An interdisciplinary code sepsis team to improve sepsis bundle compliance in the emergency department

Purpose: Sepsis is one of the leading causes of mortality with over 700,000 hospitalizations and 200,000 deaths annually. Various tools exist to aid in the early identification and treatment of sepsis including electronic alert systems, standardized order sets, nurse-initiated protocols and specialty trained teams. Despite available guidelines, mortality rates for severe sepsis and septic shock are near 50%. Methods: The aims of this rapid cycle quality improvement project were 1) to develop and implement an interdisciplinary team to address early implementation of evidence-based sepsis bundles in the emergency department and 2) to compare sepsis bundle compliance three months pre-and three months’ post-intervention implementation. The population included all patients’ over 18 years of age presenting to the emergency department with clinical indications of sepsis, severe sepsis, or septic shock. Results: The pre-post intervention analysis shows an improvement in time to each bundle element except antibiotics. There was statistical significance in time to second lactate. Statistical significance was noted in the fluid resuscitation volume met (p=.000), initial lactate collected within 180 minutes (p=.001), and second lactate within 360 minutes (.000). Mortality rates in patients with sepsis on presentation showed a steady decline from 12.45% in the first month pre-intervention to 4.55% in the last month post intervention. Conclusion: Interdisciplinary teams can utilize existing knowledge, skills and tools to improve sepsis bundle compliance and mortality outcomes in sepsis patients presenting to the emergency department

Protocol Based Screening Tools to Identify Sepsis Patients Transported by Emergency Medical Services

Sepsis is a complicated disorder in which an infection has reached the bloodstream and caused a cascade of events that in time will lead to death. Interventions aimed at identifying sepsis early in its progression are imperative to stopping the process. The purpose of this study is to examine the current state of the literature regarding sepsis screening tools utilized by emergency medical services. A literature review exploring the various tools in place was conducted to see their value in predicting sepsis and secondary what the initiation of a sepsis alert has on the patients’ outcome. Results found included that sepsis screening tools when in place decrease time to identification, decrease time to antibiotics, increase amount of fluid administration, and overall reduce hospital stay and mortality rate. With these findings educational training for EMS providers and the introduction of generalized protocols are of the upmost importance. Further research is needed to be done to create a consistent tool to be used by all EMS agencies that has a validated predictive value of sepsis

Effect of a machine learning-based severe sepsis prediction algorithm on patient survival and hospital length of stay: a randomised clinical trial.

IntroductionSeveral methods have been developed to electronically monitor patients for severe sepsis, but few provide predictive capabilities to enable early intervention; furthermore, no severe sepsis prediction systems have been previously validated in a randomised study. We tested the use of a machine learning-based severe sepsis prediction system for reductions in average length of stay and in-hospital mortality rate.MethodsWe conducted a randomised controlled clinical trial at two medical-surgical intensive care units at the University of California, San Francisco Medical Center, evaluating the primary outcome of average length of stay, and secondary outcome of in-hospital mortality rate from December 2016 to February 2017. Adult patients (18+) admitted to participating units were eligible for this factorial, open-label study. Enrolled patients were assigned to a trial arm by a random allocation sequence. In the control group, only the current severe sepsis detector was used; in the experimental group, the machine learning algorithm (MLA) was also used. On receiving an alert, the care team evaluated the patient and initiated the severe sepsis bundle, if appropriate. Although participants were randomly assigned to a trial arm, group assignments were automatically revealed for any patients who received MLA alerts.ResultsOutcomes from 75 patients in the control and 67 patients in the experimental group were analysed. Average length of stay decreased from 13.0 days in the control to 10.3 days in the experimental group (p=0.042). In-hospital mortality decreased by 12.4 percentage points when using the MLA (p=0.018), a relative reduction of 58.0%. No adverse events were reported during this trial.ConclusionThe MLA was associated with improved patient outcomes. This is the first randomised controlled trial of a sepsis surveillance system to demonstrate statistically significant differences in length of stay and in-hospital mortality.Trial registrationNCT03015454

