Manual paper or electronic tools guide clinicians through the criteria as they assess a patient. The screening process generally takes place either during a care transition (e.g., presentation at the ED or to EMS) or at regular intervals (e.g., the start of every nursing shift). A tool’s embedded logic determines if the patient is suspected of having sepsis. If so, the clinician must start treatment as quickly as possible, which has been shown to increase survival. Prehospital and nursing home The sensitivity and specificity of prehospital and nursing home screening tools varies widely. Seven of the eight prehospital studies were retrospective and they were addressed in a 2016 systematic review by Smyth and colleagues that found low to very-low quality evidence for the accuracy of prehospital sepsis screening tools. 39 The authors attributed this to lack of EMS personnel training about sepsis and the inaccuracy of using SIRS criteria alone. They conclude that more validation studies are needed to determine the efficacy of prehospital sepsis screening tools. The ultimate goal of a patient safety practice is to improve the patient outcomes. Three sepsis screening tools were studied prospectively and measured patient outcomes: one in the prehospital setting and two in the hospital setting. All three studies were observational in design and had low to moderately sized samples. The outcomes studied were mortality, ICU admissions rate, and ICU LOS. Attributing improvement in these outcomes to sepsis screening tools is difficult, however, because patients with sepsis are generally older, have multiple comorbidities, and may have advance directives for end-of-life care. In addition, reasons for ICU transfer and ICU LOS are multifactorial and not necessarily correlated with sepsis or the use of a screening tool. Hunter et al. was the only prehospital study that measured patient outcomes. This study involved an EMS screening tool with a subsequent alert to the hospital; it found a significant reduction in ICU admissions rate (33% with screening vs. 52% without screening, p=0.003), and a non-significant reduction in mortality (11% with screening, 14% without screening, p=0.565). 40 Hospital In the hospital setting, Tedesco and colleagues found that a nurse-administered screening tool in the ED of a 320-bed community hospital led to a significant reduction in mortality (18.4% vs. 13.2% days; P = 0.015). 41 Larosa and colleagues implemented an ICU sepsis screening tool in a 673- bed urban teaching hospital and found a significant reduction in mortality after controlling for factors such as mortality in emergency department sepsis (MEDS) score, leucopenia, and age (p=0.01). However, the sample size for this study was quite small (n=58). 42 Despite the lack of conclusive evidence of effectiveness, use of tools to screen patients for signs of sepsis is widespread due to the urgency
for identifying sepsis, and based on guidelines and hospital quality performance measures. However, implementing these tools can prove challenging in terms of resource use and workflow change for staff. Two common facilitators are education of the clinical staff who will be responsible for administering the screening, and a tool that is easy to learn and use. First, educating nurses and EMS staff about sepsis pathophysiology helps them to better understand and interpret screening parameters, just as these staff are trained to recognize signs of stroke or cardiac arrest. This education may have the additional effect of increasing sepsis care quality, independent of the screening tool itself. Authors stressed that screening tools cannot substitute for the clinical acumen of staff. Second, a tool should be as easy as possible to fit into a clinician’s workflow, such as a checklist using a selected number of readily available or routinely collected variables. As a result, lab test results were generally excluded from screening tools. However, it is important to balance the simplicity of a tool and its ease of use with strong sensitivity and specificity. Other facilitators mentioned in these studies included consistent and complete documentation of vital signs on which screening algorithms are based, and standardized use of the tool across hospital units to reduce confusion and communication breakdowns when patients or staff move between units. Screening every patient for signs of sepsis on a regular basis is labor and time intensive, regardless of the setting. The yield in terms of identifying emerging sepsis may also be low, depending on the prevalence of sepsis in the setting in question. Additionally, the frequency of screening (for example, once per hospital shift) can delay diagnosis of sepsis, defeating the purpose of the screening tool. As a result, transitions of care such as EMS ambulance transport and ED admission are often targeted as optimal times for screening. Other potential barriers include alert fatigue if the tool used is not specific enough, and a possible increase in drug resistance from more and longer use of antibiotics. However, there is no reported evidence about these effects. Finally, without proper training and an easy-to-use tool, adherence by clinical staff may be suboptimal, as reported by O’Shaughnessy et al., diminishing potential benefits. Sepsis patient monitoring systems Automated electronic patient monitoring (i.e., surveillance) for signs of emerging sepsis is becoming more widespread, especially in hospitals. Such systems automatically and continuously monitor data from telemetry devices and/or electronic health record (EHR) entries, and alert a clinician if set criteria for sepsis are met. If, after evaluation, a clinician determines that the patient has sepsis, the clinician must start treatment immediately to reduce mortality and improve patient outcomes. The goal is to decrease the time to treatment initiation for sepsis, which has been shown to increase survival.
An automated surveillance system is less time consuming for staff than manual screening for sepsis and alerts clinicians in near real time to a patient’s deteriorating condition, more quickly than most manual screening strategies. However, implementing an automated PMS for sepsis can be difficult technologically, financially, and in terms of workflow changes for staff. The studies we reviewed identified supporting factors that facilitate PMS implementation, as well as barriers to successful PMS implementation. As with manual screening tools, implementing a PMS will be effective only if the system has a high level of sensitivity and specificity, to engender clinician trust and reduce false-positive alerts. To achieve this, some prospective studies iteratively revised thresholds for key values, with input from the clinicians, to optimize tool performance. Some more recent studies used machine learning to optimize system performance. To improve system usability, input from clinicians was solicited in some studies, followed by adaptations. These included allowing a nurse to “snooze” an alert for 6 hours if the patient is already under assessment for sepsis, or implementing a “traffic light” system on a dashboard to visually show clinicians which patients are in a warning zone (yellow) or need urgent attention (red). Other facilitators include: consistent and complete input of vital signs on which the PMS relies, having a specific staff member assigned to receive all alerts and determine if a physician needs to be called, and designing the PMS to work reliably even if data are incomplete. Building an automated PMS from scratch is costly, but several PMS systems are now available as an add-on EHR or telemedicine module, which is more efficient for a hospital than designing and testing a de novo system. The nonspecific nature of sepsis makes achieving a highly predictive system difficult, whether on paper or in an automated PMS. This is particularly difficult in pediatric settings because the “normal” ranges for vital signs are age dependent and more difficult to fine tune. In addition, if the electronic monitoring and alerting system is poorly designed or difficult to use, it can lead to clinician confusion, frustration, and possibly to worse patient care. For example, if the alert physicians receive contains too little information (or too much), or if the action required is not clear, physicians may find the system too difficult or burdensome to use. Lack of adequate staff training on using the system is also a potential barrier, even if a system has high sensitivity and specificity. Additionally, the cost of designing and implementing a PMS can be prohibitive for smaller hospitals, and while an EHR add-on can reduce cost, it may result in less customizable functionality. Finally, after a system is implemented, refining the algorithm and updating it based on changing sepsis criteria require close work with the facility’s IT department, which can be resource and time intensive.
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