Introduction
Sepsis is a life-threatening condition that occurs when the body’s immune system responds to an infection excessively, causing inflammation and damage to vital organs. Thus, the choice of treatment methods for patients with suspected sepsis may be important for their continued recovery. Sepsis is a medical emergency that affects 1.7 million people each year, with the majority of people presenting to the emergency department (Abutheraa et al., 2020).
If not recognized and treated quickly, sepsis can turn into severe sepsis, septic shock, and even death. Sepsis accounts for one-third of deaths of patients who are admitted to the hospital by way of the emergency department (Abutheraa et al., 2020). Recognizing signs and symptoms of a patient who presents to the emergency department with sepsis and then providing care using the sepsis bundle compared to conventional emergency room care can lead to better patient outcomes and reduce mortality.
Emergency room care for a septic patient becomes crucial, and the sepsis bundle is the first line of defense against mortality. In the emergency department, if sepsis is not detected and treated on time, poor patient outcomes and mortality can become inevitable. The purpose of the study was to assess whether sepsis treatments influence short-term death outcomes compared to conventional care. In addition, the PICOT question is whether bundled sepsis therapy in patients with suspected sepsis in the emergency department, compared with conventional therapy, affects the rate of short-term mortality during the emergency department visit.
Background of Studies
A study conducted by Peng et al. (2022) compared the efficacy and safety of an antimicrobial stepped treatment strategy with the usual antimicrobial approach in the diagnosis and treatment of individuals with sepsis. The problem addressed in this study is the high rate of antimicrobial resistance and the need for effective antimicrobial therapy in the treatment of sepsis. The value of this study lies in its provision of insight into the most effective and safe treatment options for patients with sepsis, which can inform nursing practice and enhance patient outcomes.
The purpose of this research was to evaluate the clinical outcomes of antimicrobial step-down therapy compared to conventional antimicrobial therapy in patients with sepsis. The objective was to determine whether antimicrobial step-down therapy was associated with better outcomes, including a lower incidence of adverse events, lower mortality rates, and shorter hospital stays (Peng et al., 2022). The question addressed was: “Does antimicrobial step-down therapy result in better clinical outcomes for patients with sepsis compared to conventional antimicrobial therapy?”
The research conducted by Rhee et al. (2021) aimed to determine the association between the implementation of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) performance measure and outcomes in patients with suspected sepsis in US hospitals. The problem addressed in this research is the high mortality rate and morbidity associated with sepsis, which is a leading cause of death in critically ill patients.
This provides an insight into the effectiveness of the SEP-1, which is designed to enhance the early identification and treatment of sepsis in hospitalized patients. This study aimed to evaluate the impact of the SEP-1 score on clinical results in patients with potentially diagnosed sepsis (Rhee et al., 2021). The objective was to determine “whether implementing the SEP-1 performance measure is associated with improved outcomes in patients with suspected sepsis.”
Abutheraa et al. (2020) examine the Sepsis Six Care Bundle (SSCB), introduced in 2014 to enhance the care of patients presenting to the hospital with signs and symptoms of sepsis. The article aims to identify a set of evidence-based interventions that can improve patient outcomes and enhance SSCB. In addition, the article by Abutheraa et al. (2020) is important for nursing, as nurses play a crucial role in identifying and treating sepsis in maternity wards. Accordingly, understanding the barriers to SSCB implementation can help improve patient care.
Therefore, the author’s purpose is to identify the obstacles to implementing the Sepsis Six Care Bundle. Furthermore, their objective is to evaluate possible ways to remove the obstacles. Accordingly, the research questions are: “What are the barriers to the implementation of the Sepsis Six Care Bundle in maternity hospitals? How do these barriers affect the care of patients with sepsis in maternity hospitals? What strategies can be implemented to overcome these barriers?”
The article by LeBlanc et al. (2022) discusses the problem of sepsis as a leading cause of death in hospitalized patients. Meanwhile, the article is important for nursing since the continuous improvement of nurses’ knowledge can reduce mortality from sepsis. Additionally, the article published by LeBlanc et al. (2022) aims to evaluate the effectiveness of an educational intervention in managing patients with sepsis. The objective is to assess nurses’ baseline knowledge of sepsis management and compare their knowledge after the training. The research questions are: “What is the basic understanding of nurses about sepsis management, and does the educational intervention improve their learning?”
