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Mortality from severe sepsis remains unacceptably high at around 30–50%.1 Globally about 1400 people die each day from sepsis-related illness. The Surviving Sepsis Campaign was introduced in an attempt to improve the diagnosis and management of severe sepsis. Its aims include a commitment to reduce global mortality from severe sepsis by 25% within 5 years (www.survivingsepsis.com). One method of achieving this mortality reduction is by the local implementation of the sepsis-care bundle, a series of evidence-based interventions shown to improve outcome in patients with sepsis.2
We recently began a pilot campaign to implement the sepsis-care bundles in accident and emergency departments. We devised sepsis-bundle pathways and protocols, and spent considerable time educating the appropriate clinical and nursing staff in their use. We then audited the success of our implementation process in the hope of identifying any problems that may benefit other institutions going down the same road as ourselves.
Our audit was carried out over a 3-month period in early 2006, in our busy accident and emergency department at the district general hospital. During this time, we noted that 16 patients were entered into our pathway (fig 1). Disappointingly, of these 16 patients, only four had all the recommended investigations and interventions completed. We then tried to identify the reasons for difficulties in implementing and adhering to the sepsis-bundle pathway.
In the busy accident and emergency department, more paperwork and another protocol to follow means more time spent with individual patients. With the current time pressures and the high turnover of patients, this was not easy for clinicians. Also, at a more basic level, busy clinical and nursing staff would often simply forget to apply the specifics of the pathway to their patients.
We noted that the feeling among some accident and emergency department staff was that there is no need for a new protocol in the management of patients with sepsis. Many staff thought that most of the interventions described in the protocol, such as blood tests, blood cultures, fluid boluses and antibiotics, were already being implemented in an appropriate and timely manner, often well within the recommended 6 h stated in the sepsis bundle. In particular, we noted a reluctance to measure concentrations of serum lactate. This suggests a lack of understanding of the importance of this biochemical marker. Indeed, hyperlactataemia is most important in assessing any patient with sepsis, and ignoring it could easily lead to underestimation of the severity of illness in a patient with sepsis.2
It may therefore prove to be far harder to implement these guidelines than was originally envisaged, especially with accident and emergency departments under increasing pressure to meet targets. Education will obviously play a key part; it is evident that there is a disparity between the evidence-based practice we strive for and the daily clinical practice we undertake. The sepsis bundle can save lives only if it is implemented correctly and appropriately by those making initial assessment and management decisions in patients with sepsis.
Competing interests: None declared.
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