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Impact of Sepsis protocol policy in early detection of sepsis patient and their treatment

Sepsis is one of the major reasons of increasing mortality rates in the hospitals globally. Statistics reveal that one death occurs every four seconds in the world due to sepsis (Wylie-Cheer & Goodson, 2016). One of the studies conducted between 2000 and 2012 reported that for a total of 101,064 diagnosis of sepsis was made over the year in Australia and New Zealand. Out of those, 24,255 died, which led to a mortality rate of 24% (Kaukonen, et al., 2014). Sepsis is a fatal illness which arises when the body's response to infection damages its own tissues and organs. It is recognized as a medical emergency worldwide (McPherson, et al., 2013). Annually, an estimated 18,000 people suffer from sepsis, out of those around 5000 of those die and 50% of the surviving people suffer from a disability or impaired functioning (The George Institute for Global Health and the Australian Sepsis Network, 2017). In spite of these, massive statistics, awareness regarding sepsis and the need for urgent intervention is lacking. The World Health Assembly at the WHO recognised sepsis as a global health priority in May 2017 by officially taking up a resolution to advance the prevention, detection and treatment of sepsis golabally. The resolution invites every member states of the United Nations to take certain measures to lower the load of sepsis, including executing national action plans, in partnership with professional and patient-advocacy units. 

In NSW, inefficiency of not being able to recognize and respond to sepsis has been registered often. Suitable recognition techniques and on-time treatment of patients with sepsis is a major issue in not only NSW hospitals but also in health care institutions across the globe. Delay in management of sepsis has been linked with increased mortality rates, substantial morbidity and augmented financial burden to the health care system (Burrell, et al., 2016). In 2009, the Clinical Focus Report on Recognition and Management of Sepsis identified certain inadequacies in several clinical settings in NSW health care settings (Clinical Excellence Commission Patient Safety Team, 2012). CEC Quality Systems Assessment also found the failure of timely recognition and suitable management.

NSW established a protocol for sepsis called “SEPSIS KILLS” which was executed as individual emergency divisions in 2011. Its purpose is to decrease the avoidable harm to people by improving detection and treatment of severe infection and sepsis in emergency divisions and inpatient wards within the NSW. The SEPSIS KILLS pathways endorse bundles of care, with their focus on early management.

Role of evidence-based practice in informing effective clinical decision making in Sepsis management

• Recognizing the risk factors, signs and symptoms of sepsis
• Resuscitating with rapid IV fluids and antibiotics administration within the first hour of diagnosis
• Referring to senior practitioners and expert teams, comprising of the retrieval as needed.

The SEPSIS KILLS protocol is a quality-upgrading plan that has been formed from universal evidence-based practice. It provides various advantages to NSW hospitals at clinical as well as system levels such as:

• Increased practitioners skills in sepsis detection and treatment
• More timely, regulated and efficient recognition and treatment of sepsis
• Decreased death, morbidity and bed-stays rates associated with sepsis
• Improved process and quality of care for patients with sepsis in NSW hospitals
• forsafer patient experience.

Evidence-based practice recommends the nurses a method to use critically appraised and empirically established evidence for providing quality service to a particular population. In this particular scenario, nurses involved in the management of sepsis can make use of the evidence to deliver best possible care to sepsis patients. It will assist them in overcoming the barriers of sepsis management such as limited knowledge, protocol unawareness, poor communication skills, etc. So, they will be able to take evidence-informed clinical decision. Evidence-based practice points a movement among nurses from a conventional focus on expert opinions to a focus on information obtained from research and studies and it has been reported several times that nursing practice which is based on evidence presents and improved care, as opposed to conventional methods (Majid, et al., 2011). Further, since nurses are more engaged in decision-making in sepsis management, it is essential that they make use of the best evidence to make efficient and reasonable decisions. Evidence-based practice can also help the nurses in acknowledging and understanding the condition of the sepsis patient. EBPcan assist in identifying the gaps in the knowledge about sepsis recognition and management and construct questions to bridge those gaps.

