الفهرس 
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Abstract
Sepsis and septic shock are syndromes resulting in a dysregulated host response and one or more organs dysfunction following an infection. Rates of sepsis have increased regardless of the progression in treatment options. Increasing awareness and published sepsis bundles have improved efforts for reducing this condition. The six hour sepsis resuscitation bundle (SRB) is a strategy by the surviving sepsis campaign (SSC) to ensure early identification and prompt interventions for patients who develop sepsis and septic shock leading to positive outcomes.
Critical care nurses (CCNs) are vital in the recognition and resuscitation of patients with sepsis and septic shock in the ICU. The independent and interdependent roles of CCNs include taking samples for serum lactate, blood cultures, administration of antibiotics, fluids and vasopressors as well as monitoring and reassessment of patients with sepsis and septic shock. The critical role of a multidisciplinary approach to care is essential to positive outcomes.
Despite the global acceptance of the evidence based six hour sepsis resuscitation bundle, its implementation has been barricaded by important barriers in various intensive care units. Critical care nurses are vital to delivering optimal level of sepsis care, however multifactorial delays in effective resuscitation in this setting contributed to avoidable deaths, straining already scarce public assets.
The current study aimed to assess critical care nurses compliance to the six hour sepsis resuscitation bundle and identify barriers that hinder their compliance.
Materials and method
A descriptive research design was utilized in this study. The study was conducted at five ICUs of the Alexandria main university hospital.
Study subjects comprised a convenience sample of 50 CCNs offering direct patient care to patients with sepsis and septic shock.
Data for the study were obtained using the following tools:
Tool one: six hour sepsis resuscitation bundle observational checklist: it was adapted by the researcher from the surviving sepsis campaign bundles to assess CCNs compliance with SRB.
Tool two: Barriers hindering compliance of critical care nurses to the six hour sepsis resuscitation bundle questionnaire: it was developed by the researcher to identify factors hindering CCNs compliance with SRB. The barriers were grouped into three categories; nurse related barriers, organizational related barriers and patient related barriers.
Method
An official letter was send to the director Alexandria Main University Hospital (AMUH) and permission was granted. A pilot study was carried out on five CCNs to evaluate clarity, feasibility and applicability of the tools. Informed consent was obtained from the studied CCNs after explanation of the aim of study with emphasis on their privacy, confidentiality and right to withdraw at any time. The studied nurses were observed twice on different patients using the SRB observation checklist. During their break times the observed nurses were given the questionnaire to fill while the researcher was available to clarify and answer any questions. Data collection was done over three months.
Results of the current study were as follows:
I: Demographic data of the studied nurses:
Two thirds of the studied nurses were female; slightly more than half aged between 25-35 years and were single. 48% had a bachelor’s degree in nursing. The average years of experience in ICU were 9.46±6.92.
II: Compliance of the studied nurses with the six hour sepsis resuscitation bundle elements
Compliance was high regarding reassessment of vital signs, measurement of serum lactate and fluid resuscitation (98%, 92%, and 89%) among the studied nurses respectively. More than three quarters (79%) of the studied nurses initiated prescribed vasopressors during the first six hours of diagnosis of septic shock.
More than half of the studied nurses (62%) administered the prescribed antibiotics, while 59% of them monitored central venous pressure, 63% measured urine output hourly and 51% performed repeat lactate measurement. However, only 4% of the studied nurses complied with all bundle elements of SRB.
III: Barriers hindering critical care nurses compliance with SRB
Administering clinically priority medications first and the burden of caring for several critically ill patients with competing priorities at once were nurse related barriers perceived by most of the studied nurses with only 6% and 10% dissenting respectively. Communication hand off failure, documentation insufficiency, insufficient knowledge of the importance of SRB, lack of support from other staff and lack of awareness of SRB were agreed to by the studied nurses as barriers to compliance with SRB (66%, 60%, 58%, 58%, 54%) respectively.
Regarding organizational related barriers, the studied nurses strongly agreed that shortage of critical care nurses, lack of a work place library, time consumed in patient transfers and limited pharmacy resources (64%, 48%, 44% and 40%) barricaded compliance with SRB. More than two thirds (68%) of the studied nurses agreed that a variation in expertise of the multidisciplinary team was a barrier to compliance with SRB. Fifty eight percent of the studied nurses agreed that lack of continued in-service programs, lack of hospital wide processes of care and performance improvement programs were also organizational related barriers to compliance with SRB. In addition competing protocols and core measures, prolonged laboratory turnaround times, delay in prescribing, ordering and delivery of fluids, antibiotics and vasopressors and delay in diagnosis of sepsis (56%, 54%, 52% & 52%) respectively were agreed to be barriers to compliance with SRB.
Patient related barriers agreed to by the studied nurses included; heavy task load for septic patients, multiple comorbid conditions, patient receiving many intravenous medications (58%, 42% & 42%) respectively.
Organizational related barriers had the highest mean percentage score (53.22±22.37), followed by patient related barriers (48.33± 28.02) and lastly nurse related barriers (43.89± 19.87). The overall percent score was 48.54 ±19.93.
Generally the studied nurses regarded most of the suggested barriers as low level barriers; nurse related barriers, patient related and organizational related barriers (84%, 68% & 60%) respectively. Regarding overall barriers level, 76% of the studied nurses indicated that they were low level of barriers.
IV: Relationships between identified barriers, studied nurse demographics and compliance with SRB.
There was a statistically significant relationship between the ICU and patient related barriers (F=3.429 & p=0.016). There was also a statistically significant relationship between the studied nurses’ age and nurse related barriers (F=3.545 & p=0.022) as well as the overall barriers (F=2.829 & p=0.049). The relationships between the educational level of the studied nurses and nurse related barriers, organizational barriers and the overall barriers were statistically significant (F=3.711 & p=0.032; F=4.337 & p=0.019; F=4.262 & p=0.020).
There were negative correlations between all the categories of barriers and compliance to six hour sepsis resuscitation bundle. In addition there were statistically significant associations between the nurse related, organizational related, patient related and overall barriers with compliance to six hour sepsis resuscitation bundle (p=0.021, p=0.025, p=0.028, and p=0.021) respectively.
Conclusion and recommendations
It can be concluded that majority of the studied nurses were non-compliant with the SRB.
Poor compliance of the studied nurses were mainly in obtaining blood cultures prior to antibiotics, monitoring central venous oxygen saturation, and assessment of skin mottling and capillary refill time.
Organizational barriers highly contributed to the low compliance in the current study followed by nurse related barriers and lastly patient related barriers.
The more the perceived barriers by the studied nurses the lower their compliance was with SRB.
Based on the study findings the following recommendations are suggested:
Recommendations geared towards critical care nurses practice and training
- Continuous nursing education sessions and periodic resuscitation drills on six hour sepsis resuscitation bundle.
- Utilize critical care nurse driven protocols, SRB bundle checklists, sepsis screening tools and sepsis order sets.
Recommendations geared towards Organization (AMUH)
- Adjust critical care nurse-patient ratios in the initial six hours to enhance adherence to the resuscitation bundle.
- Periodic audits and feedback on implementation of SRB
- Institute a 24 hour microbiology laboratory
Recommendations geared towards Research
Further research is needed to:
- Test the feasibility and efficacy of the currently revised “Hour – 1 bundle” in this setting.
- Identify factors leading to the low compliance with time to antibiotics in this setting.
- Assess the effectiveness of nurse led protocols regarding resuscitation of patients with sepsis and septic shock in the current setting.
- Replicate this study on a larger multicenter sample for generalization of the results.