiotics in critically ill patients with sepsis and septic shock.

Quality Improvement to Promote Sepsis Reassessment: The Sepsis Reassessment Protocol Improvement Project (SRPIP)

BACKGROUND

Implementation of the Surviving Sepsis Campaign (SSC) guidelines into practice has demonstrated improved outcomes.

LOCAL PROBLEM

Compliance with a sepsis protocol, based on the SSC guidelines, in an urban teaching hospital was below the national average.

METHODS

A pre- and posttest intervention design was used to improve clinician knowledge, confidence, and compliance with the protocol.

INTERVENTIONS

Educational modules were developed on the SSC guidelines and reminder system alerts (RSA) for timely revaluation of patients with sepsis and lactate monitoring were implemented.

RESULTS

A total of 33 (48%) clinicians participated. There was an increase in knowledge, documentation of sepsis reassessment, and serum lactate monitoring. There was an improvement in clinician perceptions following the initiative.

CONCLUSIONS

The results demonstrate that education, combined with RSAs, can improve protocol knowledge and compliance.

Patient characteristics in sepsis-related deaths: prevalence of advanced frailty, comorbidity, and age in a Norwegian hospital trust

OBJECTIVE

To examine the prevalence of advanced frailty, comorbidity, and age among sepsis-related deaths in an adult hospital population.

METHODS

Retrospective chart reviews of deceased adults within a Norwegian hospital trust, with a diagnosis of infection, over 2 years (2018-2019). The likelihood of sepsis-related death was evaluated by clinicians as sepsis-related, possibly sepsis-related, or not sepsis-related.

RESULTS

Of 633 hospital deaths, 179 (28%) were sepsis-related, and 136 (21%) were possibly sepsis-related. Among these 315 patients whose deaths were sepsis-related or possibly sepsis-related, close to three in four patients (73%) were either 85 years or older, living with severe frailty (Clinical Frailty Scale, CFS, score of 7 or more), or an end-stage condition prior to the admission. Among the remaining 27%, 15% were either 80-84 years old, living with frailty corresponding to a CFS score of 6, or severe comorbidity, defined as 5 points or more on the Charlson Comorbidity Index (CCI). The last 12% constituted the presumably healthiest cluster, but in this group as well, the majority died with limitations of care due to their premorbid functional status and/ or comorbidity. Findings remained stable if the population was limited to sepsis-related deaths on clinicians' reviews or those fulfilling the Sepsis-3 criteria.

CONCLUSIONS

Advanced frailty, comorbidity, and age were predominant in hospital fatalities where infection contributed to death, with or without sepsis. This is of importance when considering sepsis-related mortality in similar populations, the applicability of study results to everyday clinical work, and future study designs.

Nurses' knowledge and confidence in recognizing and managing patients with sepsis: A multi-site cross-sectional study

AIMS

(1) To examine registered nurses' knowledge and confidence in recognizing and managing to patients with sepsis and (2) identify nurse and workplace factors that influence their knowledge on sepsis.

DESIGN

A multi-site, cross-sectional survey.

METHODS

An online survey was developed and content validated. Data was collected from registered nurses working in the inpatient wards and emergency departments of three hospitals of a single healthcare cluster in Singapore during August 2021. Statistical analyses of closed-ended responses and content analysis of open-ended responses were undertaken.

RESULTS

A total of 709 nurses completed the survey. Nurses possessed moderate levels of knowledge about sepsis (mean score = 10.56/15; SD = 2.01) and confidence in recognizing and responding to patients with sepsis (mean score = 18.46/25; SD = 2.79). However, only 369 (52.0%) could correctly define sepsis. Nurses' job grade, nursing education level and clinical work area were significant predictors of nurses' sepsis knowledge. Specifically, nurses with higher job grade, higher nursing education level or those working in acute care areas (i.e. emergency department, high dependency units or intensive care units) were more likely to obtain higher total sepsis knowledge scores. A weak positive correlation was observed between sepsis knowledge test scores and self-confidence (r = .184). Open comments revealed that participants desired for more sepsis education and training opportunities and the implementation of sepsis screening tool and sepsis care protocol.

CONCLUSION

A stronger foundation in sepsis education and training programs and the implementation of sepsis screening tools and care bundles are needed to enhance nurses' knowledge and confidence in recognizing and managing patients with sepsis.

IMPACT

The findings of this study are beneficial to administrators, educators and researchers in designing interventions to support nurses in their role in recognizing and responding to sepsis.