However, there are certain barriers to EBP for nursing practice, mainly lack of time due to heavy workload and inadequacy to understand statistical terms and jargons that are used in literature. The situation can be improved by an EBP orientation, time availability, and tutoring by nurses with EBP experience.

Development of a searchable clinical question using a recognized clinical question formula

PICO format has been used to develop a searchable clinical research question (Aslam & Emmanuel, 2010).

Population: Sepsis patients

Intervention: Sepsis protocol policy- “SEPSIS KILLS”

Control: Non-evidence based practice

Outcome- Early detection and management

Therefore, the research question is “Impact of Sepsis protocol policy in early detection of sepsis patient and their treatment”.

As a well-formed search strategy is the core of the research activity, an organized search strategy has been utilized for searching the literature to find answer to the research questions.

1. Early detection- On searching various databases, 381696 articles were found out with this keyword. 50359 met the inclusion criteria. Were found relevant to the research question.
2. Sepsis protocol policy – 54 articles were identified for this keyword. 12 of them met the inclusion criteria. Were found to be relevant to the study.
3. Sepsis kills- 112 articles were found for this key word. 16 of them met the inclusion criteria. Were found relevant to the study.
4. Sepsis patient and their treatment- 59082 articles were identified for this keyword. 5978 met the inclusion criteria. Were relevant to be included in the research.
5. Evidence based practice and sepsis- 998 articles were identified for this keyword. 97 of them met the inclusion criteria and were found relevant for the research inclusion.
6. Early detection of sepsis patient and their treatment- 4232 articles were found for this keyword on searching various databases. 580 of them met the inclusion criteria and were found relevant to be included in the research.

1. English language
2. Published within 5 years
3. Full-text available

1. Unsuitable target population
2. Irrelevant information
3. Outdated

Thorough the literature search, it was found that numerous evidence indicates that early detection and management of sepsis as per the evidence-based protocols can prevent advancement in patients, thereby improving health outcomes and avoiding associated costs. One of the study conducted in 2015, suggested that every sepsis management protocols comprise of the four fundamental components which are leadership, technology, evidence-based clinical guidelines, and workforce training and education to variable extent and in a range of constitutions (Jones, et al., 2015). Another study supported the finding by concluding that timely commencement of evidence-based protocols that are fluid resuscitation and antibiotic therapy, must improve outcomes for sepsis patients (Gauer, 2013). A study proved the use of a minimal diagnostic tool for sepsis used by the nurse as a way to effectively recognise sepsis early resulted in a more timely management in both medical and surgical patients. This was a pilot study which advocated the utilization of a screening tool as a decision support mechanism for early recognition of sepsis (Gyang, et al., 2015).

Development of a searchable clinical question using a recognized clinical question formula

A research which was conduct to execute SEPSIS KILLS protocol for early recognition and management of sepsis found that SEPSIS KILLS has enhanced the care process for patients with sepsis in NSW hospitals. The policy has emphasized attention on sepsis management in the wards. The study found antibiotic prescription as the major challenge. An evidence–practice disparity is acknowledged, and the antibiotic standard was created to encourage suitable antibiotic prescribing practices and best outcomes. Several components were included in the guideline such administration component to stop the misleading practices and avoid confusion (Burrell, et al., 2016). A cohort study found that early sepsis detection by ward nurses may have decreased advancement of the illness and increased survival for sepsis patients. Among the several reasons hypothesized for this effect, two of them were more rigorous protocols and better compliance with the sepsis bundles. Therefore, this study also confirms the positive impact of protocol in early detection of sepsis and its management (Torsvik, et al., 2016).

Further, a study mentioned goals of the sepsis bundles, out of which, the second goal to approach the sepsis diagnosis and management is to make sure more uniform and timely implementation of evidence-based practice. But a range of studies found out that that the application of sepsis bundles is quite low which confirms the challenge of shifting evidence to the clinical practice. Further, in the study it was mentioned that the total bundles adherence is nearly 5% (Miller, et al., 2013), the adherence with the 6-hour resuscitation bundles differs between from 0% (Castellanos-Ortega, et al., 2010) to 10% (Noritomi, et al., 2014) (Nguyen, et al., 2011) and the adherence to the 24-hour management sepsis bundles is nearly 15% (Levy, et al., 2010). The sepsi bundles assists in tracing the modifications in practice and stating how frequently the evidence-based practices are executed. Therefore, it was stated that both the policies and the performance upgrading pointers will progress as new evidence that enhances the understanding of how best to care for sepsis patients becomes available (Jozwiak, et al., 2016).