Sepsis Screening Tool Increased the Usage of Sepsis Order Set

Introduction: The sepsis screening tool was launched to improve the usage of the sepsis order set. Objectives: The purposes of this study were to determine whether the sepsis screening tool increased the usage of sepsis order set and whether the tool improved the primary outcomes. This study assessed the association between using sepsis order set and the compliance of the SEP-1 measure (represented by achieving total perfect care), and the primary outcomes. Furthermore, this study assessed association between the compliance with SEP-1 and the primary outcomes. The primary outcomes were a) time zero to antibiotics, b) inpatient length of stay, and c) survival at discharge. Material and Methods: Retrospective study collected data 6 months before and 6 months after the launch of sepsis screening tool at a tertiary academic hospital. A total of 632 patients were studied. The sepsis screening tool was incorporated at the nurse station at triage. The sepsis order set contained treatment guidelines based on the SEP-1 measure. Results: Our findings confirmed that the sepsis screening tool increased the usage of the order set, raised an awareness of the emergency department personnel and improved the adherence to the treatment guidelines by showing that the usage of sepsis order set significantly increased in the postintervention group (p = 0.001). However, we did not find the association between the sepsis screening tool and the primary outcomes or the total perfect care. The utilization of sepsis order set streamlined and standardized the sepsis management, shortened time to antibiotic by 54 minutes (p = 0.001) and reduced length of stay by 1.8 days (p = 0.002). However, there was no significant difference in survival between the group that used the order set and the group that did not use the order set. There was a significant association between sepsis order set use and total perfect care (p \u3c 0.001), which indicated that the order set use increased the compliance with SEP-1 measure. The group that achieved total perfect care significantly associated with all primary outcomes; 102.4 minutes shorter average time zero to antibiotic (p \u3c 0.001), 1.5 days shorter average length of stay (p = 0.004), and better survival at discharge (p \u3c 0.001, 95% CI 0.02 – 0.206, OR 0.064) than the group that did not achieve total perfect care. Conclusions: Our study confirmed that adherence to the standard treatment guidelines improved the treatment outcomes. The sepsis screening tool increased the use of the sepsis order set. When the order set was used, the compliance with the SEP-1 measure increased. The group that used sepsis order set had a significantly shorter length of stay and shorter time to antibiotic. The group that met SEP-1 measure compliance significantly received antibiotics earlier, shorter stay as an inpatient, and better survival. However, we need more studies to confirm the significant association between compliance of SEP-1 measure and the outcomes because this study did not adjust for clinical characteristics and severity of illness

Pediatric Sepsis-Development of a Clinical Pathway for the Pediatric Emergency Department

Globally, various researchers have suggested that sepsis is one of the most prominent causes of infant fatalities. Since 2004, countless guidelines have been developed to assist in the early identification and management of sepsis. The PICOT question that guided this project was: Does the implementation of a pediatric sepsis clinical pathway, compared with the standard protocol in emergency departments, decrease delays in treatment times of patients presenting with sepsis? Researchers have suggested that early recognition and interventions for septic patients can result in decreased mortality rates. A pediatric sepsis clinical pathway was implemented during this project. The pathway alerted staff members when a pediatric patient was experiencing sepsis-related symptoms. The pathway included various interventions (e.g., administration of intravenous fluids and antibiotics) and treatment goals (i.e., treatment within 60 minutes of arrival time) for clinical staff members to employ with potential septic patients. The implementation of this intervention resulted in earlier pediatric sepsis recognition and a decrease in delay in the treatment of sepsis symptoms. Implementing a protocol that is specific to pediatric patients presenting to the emergency department for sepsis can increase the recognition of sepsis symptoms and can also decrease treatment times. Implementing this protocol may also decrease patient length of stays and can possibly decrease the propensity of organ damage and other sepsis- related complications

