Evidence based practice (EBP) should be fundamental in every healthcare setting in the sense that it ensures decisions based on the best evidence integrated with clinical experience and the various expectations of patients within the healthcare setting (Gale & Schaffer, 2009). The main objective and aim in evidence-based practice protocols are to integrate the clinical expertise with the patient’s perspective and the scientific evidence in a bid to provide efficient and high quality healthcare services which are based on the needs, values, interests and culture of the patients served by the healthcare organization in question. It should be noted that evidence- based practice is essential as it does integrate the perspective of the patient, including values and culture in providing higher quality healthcare supported by research and scientific evidence (Gale & Schaffer, 2009). In essence it ensures the provision of quality and reliability of the healthcare services provided within the healthcare setting.

In regards to the healthcare organization I am currently employed by, and would opt for the implementation of EBP in, the organization is ready for the implementation of EBP in the sense that all stakeholders are in support of implementation of EBP protocols in the various units. Considering the fact that my organization is a very small critical access hospital in rural Georgia, with very limited resources, the organization is ready to fully adopt EBP. All stakeholders believe that such implementation is critical and vital for ensuring quality, and reliable healthcare service that is comprehensive and not only meets but exceeds the needs and expectations of our clients.

According to the survey, some respondents were in full support of the implantation of EBP, while others were not. It should be noted that the category scores for the survey varied due to the fact that respondents had a varied degree of preference when it comes to the implementation of EBP, and changes to practice within the facility. Most respondents responded higher in areas pertaining to changes in providing educational strategies according to EBP guidelines (Melnyk & Fineout-Overholt, 2015). Incorporating EBP within the facility basically requires all the organizational stakeholders to develop a culture of openness and inquiry since such implementation provides very clear parameters for quality and efficient care (Melnyk & Fineout-Overholt, 2015). Some of the notable barriers to the full implementation of EBP include lack of managerial commitment to the full implementation, lack of resources due to the size and financial situation of the facility. Above all lack of interest of upper management to assist staff in obtaining adequate skill and expertise to fully comprehend and implement EBP within the facility.

References part A

Gale, B. P., & Schaffer, M. A. (2009). Organizational readiness for evidence-based practice. Journal of Nurssing Administration, 39(2), 91-97. Retrieved from https://inf-fussion.ca/media/nurseone/page-content/pdf-fr/organizational-readiness-for-evidence-based-practice.pdf

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (3rd ed.). Philadelphia: .

Evidence-Based Practice Proposal- Section B: Problem Description

Problem Definition

Evidence- based Practice or EBP can help change and improve care in many different healthcare settings. It is essential therefore to assess the organizational-wide problems that require the most attention and implementation of EBP protocols. In the case of my individual organization the major problem that requires the most immediate attention is the problem of inadequate provision of quality and efficient healthcare services in the sepsis identified patient due to poor coordination among healthcare providers, physicians, and other key stakeholders within the facility. It should be noted that the major goal of every healthcare organization is to provide quality and reliability for patients seeking healthcare services (Melnyk & Fineout-Overholt, 2015). Statistics show that one out of four patients who become septic in the hospital will die due to the illness (Surviving Sepsis Campaign Guidelines Committee including the pediatric Subgroup [SSCGC], 2013). It is proven to be detrimental that these patients are identified very early and treated aggressively to decrease mortality, length of stay and reduce the cost of care. Utilization of EBP protocols during Emergency Department triage and care can provide safer, better quality care, saving lives, reducing length of stay and reducing cost of care for patients and third party payers. This should be the guiding principle of every healthcare organization, although it is the goal of this healthcare organization it has become very difficult for this organization to fully realize because of the lack of resources and poor integration of departments within the facility as well as the lack of coordination among healthcare providers, physicians and other key stakeholders. The problem of poor coordination among healthcare providers and physicians within the facility is the main contributor to inadequate provision of quality and reliable healthcare services within the facility. It is essential to adopt EBP with the facility to ensure quality and efficient care for all patients.

