Quantitative and Qualitative Health Articles Review

Write a summary of each of the articles that you identified in Topic 2.
Address the following:
Write one research summary that uses a quantitative research design.
Write one research summary that uses a qualitative research design.
Each summary should be 250-500 words and should follow the template provided in "Summarize Research Articles."
Use APA Level Heading 2 to separate the distinct parts of the study.
These article summaries will form the basis of the Critique of Research Studies Parts 1-3 assignments in Topics 4, 6, and 8.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are not required to submit this assignment to Turnitin.
NUR 504 Summarize Research Articles
Directions: Use the templates below when summarizing your research articles. Include a cover page, and start a new page for each article summary. Use level 1 and 2 headings when composing the summaries to separate distinct parts.
Title of Quantitative Article
(Example of text: This article was authored by Watson and James and published in the Journal of Nursing Research in 2008. This article was selected as an example of a quasi-experimental design. The model summary selected for this paper is found in the textbook. This is a summary of a quasi-experimental study in which though there is a comparison group; subjects were not randomly assigned to groups. The research article being summarized also is an experiment that used a comparison group without randomization.)



Problem Statement



Statement of Purpose



Research Question(s)/Hypothesis



Study Methods



Key Findings



Citation







Title of Qualitative Article



(Example of text: Ramirez (2008) studied adolescent depression and the influence of significant adults on the course of the depression. The model summary utilized is found in the textbook. It was selected because it is an example of a grounded theory study as is the article selected.)



Problem Statement



Statement of Purpose



Research Question(s)



Method



Key Findings



Citation



Please use the two attached articles for the analysis, that is required for the assignment.



http://www(dot)medscape(dot)com/viewarticle/839734-

the article is titled: A Qualitative Investigation of Patients' and Caregivers' Experiences of Severe Sepsis



Qualitative article

..A Qualitative Investigation of Experiences of Severe Sepsis page 1.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 2.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 3.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 4.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 5.pdf





Quantitative article

file:///C:/Users/sherri/Downloads/1001391_The%20role%20of%20nurses%20in%20the%20recognition%20and%20treatment%20of%20patients%20with%20sepsis.pdf



..Quantitative study The role of nurses.pdf

the DOI: :10.1016/j.ijnurstu.2010.04.007



The role of nurses in the recognition and treatment of patients with sepsis

in the emergency department: A prospective before-and-after

intervention study

Mirjam Tromp a,b,

*, Marlies Hulscher c

, Chantal P. Bleeker-Rovers a,b

, Lilian Peters d

,

Danie¨lle T.N.A. van den Berg b

, George F. Borm e

, Bart-Jan Kullberg a,b

, Theo van Achterberg c

,

Peter Pickkers a,f

aNijmegen Institute for Infection, Inflammation, and Immunity (N4i), Radboud University Nijmegen Medical Centre, The Netherlands

bDept of Internal Medicine, Radboud University Nijmegen Medical Centre, The Netherlands

c Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, The Netherlands

d Emergency Dept, Radboud University Nijmegen Medical Centre, The Netherlands

eDept of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, The Netherlands

f

Dept of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, The Netherlands

International Journal of Nursing Studies 47 (2010) 1464–1473

ARTICLE INFO

Article history:

Received 4 September 2009

Received in revised form 16 March 2010

Accepted 24 April 2010

Keywords:

Care bundle

Emergency department

Nursing interventions

Protocol compliance

Quality of health care

Sepsis

ABSTRACT

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 6 h,

obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine

for urinalysis and culture, start antibiotics within 3 h, and hospitalize or discharge the

patient within 3 h.

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 3 h (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].

* Corresponding author at: Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Internal postal code 495, PO box 9101, 6500

HB Nijmegen, The Netherlands.


Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www(dot)elsevier(dot)com/ijns

0020-7489/$ – see front matter 2010 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ijnurstu.2010.04.007

What is already known about the topic?

Rapid diagnosis and management of sepsis are crucial for

successful treatment, but implementation of and compliance

to the Surviving Sepsis Campaign guidelines

remains troublesome.

Care bundles can be used for the implementation of

evidence-based practice.

No specific role for nurses is described in the Surviving

Sepsis Campaign guidelines.

What this paper adds

Using a nurse-driven, care bundle based, sepsis protocol

followed by training and performance feedback results in

improved early recognition and treatment of patients

with sepsis who present to the ED.

More attention should be given to the role of nurses in

quality improvement of sepsis care.

