Initial, successful implementation of sepsis guidelines in an emergency department (original) (raw)
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Hong Kong Journal of Emergency Medicine, 2015
Introduction: Internationally, standard care of patients with severe sepsis consists of early detection, early antimicrobial therapy, and aggressive intravenous fluid therapy to maintain tissue oxygenation and perfusion. In this retrospective study, we aimed to examine the management of patients with severe sepsis in a local university hospital emergency department before and after the implementation of a sepsis management guideline. Method: We collected data on the management and outcome of patients during a three-month period before the implementation of a sepsis guideline (October-December 2009). We then collected similar data one year after the implementation (October-December 2010). Key sepsis management areas and in- hospital mortality rates were compared, as were length of resuscitation, three-month mortality rate, hospital length of stay (LOS) and intensive care unit (ICU) LOS. Results: Data from 115 patients were collected in the pre-implementation group, while data on 102 patients were collected for the post-implementation group. There were more patients with hypoperfusion in the post-implementation cohort (25.2% vs. 40.2%, p=0.019). There was no difference in background characteristics, average lactate value, average MAP or number of hypotensive patients between the two groups. Significantly more antibiotics were given after the intervention (13.0% vs. 23.5%, p=0.045) and more patients had a lactate level measured (43.0% vs. 73.5%; p<0.001). There was a trend towards better survival for a subgroup of patients with hypoperfusion (48.0% vs. 29.2%, p=0.060). Conclusions: Implementation of a sepsis guideline leads to more antibiotics being given and more lactate measurement in the emergency department. (Hong Kong j.emerg.med. 2015;22: 163-171) LOS
The Use of an Educational Tool to Improve Adjustment to the Sepsis Protocol and the Clinical Impact
Nursing & Care Open Access Journal, 2017
Introduction: Sepsis is a major global health problem and is responsible for the deaths of thousands of people each year. It is the second leading cause of death in intensive care units, after coronary heart disease. Due to the high mortality rate, sepsis needs to be addressed through evidence-based practice, institutionalized protocols, well-developed clinical strategies, and continuing education. This study analyzed the clinical impact of adherence to an education tool for sepsis control measures at the Adventist Hospital of Belém in Brazil. Methodology: A prospective, quasi-experimental study was carried out from March to December 2015. The study included 152 patients diagnosed as having selection criteria with suspected sepsis. The patients diagnosed in the emergency department of the hospital were divided into a control group (n=30) and a case group (n=122) based on the period in which an educational tool was applied, for adherence to the hospital sepsis protocol. Results: The best adherence measure, after the tool application, was antimicrobial therapy. There was a reduction in the hospitalization time of the surviving patients from 19.7 days to 7.7 days and the mortality rate decreased from 63.3% to 30.6%. Conclusion: Although adherence to resuscitation packages was low, the education tool increased the insight of professionals in the identification of septic patients, resulting in a diagnosis and early treatment that corresponded with a reduction in hospitalization time and a decrease in mortality.
BMC Medicine, 2013
Several factors contribute to the high mortality attributed to severe infections in resource-limited settings. While improvements in survival and processes of care have been made in high-income settings among patients with severe conditions, such as sepsis, guidelines necessary for achieving these improvements may lack applicability or have not been tested in resource-limited settings. The World Health Organization's recent publication of the Integrated Management of Adolescent and Adult Illness District Clinician Manual provides details on how to optimize management of severely ill, hospitalized patients in such settings, including specific guidance on the management of patients with septic shock and respiratory failure without shock. This manuscript provides the context, process and underpinnings of these sepsis guidelines. In light of the current deficits in care and the limitations associated with these guidelines, the authors propose implementing these standardized best practice guidelines while using them as a foundation for sepsis research undertaken in, and directly relevant to, resourcelimited settings.
Poor Compliance with Sepsis Guidelines in a Tertiary Care Children’s Hospital Emergency Room
Frontiers in Pediatrics
Objectives: This study aimed to assess factors related to adherence to the Pediatric Advanced Life Support guidelines for severe sepsis and septic shock in an emergency room (ER) of a tertiary care children's hospital. Methods: This was a retrospective, observational study of children (0-18 years old) in The Children's Hospital of San Antonio ER over 1 year with the International Consensus Definition Codes, version-9 (ICD-9) diagnostic codes for "severe sepsis" and "shocks." Patients in the adherent group were those who met all three elements of adherence: (1) rapid vascular access with at most one IV attempt before seeking alternate access (unless already in place), (2) fluids administered within 15 min from sepsis recognition, and (3) antibiotic administration started within 1 h of sepsis recognition. Comparisons between groups with and without sepsis guideline adherence were performed using Student's t-test (the measurements expressed as median values). The proportions were compared using chi-square test. p-Value ≤0.05 was considered significant. results: A total of 43 patients who visited the ER from July 2014 to July 2015 had clinically proven severe sepsis or SS ICD-9 codes. The median age was 5 years. The median triage time, times from triage to vascular access, fluid administration and antibiotic administration were 26, 48.5, 76, and 135 min, respectively. Adherence to vascular access, fluid, and antibiotic administration guidelines was 21, 26, and 34%, respectively. Appropriate fluid bolus (20 ml/kg over 15-20 min) was only seen in 6% of patients in the non-adherent group versus 38% in the adherent group (p = 0.01). All of the patients in the non-adherent group used an infusion pump for fluid resuscitation. Hypotension and ≥3 organ dysfunction were more commonly observed in patients in adherent group as compared to patients in non-adherent group (38 vs. 14% p = 0.24; 63 vs. 23% p = 0.03). conclusion: Overall adherence to sepsis guidelines was low. The factors associated with non-adherence to sepsis guidelines were >1 attempt at vascular access, delay in antibiotic ordering, fluid administration using infusion pump, absence of hypotension, and absence of three or more organs in dysfunction at ER presentation.