Recalibration of prediction model was needed for monitoring health care quality in subgroups: a retrospective cohort study

OBJECTIVES

To evaluate the predictive ability of a mortality prediction model in subgroups of intensive care unit (ICU) patients and test the validity for monitoring the outcome.

STUDY DESIGN AND SETTING

A Japanese ICU database was used for the analyses. Adults admitted to an ICU between April 1, 2019, and March 31, 2020, were included. Nine clinically relevant subgroups were selected, and we evaluated the discrimination and calibration of the Japan Risk of Death model, a recalibrated Acute Physiology and Chronic Health Evaluation III-j model. Funnel plots and exponentially weighted moving average (EWMA) charts were used to check its validity for monitoring in-hospital mortality. If the predictive performance was poor, the model was recalibrated and model performance was reassessed.

RESULTS

The study population comprised 14,513 patients across nine subgroups. The in-hospital mortality rate ranged from 11.3% to 30.9%. The calibration was poor in most subgroups, and the funnel plots and EWMA charts frequently revealed "out-of-control" signals crossing the control limit of three standard deviations (SDs). The calibration improved after recalibration, and the number of "out-of-control" signals decreased.

CONCLUSION

When monitoring the quality of care among subgroups of patients, testing the predictive ability and recalibration of the risk model are needed.

A state-wide implementation of a whole of hospital sepsis pathway with a mortality based cost-effectiveness analysis from a healthcare sector perspective

With global estimates of 15 million cases of sepsis annually, together with a 24% in-hospital mortality rate, this condition comes at a high cost to both the patient and to the health services delivering care. This translational research determined the cost-effectiveness of state-wide implementation of a whole of hospital Sepsis Pathway in reducing mortality and/or hospital admission costs from a healthcare sector perspective, and report the cost of implementation over 12-months. A non-randomised stepped wedge cluster implementation study design was used to implement an existing Sepsis Pathway ("Think sepsis. Act fast") across 10 of Victoria's public health services, comprising 23 hospitals, which provide hospital care to 63% of the State's population, or 15% of the Australian population. The pathway utilised a nurse led model with early warning and severity criteria, and actions to be initiated within 60 minutes of sepsis recognition. Pathway elements included oxygen administration; blood cultures (x2); venous blood lactate; fluid resuscitation; intravenous antibiotics, and increased monitoring. At baseline there were 876 participants (392 female (44.7%), mean 68.4 years); and during the intervention, there were 1,476 participants (684 female (46.3%), mean 66.8 years). Mortality significantly reduced from 11.4% (100/876) at baseline to 5.8% (85/1,476) during implementation (p>0.001). Respectively, at baseline and intervention the average length of stay was 9.1 (SD 10.3) and 6.2 (SD 7.9) days, and cost was $AUD22,107 (SD $26,937) and $14,203 (SD $17,611) per patient, with a significant 2.9 day reduction in length of stay (-2.9; 95%CI -3.7 to -2.2, p<0.01) and $7,904 reduction in cost (-$7,904; 95%CI -$9,707 to -$6,100, p<0.01). The Sepsis Pathway was a dominant cost-effective intervention due to reduced cost and reduced mortality. Cost of implementation was $1,845,230. In conclusion, a well-resourced state-wide Sepsis Pathway implementation initiative can save lives and dramatically reduce the health service cost per admission.

Machine-learning-derived sepsis bundle of care

PURPOSE

Compliance to the Surviving Sepsis Campaign (SSC) guidelines is limited. This is known to be associated with increased mortality. The aim of this retrospective cohort study was to identify among the SCC guidelines the optimal bundle of recommendations that minimize 28-day mortality.

METHODS

We used a training cohort to identify, using a least absolute shrinkage and selection operator penalized machine learning model, this bundle. Patients with sepsis/septic shock admitted to the intensive care unit (ICU) were extracted from two US databases, the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database (training and internal validation cohorts) and the eICU Collaborative Research Database (eICU-CRD) (external validation cohort). In the validation cohorts, we defined a bundle group that includes patients who were treated with at least all the recommendations selected in our bundle and a no-bundle group that includes patients in whom at least one recommendation from our bundle was omitted.

