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

Understanding the ageing process : pharmacology and complementary therapies

Prescription and over-the-counter medications have an important and often essential role in the promotion of optimum health and the management of medical conditions in the general population. However, as we age, medication use increases. In fact, it has been reported that most older Australians use at least one medication on a daily basis, and many use multiple medications. It is well accepted that Australia has an aging population. On average, most Australians can expect to live to at least 75 years in relatively good health. The proportion of people over the age of 65, for example, in 2011 was 13.7 per cent (Australian Bureau of Statistics, 2011) and it is predicted that this figure will increase to 26 per cent by 2051 (Elliott, 2006). The Australian healthcare sector is mandated to plan for this increase and to meet the inherent challenges of caring for an ageing population

The effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery : a systematic review protocol

This systematic review aims to investigate the effects of nurse-led CR programs on the HRQoL of patients and hospital readmissions following coronary artery bypass graft surgery. The review will add to the evidence base for nurse-led CR programs using the JBI review methodology

Effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery : a systematic review

Review objective: The objective of this review was to investigate the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on patients’ health-related quality of life and hospital readmission. Introduction: Coronary heart disease is a major cause of death and disability worldwide, putting a great strain on healthcare resources. For the past two decades, population-wide primary prevention and individual healthcare approaches have resulted in a dramatic decline in overall cardiac mortality. Over the intervening years, surgical techniques in cardiology have also improved substantially. As a result, long-term outcomes in patients treated with coronary artery bypass graft surgery have established the treatment’s effectiveness and survival benefit. Furthermore, participating in cardiac rehabilitation following coronary artery bypass graft surgery has also demonstrated a significant decrease in all-cause cardiac mortality in these patients. Inclusion criteria: This review included studies with participants aged 18 years and over, post coronary artery bypass graft surgery that evaluated nurse-led cardiac rehabilitation (CR) programs compared with usual care or other forms of CR. The outcomes of interest were the health-related quality of life and hospital readmissions following coronary artery bypass graft surgery and measured using validated scales. Randomized controlled trials reported in English between 2000 to June 2017 were considered for inclusion. Methods: The search strategy aimed to find both published and unpublished studies using a three-step search strategy. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies including Dissertation Abstracts International, ProQuest Dissertations and Theses, Google Scholar, MedNar and ClinicalTrials.gov. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal tools from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Quantitative data was extracted from papers included in the review using the standardized data extraction tool from JBI-SUMARI. No meta-analysis was undertaken due to heterogeneity of the outcome measures. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis. Results: Three trials involving 329 patients were included in the final review. The trials that investigated the effect of home based cardiac rehabilitation programs compared to usual care at six weeks, three months and six months follow-up demonstrated no statistically significant difference in health-related quality of life at any of the follow-up periods. However, one study demonstrated significantly higher scores related to health-related quality of life among those who received nurse-led home based cardiac rehabilitation (154.93 ± 4.6) compared to those who received usual care (134.20 ± 8.2) at two months follow-up. No trials were identified that compared the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on readmissions to hospital. Conclusion: There is not enough evidence to support or discourage nurse-led cardiac rehabilitation programs on health-related quality of life in patients following coronary artery bypass graft surgery. However, the sparse data available suggests improvements in health-related quality of life at two months follow-up among those who received a nurse-led program. Further large-scale multicenter trials with standardized methodology are needed to determine the effect of nurse-led cardiac rehabilitation programs on health-related quality of life and rates of readmission to hospital following coronary artery bypass graft surgery

Maintaining clinical currency : a risk management strategy for undergraduate nursing students

Western Sydney University School of Nursing and Midwifery (SoNM) has developed a model of learning that has combined the use of blended learning, reflective practice and hi fidelity simulation to provide an innovative, unique and engaging experience for students that does not add additional time or costs to their course completion. MCC integrates digital technology with face-to-face clinical workshops and selfreflection which assures students are active participants in their learning, and promotes a positive student experience. The MCC model offers a dynamic and intensive learning experience for students integrating a range of activities and learning approaches to support different styles of student learning

An undergraduate nurse’s experience of patients with drug-seeking behaviours

There is a global rise in the misuse of both legal and illegal drugs that has been correlated with an increase in the number of Emergency Department (ED) presentations (Australian Institute of Health and Welfare, 2016). Of concern, are reports that over one-third of ED presentations in New South Wales, Australia are related to the misuse of drugs and alcohol requiring some form of nursing intervention (Butler et al. 2016). This subgroup of patients are difficult to manage due to the complexities of their needs and depend greatly on ED healthcare (Palepu et al. 2001; Tait et al. 2002; Krenske et al. 2004). During an ED placement as an undergraduate nursing student, I experienced frequent encounters with patients requesting pain relief. There were several occasions when the registered nurse (RN) dismissed the patient’s request for pain relief, justifying this with the rationale that the patient was drug-seeking and not in true pain. When trying to ascertain and learn how the RNs decision making had come to this conclusion, they struggled to provide rationale

Student perceptions, experiences and support within their current Bachelor of Nursing

Background: This study was developed to assist academics and curriculum designers to understand the perspectives and expectations of students when designing a program of study and inclusive of students as partners. The purpose of this qualitative study was to explore the perceptions and experiences of students enrolled in the Bachelor of Nursing (BN). Settings, participants, methods: The setting is a multi-campus university in Australia. Participants were currently enrolled and recruited from the Bachelor of Nursing, Bachelor of Nursing Advanced and Bachelor of Nursing Graduate Entry. Semi-structured focus group interviews and thematic analysis was used to collect and analyse the data. Results: Three major themes were identified from the focus group interviews: 1. Expectations; 2. Interesting and stimulating; and 3. Preparedness for study and clinical practice. Conclusion: Students held strong personal reasons for pursuing a nursing degree. The geographic location and international rankings were factors for choosing the university in this study. Student's perceptions and experiences of the curriculum and support identified that their BN program was interesting and adequately prepared them for clinical practice. Some areas for improvement were more detail during program orientation related to clinical practice requirements and more assistance with engaging with learning and teaching technologies

A review of inpatient ward location and the relationship to Medical Emergency Team calls

Objective: To identify the relationship between in-hospital location and patient outcomes as measured by Medical Emergency Team calls. Study design: A narrative systematic review of the literature. Data sources: A systematic search of the literature was conducted in October 2014 using the electronic databases: Embase, Cochrane, Medline, CINAHL, Science Direct and Google Scholar for the most recent literature from 1997 to 2014. Inclusion criteria: Non-randomised study designs such as case control or cohort studies were eligible. Articles were selected independently by two researchers using a predetermined selection criterion. Data synthesis: The screening process removed manuscripts that did not meet the inclusion criteria resulting in an empty review with one manuscript meeting most of the criteria for inclusion. The protocol was revised to a narrative synthesis including a broader scope of studies. The search strategy was expanded and modified to include manuscripts of any study design that comprise both inlier and outlier patients. Two manuscripts were selected for the narrative synthesis. Conclusion: Two recently published studies investigated the incidence of MET calls for outlier patients, and whilst MET calls were increased in outlier hospital patients, definitive conclusions associated with patient outcomes cannot be made at this time due to paucity of studies

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