The inclusion of Evidence-based practice is essential in nursing practice to improve quality of care, patient safety and health outcomes.  Early diagnosis and effective treatment of sepsis is an important priority for policy. A consistent series of protocols for recognition and treatment of sepsis would be a considerable advancement in reducing the load of sepsis on public health. The SEPSIS KILLS program endorses early detection and treatment of sepsis during the first few hours within the NSW. Therefore, it can be concluded that implementation of evidence-based practice by using protocols such as SEPSIS KILLS can assist in early recognition of sepsis in patients which would eventually help in their suitable treatment. However, the barriers to implementation of EBP in nursing practice should be identified and efforts should be made to remove them.

Evidence of a systematic literature search strategy

References

Aslam, S. & Emmanuel, P., 2010. Formulating a researchable question: A critical step for facilitating good clinical research. Indian J Sex Transm Dis AIDS, 31(1), pp. 47-50.

Burrell, A. R. et al., 2016. SEPSIS KILLS: early intervention saves lives. MJA, 204(2).

Castellanos-Ortega, Suberviola & García-Astudillo, 2010. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study. Crit Care Med, Volume 38, pp. 1036-43.

Clinical Excellence Commission Patient Safety Team, 2012. Recognition and Management of Sepsis, s.l.: Clinical Excellence Commission.

Gauer, 2013. Early recognition and management of sepsis in adults: the first six hours. Am Fam Physician, 88(1), pp. 44-53.

Gyang, E., Shieh, L., Forsey, L. & Maggio, P., 2015. A Nurse-Driven Screening Tool for the Early Identification of Sepsis in an Intermediate Care Unit Setting. J Hosp Med, 10(2), pp. 97-103.

Jones, S. L., Ashton, C. M., Kiehne, L. & Gigliotti, E., 2015. Reductions in Sepsis Mortality and Costs After Design and Implementation of a Nurse-Based Early Recognition and Response Program. Jt Comm J Qual Patient Saf, 41(11), p. 483–491.

Jozwiak, M., Monnet, X. & Teboul, J.-L., 2016. Implementing sepsis bundles. Ann Transl Med, 4(17).

Kaukonen, Bailey & Suzuki, 2014. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012. JAMA, 311(13), p. 1308–1316.

Levy, Dellinger & Townsend, 2010. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med , Volume 36, pp. 222-31.

Majid, S., Foo, S., Luyt, B. & Zhang, X., 2011. Adopting evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers. J Med Libr Assoc, 99(3).

McPherson, Griffiths & Williams, 2013. Sepsis-associated mortality in England: an analysis of multiple cause of death data from 2001 to 2010. BMJ Open, 3(8).

Miller, Dong & Nelson, 2013. Multicenter implementation of a severe sepsis and septic shock treatment bundle. Am J Respir Crit Care Med, Volume 188, pp. 77-82.

Nguyen, Kuan & Batech, 2011. Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation. Crit Care, Volume 15.

Noritomi, Ranzani & Monteiro, 2014. Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med, Volume 40, pp. 182-91.

The George Institute for Global Health and the Australian Sepsis Network, 2017. Stopping Sepsis: A National Action Plan, s.l.: The George Institute for Global Health and the Australian Sepsis Network.

Torsvik, M. et al., 2016. Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival. Crit Care, 20(244).

Wylie-Cheer, B. & Goodson, H., 2016. Sepsis Care and Treatment in New Zealand and Australia. [Online]
Available at: https://www.jems.com/articles/print/volume-41/issue-9/special-focus-septic-alert/sepsis-care-and-treatment-in-new-zealand-and-australia.html
[Accessed 22 September 2018].