RESULTS

All-cause 28-day mortality was the primary outcome measure. A total of 42,735 patients were included. Six recommendations (antimicrobials, balanced crystalloid, insulin therapy, corticosteroids, vasopressin, and bicarbonate therapy) were identified from the training cohort to be included in our bundle. In the propensity score-(PS)-matched internal validation cohort, the bundle group was associated with a lower mortality (OR 0.41 [0.33-0.53]; p < 0.001) compared to the no-bundle group. This was confirmed in the PS-matched external validation cohort (OR 0.75 [0.60-0.94]; p 0.02).

CONCLUSION

Our bundle of six recommendations is associated with a dramatic reduction in mortality in sepsis and septic shock. This bundle needs to be evaluated prospectively.

Recognition and Management of Hospital-Acquired Sepsis Among Older General Medical Inpatients: A Multi-Site Retrospective Study

Purpose

To assess accuracy of early diagnosis, appropriateness and timeliness of response, and clinical outcomes of older general medical inpatients with hospital-acquired sepsis.

Methods

Hospital abstracts of inpatient encounters from seven digital Queensland public hospitals between July 2018 and September 2020 were screened retrospectively for diagnoses of hospital-acquired sepsis. Electronic medical records were retrieved and cases meeting selection criteria and classified as confirmed or probable sepsis using pre-specified criteria were included. Investigations and treatments following the first digitally generated alert of clinical deterioration were compared with a best practice sepsis care bundle. Outcome measures comprised 30-day all-cause mortality after deterioration, and unplanned readmissions at 14 days after discharge.

Results

Of the 169 screened care episodes, 59 comprised probable or confirmed cases of sepsis treated by general medicine teams at the time of initial deterioration. Of these, 43 (72.9%) had no mention of sepsis in the differential diagnosis on first medical review, and only 38 (64%) were managed as having sepsis. Each care bundle component of blood cultures, serum lactate, and intravenous fluid resuscitation and antibiotics was only delivered in approximately 30% of cases, and antibiotic administration was delayed more than an hour in 28 of 38 (73.7%) cases.

Conclusion

Early recognition of sepsis and timely implementation of care bundles are challenging in older general medical patients. Education programs in sepsis care standards targeting nurses and junior medical staff, closer patient monitoring, and post-discharge follow-up may improve patient outcomes.

Audit of a computerized version of the Manchester triage system and a SIRS-based system for the detection of sepsis at triage in the emergency department

BACKGROUND AND IMPORTANCE

Different triage systems can be used to screen for sepsis and are often incorporated into local electronic health records. Often the design and interface of these digitalizations are not audited, possibly leading to deleterious effects on screening test performance.

OBJECTIVE

To audit a digital version of the MTS for detection of sepsis during triage in the ED.

DESIGN

A single-center retrospective study SETTINGS AND PARTICIPANTS: Patients (n=29766) presenting to an ED of a tertiary-care center who received formal triage were included.

OUTCOME MEASURES AND ANALYSIS

Calculated performance measures included sensitivity, specificity, likelihood ratios, and AUC for the detection of sepsis. Errors in the application of the specific sepsis discriminator of the MTS were recorded.

MAIN RESULTS

A total of 189 (0.7%) subjects met the Sepsis-3 criteria, with 47 cases meeting the criteria for septic shock. The MTS had a low sensitivity of 47.6% (95% CI 40.3 to 55.0) for allocating sepsis patients to the correct triage category. However, specificity was high at 99.4% (95% CI 99.3 to 99.5).

Educational needs assessment identifying opportunities to improve sepsis care

INTRODUCTION

In 2015, the Centers for Medicare and Medicaid Services developed a national quality bundle for the management of patients with severe sepsis and septic shock (SEP-1). Despite performance improvement measures, compliance remains low. This needs assessment is the first stage of a quality improvement initiative to improve SEP-1 compliance. Using a conceptual outcomes framework, this needs assessment analyses SEP-1 compliance data, knowledge, and competence to identify gaps in care and educational opportunities.

METHODS

The needs assessment began with a review of national and statewide SEP-1 compliance data to identify a need for improvement. The needs assessment proceeded with a retrospective chart review to evaluate process measures and identify which providers would most likely benefit from educational interventions. A focus group provided perspective on the chart review findings.