Stakeholders/change agents

Successful implementation of EBP requires efficient coordination of all units and cooperation among all stakeholders within the facility. These stakeholders form part of the change agent and they include individual providers, practitioners, nurses, patients, nurse managers and other key stakeholders within the facility. These change agents play an important role in facilitating change since they coordinate the flow of information about the proposed change (Melnyk & Fineout-Overholt, 2015). It is also important to note that these change agents support and champion for the innovation and help overcome any resistance to the proposed changes (Melnyk & Fineout-Overholt, 2015).

PICOT Question

In Emergency Department patients, over eighteen years of age, what impact does implementing sepsis evidence-based protocols have on the level of compliance among nurses with best practice recommendations (early identification, diagnosis and treatment, utilizing the use of lactate levels, cultures, and the sepsis bundle) in comparison to no protocol use?

The project purpose and objective

The main purpose and objective of this project is to ensure effective provision of quality, reliable patient care through the adoption of EBP sepsis protocols that 1) ensure efficient and effective coordination of care among nurses and other key stakeholders within the facility 2) establish patient potential for sepsis early 3) implement sepsis adult evidence based protocols within one hour.

Supportive rationale

Sepsis has been one of leading causes of death in healthcare facilities around the world for many years. Even with the many campaigns and availability of evidence for the early identification and treatment there is a continued higher death rate associated with cases of sepsis (McClelland & Moxon, 2014). Efficient coordination of nurses and other key change agents enables effective provision of quality care within the facility which results in more than adequate care and improved health and safety of patients within the facility (Melnyk & Fineout-Overholt, 2015). Adopting EBP sepsis protocols will result in several changes including a more engaged facility, improved communication among healthcare providers and staff and all around improved patient care. The problem of lack of coordination among healthcare providers and other healthcare staff has resulted in poor quality of healthcare services within this facility. Implementing EBP sepsis protocols will ensure higher coordination among providers and physicians which will result in improved sepsis identification and patient care.

EBP Proposal – Section E: Duck’s Change Curve Model References section B

McClelland, H., & Moxon, A. (2014). Early identification and treatment of sepsis. Nursing Times, 110(4), 14-17. Retrieved from www.nursingtmes.net/download?ac=1275356

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (3rd ed.). Philadelphia: .

Surviving Sepsis Campaign Guidelines Committee including the pediatric Subgroup. (2013, February). Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine, 41(2), 580-637. http://dx.doi.org/doi:10.1097/CCM.0b013e31827e83af

Search Method:

An extensive literature search for the most pertinent best practice evidence on providing care for the sepsis Patient was conducted, utilizing the following search engines; a) Cochrane Library, b) Cumulative Index to Nursing and Allied Health (CINAHL) via Grand Canyon University (GCU) Fleming Library, d) Proquest via GCU Fleming Library, e) Pubmed via National Center for Biotechnology (NCBI). The key words that were searched were categorized into three groups: a) by disease- utilizing, sepsis, septic and severe sepsis, b) Interventions utilizing, early identification, diagnosis, alert, guidelines, bundles, protocols, c) population utilizing, emergency room, emergency department, ED, ER all terms were consistently used throughout the data bases to ensure search consistency.

Inclusion/Exclusion Criteria:

Inclusion criteria included peer-reviewed articles, scholarly articles published in the English language with publications dated 2012 or later. Articles pertaining to adult patient population, with focus on early identification, diagnosis and treatment of sepsis patients in the Emergency department, identified or initiated performance improvement or other protocols with included interventions consistent with recommendations in the 2012 Surviving Sepsis Guidelines, or discussed barriers to implementing sepsis protocols in the Emergency department.

Exclusion criteria included articles that focused on the advanced care of sepsis patients in intensive care units, focus on obstetric patients or pediatric patients, focused on guidelines written prior to 2012, and most articles published before 2012.

Search results returned 10 articles, Cochrane Library returned not evidence meeting criteria, CINAHL returned 22 articles, Proquest returned 16 articles (after the removal of duplicates) 38 articles were reviewed and 10 articles were included. All studies included were appraised following the hierarchy of evidence, the majority of studies are level II as they are randomized control trials, or cohort studies, one level I systematic review and Meta-analysis study as well as one nonexperimental study and Clinical Practice Guidelines.

