The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: a prospective before-and-after intervention study

Background: In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce mortality from sepsis, was launched. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, effective implementation remains troublesome and no recommendations concerning the role of nurses are given.

Objectives: To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.

Design and setting: A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the Netherlands.

Participants: Adult patients (≥16 years old) visiting the ED because of a known or suspected infection to whom two or more of the extended systemic inflammatory response syndrome (SIRS) criteria apply.

Methods: We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis: measure serum lactate within 6h, obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine for urinalysis and culture, start antibiotics within 3h, and hospitalize or discharge the patient within 3h.

Results: A total of 825 patients were included in the study. Compliance with the complete bundle significantly improved from 3.5% at baseline to 12.4% after our entire implementation program was put in place. The completion of four of six individual elements improved significantly, namely: measure serum lactate (improved from 23% to 80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from 49% to 67%), and start antibiotics within 3h (from 38% to 56%). The mean number of performed bundle elements improved significantly from 3.0 elements at baseline to 4.2 elements after intervention [1.2; 95% confidence interval=0.9-1.5].

Conclusions: Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.