Write a summary of each of the articles that you identified in Topic 2.
Address the following:
Write one research summary that uses a quantitative research design.
Write one research summary that uses a qualitative research design.
Each summary should be 250-500 words and should follow the template provided in "Summarize Research Articles."
Use APA Level Heading 2 to separate the distinct parts of the study.
These article summaries will form the basis of the Critique of Research Studies Parts 1-3 assignments in Topics 4, 6, and 8.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are not required to submit this assignment to Turnitin.
NUR 504 Summarize Research Articles
Directions: Use the templates below when summarizing your research articles. Include a cover page, and start a new page for each article summary. Use level 1 and 2 headings when composing the summaries to separate distinct parts.
Title of Quantitative Article
(Example of text: This article was authored by Watson and James and published in the Journal of Nursing Research in 2008. This article was selected as an example of a quasi-experimental design. The model summary selected for this paper is found in the textbook. This is a summary of a quasi-experimental study in which though there is a comparison group; subjects were not randomly assigned to groups. The research article being summarized also is an experiment that used a comparison group without randomization.)
Statement of Purpose
Title of Qualitative Article
(Example of text: Ramirez (2008) studied adolescent depression and the influence of significant adults on the course of the depression. The model summary utilized is found in the textbook. It was selected because it is an example of a grounded theory study as is the article selected.)
Statement of Purpose
Please use the two attached articles for the analysis, that is required for the assignment.
the article is titled: A Qualitative Investigation of Patients` and Caregivers` Experiences of Severe Sepsis
..A Qualitative Investigation of Experiences of Severe Sepsis page 1.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 2.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 3.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 4.pdf..A Qualitative Investigation of Experiences of Severe Sepsis page 5.pdf
..Quantitative study The role of nurses.pdf
the DOI: :10.1016/j.ijnurstu.2010.04.007
The role of nurses in the recognition and treatment of patients with sepsis
in the emergency department: A prospective before-and-after
Mirjam Tromp a,b,
*, Marlies Hulscher c
, Chantal P. Bleeker-Rovers a,b
, Lilian Peters d
Danie¨lle T.N.A. van den Berg b
, George F. Borm e
, Bart-Jan Kullberg a,b
, Theo van Achterberg c
Peter Pickkers a,f
aNijmegen Institute for Infection, Inflammation, and Immunity (N4i), Radboud University Nijmegen Medical Centre, The Netherlands
bDept of Internal Medicine, Radboud University Nijmegen Medical Centre, The Netherlands
c Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, The Netherlands
d Emergency Dept, Radboud University Nijmegen Medical Centre, The Netherlands
eDept of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, The Netherlands
Dept of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, The Netherlands
International Journal of Nursing Studies 47 (2010) 1464–1473
Received 4 September 2009
Received in revised form 16 March 2010
Accepted 24 April 2010
Quality of health care
Background: In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce
mortality from sepsis, was launched. Although the SSC supplies tools to measure and
improve the quality of care for patients with sepsis, effective implementation remains
troublesome and no recommendations concerning the role of nurses are given.
Objectives: To determine the effects of a multifaceted implementation program including
the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training
and performance feedback.
Design and setting: A prospective before-and-after intervention study conducted in the
emergency department (ED) of a university hospital in the Netherlands.
Participants: Adult patients (16 years old) visiting the ED because of a known or
suspected infection to whom two or more of the extended systemic inflammatory
response syndrome (SIRS) criteria apply.
Methods: We measured compliance with six bundled SSC recommendations for early
recognition and treatment of patients with sepsis: measure serum lactate within 6 h,
obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine
for urinalysis and culture, start antibiotics within 3 h, and hospitalize or discharge the
patient within 3 h.
Results: A total of 825 patients were included in the study. Compliance with the complete
bundle significantly improved from 3.5% at baseline to 12.4% after our entire
implementation program was put in place. The completion of four of six individual
elements improved significantly, namely: measure serum lactate (improved from 23% to
80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from
49% to 67%), and start antibiotics within 3 h (from 38% to 56%). The mean number of
performed bundle elements improved significantly from 3.0 elements at baseline to 4.2
elements after intervention [1.2; 95% confidence interval = 0.9–1.5].
* Corresponding author at: Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Internal postal code 495, PO box 9101, 6500
HB Nijmegen, The Netherlands. Tel.: +31 24 3617088; fax: +31 24 3617086.
E-mail address: [email protected] (M. Tromp).
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
0020-7489/$ – see front matter 2010 Elsevier Ltd. All rights reserved.
What is already known about the topic?
Rapid diagnosis and management of sepsis are crucial for
successful treatment, but implementation of and compliance
to the Surviving Sepsis Campaign guidelines
Care bundles can be used for the implementation of
No specific role for nurses is described in the Surviving
Sepsis Campaign guidelines.
What this paper adds
Using a nurse-driven, care bundle based, sepsis protocol
followed by training and performance feedback results in
improved early recognition and treatment of patients
with sepsis who present to the ED.
More attention should be given to the role of nurses in
quality improvement of sepsis care.