Improved diagnosis and management of sepsis and bloodstream infection

Sepsis is a severe organ dysfunction triggered by infections, and a leading cause of hospitalization and death. Concurrent bloodstream infection (BSI) is common and around one third of sepsis patients have positive blood cultures. Prompt diagnosis and treatment is crucial, but there is a trade-off between the negative effects of over diagnosis and failure to recognize sepsis in time. The emerging crisis of antimicrobial resistance has made bacterial infections more difficult to treat, especially gram-negative pathogens such as Pseudomonas aeruginosa. The overall aim with this thesis was to improve diagnosis, assess the influence of time to antimicrobial treatment and explore prognostic bacterial virulence markers in sepsis and BSI. The papers are based on observational data from 7 cohorts of more than 100 000 hospital episodes. In addition, whole genome sequencing has been performed on approximately 800 invasive P. aeruginosa isolates collected from centers in Europe and Australia. Paper I showed that automated surveillance of sepsis incidence using the Sepsis-3 criteria is feasible in the non-ICU setting, with examples of how implementing this model generates continuous epidemiological data down to the ward level. This information can be used for directing resources and evaluating quality-of-care interventions. In Paper II, evidence is provided for using peripheral oxygen saturation (SpO2) to diagnose respiratory dysfunction in sepsis, proposing the novel thresholds 94% and 90% to get 1 and 2 SOFA points, respectively. This has important implications for improving sepsis diagnosis, especially when conventional arterial blood gas measurements are unavailable. Paper III verified that sepsis surveillance data can be utilized to develop machine learning screening tools to improve early identification of sepsis. A Bayesian network algorithm trained on routine electronic health record data predicted sepsis onset within 48 hours with better discrimination and earlier than conventional NEWS2 outside the ICU. The results suggested that screening may primarily be suited for the early admission period, which have broader implications also for other sepsis screening tools. Paper IV demonstrated that delays in antimicrobial treatment with in vitro pathogen coverage in BSI were associated with increased mortality after 12 hours from blood culture collection, but not at 1, 3, and 6 hours. This indicates a time window where clinicians should focus on the diagnostic workup, and proposes a target for rapid diagnostics of blood cultures. Finally, Paper V showed that the virulence genotype had some influence on mortality and septic shock in P. aeruginosa BSI, however, it was not a major prognostic determinant. Together these studies contribute to better understanding of the sepsis and BSI populations, and provide several suggestions to improve diagnosis and timing of treatment, with implications for clinical practice. Future works should focus on the implementation of sepsis surveillance, clinical trials of time to antimicrobial treatment and evaluating the prognostic importance of bacterial genotype data in larger populations from diverse infection sources and pathogens

Identification of sepsis in paediatric emergency departments: A scoping review

Aim: Sepsis is an acute illness associated with significant morbidity and mortality. Early detection and time‐sensitive management of sepsis has been shown to improve outcomes. We report the results of a scoping review to explore methods evaluated for the identification of sepsis in children presenting to emergency departments. Methods: A systematic literature search was carried out on two databases, Medline and Web of Science, to identify relevant studies published from 1990 to 2022. Data were extracted for age groups including study design, reference standard used for comparison, sepsis identification method evaluated and study quality. Results: A total of 89 studies were identified from the literature search. There was significant heterogeneity in the age groups including study design and reference standards used for evaluating the performance of the sepsis identification methods. There has been a substantial increase in the number of published studies in the last 2 years. Conclusion: Our scoping review identifies marked heterogeneity in approaches to identifying sepsis but demonstrates a recent focus of research on patient outcomes. Using appropriate core outcome sets, developing reference standards, monitoring sepsis prevalence via registries and continuously monitoring process measures will provide robust evidence to identify the best performing identification tools and the impact they have on patient‐orientated outcomes

Prehospital recognition of sepsis by ambulance clinicians (PRoSAiC)

Context: Prehospital recognition of adult patients with sepsis may inform scene management by ambulance clinicians, improve decisions concerning both appropriate hospital destination and urgency of transport, as well as facilitate early intervention before arriving at hospital. Objective: To develop a prehospital sepsis screening tool, derived from prehospital data, for use by ambulance clinicians. Design: The thesis comprises a systematic review of sepsis among adult patients in the prehospital environment, followed by the derivation and validation of a sepsis screening tool, utilising a retrospective data cohort comprising data from West Midlands Ambulance Service (WMAS) and the Emergency Department at University Hospital North Staffordshire (UHNS). This is followed by a comparison with alternate screening tools. Patients: Consecutive patients transported by WMAS (n=38483) to UHNS between 01 July 2013 and 30 June 2014. Records were linked using LinkPlus® software. Successful linkage was achieved in 33289 cases (86%). Eligible patients included adult, non-trauma, non-mental health, non-cardiac arrest cases. Of 33289 linked cases, 22945 cases were eligible. The eligible cases were randomly divided into derivation (n=16063, 70%) and validation (n=6882, 30%) cohorts. Outcome Measure: High risk of sepsis, as defined by the 2016 National Institute for Health and Care Excellence (NICE) Sepsis guideline (NG51). Results: High risk of sepsis was present in 3.7% of both derivation (n=593) and validation (n=254) cohorts. The Screening to Enhance PrehoSpital Identification of Sepsis (SEPSIS) tool is composed of the following variables: age, respiratory rate, peripheral oxygen saturations, heart rate, systolic blood pressure, temperature and level of consciousness (p<0.001 for all variables). Area under the receiver operating characteristic curve was 0.87 (95%CI 0.85-0.88) for the derivation cohort, and 0.86 (95%CI 0.84-0.88) for the validation cohort. Applying a cut-off of 3 or higher, sensitivity for the SEPSIS screening tool was 0.80 (95%CI 0.74-0.84), specificity was 0.78 (95%CI 0.77-0.79), positive predictive value was 0.12 (95%CI 0.10-0.14), negative predictive value was 0.99 (95%CI 0.99-0.99), positive likelihood ratio was 3.56 (95%CI 3.30-3.85), negative likelihood ratio was 0.26 (95%CI 0.21-0.34) and the diagnostic odds ratio was 13.5 (95%CI 9.9-18.4). Conclusion: The SEPSIS screening tool was significantly associated with high risk of sepsis status on arrival at the Emergency Department. It performs marginally better than both the UK Sepsis Trust “Red Flag” algorithm and National Early Warning Score (NEWS≥5) in an undifferentiated, adult, medical population. The SEPSIS screening tool requires external validation, in clinical practice by ambulance clinicians, in an independent population