The articles by Peng et al. (2022) and Rhee et al. (2021) offer valuable insights into the use of sepsis bundles in managing sepsis, a leading cause of mortality and morbidity in critically ill patients. Research performed by Peng et al. (2022) evaluated the performance and safety of antimicrobial stepped care in combination with regular antimicrobial care for the management of septic individuals. A study conducted by Rhee et al. (2021) evaluated the impact of SEP-1 on clinical outcomes in individuals with presumptive sepsis.
To answer the question of whether sepsis bundle care affects short-term mortality rates during an emergency department visit, studies by Peng et al. (2022) and Rhee et al. (2021) can provide insight into the effectiveness of sepsis bundles in improving patient outcomes. The articles confirm the nursing practice problem and demonstrate that doctors do not follow the most effective treatment; however, the PICOT question specifically considers the emergency department.
Instead, the articles by Peng et al. (2022) and Rhee et al. (2021) examine therapy in the intensive care unit or hospitals in general. However, both articles allow for comparing mortality in the short term during the two treatment outcomes, similar to the PICOT question.
Moreover, the articles by Abutheraa et al. (2020) and LeBlanc et al. (2022) confirm the issue in nursing practice and demonstrate that new methods of sepsis treatment are necessary. In addition, the articles can be used to answer the PICOT question because they highlight the challenges in implementing sepsis treatment that contribute to patient mortality. However, the interventions and patient groups in the articles and in the PICOT question are different.
The reviewed literature features interventions targeting staff training. However, the setting and participants differ from those in the intended PICOT question. In Abutheraa et al. (2020), the intervention group consisted of maternity ward nurses and midwives who were trained on the Sepsis Six Care Bundle, whereas the comparison group received no training. Similarly, LeBlanc et al. (2022) trained an intervention group of nurses to enhance their general knowledge of sepsis care, comparing them with an untrained control group. Crucially, the PICOT question specifically concerns patients with suspected sepsis in the emergency department, a setting not addressed by either study.
Method of Studies
Research conducted by Peng et al. (2022) used a randomized controlled trial (RCT) design to compare the efficacy and safety of antimicrobial step-down therapy with conventional antimicrobial therapy in the treatment of patients with sepsis. One benefit of the RCT design is that it allows for the random assignment of participants to treatment groups, which helps to minimize bias and ensure that the groups are comparable at baseline. This enhances the internal validity of the study. Additionally, one limitation of the RCT design is that it may not be generalizable to all populations, as the study population may not be representative of the broader patient population with sepsis. This may limit the external validity of the research.
Rhee et al. (2021) used a retrospective cohort design to evaluate the impact of the SEP-1 performance measure on clinical outcomes in patients with suspected sepsis in American hospitals. One benefit of the retrospective cohort design is that it enables the evaluation of large datasets, which can provide greater statistical power and facilitate the detection of smaller effects. This enhances the external validity of the study. However, the limitation of the retrospective cohort design is that it may be subject to bias and confounding, as the study relies on existing data and may not control for all potential confounding variables. This may limit the internal validity of the study.
LeBlanc et al. (2022) conducted a focus group-style interview with 28 registered nurses (RNs). The study methodology employed in the article is a quasi-experimental post-test design. An email was sent to all nurses working in acute care units (ICU, ER, and medical-surgical units) requesting an interview for a study. All of the RNs were licensed for at least six months and are equipped with a “Rapid ID for SIRS/Sepsis” card, which is displayed behind their badges.
Each interview lasted between 44 and 52 minutes (LeBlanc et al., 2022). The RNs in this study have experience with caring for septic patients. One benefit of this study is that the nurses have experience and knowledge with sepsis and have seen how rapidly a patient’s health can deteriorate. The card held behind their badges provides a quick reference for implementing care. A disadvantage of this study is that the Electronic Health Record (EHR) lacks narrators to alert healthcare providers to the specifics of the sepsis bundle that can save a life.
Abutheraa et al. (2020) conducted a study using grounded theory and performed interviews with 13 midwives in a Scottish health region. The interviews were conducted within specific hours due to the availability of only one researcher and the midwives, and each interview lasted approximately 33 minutes. The midwives had about 15 years of experience.
