61 Utility of a Nurse-Initiated Screening Protocol in Triage on Early Identification and Treatment of Emergency Department Patients Diagnosed With Sepsis

Abstract

Sepsis carries a mortality burden of around 30% (Hayden et al 2015). Additionally, Rivers et al (2001), in a landmark trial, showed that early, goal-directed therapy significantly reduces morbidity and mortality in individuals with severe sepsis or septic shock compared to standard of care. Concurrently, CMS has also implemented a new sepsis measure which requires the completion of a 3-hour and 6-hour bundle for patients diagnosed with severe sepsis or septic shock. The goal of this study was to determine whether utilization of a nurse-initiated sepsis protocol would identify emergency department patients at risk of sepsis and improve compliance with the 3-hour sepsis bundle. A multidisciplinary team collaborated to create (a) an order set “bundle” to be initiated at triage for patients with suspected sepsis and (b) a screening protocol that emergency medicine nursing staff would utilize to identify patients as high-risk candidates for sepsis. Study objectives were to: (1) Determine sensitivity of the screening protocol in the identification of patients with sepsis in the emergency department; (2) Determine whether a nurse-initiated protocol would impact completion of the components of the 3-hour bundle both pre- and post-intervention. Prior to implementation of the screening and treatment protocols, 296 patient records identified as having been admitted from the emergency department with a diagnosis of sepsis within the prior 6 months were reviewed for completion of the 3-hour bundle components by two physicians. Following implementation of the protocol, all patients who were screened in the ED for sepsis or eventually diagnosed with sepsis were reviewed on a weekly basis by an emergency physician and nurse. Feedback was sent to all ED providers and nurses that were involved in each patient’s care. Data compared for the 296 patients pre-intervention and 91 patients post-intervention identified as having sepsis reveals the following: Percentage of 3-hour bundle completed: 13.9% pre-intervention vs 38.5% post-intervention Antibiotic administration within 3 hours: 44.9% pre-intervention vs 73.6% post-intervention At least 30 mL/kg fluids given in ED: 35.14% pre-intervention vs 53.9% post-intervention Lactate obtained within 3 hours of entry to ED: 49.7% vs 92.3% post intervention Blood cultures obtained in ED: 84.1% pre-intervention vs 85.7% post-intervention Overall sensitivity of the protocol in early identification of patients diagnosed with sepsis: 76.5% (95% CI: 65.8%-85.25%) Compliance with 3-hour bundle components in the ED has been 100% on cases selected for review by CMS. The reviewed data demonstrates an increased compliance with recommended sepsis screening and treatment with implementation of nurse-initiated sepsis screening and treatment protocol. Sensitivity continues to improve since implementation due to increasing adoption of the protocol. Overall fluid administration of 30mL/kg was only 53.9% as this study did not delineate whether patients diagnosed with sepsis were eventually diagnosed with severe sepsis/septic shock. It follows that the intervention also decreases overall morbidity and mortality of sepsis patients, although this has yet to be measured and indicates potential for future studies.