Postgraduate medical journal, 2018
To evaluate the impact of a collaborative programme for the early recognition and management of patients admitted with sepsis in the northwest of England. 14 hospitals in the northwest of England. A quality improvement programme (Advancing Quality (AQ) Sepsis) that promoted a sepsis care bundle including time-based recording of early warning scores, documenting systemic inflammatory response syndrome criteria and suspected source of infection, taking of blood cultures, measuring serum lactate levels, administration of intravenous antibiotics, administration of oxygen, fluid resuscitation, measurement of fluid balance and senior review. Inpatient mortality, 30-day readmission rates and duration of hospital ≥10 days. Data for 7776 patients were included in this study between 1 July 2014 and 29 December 2015. Participation in the AQ Sepsis programme was associated with a reduction in readmissions within 30 days (OR 0.81 (0.69-0.95)) and hospital stays over 10 days (OR 0.69 (0.60-0.78))...
SBMU publishing, 2017
Introduction: Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans' lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines. Methods: This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21. Results: 30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2) in pre education and 8.17 ± 1.31 (IQR = 85) in post education phase (p < 0.001). There was excellent compliance with standard in 4 (22%) studied measures, good in 2 (11%), fair in 1 (6%), weak in 2 (11%), and poor in 9 (50%). 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressure measurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O 2 therapy were improved clinically, but not statistically. Conclusion: The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O 2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents' adherence to current standard guidelines regarding severe sepsis and septic shock.
2023
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.
International Journal of Nursing Studies, 2010
Background: In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce mortality from sepsis, was launched. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, effective implementation remains troublesome and no recommendations concerning the role of nurses are given. Objectives: To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback. Design and setting: A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the Netherlands. Participants: Adult patients (16 years old) visiting the ED because of a known or suspected infection to whom two or more of the extended systemic inflammatory response syndrome (SIRS) criteria apply. Methods: We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis: measure serum lactate within 6 h, obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine for urinalysis and culture, start antibiotics within 3 h, and hospitalize or discharge the patient within 3 h. Results: A total of 825 patients were included in the study. Compliance with the complete bundle significantly improved from 3.5% at baseline to 12.4% after our entire implementation program was put in place. The completion of four of six individual elements improved significantly, namely: measure serum lactate (improved from 23% to 80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from 49% to 67%), and start antibiotics within 3 h (from 38% to 56%). The mean number of performed bundle elements improved significantly from 3.0 elements at baseline to 4.2 elements after intervention [1.2; 95% confidence interval = 0.9-1.5].
The Journal of Emergency Medicine, 2010
e Abstract-Background: Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies. Objective: The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies. Methods: In a crosssectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes. Results: Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6 -12 months. Eightyeight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninetyfive percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively. Conclusions: Implementation of a sepsis management pro-tocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome.
Improving Care of the Sepsis Patient
The Joint Commission Journal on Quality and Patient Safety, 2008
Background: In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care facility, used the Surviving Sepsis Campaign guidelines as the foundation for an independent initiative to reduce the mortality rate by at least 25%. Methods: In 2004, an interdisciplinary sepsis team developed a process for rapidly recognizing at-risk patients; evaluating a patient's clinical status; and providing appropriate, timely therapy in three major areas of sepsis care; recognition of the sepsis patient, resuscitation priorities, and intensive care management. The Sepsis Alert program, which did not require additional staffing, was developed and implemented in 10 months. The Sepsis Alert packet included a care management guideline, a treatment algorithm, an emergency department treatment order set, and multiple adjuncts to streamline patient identification and management. Results: Introduction of sepsis resuscitation and critical care management standards led to a 49.4% decrease in mortality rates (p < .0001), a 34.0% decrease in average length of hospital stay (p < .0002), and a 188.2% increase in the proportion of patients discharged to home (p < .0001) when the historic control group is compared with the postimplementation group from January 2005 through December 2007. Discussion: An integrated leadership team, using existing resources, transformed frontline clinical practice by providers from multiple disciplines to reduce mortality in the population of patients with sepsis.