Summary of Research

The research found supports the clinical question and has been utilized in developing protocols for early identification and treatment of sepsis utilizing lactate levels, and sepsis bundles. All studies identified sepsis as being a time-critical medical emergency, requiring early intervention, making early identification and treatment with sepsis bundles key to patient survival. Mortality rates for sepsis is identified at 28% to 50% with a 7.6% increase for every hour without directed and specific interventions (Perman, Goyal, & Gaieski, 2012). Studies reviewed showed use of protocols in the emergency department increased education and awareness in emergency department nurses leading to an increased use of sepsis of sepsis guidelines, further proving nurses are vital to identifying patients presenting with sepsis and to early intervention and treatment protocols that demonstrated early screening interventions lead to expedited delivery of interventions and care for sepsis identified patients. Each study identified screening criteria including systemic inflammatory response syndrome (SIRS) including systolic blood pressure < 90mmHg, heart rate > 90 bpm, respiratory rate> 20, temperature > 38C or <36C, and presence of suspected or known infection (Hayden et al., 2015). All studies reviewed combined early warning scores (EWS) and introduction of evidence-based protocols, with early intervention using serum lactate levels, obtaining appropriate cultures and intravenous fluid resuscitation and early treatment with antibiotics can significantly reduce mortality in patients with severe sepsis and septic shock (McClelland & Moxon, 2014). The studies revealed that education alone was able to improve nurses compliance and adherence to resuscitation and management bundles, and reduced mortality rates. The inclusion of evidence based protocols and changes were associated with even more reduction in mortality rates (Damiani et al., 2015)

Limitations of Research studies

Limitations include some studies lacked generalizability, due to being single site, retrospective studies that the original information was not documented for the purpose of the study. One study although information was collected and documented for the study only a single site was included in the study. One study all the included studies were observational investigations and cannot support connection between performance improvement, increase in bundle compliance and decrease in patient mortality with uncomplicated septic shock or severe sepsis.

External validity as well generalizability of the different versions of protocols and resuscitation bundles was established. Patient populations of studies were representative of the adult emergency department patient population. The patient populations and data collected was typical of emergency department adult sepsis patient. Goal- directed therapy and protocols early was shown to decrease cost of care, significantly reduce mortality, and increase clinician adherence to clinical guidelines and modification of clinician behavior associated with identification of the sepsis patient.

The author expertise was unassailable, all recommendations are supported by high quality evidence and clinical guidelines. Most studies were observational and were dedicated to educating emergency department nurses on the importance of compliance with sepsis guidelines through the use of protocols (Gatewood, Wemple, Greco, Kritek, & Durvasula, 2015).

EBP Proposal – Section E: Duck’s Change Curve Model References Section C

Damiani, E., Donati, A., Serafini, G., Rinaldi, L., Adrario, E., Pelaia, P., … Girardis, M. (2015, May 6, ). Effect of performance improvment programs on compliance with sepsis bundles and mortality: A systematic review and meta-analysis of oberservational studies. PLOS One, 10(5). http://dx.doi.org/doi:10.137/journal.pone.0125827

Gatewood, M. O., Wemple, M., Greco, S., Kritek, P. A., & Durvasula, R. (2015, August 6,). A quality improvement project to improve early sepsis care in the emergency department. The Health Foundation Inspiring Improvement, 787-795. http://dx.doi.org/doi:10.1136/bmjqs-2014-003552

Hayden, G. E., Tuuri, R. E., Scott, R., Losek, J. D., Blackshaw, A. M., Schoenling, A. J., … Hall, G. A. (2015). Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. American Journal of Emergency Medicine, (), . http://dx.doi.org/Retrieved from

McClelland, H., & Moxon, A. (2014). Early identification and treatment of sepsis. Nursing Times, 110(4), 14-17. Retrieved from

Perman, S. M., Goyal, M., & Gaieski, D. F. (2012). Initial emergency department diagnosis and management of adult patients with severe sepsis and septic shock. Scandinavian Journal of Trauma, Resusitation & Emergency Medicine, 20(41). http://dx.doi.org/doi:10.1186/1757-7241-20-41

Evidence Based Practice Proposal- Section D

Proposed Solution

Quality of care for septic patients can improve through implementing simple low-cost EBP care bundles (Perman, Goyal, & Gaieski, 2012). This plan for changes in the early identification and treatment of adult sepsis patients > 18 years of age in the ED with best practice recommendations for identification and treatment with utilization of the International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. The proposed change will add an EBP protocol for changes in how the emergency department triage nurse and staff will screen adult patients for signs of sepsis Utilizing early warning scores (EWS) that trigger systems within the computer based program. For the EWS this protocol will follow the standardized national EWS or NEWS that was introduced in the UK. The use of NEWS for patients presenting with sepsis in the ED shows a positive correlation with increased NEWS scores during triage and adverse patient outcomes including Intensive Care Unit (ICU) admission and increased mortality (Keep et al., 2015). Utilizing systemic inflammatory response syndrome (SIRS) criteria, per the most recent Surviving Sepsis Campaign Guidelines. With a NEWS score of 3 or > triggering the initiation of the sepsis protocol, beginning with obtaining blood samples including; compete blood count (CBC), serum lactate, complete metabolic panel, cardiac isoenzymes, blood cultures, urine cultures and sputum cultures as needed, along with chest radiographs as defined by the Surviving Sepsis Campaign Guidelines of 2012 and initiation of intravenous fluid (IVF) resuscitation, antibiotics, and the sepsis bundles also defined by the guidelines (Dellinger et al., 2013). NEWS score of 3 is 92% effective in predicting patients at risk for severe sepsis and septic shock, with a specificity of 77% making NEWS the best potential trigger for use in early identification of potential sepsis (Keep et al., 2015). The activation of triggers will begin a series of steps that includes immediate transfer of the patient to an ED room, activation of codes sepsis alerting providers, and ancillary departments of a potential sepsis patient. ED staff will be educated on the policy and prior to implementation. ID badge clips that highlight all steps in the sepsis protocol will be given to all staff in the ED. The major changes will occur with the addition of NEWS score triggers within the computer based emergency department triage, and the addition of down time sepsis screening tools, alerting nurses to a NEWS score of < 3. Due to lack of resources only point of care blood glucose testing is available, all laboratory testing will be marked sepsis protocol, and be done in the hospital lab with a turn- around time of > 1 hour.

Organization Culture

This proposed plan will be implemented in Monroe County Hospital. The project is planned to begin an organizational initiative regarding sepsis, and to improve the care and outcomes of sepsis patients. The proposed plan can create a sense of urgency among staff regarding the timely and appropriate treatment of patients identified as potentially septic. Another possible strength is through success in the Emergency Department a hospital wide protocol can receive administrative support.

Expected Outcomes

The primary outcomes expected are; 1) increased staff compliance with NEWS score triggers, and sepsis EBP protocols that are defined by the Surviving Sepsis Guidelines. 2) Decreased patient mortality resulting from increased staff compliance with sepsis protocols and guidelines. 3) Decreased patient length of stay resulting from the increased compliance. 4) Facility wide sepsis protocols to increase the early identification and treatment of sepsis patient previously admitted following the guidelines defined in the Guidelines for Surviving Sepsis 2012 (SSGL 2012).

Methods to achieve Outcomes

Achieving the outcomes will begin with introduction of the NEWS screening tool, introduction of Systemic Inflammatory Response Syndrome (SIRS) criteria. Sepsis is confirmed by 3 or more clinical indicators, known infection or both.

The educational strategies will begin with group educational inservice meetings. Requiring that all nurses fulltime, part time and PRN or as needed staff attend and are educated on the NEWS score, SIRS criteria, blood samples and testing, cultures, and IVF resuscitation, antibiotic therapy and sepsis bundles. All nurses will have a group educational training session with computer training on computer changes, the NEWS triggers as activated by SIRS criteria. This will include the education and training of physicians, ancillary staff, and other providers on the NEWS Triggers, SIRS criteria, code sepsis alerts, IVF resuscitation and all other sepsis guidelines and testing to be included in the sepsis EBP protocol. There will be one on one training with all triage trained nurses in the ED ensuring their understanding of SIRS criteria and NEWS triggers. Education on the importance of early identification as the key to survival, good clinical assessments and history to ensure accurate diagnosis and early intervention (Tromp et al., 2010). There will be an ongoing educational training phase that will include the training of all other nurses and any newly trained triage nurses and newly hired nurses on all the same information the initial triage nurses were given.

Barriers

Barriers to be assessed are limited to laboratory and radiology staff, by implementing and training on the code sepsis all departments will be alerted, there will be mock drills done to train all involved departments in preparation of protocol implementations. Physician buy in is another barrier, this will be eliminated through education on SSGL 2012 and through passing the protocol through the Medical Executive Committee.

Quality care improvement and patient centered quality care- Quality of care will be improved through early identification of potential sepsis, decreasing time to appropriate antibiotics and IVF resuscitation (Hayden et al., 2015). Early intervention is proven to significantly reduce patient mortality, length of stay, and cost of care. Studies are showing implementing nurse-driven care bundles based on the 2012 guidelines, followed with training and performance improvement feedback results in early identification and treatment of patients presenting to the ED with sepsis or severe sepsis and shock (Tromp et al., 2010).

Efficiency of Processes

One of the JCAOH National Patient Safety Goals for 2016 identified effective communication as one of the goals, the update includes get important information to the correct staff in 30 minutes or less. Initiation of sepsis care bundles and code sepsis alerts all staff, physicians and other departments, of the patient arrival decreasing time to test results and time to treatment interventions. Increasing knowledge of sepsis screening and providing knowledge of communication will support nurses in providing positive sepsis screening to providers in a timelier manner (Drahnak, Hravnak, Ren, Haines, & Tuite, 2016).

Environmental changes

Environmental changes include an increased awareness of sepsis throughout the facility, increasing the possibility of implementing protocols for early detection of severe sepsis on Medical Surgical Units reducing patient mortality and reducing the need for admission to the need for admission to ICU (Westphal et al., 2011).

Professional Expertise

By increasing nurses’ knowledge and awareness of sepsis and treatment protocols for sepsis, there is positive effects on professional expertise. Nurses will be introduced to best practice guidelines and best available research on sepsis identification and treatment, increasing the awareness and expertise in the care of sepsis patients. Providing tools and education for ancillary staff and physicians will also produce professional expertise in other care areas and providers.

EBP Proposal – Section E: Duck’s Change Curve Model References Section D

Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S., … Moreno, R. (2013). Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock:2012. Retrieved from www.sccm.org/Research/Quality/Pages/Surviving-Sepsis-Campaign.aspx?gclid=cotcw_qcbdECFRc7gQod0M8POQ

Drahnak, D. M., Hravnak, M., Ren, D., Haines, A. J., & Tuite, P. (2016, July-August). Scripting nurse communication to improve sepsis care. Medsurge Nursing , 25(4), 233-239. Retrieved from https://lopes.idm.oclc.org/login?url=http://search.ebscohost.come/login.aspx?direct=true&db=ccm&AN=117499579&site=eds-live&scope=site

Hayden, G. E., Tuuri, R. E., Scott, R., Losek, J. D., Blackshaw, A. M., Schoenling, A. J., … Hall, G. A. (2015, April 27). Triage Sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. American Journal of Emergency Medicine, 34, 1-9. http://dx.doi.org/http://dx.doi.org/10.1016/j.ajem.2015.08.039

Keep, J., Messmer, A., Burrell, N., Pinate, R., Tunnicliff, M., & Glucksman, E. (2015). National early warning score at Emergency Department triage may allow earlier identificaion of patients with sever sepsis and septic shock: a retrospective observational study. Emergency Medicine Journal, 33, 37-41. http://dx.doi.org/doi:10.1136/emermed-2014-204465

Perman, S. M., Goyal, M., & Gaieski, D. F. (2012). Initial emergency department diagnosis and management of adult patients with severe sepsis and septic shock. Scandinavian Journal of Trauma, Resusitation & Emergency Medicine, 20(41).