Automated electronic medical record sepsis detection in the emergency department

Background. While often first treated in the emergency department (ED), identification of sepsis is difficult. Electronic medical record (EMR) clinical decision tools offer a novel strategy for identifying patients with sepsis. The objective of this study was to test the accuracy of an EMR-based, automated sepsis identification system.Methods. We tested an EMR-based sepsis identification tool at a major academic, urban ED with 64,000 annual visits. The EMR system collected vital sign and laboratory test information on all ED patients, triggering a “sepsis alert” for those with ≥2 SIRS (systemic inflammatory response syndrome) criteria (fever, tachycardia, tachypnea, leukocytosis) plus ≥1 major organ dysfunction (SBP ≤ 90 mm Hg, lactic acid ≥2.0 mg/dL). We confirmed the presence of sepsis through manual review of physician, nursing, and laboratory records. We also reviewed a random selection of ED cases that did not trigger a sepsis alert. We evaluated the diagnostic accuracy of the sepsis identification tool.Results. From January 1 through March 31, 2012, there were 795 automated sepsis alerts. We randomly selected 300 cases without a sepsis alert from the same period. The true prevalence of sepsis was 355/795 (44.7%) among alerts and 0/300 (0%) among non-alerts. The positive predictive value of the sepsis alert was 44.7% (95% CI [41.2–48.2%]). Pneumonia and respiratory infections (38%) and urinary tract infection (32.7%) were the most common infections among the 355 patients with true sepsis (true positives). Among false-positive sepsis alerts, the most common medical conditions were gastrointestinal (26.1%), traumatic (25.7%), and cardiovascular (20.0%) conditions. Rates of hospital admission were: true-positive sepsis alert 91.0%, false-positive alert 83.0%, no sepsis alert 5.7%.Conclusions. This ED EMR-based automated sepsis identification system was able to detect cases with sepsis. Automated EMR-based detection may provide a viable strategy for identifying sepsis in the ED

Early Recognition of Severe Sepsis

Early Recognition of Severe Sepsis Presentation: A Quality Improvement Project Abstract Sepsis is a medical emergency. If not treated immediately a patient may quickly progress to severe sepsis, septic shock and eventually death. The early recognition of severe sepsis presentation project is an evidence based project for the medical-surgical floor to decrease the amount of time from early signs of sepsis to treatment of sepsis. In October 2017, the average hospital compliance for the severe sepsis bundle for the fiscal year decreased from 80% down to 55%. Further review showed the decrease in compliance was from the medical-surgical floor nursing staff not notifying physicians when patients showed signs of sepsis. This microsystem needed to have changes developed and implemented to assist the staff with an improved way for recognition of the early signs of sepsis for patients on this unit. Interventions for nursing staff were needed to increase education through repetitive reminders. If the staff had additional sepsis information, with a focus on improving patient care, staff would be more engaged and willing to change current practices. An expectation is that the hospital will have bundle results consistently at a minimum of 80% every month. The conclusion is that by continuing to increase knowledge of sepsis to staff, they will contact the physician immediately when a patient begins showing signs and symptoms