Sepsis is a life threatening condition. This study is focused on improving patient outcomes with a 3-hour sepsis care bundle. Early detection can help to improve positive patient outcomes. A checklist using the DART protocol was put in place by this study to determine if nurses could implement sepsis care at an early stage in the patient’s care. 90 charts were reviewed prior to implementing the checklist and researchers found that only 30% was compliant with sepsis care. One month in to the implementation period 50% was compliant with the sepsis care bundle. After the implementation period, 80% were compliant with quality reporting metrics. The study showed that nurse driven protocols can help to improve patient’s outcomes significantly. After the study was completed, a survey was sent to the nurses. They reported that the checklist was helpful in making sure that everything was completed in a time sensitive manner for the sepsis care bundle.
References
Moore, W. R., Vermuelen, A., Taylor, R., Kihara, D., & Wahome, E. (2019). Improving 3-Hour Sepsis Bundled Care Outcomes: Implementation of a Nurse-Driven Sepsis Protocol in the Emergency Department. Journal of Emergency Nursing, 45(6), 690–698. doi: 10.1016/j.jen.2019.05.005
Teles et al (2017) stated in their study that patients who were screened and treated using a 3 hour sepsis bundle had a mortality rate reduction of 44% compared to those who did not. While sepsis screenings and protocols are always evolving what do you think can be done to close that gap on the 20% who are not compliant? Is more education needed? Would a break down of the charting find a break down in the system? What do you think is holding us back from a 100% coverage rate. We all know how important it is to catch sepsis early.
Teles, F., Rodrigues, W. G., Alves, M. G. T. C., Albuquerque, C. F. T., Bastos, S. M. O., Mota, M. F. A., Mota, E. S., & Silva, F. J. L. (2017). Impact of a sepsis bundle in wards of a tertiary hospital. Journal of Intensive Care, 5, 1–5. https://doi-org.ezproxy.fhsu.edu/10.1186/s40560-017-0231-2
It is hard to make everyone be 100% compliant with protocols and screenings related to sepsis because there are so many things that need to come together for a sepsis diagnosis to occur. I think that more education is definitely needed in acute care areas. We receive education once a year about sepsis through an online program, however, I do not find it helpful because the way they introduce the information is not interesting. Most people just click their way through the powerpoint and then guess at the quiz or test that is at the end.
Sepsis is a life-threatening emergency and in 2017 an estimated 48.9 million cases of sepsis were documented worldwide (Rudd et. al, 2019). Having a safety bundle readily available is helpful to ensure that everything is done timely and correctly. There have been many different types of “bundles” adopted by emergency departments throughout the world with the same goal of giving the patient the best possible outcome. Compliance with the bundles and protocols seem to be a problem everywhere. Right now, during the Covid-19, the argument could be made in some cases that there is not enough staff to complete everything on time. Another possibility could be that staff were just told to do enact these protocols and bundles but do not fully understand the importance of it. Perhaps more education is needed?
Frankling, C., Patel, J., Sharif, B., Melody, T., Yeung, J., Gao, F., & Szakmany, T. (2019). A Snapshot of Compliance with the Sepsis Six Care Bundle in Two Acute Hospitals in the West Midlands, UK. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 23(7), 310–315. https://doi.org/10.5005/jp-journals-10071-23204
Rudd, K. E., Johnson, S. C., Agesa, K. M., Shackelford, K. A., Tsoi, D., Kievlan, D. R., Colombara, D. V., Ikuta, K. S., Kissoon, N., Finfer, S., Fleischmann-Struzek, C., Machado, F. R., Reinhart, K. K., Rowan, K., Seymour, C. W., Watson, R. S., West, T. E., Marinho, F., Hay, S. I., Lozano, R., … Naghavi, M. (2020). Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet (London, England), 395(10219), 200–211. https://doi.org/10.1016/S0140-6736(19)32989-7
Sepsis care has always been important at the hospital that I work at. In January 2020, we implemented a new bundle because the sepsis care bundle is that main goal for our hospital for the year. We have seen improvements to the metrics in the past couple of months even with COVID-19 going on. Those patients have been some of the sickest that we’ve seen in months. I do believe more education about the importance of the sepsis care bundle would help even more.