1. Introduction

Approximately 2% of all hospitalized patients are

diagnosed with severe sepsis or septic shock. Intensive

care and the long recovery period for patients with sepsis

come with considerable costs, and the mortality rate

remains high: 30–40% for patients with severe sepsis and

40–50% for those with septic shock (Angus et al., 2001;

Dellinger et al., 2008; Gao et al., 2005). Rapid diagnosis and

management of sepsis are crucial for successful treatment

(Dellinger et al., 2004); early goal-directed therapy and

antibiotic treatment within 3 h after admission have

proven their value (Levy et al., 2003; Rivers et al., 2005).

In 2004, the Surviving Sepsis Campaign (SSC) was

launched by the European Society of Intensive Care

Medicine, the International Sepsis Forum, and the Society

of Critical Care Medicine. The SSC is a global initiative to

create an international effort to improve the treatment of

sepsis and reduce sepsis mortality. The SSC provides

helpful tools and implementation techniques for improving

rapid diagnosis and management of sepsis and for

measuring and improving the quality of care for patients

with sepsis. The most important SSC recommendations are

summarized in ‘‘6-h’’ and ‘‘24-h’’ bundles, also referred to

as the resuscitation and management bundles (Dellinger

et al., 2008).

A bundle is a group of three to six care elements related

to a disease process. When executed together, the

performance of the care elements produce better outcomes

then when implemented individually. The individual

bundle elements are built on evidence-based practice

guidelines and provide healthcare workers with a practical

method for implementing evidence-based practice (Fulbrook

and Mooney, 2003; IHI, 2006a,b). According to the

IHI, the creator of the bundle, a bundle should be small and

straightforward. The impact of a bundle depends both on

the evidence that supports the recommended care process

and on the implementation and spread of its recommendations

(Marwick and Davey, 2009). Various care bundles

have been created, including the ventilator care bundle,

the central line bundle, and the sepsis bundle.

Although the SSC recommendations, described in the

sepsis bundle, focus on those patients with severe sepsis or

septic shock, all patients with sepsis need to be screened so

that we can recognize those most affected. Since most

patients with sepsis present themselves at the emergency

department (ED), this department is an important location

for early recognition and treatment of sepsis (Osborn et al.,

2005; Shapiro et al., 2006; Wang et al., 2007). However,

implementation of the SSC recommendations at the ED

appears to be difficult; the overall level of compliance to

the bundle and the compliance to the individual elements

remains low (Baldwin et al., 2008; De Miguel-Yanes et al.,

2006; Levy et al., 2010).

The literature provides a large number of different

strategies to implement innovations like the SSC recommendations,

e.g., educational meetings, reminders, and

audit and feedback. Many studies have assessed the

effectiveness of these strategies for improving patient

care and many reviews have summarized them; for

example the numerous reviews listed by the Cochrane

Effective Practice and Organisation of Care group (http://

www(dot)mrw(dot)interscience(dot)wiley(dot)com/cochrane/cochrane_clsysrev_crglist_fs.html).

In general, evidence shows that

none of these strategies is superior; most show mixed

results. Substantial evidence suggests that successful

implementation strategies should be based on obstacles

and facilitators to change (Bero et al., 1998; Grimshaw

et al., 2001; Grimshaw et al., 2004).

Various obstacles and facilitators may influence successful

implementation of the SSC recommendations.

Nurses are often the first to triage a patient, and they

have an important role in recognizing patients’ signs and

symptoms. Nevertheless, the role of nurses is not formalized

in guidelines and is not fully exploited at this time

(Funk et al., 2009; Kumar et al., 2006). In daily practice, a

multidisciplinary protocol for patients with sepsis proved

to facilitate the recognition and treatment of sepsis (Ferrer

et al., 2008; Jones et al., 2007; Nguyen et al., 2007a).

However, recognizing patients with sepsis can be difficult;

lack of detailed knowledge was shown to impair the

recognition (Carlbom and Rubenfeld, 2007; Robson et al.,

2007). For example, only about 20% of the nurses thought

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.

2010 Elsevier Ltd. All rights reserved.

M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1465

that a temperature less than 36 8C or a low white cell count

could be a sign of sepsis (Robson et al., 2007).

Using this information on obstacles and facilitators,

we developed an implementation program to implement

the SSC recommendations in our ED. As nurses are

important in the triage of patients presenting to the

ED, we specifically focused on nurses and their role

in the recognition and treatment of patients with sepsis.