RESULTS

During the period of 1 April 2017-31 March 2018, national SEP-1 compliance was 51% and compliance at the studied institution was 19%. The chart review included 51 patients (66.7% severe sepsis, 33.3% septic shock). Frequently missed SEP-1 measures included administration of intravenous fluids (0% severe sepsis, 58.8% septic shock), repeat lactate levels (52.6% severe sepsis, 60% septic shock), documentation of volume and tissue perfusion assessment (58.8%), vasopressor administration (73.3%) and administration of broad-spectrum antibiotics (76.5%, severe sepsis). Focus group perceptions identified themes related to gaps in declarative and dispositional knowledge.

CONCLUSIONS

This educational needs assessment highlights gaps in SEP-1 clinician performance, competence and knowledge. A multifaceted education programme is the next step for this performance improvement project. Education should include a series of meetings, activities, and workshops that include declarative knowledge, procedural knowledge and dispositional knowledge. Simulation activities can provide an opportunity for providers to demonstrate competence. Point-of-care prompts and performance measurement and feedback of patient care data can support clinician performance. This needs assessment underscores the need for a multifaceted approach to clinician education and performance to improve SEP-1 compliance.

The impact of a sepsis performance improvement program in the emergency department: a before–after intervention study

Purpose

The latest Surviving Sepsis Campaign guidelines advocate that all hospitals use sepsis performance improvement programs. However, there is a limited evidence about how to structure such programs and what their potential impact is on sepsis management and outcomes in the emergency department (ED). In this study, we evaluated the implementation of a sepsis performance improvement program in the ED including a dedicated sepsis response team and analyzed the management and outcomes of sepsis patients before and after.

Methods

We conducted a before–after interventional study in the ED of the Amsterdam University Medical Centers, the Netherlands. The sepsis performance improvement program included regular educational meetings, daily audits and weekly feedback, a screening tool, and a dedicated multidisciplinary sepsis response team. We studied all adult patients who presented to the ED with a suspected infection and a Modified Early Warning Score (MEWS) ≥ 3 during their stay. In the postintervention phase, these patients were seen by the sepsis team. Process-related and patient-related outcomes were measured between November 2019 and February 2020 (preintervention) and December 2021–May 2022 (postintervention).

Results

A total of 265 patients were included in the primary study, 132 patients preintervention and 133 patients postintervention. The postintervention phase was associated with improvements in nearly all process-related outcomes, such as a shorter time to antibiotics (66 vs. 143 min; p < 0.001), increased number of lactate measurements (72.9 vs. 46.2%; p < 0.001), and improved completeness of documented MEWS scores (85.0 vs. 62.9%; p < 0.001). Except for an improvement in the number of immediate versus delayed ICU admissions (100% immediate vs. 64.3% immediate; p = 0.012), there was no improvement in the other patient-related outcomes such as 28 days mortality (14.3 vs. 9.1%; p = 0.261), during the postintervention phase.

Conclusion

Our program stimulated physicians to make timely decisions regarding diagnostics and treatment of sepsis in the ED. Implementing the sepsis performance improvement program was associated with significant improvements in most process-related outcomes but with minimal improvements in patient-related outcomes in our cohort.

Knowledge, Practice and Attitudes to the Management of Sepsis in Jamaica

Introduction

Sepsis is a life-threatening dysfunction resulting from the dysregulated host response to infection. The mortality of sepsis in Jamaica remains high amid the proven efficacy of the Surviving Sepsis Guidelines implementation in some countries.

Aim of study

To evaluate the inter-relationship of healthcare workers’ attitude towards, knowledge of and practice of sepsis management in Jamaica.

Material and methods

A survey was done using an anonymous self-administered validated questionnaire to healthcare workers across Jamaica. Questions on knowledge, attitude, and practice of sepsis within private and public hospitals were answered.

Results

A total of 616 healthcare workers were eligible for analysis. Most respondents agree that healthcare workers need more training on sepsis (93.7%) and that formal sepsis training modules should be implemented at their hospitals or practice (93.2%). Several signs of sepsis as outlined by qSOFA were correctly identified as such by most respondents (60.6% to 76.4%), with the exception of a low PaCO2 (34.9%), which was correctly identified by a minority of respondents. While a majority (69.3%) were able to correctly define sepsis, only 8.8% of respondents knew the annual sepsis mortality rate. Postgraduate training (p<0.01) and formal sepsis training (p<0.05) were both predictive of high correct knowledge and practice scores. Specialization in Anaesthesia/ Critical Care Medicine (p<0.05) or Emergency Medicine (p<0.05) was predictive of high knowledge scores and Internal Medicine predictive of high practice scores (p<0.01).

