According to the Centers for Disease Control and Prevention (CDC, 2018), more than 1.5 million people are diagnosed with sepsis each year in the United States and approximately 250,000 Americans die from sepsis each year. One of three patients who die in a hospital incur sepsis, and seven of 10 patients with sepsis have recently used health care services or have chronic diseases requiring frequent medical care (CDC, 2018). Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al., 2016). The signs and symptoms are nonspecific in the early stages of sepsis. This requires health care providers to think critically to rapidly identify a patient with suspected or documented infection (Karikari-Boateng, 2017). Though significant research and effort has been taken to treat sepsis, early identification remains difficult because its manifestations are ambiguous in nature (Goerlich et al., 2014).
Although the literature indicates that early identification of sepsis is essential for sepsis survival, it was not known whether structured education about sepsis would influence the time taken to identify sepsis among emergency department nurses in a 13-bed emergency department with 35,000 visits per year in an acute care hospital in central Phoenix. This emergency department already had nursing standing orders in place for sepsis identification and treatment. The purpose of this quantitative descriptive correlational project was to identify a relationship between structured education on sepsis and the time taken to identify possible sepsis and initiate standing orders by emergency department nurses at an acute care facility in central Phoenix.
The clinical question used to guide this quantitative project was: Did formal education provided to nurses on sepsis related organizational policies and sepsis screening tool, decrease the time taken to identify sepsis, when compared to no formal education provided to emergency department nurses in an acute care hospital over a period of 2 months? Even though the organization had a standing order set for nurses to initiate a sepsis bundle, compliance with this protocol was inconsistent. This project strived to increase compliance by providing structured education to emergency department nurses on signs of sepsis, available standing orders, and policy on sepsis.
The theory used to guide this project was the theory of planned behavior by Ajzen (1985): A person would expect to perform a behavior if they have the intention to try it and believe they can control the factors that affect their behavior. An emergency department nurse can be expected to follow sepsis protocol by increasing their control factors by improving their knowledge through education and demonstration of using appropriate order sets.
A literature review was done using CINAHL® and OVID® databases including the key words sepsis education, standing order, and emergency department nurse. Sepsis is considered a syndrome where infection triggers an abnormal response in the host (Cutting, 2017). A nurses' ability to quickly identify a patient at risk and bring it to the attention of providers is a clinical skill requiring continuous maintenance. Providing this education can be challenging due to time constraints and professional responsibilities (Cutting, 2017).
Early recognition of sepsis leads to timely initiation of treatment by following order sets and protocols (Walters, 2017). However, early indicators of sepsis could be overlooked and patients can deteriorate even when the vital signs are within normal limits (Vaughan & Parry, 2016). Although many tools for sepsis screening exist, many emergency departments focus on monitoring changes in vital signs to identify sepsis (Walters, 2017). Efficient and timely workflow in the emergency department includes sepsis screening, which is vital to survival (Walters, 2017). After identifying sepsis, it is vital to escalate to medical emergency team (Vaughan & Parry, 2016).
When considering sepsis, time is of the essence and every triage nurse needs to understand the nature of sepsis and take appropriate steps following a positive sepsis screen (Walters, 2017). Sepsis screening in triage can save many lives. Improving sepsis education and awareness is a best practice (Walters, 2017).
Standing orders in triage are orders derived from consensus and clinical practice guidelines for a particular patient condition that are implemented in the emergency department to improve efficiency (Hwang et al., 2016). Standing orders are initiated by nursing staff prior to physician evaluation to enhance diagnostic evaluation, accelerating medical decision making and improving emergency department throughput (Hwang et al., 2016). Standing orders facilitate early diagnostic workup and early patient access to care during their emergency department visit, which is particularly important in time-sensitive conditions such as sepsis (Hwang et al., 2016).
Using quantitative methodology, this project explored the differences between emergency department nurses who received education on the early identification and treatment of sepsis and using the sepsis order set and emergency department nurses who did not receive this education. These two groups were examined to determine whether any difference was observed in the amount of time taken to identify sepsis and initiate a sepsis order set in the emergency department. The time taken to identify sepsis was calculated by the minutes between the emergency department check-in time and the time a sepsis order was placed in electronic health record. A descriptive correlational design was used to determine and explore this relationship (Melnyk & Fineout-Overholt, 2010).