To improve nurses’ ability to recognize sepsis and

SSC-recommended care, we introduced a care bundle

based sepsis protocol and trained ED nurses about the

signs and symptoms of sepsis. During the development

of the implementation program, it turned out that

insight into the performance of the sepsis bundle

and the individual elements by the ED nurses was

lacking. Therefore, feedback about their performance

was part of the implementation program. The aim of

the current study was to determine the effects of

our implementation program for following SSC-based

recommendations.

2. Method

We conducted a prospective before-and-after intervention

study in which we carried out two consecutive

interventions: the use of a newly developed, nurse-driven,

care bundle based, sepsis protocol (intervention 1) and

training about sepsis that included feedback about

performance before and after the sepsis protocol was

introduced (intervention 2).

The study consisted of three dense measurement

periods:

Period 1: Before using the new care bundle based sepsis

protocol (July 1, 2006–November 6, 2006).

Period 2: After the sepsis protocol was put to use

(November 6, 2006–June 25, 2007) and before training

and performance feedback.

Period 3: After training and performance feedback (June

25, 2007–October 1, 2007).

In most implementation programs, it is not possible to

disentangle the separate effects of the various implementation

activities (Grimshaw et al., 2004). The two

consecutive interventions were followed by measurement

periods, so that we could measure the effects of introducing

a protocol and the additional effects of training and

performance feedback.

2.1. Study setting and population

Every year, approximately 20,000 patients visit the ED

of a 953-bed university hospital in the Netherlands, where

35 registered nurses are employed. The study inclusion

criteria were: adult patients (16 years old) visiting the ED

because of the presence of a known or suspected infection,

to whom at least two of the following diagnostic criteria for

systemic inflammation apply: temperature greater than

38.3 8C, temperature less than 36 8C, heart rate greater than

90/min, respiratory rate greater than 20/min, cold chills,

altered mental status, systolic blood pressure less than

90 mm Hg, mean arterial pressure less than 65 mm Hg, and

hyperglycaemia in the absence of diabetes mellitus (Levy

et al., 2003; Nguyen et al., 2006). Patient data were

collected from July 1, 2006 until October 1, 2007.

2.2. Implementation program

The ED manager and three ED nurses (our ‘‘contact

nurses’’) were involved in the process of developing the

implementation program.

2.2.1. Development of a care bundle based sepsis protocol

A sepsis protocol (hereafter referred to as ‘‘protocol’’)

for nurses and physicians in the ED was developed by a

multidisciplinary team including an intensivist, ED internist,

a surgeon, a medical microbiologist, a clinical

pharmacist, ED nurses, and a nurse practitioner. Everybody

involved was familiar with the hospital organization,

organization of the ED, and the physicians and nurses

working in the ED (Grol et al., 2005; Wensing et al., 2006).

They developed a protocol, based on the SSC care bundle

mechanism (Burgers et al., 2003; Shapiro et al., 2005a,

2008). For the selection of the required bundle elements,

two different levels of evidence were used: evidence-based

practices described in the present sepsis guidelines (Green

et al., 2008; Robson and Daniel, 2008; Shapiro et al.,

2005b), and expert opinion.

The content of the protocol was discussed with the ED

manager and the three contact nurses. The nurses

suggested including the hospitalization or discharge of

the patient from the ED within 3 h as an additional bundle

element. The final protocol consisted of two parts: a sepsis

screening list for nurses and a sepsis performance list,

including seven bundle elements.

2.2.1.1. Sepsis screening list. The screening list was developed

to help the nurses identify patients with sepsis. The

nurses had to note any focus suspected of being infectious

and the two or more systemic inflammatory response

syndrome (SIRS) criteria on the screening list. Then the

physician had to be informed of the identification of a

patient with sepsis.

2.2.1.2. Sepsis performance list. To guide the nurses and

physicians in the ED, we developed a list with seven

relevant bundle elements. They were:

1. Measure the serum lactate concentration within 6 h

2. Obtain two blood cultures before starting antibiotics

3. Make a chest radiograph

4. Take a urine sample for urinalysis and culture

5. Start antibiotics within 3 h

6. Volume resuscitation in case of serum lactate

>4.0 mmol/L or hypotension

7. Hospitalize or discharge the patient within 3 h.

The nurses and physicians were expected to take

elements 1–5 and 7 for all patients included in the

protocol. Element 6 (volume resuscitation) was only

necessary in case the included patient had a serum lactate

>4.0 mmol/L or hypotension.

