Improving the Uniformity of Care with a Sepsis Bundle in the Emergency Department

AbstractBackgroundIn 2008–2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality.MethodsThis before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use.ResultsWe included a total of 167 and 185 patients in the pre- and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8–17.0; p=0.006). There was also a higher rate of sepsis protocol use in the post-intervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1–65.3; p<0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission.InterpretationThe implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.

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The 28-Day Mortality Outcome of the Complete Hour-1 Sepsis Bundle in the Emergency Department

Shock ◽

10.1097/shk.0000000000001815 ◽

2021 ◽

Vol 56 (6) ◽

pp. 969-974 ◽

Cited By ~ 1

Author(s):

Thidathit Prachanukool ◽

Pitsucha Sanguanwit ◽

Fuangsiri Thodamrong ◽

Karn Suttapanit

Keyword(s):

Emergency Department ◽

Mortality Outcome ◽

Sepsis Bundle

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Emergency service units in Turkey dont have enough resources to implement the one- hour sepsis bundle components and sepsis guidelines recommendations, 238 emergency department directors opinion

Annals of Medical Research ◽

10.5455/annalsmedres.2020.03.205 ◽

2020 ◽

Vol 27 (9) ◽

pp. 2453

Author(s):

Gulseren Elay ◽

Behcet Al

Keyword(s):

Emergency Department ◽

Emergency Service ◽

Department Directors ◽

The One ◽

Sepsis Bundle

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Prognostic significance of body temperature in the emergency department vs the ICU in Patients with severe sepsis or septic shock: A nationwide cohort study

PLoS ONE ◽

10.1371/journal.pone.0243990 ◽

2020 ◽

Vol 15 (12) ◽

pp. e0243990

Author(s):

Malin Inghammar ◽

Jonas Sunden-Cullberg

Keyword(s):

Emergency Department ◽

Septic Shock ◽

Severe Sepsis ◽

Quality Of Care ◽

Body Temperature ◽

Prognostic Significance ◽

Low Grade ◽

Nurse Workload ◽

Sepsis Bundle

Background Increased body temperature in the Emergency Department (BT-ED) and the ICU (BT-ICU) is associated with lower mortality in patients with sepsis. Here, we compared how well BT-ED and BT-ICU predict mortality; investigated mortality in various combinations of BT-ED and BT-ICU, and; compared degree of fever in the ED and ICU and associated quality of care. Methods 2385 adults who were admitted to an ICU within 24 hours of ED arrival with severe sepsis or septic shock were included. Results Thirty-day mortality was 23.6%. Median BT-ED and BT-ICU was 38.1 and 37.6°C. Crude mortality decreased more than 5% points per°C increase for both BT-ED and BT-ICU. Adjusted OR for mortality was 0.82/°C increase for BT-ED (0.76–0.88, p < 0.001), and 0.89 for BT-ICU (0.83–0.95, p<0.001). Patients who were at/below median temperature in both the ED and in the ICU had the highest mortality, 32%, and those with over median in the ED and at/below in the ICU had the lowest, 16%, (p<0.001). Women had 0.2°C lower median BT-ED (p = 0.03) and 0.3°C lower BT-ICU (p<0.0001) than men. Older patients had lower BT in the ICU, but not in the ED. Fever was associated with a higher rate of sepsis bundle achievement in the ED, but lower nurse workload in the ICU. Conclusions BT-ED was more useful to prognosticate mortality than BT-ICU. Despite better prognosis in patients with elevated BT, fever was associated with higher quality of care in the ED. Future studies should assess how BT-ED can be used to improve triage of infected patients, assigning higher priority to patients with low-grade/no fever and vice versa. Patients with at/below median BT in both ED and ICU have the highest mortality and should receive special attention. Different BT according to sex and age also needs further study.

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Pharmacist impact on sepsis bundle compliance through participation on an emergency department sepsis alert team

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2018.08.009 ◽

2019 ◽

Vol 37 (4) ◽

pp. 762-763

Author(s):

Nicholas Yarbrough ◽

Meghan Bloxam ◽

James Priano ◽

Patricia Louzon Lynch ◽

Lauren N. Hunt ◽

...

Keyword(s):

Emergency Department ◽

Bundle Compliance ◽

Sepsis Bundle

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Impact of an Antibiotic-specific Sepsis Bundle on Appropriate and Timely Antibiotic Administration for Severe Sepsis in the Emergency Department

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2015.09.007 ◽

2016 ◽

Vol 50 (1) ◽

pp. 79-88.e1 ◽

Cited By ~ 11

Author(s):

Bethany A. Kalich ◽

Jennifer M. Maguire ◽

Stacy L. Campbell-Bright ◽

Abhi Mehrotra ◽

Tom Caffey ◽

...