Conclusions

This study revealed that education for healthcare workers on sepsis and the implementation of SSC is needed in Jamaica.

The Survival of the Surviving Sepsis Campaign

Even well-intentioned policies have great potential to cause harm. This statement is vividly illustrated by the influential, yet controversial, Surviving Sepsis Campaign guidelines and subsequent CMS benchmarks. Despite low-quality evidence, tendentious industry ties, and rebuke from the Infectious Disease Society of America (IDSA), these benchmarks continue to eschew therapy driven by clinician expertise and individual patient needs in favor of mandating an arbitrary, one-size-fits-all approach that suspends clinical judgment and promotes indiscriminate use of treatments that have the potential to cause great harm.

Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis

Early recognition and treatment of sepsis are linked to improved patient outcomes. Machine learning-based early warning systems may reduce the time to recognition, but few systems have undergone clinical evaluation. In this prospective, multi-site cohort study, we examined the association between patient outcomes and provider interaction with a deployed sepsis alert system called the Targeted Real-time Early Warning System (TREWS). During the study, 590,736 patients were monitored by TREWS across five hospitals. We focused our analysis on 6,877 patients with sepsis who were identified by the alert before initiation of antibiotic therapy. Adjusting for patient presentation and severity, patients in this group whose alert was confirmed by a provider within 3 h of the alert had a reduced in-hospital mortality rate (3.3%, confidence interval (CI) 1.7, 5.1%, adjusted absolute reduction, and 18.7%, CI 9.4, 27.0%, adjusted relative reduction), organ failure and length of stay compared with patients whose alert was not confirmed by a provider within 3 h. Improvements in mortality rate (4.5%, CI 0.8, 8.3%, adjusted absolute reduction) and organ failure were larger among those patients who were additionally flagged as high risk. Our findings indicate that early warning systems have the potential to identify sepsis patients early and improve patient outcomes and that sepsis patients who would benefit the most from early treatment can be identified and prioritized at the time of the alert.

Die neue internationale Sepsis-Leitlinie der Surviving Sepsis Campaign 2021

The new Surviving Sepsis Campaign (SSC) guideline was substantially revised in 2021. These updated recommendations are intended to guide intensivists in providing adequate care to adult patients with sepsis or septic shock. In particular, the current SSC guideline emphasizes early recognition and stringent management in the first hours after the onset of sepsis. In particular, the implementation of acute interventions should help to improve the chances of survival of sepsis patients.This article summarizes the most important recommendations for acute therapy and presents them as a comparative overview to the previous SSC guideline and the German S3 guideline. This should allow the reader to adopt the knowledge from the new guideline into clinical practice as quickly as possible in order to improve the quality of treatment of patients with sepsis or septic shock.

The German Quality Network Sepsis: Evaluation of a Quality Collaborative on Decreasing Sepsis-Related Mortality in a Controlled Interrupted Time Series Analysis

Background

Sepsis is one of the leading causes of preventable deaths in hospitals. This study presents the evaluation of a quality collaborative, which aimed to decrease sepsis-related hospital mortality.

Methods

The German Quality Network Sepsis (GQNS) offers quality reporting based on claims data, peer reviews, and support for establishing continuous quality management and staff education. This study evaluates the effects of participating in the GQNS during the intervention period (April 2016–June 2018) in comparison to a retrospective baseline (January 2014–March 2016). The primary outcome was all-cause risk-adjusted hospital mortality among cases with sepsis. Sepsis was identified by International Classification of Diseases (ICD) codes in claims data. A controlled time series analysis was conducted to analyze changes from the baseline to the intervention period comparing GQNS hospitals with the population of all German hospitals assessed via the national diagnosis-related groups (DRGs)-statistics. Tests were conducted using piecewise hierarchical models. Implementation processes and barriers were assessed by surveys of local leaders of quality improvement teams.

Results

Seventy-four hospitals participated, of which 17 were university hospitals and 18 were tertiary care facilities. Observed mortality was 43.5% during baseline period and 42.7% during intervention period. Interrupted time-series analyses did not show effects on course or level of risk-adjusted mortality of cases with sepsis compared to the national DRG-statistics after the beginning of the intervention period (p = 0.632 and p = 0.512, respectively). There was no significant mortality decrease in the subgroups of patients with septic shock or ventilation >24 h or predefined subgroups of hospitals. A standardized survey among 49 local quality improvement leaders in autumn of 2018 revealed that most hospitals did not succeed in implementing a continuous quality management program or relevant measures to improve early recognition and treatment of sepsis. Barriers perceived most commonly were lack of time (77.6%), staff shortage (59.2%), and lack of participation of relevant departments (38.8%).

