title: Impact of nurse-initiated ED sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality.
abstract: BACKGROUND
  Emergency nurses play a key role in the initial triage and care of patients with potentially life-threatening illnesses. The aims of this study were to (1) evaluate the impact of a nurse-initiated ED sepsis protocol on time to initial antibiotic administration, (2) ascertain compliance with 3-hour Surviving Sepsis Campaign (SSC) targets, and (3) identify predictors of in-hospital sepsis mortality.
  
  
  METHODS
  A retrospective chart review investigated all adult patients-admitted through either of 2 academic tertiary medical center emergency departments-who were discharged with a diagnosis of severe sepsis or septic shock (N = 195). Pre- and post-protocol implementation data examined both compliance with 3-hour SSC bundle targets and patient outcomes. Multivariate logistic regression analysis identified predictors of in-hospital mortality.
  
  
  RESULTS
  Serum lactate measurement (83.9% vs 98.7%, P = .003) and median time to initial antibiotic administration (135 minutes vs 108 minutes, P = .021) improved significantly after protocol implementation. However, one quarter of antibiotic administration times still exceeded the 3-hour target. Significant predictors of in-hospital mortality were respiratory dysfunction, central nervous system dysfunction, urinary tract infection, vasopressor administration, and patient body weight (P < .05). There were no in-hospital mortality rate differences between the pre- and post-protocol implementation groups.
  
  
  CONCLUSIONS
  Compliance with serum lactate measurement and blood culture collection goals approached 100% in the post-protocol group. However, compliance with medical interventions requiring multiple health care-provider involvement (ie, antibiotic and fluid administration) remained suboptimal. Efforts focused on multidisciplinary bundle elements are necessary to achieve full compliance with SSC targets.
authors.affiliation: Lakewood, WA; San Diego, CA; Round Rock, TX.
authors.forename: Heather Rose
authors.initials: HR
authors.lastname: Bruce
authors.affiliation: Lakewood, WA; San Diego, CA; Round Rock, TX.
authors.forename: Jeanne
authors.initials: J
authors.lastname: Maiden
authors.affiliation: Lakewood, WA; San Diego, CA; Round Rock, TX.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Fedullo
authors.affiliation: Lakewood, WA; San Diego, CA; Round Rock, TX. Electronic address: sck30@txstate.edu.
authors.forename: Son Chae
authors.initials: SC
authors.lastname: Kim
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016529:Emergency Nursing / Q000379:methods*; D004636:Emergency Service, Hospital; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality*; D013997:Time Factors; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: Bundles; Compliance; Mortality; Predictors; Protocol; Sepsis