Keyword(s):

Emergency Department ◽

Severe Sepsis ◽

Antibiotic Administration ◽

Sepsis Bundle

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Quality initiative to improve emergency department sepsis bundle compliance through utilisation of an electronic health record tool

BMJ Open Quality ◽

10.1136/bmjoq-2021-001624 ◽

2022 ◽

Vol 11 (1) ◽

pp. e001624

Author(s):

Nicholus Michael Warstadt ◽

J Reed Caldwell ◽

Nicole Tang ◽

Staci Mandola ◽

Catherine Jamin ◽

...

Keyword(s):

Emergency Department ◽

Septic Shock ◽

Severe Sepsis ◽

Electronic Health Record ◽

Health Record ◽

Intention To Treat ◽

Significant Difference ◽

Bundle Compliance ◽

Electronic Health ◽

Sepsis Bundle

IntroductionSepsis is a common cause of emergency department (ED) presentation and hospital admission, accounting for a disproportionate number of deaths each year relative to its incidence. Sepsis outcomes have improved with increased recognition and treatment standards promoted by the Surviving Sepsis Campaign. Due to delay in recognition and other barriers, sepsis bundle compliance remains low nationally. We hypothesised that a targeted education intervention regarding use of an electronic health record (EHR) tool for identification and management of sepsis would lead to increased EHR tool utilisation and increased sepsis bundle compliance.MethodsWe created a multidisciplinary quality improvement team to provide training and feedback on EHR tool utilisation within our ED. A prospective evaluation of the rate of EHR tool utilisation was monitored from June through December 2020. Simultaneously, we conducted two retrospective cohort studies comparing overall sepsis bundle compliance for patients when EHR tool was used versus not used. The first cohort was all patients with intention-to-treat for any sepsis severity. The second cohort of patients included adult patients with time of recognition of sepsis in the ED admitted with a diagnosis of severe sepsis or septic shock.ResultsEHR tool utilisation increased from 23.3% baseline prior to intervention to 87.2% during the study. In the intention-to-treat cohort, there was a statistically significant difference in compliance between EHR tool utilisation versus no utilisation in overall bundle compliance (p<0.001) and for several individual components: initial lactate (p=0.009), repeat lactate (p=0.001), timely antibiotics (p=0.031), blood cultures before antibiotics (p=0.001), initial fluid bolus (p<0.001) and fluid reassessment (p<0.001). In the severe sepsis and septic shock cohort, EHR tool use increased from 71.2% pre-intervention to 85.0% post-intervention (p=0.008).ConclusionWith training, feedback and EHR optimisation, an EHR tool can be successfully integrated into current workflows and appears to increase sepsis bundle compliance.

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Relationship Between Nighttime Emergency Department Admission and Adherence to a Sepsis Treatment Bundle

10.21203/rs.3.rs-467514/v1 ◽

2021 ◽

Author(s):

Je Sung You ◽

Yoo Seok Park ◽

Sung Phil Chung ◽

Hye Sun Lee ◽

Soyoung Jeon ◽

...

Keyword(s):

Emergency Department ◽

Septic Shock ◽

Hospital Admission ◽

Compliance Rate ◽

Time Of Arrival ◽

Emergency Department Admission ◽

Bundle Compliance ◽

Using Data ◽

Sepsis Bundle ◽

Implementation Factors

Abstract Background: Nighttime hospital admission is often associated with increased mortality risk in various diseases. Following sepsis campaign implementation, this study investigated compliance rates with the Surviving Sepsis Campaign 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality. Methods: We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the complete 3-hour treatment bundle according to the time of arrival in the ED. Mediation analysis was conducted to evaluate the proportion of the total effect that could be explained by hospital admission times.Results: A total of 2,247 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance for the administration of antibiotics within 3-h (adjusted odds ratio (AOR), 1.276; 95% confidence interval (95% CI), 1.050–1.550, p=0.014), vasopressor within 3-h (AOR, 1.235; 95% CI, 1.009–1.512; P=0.031) and for the administration of the complete 3-h bundle (AOR, 1.231; 95% CI, 1.004–1.501; P=0.046), likely as a result of the increased volume of patients admitted during daytime hours. Consequently, daytime hospital admission adversely affected in-hospital and 28-day mortality rates, mediated by decreased compliance with the complete 3-h bundle. Conclusions: Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Despite sepsis campaign implementation, factors that decrease bundle compliance should be reconsidered in patients with septic shock.

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