Conclusion

As long as hospital-wide sepsis quality improvement efforts will not become a high priority for the hospital leadership by assuring adequate resources and involvement of all pertinent stakeholders, voluntary initiatives to improve the quality of sepsis care will remain prone to failure.

Temporal trends in the epidemiology, management, and outcome of sepsis-A nationwide observational study

BACKGROUND

Registry-based studies have shown increasing incidence of sepsis and declining mortality rates in recent years, but are inherently at risk of bias. The objectives of this study were to describe 11-year trends in the incidence, treatment and outcome of sepsis using clinical criteria with chart review.

METHODS

This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014, and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria (sepsis-2). Incidence, patient characteristics, treatment and outcome were compared across the study years.

RESULTS

During the six study years, 9166 patients were admitted to Icelandic ICUs, 971 (10.6%) because of severe sepsis or septic shock. The crude incidence of sepsis requiring admission to ICU remained stable between 0.55 and 0.75 per 1000 inhabitants. No statistically significant trends were observed over time in median patient age (67 years), APACHE II score (21), SOFA score (8) or Charlson Comorbidity Index (4). The time to antibiotic administration (median 1.8 h) in the emergency departments was stable over the study period but the time to lactate measurements decreased from 4.1 h in 2006 to 1.2 h in 2016, p < .001. The 28-day mortality was 25% and 1-year mortality 41%, both with no observed change with time.

CONCLUSIONS

In a nationwide cohort, diagnosed with clinical criteria, the incidence of sepsis requiring intensive care did not change over an 11-year period. Mortality remained stable and only minimal changes were observed in initial resuscitation in the emergency departments.

Sepsis Performance Improvement Programs: From Evidence Toward Clinical Implementation

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901.

A multifaceted educational intervention improved anti-infectious measures but had no effect on mortality in patients with severe sepsis

Sepsis is a major reason for preventable hospital deaths. A cluster-randomized controlled trial on an educational intervention did not show improvements of sepsis management or outcome. We now aimed to test an improved implementation strategy in a second intervention phase in which new intervention hospitals (former controls) received a multifaceted educational intervention, while controls (former intervention hospitals) only received feedback of quality indicators. Changes in outcomes from the first to the second intervention phase were compared between groups using hierarchical generalized linear models controlling for possible confounders. During the two phases, 19 control hospitals included 4050 patients with sepsis and 21 intervention hospitals included 2526 patients. 28-day mortality did not show significant changes between study phases in both groups. The proportion of patients receiving antimicrobial therapy within one hour increased in intervention hospitals, but not in control hospitals. Taking at least two sets of blood cultures increased significantly in both groups. During phase 2, intervention hospitals showed higher proportion of adequate initial antimicrobial therapy and de-escalation within 5 days. A survey among involved clinicians indicated lacking resources for quality improvement. Therefore, quality improvement programs should include all elements of sepsis guidelines and provide hospitals with sufficient resources for quality improvement.

Trial registration: ClinicalTrials.gov, NCT01187134. Registered 23 August 2010, https://www.clinicaltrials.gov/ct2/show/study/NCT01187134.

Sepsis, Septic Shock, and Differences in Cardiovascular Event Occurrence

Introduction: Mortality estimates from sepsis and septic shock ranged from 18% to 35% and 40% to 60%, respectively, prior to 2014. Sepsis patients who experience subsequent cardiovascular events have increased mortality; however, data are limited among septic shock patients. This study reports in-hospital mortality, incident cardiovascular events, and cardiovascular procedures among sepsis patients with and without subsequent septic shock. Methods: Patients with a primary diagnosis of sepsis with and without a secondary diagnosis of septic shock were identified from the 2016 and 2017 National Readmissions Database. These patients were then evaluated for the occurrence of cardiovascular events and procedures. Results: A total of 2,127,137 patients were included in the study, with a mean age of 66 years. Twenty percent of patients (n = 420,135) developed subsequent septic shock. In-hospital mortality among patients with a primary diagnosis of sepsis was 5.3%, and it was 31.2% for those with subsequent septic shock. Notable cardiovascular events occurring among sepsis patients with and without subsequent septic shock, respectively, included: acute kidney injury (65.1% vs. 32.8%, P < .0001), acute systolic heart failure (9.8% vs. 5.1%, P < .0001), NSTEMI (8.8% vs. 3.2%, P < .0001), and ischemic stroke (2.3% vs. 0.9%, P < .0001). Similarly, the most common cardiovascular procedures between the two groups were: percutaneous coronary intervention (0.37% vs. 0.20%, P < .0001), intra-aortic balloon pump (0.19% vs. 0.02%, P < .0001), and extracorporeal membrane oxygenation (0.18% vs. 0.01%, P < .0001). Conclusions: Sepsis with subsequent septic shock is associated with an increased frequency of in-hospital cardiovascular events and procedures.

