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

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

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

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

Objectives: To investigate the association between the timing and adequacy of antibiotics administered to patients presenting with culturepositive sepsis and septic shock to the ED and in-hospital mortality and/or intensive care unit (ICU) admission. Methods: Multicentre retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia between January 2017 and November 2019. Encounters for patients aged ≥16 years meeting specified criteria for sepsis or septic shock with antibiotic administration within the first 6 h of presentation were included. Results: Of 7611 encounters included in the study, 2328 (31%) were culture positive, and 2228 (29%) met the criteria for septic shock. In culturepositive sepsis encounters, partial or inadequate antibiotic coverage was associated with higher risk of death or ICU admission (adjusted odds ratio [AOR] 1.50, 95% confidence interval [CI] 1.04–2.06 and 1.95, 95% CI 1.28–2.99, respectively). This effect was not significant in septic shock encounters (AOR 1.10, 95% CI 0.64– 1.88) with partial coverage and (AOR 1.63, 95% CI 0.81–3.3) inadequate coverage. Time to antibiotics was not significantly associated with the risk of mortality/ICU admission. This inference remained the same when analysis was restricted to cases with adequate antibiotic coverage. Conclusions: In a large multicentre sample of patients with culture-positive sepsis, inadequacy of antibiotics was associated with higher risk of inhospital mortality or ICU admission

Association between intravenous fluid resuscitation and outcome among patients with suspected infection and sepsis : a retrospective cohort study

Objective: To investigate the association between timing and volume of intravenous fluids administered to ED patients with suspected infection and all-cause in-hospital mortality. Methods: Retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia, between October 2018 and May2019. Patients over 16 years of age with suspected infection who received intravenous fluids within 24 h of presentation were included. Results: During the study period,7533 patients with suspected infection received intravenous fluids. Of these, 1996 (26.5%) and 231 (3.1%) had suspected sepsis and septic shock, respectively. Each 1000 mL increase in intravenous fluids administered was associated with a reduction in risk of in-hospital mortality (adjusted odds ratio [AOR] 0.87, 95%confidence interval [CI] 0.76–0.99). This association was stronger in patients with septic shock (AOR 0.66, 95% CI 0.49–0.89), and those admitted to intensive care unit (ICU) (AOR 0.74, 95% CI0.56–0.96). Patients with suspected sepsis and septic shock who received a total volume of >3600 mL had lower in-hospital mortality (AOR 0.44, 95%CI 0.22–0.91; AOR 0.16, 95% CI0.05–0.57) compared to those administered <3600 mL within the first 24 h of presenting to the ED. There was no association between the time of initiation of fluids and in-hospital mortality among survivors and non-survivors (2.3vs2.5 h,P=0.50)