A pilot study with a convenient sample of readily available emergency department nurses who were willing to participate were included in the project (Polit & Beck, 2017). To assure participants of their privacy and to protect the rights of human participants, this project was submitted to the institutional review board of the organization and began only after receiving approval. During the educational session, employees were assured that no names of staff were revealed to supervisors regarding their performance.
The intervention in this project was providing 15 minutes of structured education to emergency department nurses on systemic inflammatory response syndrome criteria, sepsis, policies, standing orders on sepsis, and the sepsis screening tool. After the educational sessions, a publicly available sepsis screening tool from the Surviving Sepsis Campaign was given as a resource to emergency department nurses (Surviving Sepsis, n.d.). The first step in data collection was identifying patients who were diagnosed with sepsis through a chart review. A panel of patients diagnosed with sepsis or related diagnosis to include pneumonia, cellulitis, pyelonephritis, urinary tract infection, bacterial infection, and septic shock were abstracted using a data abstraction software. Next, raw data were collected for analysis. Patients' charts were reviewed manually by the principal investigator to collect raw data, including the time the patient checked into the emergency department and the time a sepsis order set was initiated. Figure 1 provides a visual representation of the time taken to identify sepsis. Patient information was deidentified by only obtaining serial number that corresponded to the patient in panel and the minutes between the patient check in and initiating standing order from chart review was collected. Data analysis then calculated the mean time to initiate sepsis standing order in emergency department on patients who are diagnosed with sepsis (Figure 1).
Time taken to identify sepsis. Note. ED = emergency department.
Using SPSS® software version 24, the preimplementation and postimplementation data were analyzed. An independent t test compared mean time to initiate a sepsis order set between the control group and the implementation group. Descriptive statistics were analyzed (Sylvia & Terhaar, 2014).
Twenty-two full-time emergency department nurses were working in the organization when the project was implemented. Eleven emergency department nurses attended the staff meeting and were included in the educational session. The 11 nurses who did not attend the educational session were categorized as the control group, and nurses who attended the educational session were in the implementation group.
The mean time to order a sepsis order set in the control group was 95 minutes, with a standard deviation of 146. The shortest time to order a sepsis order set in the control group was 4 minutes and the longest time was 817 minutes. The mean time to order a sepsis order set in the implementation group was 62 minutes, with a standard deviation of 60. The shortest time to order a sepsis order set in the implementation group was 4 minutes and the longest time was 207 minutes. The mean time to identify sepsis in the implementation group was decreased by 33 minutes. Table 1 provides the output from descriptives.
Figure 2 provides a visual representation of the mean time to order a sepsis order set in the control group and the implementation group.
Mean time to identify sepsis in control group and implementation group (y-axis = minutes).
A total of 122 charts were reviewed and 101 were included in data collection. Twenty-one charts were excluded because a sepsis order set was not initiated. An independent t test was used to compare mean time to initiate a sepsis order set between the control group and the intervention group. Descriptive statistics compared and analyzed the means between the groups. The p value was .018, indicating statistical significance (Sylvia & Terhaar, 2014). The mean time to identify sepsis was decreased by 33 minutes in the implementation group.
A limitation of this project was that data were collected for only 2 months in a single emergency department. The short intervention period and the project being done in a single emergency department provided a smaller sample size (Creswell & Creswell, 2018). Another limitation was that when using a sepsis screening protocol, nurses were responsible for deciding whether the patient had a possible infection. Nurses' recognition of infection symptoms is an area of opportunity for further research.
Recommendations for Future Projects
This project was implemented in a single emergency department, which resulted in a smaller sample size. It is recommended that future projects include multiple emergency departments for a diverse and larger sample. The duration of data collection was only 2 months. Time constraints in this project did not allow for a longer period of data collection, which is recommended. Although the sepsis screening tool was given as a resource to emergency department nurses, this project did not monitor how many emergency department nurses used the tool. Future projects could include tracking the use of a sepsis screening tool by emergency department nurses.
After receiving an educational intervention, the mean time to identify sepsis was decreased by 33 minutes. The results of this project are beneficial to nurse leaders because they demonstrate that sepsis education could potentially decrease the time to identify sepsis. It is recommended that nurse leaders provide initial and ongoing educational support to staff following standing orders and policies.
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| 95% CI, lower bound||43.7069|
| 95% CI, upper bound||80.6568|
| 5% trimmed mean||57.5909|
| Interquartile range||84.25|
| 95% CI, lower bound||50.4010|
| 95% CI, upper bound||139.5990|
| 5% trimmed mean||73.5253|
| Interquartile range||95.25|