Enhancing sepsis management through machine learning techniques: A review

Sepsis is a major public health problem and a leading cause of death in the world, where delay in the beginning of treatment, along with clinical guidelines non-adherence have been proved to be associated with higher mortality. Machine Learning is increasingly being adopted in developing innovative Clinical Decision Support Systems in many areas of medicine, showing a great potential for automatic prediction of diverse patient conditions, as well as assistance in clinical decision making. In this context, this work conducts a narrative review to provide an overview of how specific Machine Learning techniques can be used to improve sepsis management, discussing the main tasks addressed, the most popular methods and techniques, as well as the obtained results, in terms of both intelligent system accuracy and clinical outcomes improvement.

Sepsis and Septic Shock: Evolving Evidence, Evolving Paradigms

Sepsis and septic shock represent important infection-related medical emergencies that result in significant morbidity and mortality. The prevalence and microbiology of these processes are evolving. Nonetheless, timely and appropriate antibiotic therapy continues to represent the most important determinant of survival. Recent trials have clarified that crystalloids are preferred for initial resuscitation, and balanced crystalloids appear superior to 0.9% saline. Controversy remains regarding not only the rate and rapidity of fluid resuscitation but also about the timing and use of vasopressors to maintain blood pressure. While some newer alternative vasopressors may have a role in sepsis, more evidence supporting their use is required. Conflicting data exist regarding the impact of corticosteroids on mortality in septic shock. However, these reports indicate that adjunctive hydrocortisone can lead to more rapid shock reversal.

Impact of sepsis education for healthcare professionals and students on learner and patient outcomes: A systematic review

BACKGROUND

Sepsis is an important global healthcare problem that is a key challenge faced by healthcare professionals face worldwide. One key effort aimed at reducing the global burden of sepsis is educating healthcare professionals about early identification and management of sepsis.

AIM

To provide a comprehensive evaluation of sepsis education among healthcare professionals and students.

METHODS

Six databases (PubMed, CINAHL, Embase, MEDLINE, Cochrane Central Register of Controlled Trials, and Scopus) were searched. We included studies that described and evaluated any form of education or training on sepsis delivered to healthcare professionals and students. Study outcomes were summarised according to the adapted Kirkpatrick model of training evaluation.

RESULTS

Thirty-two studies were included in the review. The learning contents were reported to be in accordance with the Surviving Sepsis Campaign guidelines. Seven studies included the topic of interprofessional teamwork and communication in their sepsis education content. Most educational programs were effective and reported positive effects on immediate knowledge outcomes. Interventions that were delivered through an active learning approach such as simulation and game-based learning generally produced greater gains than didactic teaching. Improvements in patient care processes and patient outcomes were associated with the concomitant existence or implementation of a hospital sepsis care bundle.

CONCLUSION

Incorporating active learning strategies into sepsis education interventions has the potential to improve learners' long-term outcomes. In addition, sepsis education and protocol-based sepsis care bundle act in synergy to augment greater improvements in care processes and patient benefits.

Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis

Background

Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood.

Methods

We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors.

Results

We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)].

Conclusion

Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects.

PROSPERO Registration ID

CRD42021225417.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00558-5.

Pediatric Sepsis Research: Where Are We and Where Are We Going?

Sepsis continues to be one of the leading causes of admission to the Pediatric Intensive Care Unit, representing a great challenge for researchers and healthcare staff. This mini review aims to assess research on pediatric sepsis over the years. Of the 2,698 articles retrieved from the Scopus database, the 100 most cited were selected (50 published since 2000 and 50 published since 2016). The most cited studies, published in the 21st century, are highlighted, with their main findings and perspectives.

