Emergency nurses’ experiences of the implementation of early goal-directed fluid resuscitation therapy in the management of sepsis

Background: Severe sepsis is a life-threatening condition caused by the body’s overwhelming immune response to an infection. It can lead to organ failure and death if immediate treatment, such as intravenous (IV) fluids and antibiotics, are not commenced within the first hour. While a large number of studies have analysed the administration of first-dose antibiotics, the time-critical initiation of IV fluids has not always been given its deserved priority. To date, studies have not explored factors that inhibit timely IV fluid administration and the experience of emergency nurses relating to initiating early goal-directed fluid resuscitation (EGDFR). Purpose: To explore the experiences of emergency nurses related to initiating EGDFR in the care of patients with sepsis Methods: A qualitative exploratory approach, encompassing face-to-face semi-structured interviews, was used for data collection. Ten registered nurses were interviewed, who were currently practicing in emergency settings across New South Wales (NSW). Braun and Clarke’s (2006) thematic analysis framework guided the data analysis. Findings: Three themes and associated subthemes were identified. The three themes are (i) Nurses’ perceptions and experiences regarding IV fluid administration in sepsis, (ii) Challenges related to initiating IV fluid, and (iii) Strategies to improve compliance with EGDFR. Participants described various factors they found that inhibited timely initiation of IV fluids, including busyness of the department, delayed diagnosis of sepsis, complex patient presentations and limited scope of nurses’ practice to initiate IV fluids. Conclusion: It is anticipated that the outcomes of this research will provide an impetus for re-evaluating current protocol guidelines to provide a positive impact on the scope of emergency nurse practice for initiating EGDFR

Early fluid bolus in adults with sepsis in the emergency department : a systematic review, meta-analysis and narrative synthesis

Background: Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood. Methods: We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors. Results: We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)]. Conclusion: Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects

Identifying factors associated with intravenous fluid administration in patients with sepsis presenting to the emergency department : a retrospective cohort study

Background: Appropriate and timely administration of intravenous fluids to patients with sepsis-induced hypotension is one of the mainstays of sepsis management in the emergency department (ED), however, fluid resuscitation remains an ongoing challenge in ED. Our study has been undertaken with two specific aims: firstly, for patients with sepsis, to identify factors associated with receiving intravenous fluids while in the ED; and, secondly to identify determinants associated with the actual time to fluid administration. Methods: We conducted a retrospective multicentre cohort study of adult ED presentations between October 2018 and May 2019 in four metropolitan hospitals in Western Sydney, Australia. Patients meeting pre-specified criteria for sepsis and septic shock and treated with antibiotics within the first 24 h of presentation were included. Multivariable models were used to identify factors associated with fluid administration in sepsis. Results: Four thousand one hundred forty-six patients met the inclusion criteria, among these 2,300 (55.5%) patients with sepsis received intravenous fluids in ED. The median time to fluid administration from the time of diagnosis of sepsis was 1.6 h (Interquartile Range (IQR) 0.5 to 3.8), and the median volume of fluids administered was 1,100 mL (IQR 750 to 2058). Factors associated with patients receiving fluids were younger age (Odds Ratio (OR) 1.05, 95% Confidence Interval (CI (1.03 to 1.07), p < 0.001); lower systolic blood pressure (OR 1.11, 95% CI (1.08 to 1.13), p < 0.001); presenting to smaller hospital (OR 1.48, 95% CI (1.25 to 1.75, p < 0.001) and a Clinical Rapid Response alert activated (OR 1.64, 95% CI (1.28 to 2.11), p < 0.001). Patients with Triage Category 1 received fluids 101.22 min earlier (95% CI (59.3 to131.2), p < 0.001) and those with Category 2 received fluids 43.58 min earlier (95% CI (9.6 to 63.1), p < 0.001) compared to patients with Triage Category 3-5. Other factors associated with receiving fluids earlier included septic shock (-49.37 min (95% CI (-86.4 to -12.4), p < 0.001)); each mmol/L increase in serum lactate levels (-9.0 min, 95% CI (-15.7 to -2.3), p < 0.001) and presenting to smaller hospitals (-74.61 min, 95% CI (-94.0 to -55.3), p < 0.001). Conclusions: Younger age, greater severity of sepsis, and presenting to a smaller hospital increased the probability of receiving fluids and receiving it earlier. Recognition of these factors may assist in effective implementation of sepsis management guidelines which should translate into better patient outcomes. Future studies are needed to identify other associated factors that we have not explored