1466 M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473

It was agreed that, after identifying a patient with

sepsis, the responsible nurse should start immediately

with obtaining blood for chemistry tests and culture, and

urine for urinalysis and culture. Furthermore, prior to the

implementation of the protocol, we agreed with our

radiologists that, in patients included in the protocol, a

chest radiograph would be performed without a physicians’

prescription. Finally, the nurses played an important

role in timely obtaining the physician’s prescription for

antibiotic treatment.

To collect all data and for the general necessity of

accurate registration of the performed elements, the

nurses had to sign off the performed elements and note

the time they were done on the performance list.

After it was fully developed and accepted by all those

involved in sepsis care, the protocol was placed on the

University Medical Centre (UMC) Intranet website, available

to all UMC employees, to facilitate access to it.

2.2.2. Initiation of the sepsis protocol (intervention 1)

The new protocol was formally introduced during the

change of duty in the ED on November 6, 2006. From that

moment on, the protocol was available to the ED. In

addition to the formal introduction, all the ED nurses

received an e-mail message with instructions about how to

use the screening and performance lists. They were

emphatically asked to use the lists each time a patient

met the inclusion criteria. If there were any questions, the

nurse practitioner in the implementation team could be

reached during office hours or by e-mail.

As part of this implementation strategy, the contact

nurses were repeatedly requested to motivate and assist

the other ED nurses in using the protocol. In the meantime,

data collection was started. One of the contact nurses (LP)

was frequently consulted about implementation issues,

such as incomplete filled out screening and performance

lists. The ED nurses’ questions were answered personally

or by e-mail.

2.2.3. Training and performance feedback (intervention 2)

Six months after initiation of the protocol, training

began. Training about sepsis, and the presentation of

feedback on performance data of periods 1 and 2, took

place during a department meeting for all ED nurses on

June 25, 2007. The training focused on sepsis, severe sepsis,

septic shock, and the clinical importance of early recognition

and treatment. Although they could not provide data

to support this, the nurses presumed that their compliance

to the bundle was already optimal at baseline. Therefore,

the training also included performance feedback. Feedback

about the group performance of the bundle elements in the

first two periods was presented, as were changes in the

performance of each element from the first to the second

period. Feedback focused on the elements which the

nurses and physicians were generally completing adequately

and those that needed more attention. The aim of

the presentation was to give the nurses a clear overview of

their own practice and to encourage them to improve the

diagnosis and management of sepsis. Further, the nurses’

experience with applying the protocol in daily practice was

evaluated by means of short interviews. Finally, to reach

the whole group of nurses in the ED, all of them received

the presentation by e-mail, and a poster was presented in

the ED. Besides the group training and performance

feedback intervention, the contact nurses and nurse

practitioner gave regular feedback to the individual ED

nurses on their use of the protocol.

To improve the physicians’ knowledge about sepsis and

the use of the protocol in the ED, the intensivist instructed

every new group of ED residents every 2 months. This

training started at the end of February 2007. A training

program and a conference for medical residents were

organized (Tromp et al., 2009).

2.3. Data collection and processing

Data collection included patient data and performance

data. The data collection team consisted of a nurse

practitioner, an undergraduate, and an internist.

2.3.1. Patient data

The relevant patient characteristics included gender,

age, suspected focus of infection, and final documented

diagnosis at the time of discharge from hospital. Information

about the clinical end points included the length of the

hospital stay and the in-hospital mortality rate. The

baseline data were collected by retrospectively checking

the diagnoses on the ED admission list for patients with

sepsis. The required data (including the two or more

diagnostic criteria for systemic inflammation) were

collected from the clinical patient databases, medical

records, and nursing records. The final documented

diagnoses were obtained from medical discharge records.

After use of the protocol was started, the data were

prospectively collected from the screening and performance

lists. Missing data were collected from the clinical

patient databases, medical records, and nursing records. If,

during the study period, a patient with sepsis was

registered at the ED more than once, he/she was included

in the study each time.

Although most of the patients with sepsis were triaged

and included in the protocol by the nurses, some patients

were erroneously not included in the protocol by them: the

nurse did not recognize a patient with sepsis or forgot to fill

out the screening and performance list. To compare the

differences in the performance of the bundle elements

between those patients included in the protocol by the

nurses and those who were not, the patients who were not

included in the protocol were still included in the study. To

recover patients who were undeservedly not included in

the protocol, we retrospectively checked the diagnoses

against the ED admission list for patients with sepsis.

2.3.2. Performance data

The goal of the protocol was to improve and evaluate

the care of the total group of patients with sepsis, and not

only those with severe sepsis or septic shock. Since high

serum lactate concentrations and/or hypotension only

occurs in a small proportion of the patients with sepsis

who present themselves at the ED, early goal-directed

therapy was included as a bundle element in the protocol

(element 6) but not included as a measure of protocol

M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1467

adherence for this study. Therefore, completion of six

bundle elements and compliance with them were measured.

Baseline performance data were collected from

clinical patient databases, medical records, and nursing

records. After use of the protocol was started, all data were

collected from the performance lists. Missing data were

collected from the clinical patient databases, medical

records, and nursing records.

2.4. Data analysis

The primary outcome measure was compliance with

the bundle of six elements and the completion of the

individual elements. The theory behind care bundles is that

when several evidence-based interventions are grouped

together in a single protocol, it will improve patient

outcome. Although the study was not powered to

demonstrate a statistically significant effect on the clinical

end points, we included the length of the hospital stay and

the in-hospital mortality rate as secondary outcome

measures.

Descriptive statistics regarding the performance of the

bundle of six elements, the performance of the individual

elements, length of hospital stay, and mortality rate

included frequencies, percentages, medians, and means.

The compliance was expressed as a percentage, and the

compliance to the bundle was also expressed as the total

number of elements that were correctly performed (on a

scale of 0–6).

To analyze the differences in compliance between the

measurements, both overall and for each of the six

separate elements, we used a generalized linear model

with a logarithmic link and Bernoulli distribution function.

In our secondary, subgroup analysis, we added the impact

of the nurses’ triage in periods 2 and 3 as a cofactor.

In a similar way, analysis of variance was used to

compare the mean of the total number of times that the

elements were correctly taken between baseline and the

two post-intervention measurements. Each of many

nurses treated several patients, which had to be accounted

for in the statistical analysis. Therefore, we estimated the

intraclass correlation coefficient, based on a mixed model

analysis of the cases in which the nurse was known, and we

used this coefficient to adjust the results of the analysis of

variance of all data.

3. Results

3.1. Patient population

The study included 825 patients presenting with sepsis

at the ED (Fig. 1). There were no statistically significant

differences in patient characteristics per period (Table 1).

Eighty-nine percent of the participants were admitted to a

nursing ward or intensive care unit. The ED nurses

registered pneumonia and urogenital infection as the

most commonly suspected infections. In 680 of the 825

cases (82%), the final diagnosis was a bacterial infection,

most commonly in the lungs (33%), followed by urinary

tract and/or genitalia infections (21%).

3.2. Effects on performance of the bundle and the bundle

elements

In 731 of 825 cases, information about all six elements

was available. In 3.5% of the cases in period 1, all six

elements were performed and improved significantly to

10.8% after period 2, and 12.4% after period 3 (Table 2).

When analyzing the completion of the individual

elements, there was a significant improvement in

completing three of six elements after period 2

(Table 2), and there was a significant improvement in

completing four of the six elements after period 3: 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 3 h

(from 38% to 56%).

The mean number of performed bundle elements

improved significantly in period 2 versus period 1 (from

3.0 to 3.9, 95% CI = 0.7–1.2) and further increased after

period 3 (from 3.9 to 4.2, 95% CI = 0.03–0.5), as Fig. 2 shows.

The outcome of the analysis of variance of all cases

(n = 825) is comparable to the outcomes of cases with

complete data. Furthermore, no differences between the

analysis of variance of all data and the analysis of only the

cases for which the nurse was known were found.

3.3. Recognition of patients with sepsis

We examined whether patients were erroneously not

included in the protocol by the nurses, and it turned out

that in period 2, 71% of the cases were included in the

protocol by the ED nurses and this percentage further

improved to the inclusion of 82% patients with sepsis in

period 3 (p = 0.005).

In the patients with sepsis that were erroneously not

included in the protocol by the nurses, we also examined

whether the compliance with the bundle elements was

different. For 589 of the 666 cases included in periods 2 and

3, information about the completion of all six elements was

available (88%). The subgroup analysis of the impact of the

nurses’ inclusion showed that the completion of the six

elements in the cases that were included by the nurses was

significantly better (1.2 elements more; 95% CI = 1.0–1.4)

Fig. 1. Overall number of patients presenting to the ED during the study

and patients with sepsis included per study period.

1468 M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473

than the completion of the six elements in the cases that

were afterwards included by the study team (Table 3).

3.4. Effects on the hospital mortality rate and length of

hospital stay

The in-hospital mortality rate decreased from 6.3% in

period 1 to 5.5% in period 3, which was not significant. The

median (interquartile range) length of hospital stay did not

change (6 (2–12) to 6 (3–11) days).

4. Discussion

Our study demonstrates that using a nurse-driven, care

bundle based, sepsis protocol followed by training and

performance feedback results in improved early recognition

and treatment of patients with sepsis who present to

the ED. The implementation program resulted in signifi-

cant improvement of the compliance with the bundle

(from 3.5% to 12.4%) and significant changes in four of the

six individual elements. The process of obtaining two

blood cultures before starting antibiotics did not improve

significantly, probably because of the already good

compliance at baseline. Further, the median time of

hospitalization or discharge of the patient did not improve

significantly.

We can improve the quality of care for patients with

sepsis by using a relatively simple and inexpensive

implementation program. Although care bundles can be

a powerful stimulus to focusing the multidisciplinary

team on working together to deliver reliable care, the

development of a bundle is only one component in an

overall improvement strategy (Marwick and Davey,

2009). To further improve the recognition of patients

with sepsis and the performance of SSC-based recommendations

in our ED, additional improvement activities

are required.

Interestingly, subgroup analysis showed that compliance

with the six bundle elements was significantly better

in the cases that the nurses included than in the cases that

they did not. This shows that recognizing sepsis with the

use of the sepsis screening list alone resulted in better

compliance with completion of the six elements. Without

the list, some patients with sepsis were initially missed in

the nurses’ triage, but the attending physicians ultimately

identified and treated them.

Table 1

Characteristics of the patients (n = 825).

Variable Period 1 Period 2 Period 3

Cases included (n) 159 447 219

Cases included by nurses – 317 179

Cases with complete data set – 269 162

Cases included by the researcher 159 130 40

Cases with complete data set 142 119 39

Gender (female)a 74 (47) 172 (39) 95 (43)

Age (years)b 55 (43–71) 60 (45–71) 59 (43–70)

Patients admitted to nursing ward or ICUa 135 (85) 405 (91) 189 (88)

Septic shocka 8 (5.0) 18 (4.0) 4 (1.8)

Length of hospital stay (days)b 6 (2–12) 7 (3–12) 6 (3–11)

In-hospital mortality ratea 10 (6.3) 27 (6.0) 12 (5.5)

Triage nurse’s diagnosis in emergency departmenta

Pneumonia 96 (21.5) 60 (27.4)

Urogenital infection 55 (12.3) 43 (19.6)

Wound infection 19 (4.3) 13 (5.9)

Abdominal infection 18 (4.0) 13 (5.9)

Circulatory system/catheter infection 9 (2.0) 5 (2.3)

Skin/soft tissue 7 (1.6) 6 (2.7)

Bone/joint 8 (1.8) 3 (1.4)

Implant/prosthesis infection 3 (.7) 3 (1.4)

Meningitis 3 (.7) 2 (.9)

Endocarditis 1 (.2) –

Other/unknown focus 73 (16.3) 38 (17.4)

No clear diagnosis 208 (46.5) 64 (29.2)

Final confirmed diagnosis at dischargea

Pulmonary 34 (21.4) 169 (37.8) 65 (29.7)

Urinary tract/genital 37 (23.3) 81 (18.1) 51 (23.3)

Skin/soft tissue 21 (13.2) 26 (5.8) 24 (11.0)

Abdominal 18 (11.3) 45 (10.1) 25 (11.4)

Circulatory system 7 (4.4) 16 (3.6) 9 (4.1)

Bone/joint 3 (1.9) 11 (2.5) –

Cerebral 2 (1.3) 7 (1.6) 1 (.5)

Ear/nose/throat 4 (2.5) 6 (1.3) 5 (2.3)

Other focus – 7 (1.6) 6 (2.7)

Diagnosis not related to infection 14 (8.8) 43 (9.6) 23 (10.5)

No final diagnosis reached 19 (11.9) 36 (8.1) 10 (4.6)

ICU = intensive care unit.

a Results expressed as number and (percentage). b Results expressed as median and (interquartile range).

M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1469

As nurses are often the first to see and triage a patient,

in our view their position in the current organization

structure should be exploited to a greater extent.

Therefore, the role of the nurses in the development and

implementation of the protocol was emphasized in our

study. By giving the nurses a greater responsibility in the

recognition and treatment of patients with sepsis, the care

for these patients obtained a more multidisciplinary

character and our study demonstrates that this was

associated with an improvement of the quality of care.

In our study, the six bundle elements focused on all

patients with sepsis. Most studies about implementation

of the SSC bundles specifically focus on patients with

severe sepsis and septic shock (Carter, 2007; Nguyen et al.,

2007b; Shorr et al., 2007). In our patient group, 3.6% had

septic shock. We deliberately included all patients with

sepsis because the bundle should be performed in all

patients so that we can identify the most affected ones. In

addition, the first step to reduce the mortality due to severe

sepsis or septic shock is to prevent the progression of

sepsis to severe sepsis and septic shock (Annane et al.,

2005). The early recognition and treatment of patients

with sepsis will help achieve this prevention. Our study

was not powered to identify a positive effect on patient

outcome. However, hospital mortality was low in our

patient group and tended to decrease during our study.

Previous studies describe the effects of implementation

activities to improve sepsis diagnosis and treatment in the

ED. Our results confirm those of a smaller study evaluating

the effectiveness of a standardized, SSC-based, set of

elements for managing sepsis in the ED of a university

medical centre (Micek et al., 2006). In this study, 60

patients with septic shock were included before implementation

of the standardized set of elements and 60

patients afterwards, and ten process-of-care variables

were evaluated. As in our study, formal clinical training

was part of the implementation activities. Similarly to our

study, several improvements were reached, e.g., measurement

of serum lactate improved from 17% to 78%. Contrary

to Micek et al.s’ study (2006), our study focused on all

patients with sepsis, not only on those with septic shock.

4.1. Limitations

Our study is limited in being an uncontrolled study in

only a single centre. Our implementation program was

tailor-made to the situation of our hospital, so the results

cannot be extrapolated. Theoretically it is possible that, in

the course of time and based on the last evidence,

diagnostic and therapeutic procedures change. Therefore,

the possibility of a time effect, independently of our

performed implementation strategies, cannot be excluded.

However, no changes in hospital practice during the study

that may have led to confounding were present, as local

and national protocols and guidelines on the treatment of

pneumonia, urinary tract infections, and sepsis remained

unchanged during the study period.

The sepsis screening and performance list itself may

have limitations. The clinical signs included in the sepsis

screening list are very sensitive, but not very specific

Table 2

The performance of the complete sepsis bundle and the six individual bundle elements at baseline (period 1), after introduction of the sepsis protoco

(Robson and Daniel, 2008; Talan, 2006; Talan et al., 2008),

l (period 2), and after training and performance feedback (period

3) (n = 731).

Variable Usage in period

1 (n = 142)

Usage in period

2 (n = 388)

Relative incidence

(95% CI)a of period

2 versus period 1

Usage in period

3 (n = 201)

Relative incidence

(95% CI)a of period

3 versus period 1

Performance of the complete sepsis bundle

(all six elements)

3.5% 10.8% 3.1 (1.2–7.6)* 12.4% 3.6 (1.4–9.0)*

Measure lactate within 6 h 22.6% 73.5% 2.9 (2.5–3.5)* 80.3% 3.9 (3.0–5.2)*

Take two blood cultures before start antibiotics 83.1% 78.6% 0.8 (0.5–1.2) 86.3% 1.2 (0.7–2.0)

Take a chest radiograph 67.3% 88.1% 2.8 (2.0–3.9)* 82.7% 1.9 (1.3–2.7)*

Take urine for urinalysis and culture 49.0% 54.6% 1.1 (0.9–1.3) 66.7% 1.5 (1.2–1.9)*

Start antibiotics within 3 h 37.7% 49.6% 1.2 (1.1–1.4)* 55.9% 1.4 (1.2–1.7)*

Time from ED admission till administration

of antibioticsb

2 h 25 min

(1 h 35 min–3 h 0 )

2 h 5 min

(1 h 20 min–3 h 0 min)

1 h 45 min

(1 h 15 min–2 h 25 min)

Admit or discharge patient within 3 h 44.0% 46.2% 1.0 (0.9–1.2) 48.9% 1.1 (0.9–1.3)

Time from ED admission till admission

to a nursing ward or dischargeb

3 h 12 min

(2 h 25 min–4 h 20 min)

3 h 15 min

(2 h 25 min–4 h 10 min)

3 h 5 min

(2 h 15 min–4 h 5 min)

a Relative incidence (95% confidence interval) i.e. the ratio of the percentages (cases with complete data set). b Results expressed as median (interquartile range). * Significant differences.

1470 M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473

which may have led to overdiagnosis and overtreatment.

Of course this results in unnecessary treatment costs.

However, unnecessary costs for a chest radiograph or a

urine examination is probably outweighed by the high

costs of treatment of patients with severe sepsis or septic

shock or the consequences of missing a diagnosis of severe

sepsis or septic shock. The fact that 82% of the patients

were ultimately diagnosed with an infection indicates that

not many patients who were false-positively found to have

sepsis were unnecessarily treated with antibiotics. As only

the physicians can prescribe antibiotic therapy, it remains

the responsibility of the treating physician to decide

whether to treat a patient with antibiotics, but better

compliance with the bundle led to a more complete and

appropriate work-up.

5. Conclusions and future research

Our data suggest that the use of a predominantly nursedriven,

care bundle based, sepsis protocol combined with

training and performance feedback can significantly

improve the recognition of patients with sepsis at the

ED and the taking of elements based on SSC recommendations

for these patients. More attention should be given to

the role of nurses in quality improvement of sepsis care.

Our pilot study turned out to be both effective and feasible

Fig. 2. Nurses’ compliance (%) in the performance of the protocol elements (0–6 elements correctly performed), every 3 months.

Table 3

Differences between cases included by the ED nurses and cases initially not included by ED nurses, at the level of the performance of the complete sepsis

bundle and the six individual bundle elements (n = 589).

Variable Cases included by

ED nurses (n = 431) n (%)

Cases initially not included by

ED nurses (n = 158) n (%)

Performance of the complete sepsis bundle (all six elements) 56 (13.0) 11 (7.0)

Measure lactate within 6 h 374 (86.8) 75 (47.5)

Take two blood cultures before starting antibiotics 385 (89.3) 99 (62.7)

Take a chest radiograph 375 (87.0) 136 (86.1)

Take a urine sample for urinalysis and culture 280 (65.0) 62 (39.2)

Start antibiotics within 3 h 241 (55.9) 56 (35.4)

Admit or discharge the patient within 3 h 207 (48.0) 68 (43.0)

Patients with sepsis and complete data set noted after the start of the sepsis protocol. ED = emergency department.

M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1471

in a university hospital. Future research should aim at

testing this promising implementation strategy in a

multicenter controlled trial.

Conflict of interest

There are no financial or commercial conflicts of

interest concerning this study.

Funding

No financial support was received.

Ethical approval

The local medical ethics committee waived the need for

written informed consent before this study began.

Acknowledgements

We thank the nurses from the ED of the Radboud

University Nijmegen Medical Centre for including the

patients in the sepsis protocol, and for registration of the

recommendations they performed in case of hospitalizing

a patient with sepsis.

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Here is a copy of my paper to show the articles chosen:

Quantitative

The first article I choose is a quantitative research review of the nurses role in recognizing and treating patients with sepsis in an emergency department, the article describes a before and after study of interventions implemented to help reduce sepsis mortality. The research study evaluated two consecutive interventions and provided data to show the before intervention and after intervention implementation of a nurse driven care bundle set and education with performance feedback. The research starts with data collected before a new care bundle was initiated, continues with data collection for the implementation, and finishes with the third phase of data collection to include the effects of training and performance feedback. This study is based on an emergency room with 35 registered nurses with a patient population of 20,000 visits per year. The study criteria involved adult patients 16 years and older, presentation of a known or suspected infection and at least two abnormal vital signs. The research study presents quantitative data relating to 825 patients with statistical findings for a multi facade implemented process showing the before and after effects of a nurse driven process. I choose this journal because it is an international nursing journal related to my field of nursing. (Tromp et al., 2010, p. 1464)

Qualitative

The second article I choose is a qualitative research review of the patients and caregivers experience related to sepsis. This study used a method of face to face or telephone interviews to gather information. The research was based on patient’s age 18 and older and diagnosed with sepsis within a 12 month time frame. The caregivers were defined as family members or friends that provided care to the patient during or after their diagnosis of sepsis. This study was an explorative review with a small sample size of 22 patients, 17 caregivers and a total of 39 interviews. The objective of the research was to understand, explore the patient’s awareness, knowledge and understanding of their experience after they were affected with a hospitalization of sepsis. The study also focused on the impact of this illness related to the caregiver’s experience. I had a very hard time finding a qualitative study related to sepsis, the article I found was in a critical care medicine journal still relating to my field of nursing. (Gallop et al., 2015, para. 3)





References

Gallop, K. H., Kerr, C. E., Nixon, A., Verdian, L., Barney, J. B., & Beale, R. J. (20