Prehospital delay is an important risk factor for mortality in community-acquired bloodstream infection (CA-BSI): a matched case-control study

OBJECTIVES

The aim of this study was to identify prehospital and early hospital risk factors associated with 30-day mortality in patients with blood culture-confirmed community-acquired bloodstream infection (CA-BSI) in Sweden.

METHODS

A retrospective case-control study of 1624 patients with CA-BSI (2015-2016), 195 non-survivors satisfying the inclusion criteria were matched 1:1 with 195 survivors for age, gender and microorganism. All forms of contact with a healthcare provider for symptoms of infection within 7 days prior CA-BSI episode were registered. Logistic regression was used to analyse risk factors for 30-day all-cause mortality.

RESULTS

Of the 390 patients, 61% (115 non-survivors and 121 survivors) sought prehospital contact. The median time from first prehospital contact till hospital admission was 13 hours (6-52) for non-survivors and 7 hours (3-24) for survivors (p<0.01). Several risk factors for 30-day all-cause mortality were identified: prehospital delay OR=1.26 (95% CI: 1.07 to 1.47), p<0.01; severity of illness (Sequential Organ Failure Assessment score) OR=1.60 (95% CI: 1.40 to 1.83), p<0.01; comorbidity score (updated Charlson Index) OR=1.13 (95% CI: 1.05 to 1.22), p<0.01 and inadequate empirical antimicrobial therapy OR=3.92 (95% CI: 1.64 to 9.33), p<0.01. In a multivariable model, prehospital delay >24 hours from first contact remained an important risk factor for 30-day all-cause mortality due to CA-BSI OR=6.17 (95% CI: 2.19 to 17.38), p<0.01.

CONCLUSION

Prehospital delay and inappropriate empirical antibiotic therapy were found to be important risk factors for 30-day all-cause mortality associated with CA-BSI. Increased awareness and earlier detection of BSI in prehospital and early hospital care is critical for rapid initiation of adequate management and antibiotic treatment.

Sex and Gender Appraisal Tool-Systematic Reviews-2 and Participation-To-Prevalence Ratio assessed to whom the evidence applies in sepsis reviews

OBJECTIVES

To revise a sex and gender appraisal tool for systematic reviews (SGAT-SR) and apply it to Cochrane sepsis reviews.

STUDY DESIGN AND SETTING

The revision process was informed by existing literature on sex, gender, intersectionality, and feedback from an expert advisory board. We revised the items to consider additional factors associated with health inequities and appraised sex and gender considerations using the SGAT-SR-2 and female Participation-to-Prevalence Ratio (PPR) in Cochrane sepsis reviews.

RESULTS

SGAT-SR-2 consists of 19 questions appraising the review's sections and use of the terms sex and gender. amongst 71 SRs assessed, 50.7% included at least one tool item, the most frequent being the number of participants by sex or gender at included study-level (24/71 reviews). Only four reviews provided disaggregated data for the full set of included trials, while two considered other equity-related factors. Reviews rarely appraised possible similarities and differences across sex and gender. In half of a subset of reviews, female participants were under-represented relative to their share of the sepsis population (PPR<0.8).

CONCLUSION

The SGAT-SR-2 tool and the PPR can support the design and appraisal of systematic reviews to assess sex and gender considerations, address to whom evidence applies, and determine future research needs.

Diagnostic Challenges in Sepsis

Purpose of Review

Sepsis is a leading cause of death worldwide. Groundbreaking international collaborative efforts have culminated in the widely accepted surviving sepsis guidelines, with iterative improvements in management strategies and definitions providing important advances in care for patients. Key to the diagnosis of sepsis is identification of infection, and whilst the diagnostic criteria for sepsis is now clear, the diagnosis of infection remains a challenge and there is often discordance between clinician assessments for infection.

Recent Findings

We review the utility of common biochemical, microbiological and radiological tools employed by clinicians to diagnose infection and explore the difficulty of making a diagnosis of infection in severe inflammatory states through illustrative case reports. Finally, we discuss some of the novel and emerging approaches in diagnosis of infection and sepsis.

Summary

While prompt diagnosis and treatment of sepsis is essential to improve outcomes in sepsis, there remains no single tool to reliably identify or exclude infection. This contributes to unnecessary antimicrobial use that is harmful to individuals and populations. There is therefore a pressing need for novel solutions. Machine learning approaches using multiple diagnostic and clinical inputs may offer a potential solution but as yet these approaches remain experimental.