Response to Re: Association between timing and adequacy of antibiotics and adverse outcomes in patients with sepsis and septic shock : a multicentre retrospective cohort study

We appreciate the opportunity to respond to the letter by Ito in reference to our original publication. Ito makes some valuable points regarding adjusting for severity of sepsis when assessing the timing of antibiotic administration. Our study analysis has already adjusted for sepsis severity, using modified sequential organ failure assessment (mSOFA) score, and explained in the Methods section. High SOFA scores were associated with worse patient outcome after adjusting for other relevant patient and clinical factors including timing and adequacy of antibiotics

Nursing adults in general medical or surgical contexts

This chapter will offer the reader an outline of the current medical and surgical setting in Australia, and a description of contemporary key practice challenges that medical and surgical nurses face. It will also offer a description of pathways to practice in medical and surgical nursing and an overview of future challenges to nursing and nurses who practice in this area

Facilitators and barriers of appropriate and timely initiation of intravenous fluids in patients with sepsis in emergency departments: a consensus development Delphi study

Background: Sepsis is a life-threatening medical emergency in which appropriate and timely administration of intravenous fluids to patients with features of hypotension is critical to prevent multi-organ failure and subsequent death. However, compliance with recommended fluid administration is reported to be poor. There is a lack of consensus among emergency clinicians on some of the determinant factors influencing fluid administration in sepsis. Thus, the aim of this study was to identify the level of consensus among key stakeholders in emergency departments regarding the facilitators, barriers, and strategies to improve fluid administration. Methods: The modified Delphi questionnaire with 23 statements exploring barriers, facilitators, and strategies to improve fluid administration was developed from the integration of findings from previous phases of the study involving emergency department clinicians. A two-round modified Delphi survey was conducted among key stakeholders with managerial, educational, supervision and leadership responsibilities using a “Reactive Delphi technique” from March 2023 to June 2023. The statements were rated for importance on a 9-point Likert scale. The RAND/UCLA Appropriateness Method (RAM) was used to identify the level of consensus (agreement/disagreement). Results: Of the 21 panellists who completed Round 1 survey, 18 (86%) also completed Round 2. The panellists rated 9 out of 10 (90%) barriers, 3 out of 4 (75%) facilitators and all 9 (100%) improvement strategies as important. Out of the total 23 statements, 18 (78%) had agreement among the panellists. Incomplete vital signs at triage (Median = 9, IQR 7.25 to 9.00) as a barrier, awareness of importance of fluid administration in sepsis (Median = 9, IQR 8.00 to 9.00) as facilitator and provision of nurse-initiated intravenous fluids (Median = 9, IQR 8.00 to 9.00) as an improvement strategy were the highest rated statements. Conclusion: This is the first Delphi study identifying consensus on facilitators, barriers, and strategies to specifically improve intravenous fluid administration in sepsis in Australia. We identified 18 consensus-based factors associated with appropriate and timely administration of intravenous fluids in sepsis. This study offers empirical evidence to support the implementation of the identified strategies to improve patient outcomes

Reading between the lines of an adult sepsis pathway : why and how nurses can initiate change

Nurses are acclaimed critical thinkers practising in numerous specialties such as emergency departments where patients regularly present with life threatening conditions requiring timely intervention by nurses. While many milestones have been achieved in the critical thinking journey of nurses, some low performance areas make us consider why and what barriers stop nurses from initiating treatment. A relevant example is the timely initiation of intravenous fluids (IVF) in patients with sepsis or severe infection. Studies show lack of adherence to early fluid resuscitation (Bentley et al. 2016; Leung et al. 2017). Severe sepsis can quickly progress to multi organ failure if adequate IVF are not commenced within the recommended timeframe of 30 minutes (Miller 2014). Despite compelling evidence of urgency, application of this recommendation seems lacking