The researcher visited each maternity ward to recruit volunteer participants for the study over six weeks (Abutheraa et al., 2020). A disadvantage of this study was that the interviews were conducted face-to-face, which may have caused some inhibitions for the nurses to be forthright with their answers. A benefit of this study is that all acute care departments were visited to gather information. This will enable the researcher to determine if the different departments have been provided with the same information regarding sepsis bundles.
Overall, Peng et al. (2022) and Rhee et al. (2021) provide valuable insights into the use of sepsis bundles in sepsis management. However, their methods and the types of questions they address differ. The RCT design used in the Peng et al. (2022) study is appropriate for evaluating the efficacy and safety of specific treatments.
In contrast, the retrospective cohort design used in the Rhee et al. (2021) study is better adapted to assess the impact of broader interventions on clinical outcomes in large populations. Additionally, Abutheraa et al. (2020) conducted interviews with nurses to gather information about the existing gaps in sepsis treatment. In addition, LeBlanc et al. (2022) examined data obtained from interviews with nurses about their experience and education, which they use when working with patients.
Results of Studies
The study by Peng et al. (2022) found that both treatment strategies had similar efficacy in terms of clinical cure rates, mortality rates, and hospital length of stay. However, patients in the antimicrobial step-down therapy group had a lower incidence of adverse events, suggesting that this treatment strategy may be safer and better tolerated by patients. The authors provide evidence that patients who received antimicrobial stepped treatment had lower rates of WBC count and CRP (Peng et al., 2022). The study suggests that antimicrobial step-down therapy may be a viable alternative to conventional antimicrobial therapy for treating sepsis.
Research by Rhee et al. (2021) indicates that implementing the SEP-1 was associated with improved patient outcomes in the cases of suspected sepsis in US hospitals. The study showed that hospitals implementing it had lower mortality rates, shorter hospital stays, and lower care costs compared to hospitals that had not implemented the performance measure. The authors found that mortality before discharge from hospice care decreased from 14.0% in the period before SEP-1 to 13.2% (Rhee et al., 2021). The analysis suggests that enforcing it may enhance the quality of care and outcomes for patients with sepsis in hospital settings.
LeBlanc et al. (2022) found “themes” across all of the nurses interviewed. The themes were: knowledge deficit, feeling uncertain and overwhelmed, lack of resources, being in the dark, and a lack of partnership/respect. The nurses were unable to explain what they were supposed to be looking for when caring for a patient with an illness (LeBlanc et al., 2022). Subtle changes in a patient’s assessment can show signs of deterioration. Most of the nurses interviewed lacked an understanding of the sepsis bundle and its components.
Abutheraa et al. (2020) found “themes” from the data collected during the interviews. These topics covered complications in identifying sepsis, the relevance of the SSCB in the maternity hospital setting as part of the background phase, and the absence of sufficient staff education and awareness. Diagnosis of sepsis using the SIRS score resulted in patients being treated with unnecessary administration of antibiotics. SSCB was either not completed on all patients or the implementation of SSCB was confusing to the midwives (Abutheraa et al., 2020).
Sepsis bundle use education was completed, and the midwives understood the bundle; however, the SSCB remained complicated. The study by Rhee et al. (2021) emphasizes the importance of early recognition and management of sepsis, highlighting the critical role nurses can play in identifying and treating patients with sepsis in emergency departments and other hospital settings.
The implementation of the SEP-1 performance measure may also necessitate adjustments in nursing practice, including the adoption of standardized protocols and guidelines for sepsis management. The implications of Abutheraa et al. (2020) and LeBlanc et al. (2022) refer to education deficits and concerns regarding early diagnosis. Correct initial assessment by nurses and understanding of sepsis can be the determining factor in calling a sepsis alert and using the sepsis bundle. Abutheraa et al. (2020) and LeBlanc et al. (2022) found a lack of education and knowledge regarding diagnosis, and that the administration of the sepsis bundle protocol requires review by staff.
