RECENT NEWS: Barriers to Timely Fluid Resuscitation for Patients with Sepsis: Emergency Nurses’ Perspectives

emergency nurses

One in three hospital deaths in the US are due to sepsis, and one in five worldwide.1 Early Goal Directed Therapy (EGDT), a protocolized care bundle, was initially proposed by Rivers et al. in 2001 for the treatment of patients with severe sepsis and septic shock.Though there continues to be some debate around the findings and methods of the Rivers study, worldwide adoption of EGDT has proven to be a major factor in improving outcomes for patients with sepsis and has decreased mortality in these patients by approximately 16%.3,4

Sepsis can lead to organ failure or death if important bundle components such as fluid resuscitation are not initiated within the first hour of a patient’s presentation to the Emergency Department, especially when the patient is hypotensive.3  Early Goal Directed Fluid Resuscitation improves microcirculation, optimizes organ perfusion, and improves outcomes in patients with sepsis.5  In spite of this evidence many patients with severe sepsis or septic shock continue to experience delays in this needed care.

In a recent issue of Australasian Emergency Care (https://doi.org/10.1016/j.auec.2020.07.002), Kabil et al. presented the results of a qualitative study that explored the factors that inhibit the fluid resuscitation component of EGDT.6 The research team conducted face-to-face, semi-structured interviews with ten emergency nurses of varied experience levels, working across various types of emergency departments in Australia. The interviewing and concurrent data analysis continued until data saturation was achieved and no new themes emerged.  All interviews were audio-recorded.

“With the delay of treatment, they became more unwell. They end up in resuscitation area with inotropes, arterial lines and in High Dependency Unit”

“I just see a big response to it (IV fluids). It seems to work better than anything. . ., 100%”

Three major themes emerged from the interviews:

-Experience drives perception: More experienced nurses placed a higher priority on initiating fluids. Also, they are more experienced with IV cannulation, which can facilitate Early, Goal-Directed Fluid Resuscitation (“EGDFR”).

-Clinical practice challenges limit successful EGDFR: Early recognition of sepsis is challenging and waiting for a medical provider’s order to initiate IV fluids is also a significant cause of delays of treatment.

-Multiple strategies to improve compliance:  Participants had many ideas from improving EGDFR compliance including improved education and creating standing orders which would allow nurses to initiate intravenous fluids for patients with suspected sepsis.

The results of this study and a similar study by Brooks et al. that examined US provider attitudes toward fluid resuscitation in sepsis provides useful insights regarding some of the key barriers to EGDFR and offer strategies to help address these barriers. 7 Based on their findings, Kabil and colleagues make several recommendations to improve EGDFR compliance.

  • Authorization of standing orders for nurses to initiate intravenous fluids in patients with suspected sepsis
  • Additional education and advanced skills training
  • More staffing and resources

 

References

  1. Lelubre C, et al. Mechanisms and treatment of organ failure in sepsis. Nat Rev Nephrol 14, 417–427 (2018) doi:10.1038/s41581-018-0005-.
  2. Rivers E., Nguyen B., Havstad S., Ressler J., Muzzin A., Knoblich B. et al. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Emergency Medicine. 345(19):1368-77.
  3. Levy, Mitchell M. MD, MCCM1; Evans, Laura E. MD, MSc, FCCM2; Rhodes, Andrew MBBS, FRCA, FRCP, FFICM, MD (res)3The Surviving Sepsis Campaign Bundle: 2018 Update, Critical Care Medicine: June 2018 – Volume 46 – Issue 6 – p 997-1000 doi: 10.1097/CCM.0000000000003119.
  4. Dhooria S., & Agarwal R. (2015). Early goal-directed therapy versus early and goal-directed therapy for severe sepsis and septic shock: time to rationalize. Lung India; 325):521-3.
  5. Madhusudan P, Tirupakuzhi Vijayaraghavan BK, Cove ME. Fluid resuscitation in sepsis: reexamining the paradigm. Biomed Res Int 2014;2014:984082-.
  6. Kabil G., Hatcher D., Alexandrou E., & McNally S. (2020). Emergency nurses’ experiences of the implementation of early goal directed fluid resuscitation therapy in the management of sepsis: a qualitative study. Australasian Emergency Care. Doi: https://doi.org/10.1016/j.auec.2020.07.002.
  7. Brooks et al. (2020). Fluid Resuscitation in Septic Shock:  An Exploration of Emergency Department and Critical Care Clinician Perceptions and Decision-Making.  White Paper.