Emergency nurses' experiences of the implementation of early goal directed fluid resuscitation therapy in the management of sepsis : a qualitative study

Background: Severe sepsis can lead to organ failure and death if immediate treatment, such as intravenous fluids and antibiotics, are not commenced within the first hour. Time - critical initiation of intravenous fluids which in other words is early goal directed fluid resuscitation has not always been given its clinical priority. This qualitative study aimed at exploring the experiences of emergency nurses initiating early goal directed fluid resuscitation in patients with sepsis. Methods: Using an exploratory approach, face - to - face semi - structured interviews were conducted with ten registered nurses working in emergency departments across New South Wales, Australia. Thematic analysis was used for data analysis. Findings: Participants described various factors that inhibited the timely initiation of early goal directed fluid resuscitation, some clinical practice challenges, and strategies to improve nursing practice. Most participants, particularly those practicing as Clinical Initiatives Nurses suggested the incorporation of nurse initiated early goal directed fluid resuscitation for patients with sepsis as part of their scope of practice. Conclusion: Our findings identified several barriers that inhibit effective nurse - initiated early goal directed fluid resuscitation. It is anticipated that these findings will provide validation for the re-evaluation of the existing protocols and practice guidelines to increase the scope of practice of emergency nurses initiating early goal directed fluid resuscitation

Advancing Care Equity and Sepsis Outcomes: ACESO study

Background: Sepsis is the dysfunctional inflammatory and immunological host response to infection and a major cause of avoidable hospital death in Australia.  Aims: The aim of the project is to analyse patient care and improve clinical pratice of patients presenting to Emergency departments (ED), at risk of developing sepsis using routinely collected data under the ACESO collaboration.Methods: Data was extracted from the Western Sydney Local Health District eMR. Multi-disciplinary teams processed and analysed the data to inform current practice, interventions, benchmark care and the development of new clinical decision support tools to provide feedback to the participating hospitals.  Results:  The study period, 1st of January 2017 till the 30th of November 2019, registered ~480k presentations (aged &gt; 16), originating at any ED within WSLHD.Only 3873 (0.8%) had an ED documented diagnosis of sepsis while 21 % (n = 102,663) were categorised as suspected infection and 6 % (n = 27,408) as suspected sepsis.  We aim to share the progress on the aims and the function of the collaboration. We have published on the impact that intravenous fluids have on the risk of in-hospital mortality. Uncovered bias in the provision of care in the elderly population (aged ≥ 65) with respect to a younger population (aged &lt; 65) and developed a sepsis screening algorithm for triage to promote timely interventions. Conclusions: Multiple teams working under a common collaboration have had a positive impact on generating insights associated with patient outcome and clinical practice using a single source of information

Facilitators and barriers of appropriate and timely initial fluid administration in sepsis : a qualitative study

Background: Sepsis is a medical emergency requiring prompt recognition, and early administration of intravenous fluids and antibiotics. While compliance with appropriate and timely administration of intravenous fluids has been found to be poor, the reasons are not well understood. Therefore, we have explored the experiences and perceptions of emergency nurses and medical officers from four hospitals to identify the associated facilitators and barriers. Methods: Qualitative design incorporating six focus group discussions and thematic analysis of data. A hybrid approach using both inductive and deductive reasoning was used. Findings: Four key themes were developed: 1. Overcrowding and understaffing threaten appropriate fluid management in sepsis; 2. Variations in clinical practice results in suboptimal fluid management; 3. Challenges with clinical recognition of sepsis impedes timely fluid administration; 4. Top-down approach is necessary to improve fluid management. Conclusion: Themes highlighted the specific challenges associated with fluid administration in sepsis in the emergency department setting providing potential strategies to be implemented to improve practice and ultimately patient outcomes