I work on a respiratory step-down unit, so we frequently admit patients with sepsis. One thing I have noticed with the sepsis checklists in my facility are that they are printed pieces of paper that the ED nurses start to check-off in the ED and send up with the patient, once they are admitted. Sadly, I rarely see these checklists be used or followed-up on once on the unit.
Early recognition is imperative for prompt treatment of sepsis. “The reduction in in-hospital mortality rate and hospital readmission rate confirms that the Surviving Sepsis Guideline revisions and updates are improving patient care resulting in better outcomes” (Farrell & Casserly, 2018).
The study you discussed supports this statement. Still, a 20% that is unaccounted for remains. Like our peers, I too question what could be done to lessen the gap. Also, did you come across any information related to the proposed 1-hour sepsis bundle? If so, what were your thoughts on it?
Farrell, C., & Casserly, B. (2018, October 30). Sepsis, the earlier the better, 3- to 1-hour bundle. Retrieved from http://jeccm.amegroups.com/article/view/4712/5253
We also started to use paper checklists in January because when we got an update to our EPIC system, it messed up our in chart sepsis checklists. They did not transfer from the ED to the inpatient units for some reason. The checklist follows the patient to the inpatient unit but is not used again and is just turned in to management. When the checklist was in EPIC, it flagged to for the user to do something for the patient and chart that it was done. I think that this was a better tool. I think that a 1 hour sepsis bundle would be beneficial to the patient but would be difficult for the staff. It is often hard to get testing done in 1 hour to be able to treat the patient appropriately especially if there is not enough staff or resources.
I believe that electronic checklists that flag interventions/medications are definitely a much better tool. This also creates more accountability. Things get missed a lot less, and if they are dismissed/ignored, then they can be traced back to who missed a step, etc. During my research, I found that most providers did not like the 1 hour bundle as it was not necessarily something that was realistic in relation to time.
Megan,
Patient outcomes is dependent on appropriate therapy and the early initiation of sepsis bundles. Implementation of sepsis bundles, education for early detection and treatment can help lower patient mortality. This is something that should be implemented throughout all hospitals to help improve outcomes for this at risk group.
Reference:
McColl, T., Gatien, M., Calder, L., Yadav, K., Tam, R., Ong, M., . . . Stiell, I. (2017). Implementation of an emergency department sepsis bundle and system redesign: A process improvement initiative. CJEM : Journal of the Canadian Association of Emergency Physicians, 19(2), 112-121. doi:http://dx.doi.org.ezproxy.fhsu.edu:2048/10.1017/cem.2016.351
Education is a very important part of the sepsis bundle of care.
Early sepsis detection is key to a better patient prognosis. The DART checklist is an extremely helpful tool to help nurses identify sepsis. In an article by (Burog et al;2020) they focus on educating nurses on the signs and symptoms of sepsis as well as the screening tools used within the charting system. Is further nursing education beneficial to improving the outcomes of patients seen in the ER? Would the education make a difference in the emergency setting?
Burog, R. Carrion, J. Luna, N. Silverstr-Elmore, A. Turner, B.S.(2020) A quality Improvement Project to Evaluate the Implementation of a Sepsis Education Program in a Medical-Surgical Department. Medsurg Nursing; Vol 29, Iss. 1, pg34-37
Furthering education in the ER is would most definitely help to improve the outcomes of patients. I think the main focus of sepsis care education should be focused on the emergency setting. Sepsis care often is initiated in the ER.
I found an article that talks about the 1 hour bundle and all that entails with following that protocol. The 1 hour bundle encourages clinicians to act as quickly as possible to obtain blood cultures, administer broad spectrum antibiotics, start appropriate fluid resuscitation, measure lactate, and begin vasopressors if clinically indicated. Reading the article the 1 hour bundle seems like it would be ideal but the fact everything would ideally be done in that hour may not be realistic. But as long as we do are best to start intervention as early as possible to help the patient.
SCCM: Adult Patients. (n.d.). Retrieved from http://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients