Zia Iqra, Zaidi Syeda Kisa Fatima
Acute Medicine, Royal Free Hospital, London, GBR.
Applied Clinical Research, McMaster University, Hamilton, CAN.
Cureus. 2023 Nov 23;15(11):e49275. doi: 10.7759/cureus.49275. eCollection 2023 Nov.
Introduction Sepsis is a preventable cause of mortality and presents challenges in triage and management. The Surviving Sepsis Campaign care bundles improve patient outcomes; however, non-compliance with guidelines, understaffing, and scarcity of training opportunities undermine care quality in resource-limited countries. We aimed to implement the sepsis hour-1 care bundle in the emergency department of a tertiary-care hospital in Pakistan and develop hospital antimicrobial guidelines. Methods The baseline assessment included a survey of knowledge and confidence in sepsis management and a retrospective audit of inpatient medical records. The inclusion criteria were age ≥ 18 years with a systemic inflammatory response score ≥ 2 or a National Early Warning Score ≥ 3. Improvement strategies included (a) educational intervention, (b) adult sepsis screening tool and sepsis 1-hour bundle checklist, and (c) recommendations for empirical antibiotics. These were implemented and assessed via Plan-Do-Study-Act (PDSA) cycles: (a) multi-tiered educational campaigns, (b) implementation of hospital protocols/guidelines, and (c) antimicrobial policy and sustainability. The process measures were hour-1 bundle components and the outcome measures were in-hospital mortality, ICU admission, length of hospital stay, and ICU stay. Results The baseline survey revealed that the majority of participants had formal training and felt confident in managing septic patients but none of the respondents had used a sepsis scoring system, and only 29.4% had used an hour-1 bundle previously. There was a sustained improvement in bundle compliance from 0% at baseline to 57.7% at PDSA-3. Inappreciable variation (p > 0.05) was reflected in the length of hospital and ICU stay and in-hospital mortality, whereas ICU admission decreased insignificantly (p > 0.05). The antimicrobial therapy practice, as per the guidelines, increased remarkably (p < 0.05). Conclusion Regular training and feedback are pivotal for practice change, yet integrating structured screening tools and bundled checklists into current workflows can significantly improve compliance.
引言
脓毒症是一种可预防的致死原因，在分诊和管理方面存在挑战。拯救脓毒症运动护理集束可改善患者预后；然而，在资源有限的国家，不遵守指南、人员配备不足以及培训机会匮乏会损害护理质量。我们旨在巴基斯坦一家三级医院的急诊科实施脓毒症1小时护理集束，并制定医院抗菌药物指南。
方法
基线评估包括对脓毒症管理知识和信心的调查以及对住院病历的回顾性审核。纳入标准为年龄≥18岁，全身炎症反应评分≥2或国家早期预警评分≥3。改进策略包括：(a)教育干预；(b)成人脓毒症筛查工具和脓毒症1小时集束检查表；(c)经验性抗生素使用建议。通过计划-实施-研究-改进（PDSA）循环实施并评估这些策略：(a)多层次教育活动；(b)医院协议/指南的实施；(c)抗菌药物政策及可持续性。过程指标为1小时集束的组成部分，结果指标为住院死亡率、入住重症监护病房（ICU）情况、住院时间和ICU住院时间。
结果
基线调查显示，大多数参与者接受过正规培训，对管理脓毒症患者有信心，但没有受访者使用过脓毒症评分系统，只有29.4%的人之前使用过1小时集束。集束依从性从基线时的0%持续提高到PDSA-3时的57.7%。住院时间、ICU住院时间和住院死亡率方面无明显差异（p>0.05），而ICU入住率略有下降（p>0.05）。按照指南，抗菌治疗的实施显著增加（p<0.05）。
结论
定期培训和反馈对于实践改变至关重要，然而将结构化筛查工具和集束检查表纳入当前工作流程可显著提高依从性。
