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

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.

It Takes a Village - Atypical Presentation Warrants Teamwork for Sepsis Care

Sepsis is the body’s overwhelming response to infection that can lead to tissue damage, organ failure, and death. Sepsis, disproportionately, affects older adults due to an aging immune system and chronic illness. Older adults present atypically delaying diagnosis and intervention. This delay has been associated with increased morbidity and mortality. However, with early detection and rapid treatment there can be a reduction in poor outcomes. It is key, that clinicians practice collaboration and communication when diagnosing & treating patients that may have a different presentation. Early detection, monitoring, and intervention are crucial to survival of the older septic patient. The Continuous Monitoring Unit (CMU) consists of RNs, who monitor telemetry, video, and the Sepsis BPA/Checklist 24 hours/7 days a week. These nurses evaluate all active ED and acute care BPA data points. With their specific training, they dismiss the irrelevant and align the significant data while looking for possible notes of infection. They do not act upon the BPA unless the patient meets criteria. If there is confirmation of the BPA, the nurse collaborates with the primary provider to initiate recommended sepsis care. Since the beginning of August 2021, the CMU RN is utilizing the Sepsis Checklist, a customized tool built into the EMR that allows the CMU nurse to monitor the key elements of the Sepsis Bundle and intervene concurrently to complete the CMS SEP1 recommendations. Recommendations are based on the Surviving Sepsis Campaign.

Predictor of Early Administration of Antibiotics and a Volume Resuscitation for Young Infants with Septic Shock

(1) Background: It is critical to administer antibiotics and fluid bolus within 1 h of recognizing sepsis in pediatric patients. This study aimed to identify the predictor of the successful completion of a 1-h sepsis bundle for infants with suspected sepsis. (2) Methods: This is an observational study using a prospective registry including febrile young infants (aged < 90 days) who visited a pediatric emergency department with a core body temperature of 38.0 °C or higher and 36.0 °C or lower. Univariate and logistic regression analyses were conducted to determine the predictor (s) of successful sepsis bundle completion. (3) Results: Of the 323 registered patients, 118 patients with suspected sepsis were analyzed, and 38 patients (32.2%) received a bundle-compliant treatment. Among potential variables, such as age, sex, and vital sign parameters, the logistic regression analysis showed that heart rate (odds ratio: OR 1.02; 95% confidence interval: 1.00–1.04) is a significant predictor of the completion of a 1-h sepsis bundle. (4) Conclusions: We found that tachycardia facilitated the sepsis recognition and promoted the successful completion of a 1-h sepsis bundle for young infants with suspected septic shock and a possible indicator for improving the quality of the team-based sepsis management.

Rapid Response System Improves Sepsis Bundle Compliances and Survival in Hospital Wards for 10 Years

Background: Hospitalized patients can develop septic shock at any time. Therefore, it is important to identify septic patients in hospital wards and rapidly perform the optimal treatment. Although the sepsis bundle has already been reported to improve survival rates, the controversy over evidence of the effect of in-hospital sepsis continues to exist. We aimed to estimate the outcomes and bundle compliance of patients with septic shock in hospital wards managed through the rapid response system (RRS). Methods: A retrospective cohort study of 976 patients with septic shock managed through the RRS at an academic, tertiary care hospital in Korea from 2008 to 2017. Results: Of the 976 enrolled patients, the compliance of each sepsis bundle was high (80.8–100.0%), but the overall success rate of the bundle was low (58.3%). The compliance rate for achieving the overall sepsis bundle increased from 26.5% to 70.0%, and the 28-day mortality continuously decreased from 50% to 32.1% over 10 years. We analyzed the two groups according to whether they completed the overall sepsis bundle or not. Of the 976 enrolled patients, 569 (58.3%) sepsis bundles were completed, whereas 407 (41.7%) were incomplete. The complete bundle group showed lower 28-day mortality than the incomplete bundle group (37.1% vs. 53.6%, p < 0.001). In the multivariate multiple logistic regression model, the 28-day mortality was significantly associated with the complete bundle (adjusted odds ratio (OR), 0.61; 95% confidence intervals (CI), 0.40–0.91; p = 0.017). The obtaining of blood cultures (adjusted OR, 0.45; 95% CI, 0.33–0.63; p < 0.001) and lactate re-measurement (adjusted OR, 0.69; 95% CI, 0.50–0.95; p = 0.024) in each component of the sepsis bundle were associated with the 28-day mortality. Conclusions: The rapid response system provides improving sepsis bundle compliances and survival in patients with septic shock in hospital wards.

Sepsis knowledge, skills and attitudes among ward-based nurses

Background: Nurses are in a prime position to identify sepsis early by screening patients for sepsis, a skill that should be embedded into their daily practice. However, compliance with the sepsis bundle remains low. Aims: To explore the effects of sepsis training on knowledge, skills and attitude among ward-based nurses. Methods: Registered nurses from 16 acute surgical and medical wards were invited to anonymously complete a questionnaire. Findings: Response rate was 39% (98/250). Nurses with sepsis training had better knowledge of the National Early Warning Score 2 for sepsis screening, and the systemic inflammatory response syndrome (SIRS) criteria, demonstrated a more positive attitude towards sepsis screening and management, were more confident in screening patients for sepsis and more likely to have screened a patient for sepsis. Conclusions: Sepsis training improves nurses' attitudes, knowledge and confidence with regards to sepsis screening and management, resulting in adherence to evidence-based care, and should become mandatory for all clinical staff.

Rapid Response System Improves Sepsis Bundle Compliances & Survival in Hospital Wards for 10 Years

Background Hospitalized patients can develop septic shock at any time. Therefore, it is important to identify septic patients in hospital wards and rapidly perform the optimal treatment. Although the sepsis bundle has already been reported to improve survival rates, the controversy over evidence of the effect of in-hospital sepsis continues to exist. We aimed to estimate the outcomes and bundle compliance of patients with septic shock in hospital wards managed through the rapid response system (RRS). Methods Retrospective cohort study of 976 patients with septic shock managed through the RRS at an academic, tertiary care hospital in South Korea from 2008 to 2017. Results Of the 976 enrolled patients, the compliance of each sepsis bundle was high (80.8–100.0%), but the overall success rate of the bundle was low (58.3%). The compliance rate for achieving the overall sepsis bundle increased from 26.5–70.0%, and the 28-day mortality continuously decreased from 50–32.1% over 10 years. We analyzed the two groups according to whether they completed the overall sepsis bundle or not. Of the 976 enrolled patients, 569 (58.3%) sepsis bundles were completed, whereas 407 (41.7%) were incomplete. The complete bundle group showed lower 28-day mortality than the incomplete bundle group (37.1% vs. 53.6%, p < 0.001). In the multivariate multiple logistic regression model, the 28-day mortality was significantly associated with the complete bundle (adjusted odds ratio (OR), 0.58; 95% confidence intervals (CI), 0.39–0.87; p = 0.008). Obtention of blood cultures (adjusted OR, 0.45; 95% CI, 0.33–0.63; p < 0.001) and lactate remeasurement (adjusted OR, 0.69; 95% CI, 0.50–0.95; p = 0.024) in each component of the sepsis bundle were associated with the 28-day mortality. Conclusions The rapid response system provides improving sepsis bundle compliances and survival in patients with septic shock in hospital wards.