Ethical Considerations
One of the key ethical considerations in research is the protection of human subjects. Researchers have an ethical responsibility to ensure that the rights and welfare of study participants are protected, and that they are not subjected to any harm or undue risk (Fleming & Zegwaard, 2018). In all studies, the researchers obtained informed consent from all study participants or their legal representatives. They ensured that the study was conducted in compliance with all relevant ethical guidelines and regulations. Another important ethical consideration in research is the need for confidentiality and privacy (Ferguson et al., 2019).
Peng et al. (2022) and Rhee et al. (2021) obtained approval from institutional review boards to conduct the research. Additionally, Abutheraa et al. (2020) and LeBlanc et al. (2022) did not provide evidence of confidentiality. One of the studies used focus groups to gather data. The other researcher may have been more confidential, but did not inform the reader of the confidentiality (LeBlanc et al., 2022).
Outcomes Comparison
It is crucial to note that the expected outcome of the PICOT question is to establish effective methods for managing patients with suspected sepsis in the emergency department. Accordingly, the findings of the four articles provide comprehensive methods and practices that can be implemented to enhance the patient experience. These practices include increased nurse education, reduced barriers to implementation of the Sepsis Six Care Bundle, and evidence of the use of sepsis bundle care. Therefore, once introduced into practice, the main objective of the PICOT question can be achieved, which is to reduce mortality in the emergency department.
Evidence-Based Practice Change
The main connection between all the articles, the PICOT issue, and the problems faced by nurses in practice is the lack of identification of effective medicines and methods for treating sepsis. This is because this disease often leads to death in the short term after hospitalization. Studies have shown that continuous improvement in nursing education leads to better patient care (LeBlanc et al., 2022).
Additionally, Abutheraa et al. (2020) pointed out the need to introduce an SSCB program and the use of antibiotics. At the same time, Peng et al. (2022) and Rhee et al. (2021) report that the use of sepsis bundle care reduces the risk of mortality in patients. Accordingly, the findings of all articles should be applied to combat sepsis effectively.
Conclusion
To conclude, using a sepsis bundle care protocol, as opposed to conventional methods, has a positive influence on the health of patients with suspected sepsis. All available research indicates that implementing this protocol significantly improves short-term outcomes for pediatric patients, specifically by being associated with reduced mortality rates and shorter hospital stays, even across studies that used varied methodologies and patient groups.
The research has shown that education that includes understanding sepsis, the sepsis bundle, and training with implementation and assessments is needed. Enhanced nurse surveillance, achieved through increased attention to assessments and teamwork, is necessary to deliver high-quality care to patients with sepsis. Teamwork is the key to having positive patient outcomes. Sepsis continues to be a medical emergency; by improving the understanding and practice of health care professionals with sepsis through continued education, patients will continue to survive being diagnosed with sepsis.
References
Abutheraa, N., Mullen, A. B., Grant, J., & Akram, G. (2020). A qualitative study investigating the barriers to the implementation of the ‘sepsis six care bundle’in maternity wards. Healthcare, 8(4), 360- 374. Web.
Ferguson, A., Coates, D. E., Osborn, S., Blackmore, C. C., & Williams, B. (2019). Early nurse-directed sepsis care. AJN The American Journal of Nursing, 119(1), 52-58. Web.
Fleming, J., & Zegwaard, K. E. (2018). Methodologies, methods and ethical considerations for conducting research in work-integrated learning. International Journal of Work-Integrated Learning, 19(3), 205-213. Web.
LeBlanc, P., Kabbe, A. & Letvak, S. (2022). Nurses’ knowledge regarding nursing surveillance of the septic patient. Clinical Nurse Specialist, 36 (6), 309-316. Web.
Peng, Z., Niu, Z., Zhang, R., Pan, L., Feng, H., Zhou, Y., & Pei, H. (2022). Antimicrobial step-down Therapy versus conventional antimicrobial therapy in the treatment of patients with sepsis. Disease Markers, 3, 1-6. Web.
Rhee, C., Yu, T., Wang, R., Kadri, S. S., Fram, D., Chen, H. C., & Centers for Disease Control and Prevention Epicenters Program. (2021). Association between implementation of the severe sepsis and septic shock early management bundle performance measure and outcomes in patients with suspected sepsis in US hospitals. JAMA Network Open, 4(12), p. 1-10. Web.