title: Early detection and treatment of severe sepsis in the emergency department: identifying barriers to implementation of a protocol-based approach.
abstract: BACKGROUND
  Despite evidence to support efficacy of early goal-directed therapy for resuscitation of patients with severe sepsis and septic shock in the emergency department, implementation remains incomplete. To identify and address specific barriers at our institution and maximize benefits of a planned sepsis treatment initiative, a baseline assessment of knowledge, attitudes, and behaviors regarding detection and treatment of severe sepsis was performed.
  
  
  METHODS
  An online survey was offered to nurses and physicians in the emergency department of a major urban academic medical center. The questionnaire was designed to assess (1) baseline knowledge and self-reported confidence in identification of systemic inflammatory response syndrome and sepsis; (2) current practices in treatment; (3) difficulties encountered in managing sepsis cases; (4) perceived barriers to implementation of a clinical pathway based on early quantitative resuscitation goals; and (5) to elicit suggestions for improvement of sepsis treatment within the department.
  
  
  RESULTS
  Respondents (n = 101) identified barriers to a quantitative resuscitation protocol for sepsis. These barriers included the inability to perform central venous pressure/central venous oxygen saturation monitoring, limited physical space in the emergency department, and lack of sufficient nursing staff. Among nurses, the greatest perceived contributor to delays in treatment was a delay in diagnosis by physicians; among physicians, a delay in availability of ICU beds and nursing delays were the greatest barriers. Despite these issues, respondents indicated that a written protocol would be helpful to them.
  
  
  CONCLUSIONS
  Knowledge gaps and procedural hurdles identified by the survey will inform both educational and process components of an initiative to improve sepsis care in the emergency department.
authors.affiliation: Emergency Department, New York-Presbyterian Hospital–Columbia University Medical Center, New York, NY, USA. mb3107@columbia.edu
authors.forename: Mara
authors.initials: M
authors.lastname: Burney
authors.forename: Joseph
authors.initials: J
authors.lastname: Underwood
authors.forename: Shayna
authors.initials: S
authors.lastname: McEvoy
authors.forename: Germaine
authors.initials: G
authors.lastname: Nelson
authors.forename: Amy
authors.initials: A
authors.lastname: Dzierba
authors.forename: Vepuka
authors.initials: V
authors.lastname: Kauari
authors.forename: David
authors.initials: D
authors.lastname: Chong
mesh_terms: D000046:Academic Medical Centers; D019091:Critical Pathways; D042241:Early Diagnosis; D004636:Emergency Service, Hospital; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006284:Health Plan Implementation; D006801:Humans; D057184:Practice Patterns, Nurses'; D010818:Practice Patterns, Physicians'; D058996:Quality Improvement; D018805:Sepsis / Q000175:diagnosis / Q000451:nursing / Q000628:therapy; D012772:Shock, Septic / Q000175:diagnosis / Q000628:therapy; D018746:Systemic Inflammatory Response Syndrome / Q000175:diagnosis / Q000628:therapy; D014481:United States