Challenges to implementation of sepsis guidelines

Introduction

International surviving sepsis guidelines identified an important role for acute medicine in early management of severe sepsis, but local and multicentre international audits show poor adherence to these guidelines.

Materials

We evaluated the use of a Sepsis Case Record (SCR) supported by a systematic educational programme to improve standards. A one-page SCR was derived from surviving sepsis guidelines, to prompt recognition of sepsis syndromes, comprehensive secondary assessment, initiation of resuscitation and antibiotic treatment bundles, and appropriate specialist consultations. The SCR was introduced in the emergency and acute assessment units in our teaching hospital setting within central London, accompanied by a seminar-based educational programme for medical and nursing staff.

Methods

Two months after its introduction, the use of the SCR form was audited in all acute medical admissions who met the clinical criteria for sepsis. One hundred sequential patients were assessed in a 6-week period over the winter.

Results

One-half of the audit sample had SCR forms completed. Specificity of the sepsis criteria was good, with <10% of patients subsequently judged not to have had sepsis. The patients with and without audit forms had comparable demographics, severity of illness and microbiology (Figure 1). Frequency of abnormal temperature was significantly higher in patients with the SCR, suggesting fever remains an important prompt for physicians to consider sepsis. The use of the SCR was also associated with significantly improved assessment of GCS, lactate, travel history and the need for isolation, as well as significantly greater number of specialist consultations (Table 1), albeit still inadequate, ~10% (without SCR) to ~20% (with SCR). The SCR had no effect on frequency of clinical review by senior resident physicians, recording of FiO₂, antibiotic guidelines compliance or blood/urine culture requests, all evident in 40 to 60% of patients. Approximately 75% of all patients received antibiotics within 2 to 6 hours, and a trend for earlier antibiotics was associated with use of the SCR (Figure 2).

Figure 1

(abstract P29)

Table 1 abstract P29

Figure 2

(abstract P29)

Conclusion

The SCR was well received but not used consistently. The lack of abnormal temperature may contribute to this. The use of the SCR did improve early management of sepsis, but a number of deficiencies persisted. Implementation of sepsis guidelines remains a major challenge in clinical practice. Succinct guidelines were helpful in this setting but need additional educational and feedback support to improve standards of practice.