Approximately 2% of all hospitalized patients are
diagnosed with severe sepsis or septic shock. Intensive
care and the long recovery period for patients with sepsis
come with considerable costs, and the mortality rate
remains high: 30–40% for patients with severe sepsis and
40–50% for those with septic shock (Angus et al., 2001;
Dellinger et al., 2008; Gao et al., 2005). Rapid diagnosis and
management of sepsis are crucial for successful treatment
(Dellinger et al., 2004); early goal-directed therapy and
antibiotic treatment within 3 h after admission have
proven their value (Levy et al., 2003; Rivers et al., 2005).
In 2004, the Surviving Sepsis Campaign (SSC) was
launched by the European Society of Intensive Care
Medicine, the International Sepsis Forum, and the Society
of Critical Care Medicine. The SSC is a global initiative to
create an international effort to improve the treatment of
sepsis and reduce sepsis mortality. The SSC provides
helpful tools and implementation techniques for improving
rapid diagnosis and management of sepsis and for
measuring and improving the quality of care for patients
with sepsis. The most important SSC recommendations are
summarized in ‘‘6-h’’ and ‘‘24-h’’ bundles, also referred to
as the resuscitation and management bundles (Dellinger
et al., 2008).
A bundle is a group of three to six care elements related
to a disease process. When executed together, the
performance of the care elements produce better outcomes
then when implemented individually. The individual
bundle elements are built on evidence-based practice
guidelines and provide healthcare workers with a practical
method for implementing evidence-based practice (Fulbrook
and Mooney, 2003; IHI, 2006a,b). According to the
IHI, the creator of the bundle, a bundle should be small and
straightforward. The impact of a bundle depends both on
the evidence that supports the recommended care process
and on the implementation and spread of its recommendations
(Marwick and Davey, 2009). Various care bundles
have been created, including the ventilator care bundle,
the central line bundle, and the sepsis bundle.
Although the SSC recommendations, described in the
sepsis bundle, focus on those patients with severe sepsis or
septic shock, all patients with sepsis need to be screened so
that we can recognize those most affected. Since most
patients with sepsis present themselves at the emergency
department (ED), this department is an important location
for early recognition and treatment of sepsis (Osborn et al.,
2005; Shapiro et al., 2006; Wang et al., 2007). However,
implementation of the SSC recommendations at the ED
appears to be difficult; the overall level of compliance to
the bundle and the compliance to the individual elements
remains low (Baldwin et al., 2008; De Miguel-Yanes et al.,
2006; Levy et al., 2010).
The literature provides a large number of different
strategies to implement innovations like the SSC recommendations,
e.g., educational meetings, reminders, and
audit and feedback. Many studies have assessed the
effectiveness of these strategies for improving patient
care and many reviews have summarized them; for
example the numerous reviews listed by the Cochrane
Effective Practice and Organisation of Care group (http://
In general, evidence shows that
none of these strategies is superior; most show mixed
results. Substantial evidence suggests that successful
implementation strategies should be based on obstacles
and facilitators to change (Bero et al., 1998; Grimshaw
et al., 2001; Grimshaw et al., 2004).
Various obstacles and facilitators may influence successful
implementation of the SSC recommendations.
Nurses are often the first to triage a patient, and they
have an important role in recognizing patients’ signs and
symptoms. Nevertheless, the role of nurses is not formalized
in guidelines and is not fully exploited at this time
(Funk et al., 2009; Kumar et al., 2006). In daily practice, a
multidisciplinary protocol for patients with sepsis proved
to facilitate the recognition and treatment of sepsis (Ferrer
et al., 2008; Jones et al., 2007; Nguyen et al., 2007a).
However, recognizing patients with sepsis can be difficult;
lack of detailed knowledge was shown to impair the
recognition (Carlbom and Rubenfeld, 2007; Robson et al.,
2007). For example, only about 20% of the nurses thought
Conclusions: Early recognition of sepsis in patients presenting to the ED and compliance
with SSC recommendations significantly improved after the introduction of a
predominantly nurse-driven, care bundle based, sepsis protocol followed by training
and performance feedback.
2010 Elsevier Ltd. All rights reserved.
M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1465
that a temperature less than 36 8C or a low white cell count
could be a sign of sepsis (Robson et al., 2007).
Using this information on obstacles and facilitators,
we developed an implementation program to implement
the SSC recommendations in our ED. As nurses are
important in the triage of patients presenting to the
ED, we specifically focused on nurses and their role
in the recognition and treatment of patients with sepsis.
To improve nurses’ ability to recognize sepsis and
SSC-recommended care, we introduced a care bundle
based sepsis protocol and trained ED nurses about the
signs and symptoms of sepsis. During the development
of the implementation program, it turned out that
insight into the performance of the sepsis bundle
and the individual elements by the ED nurses was
lacking. Therefore, feedback about their performance
was part of the implementation program. The aim of
the current study was to determine the effects of
our implementation program for following SSC-based
We conducted a prospective before-and-after intervention
study in which we carried out two consecutive
interventions: the use of a newly developed, nurse-driven,
care bundle based, sepsis protocol (intervention 1) and
training about sepsis that included feedback about
performance before and after the sepsis protocol was
introduced (intervention 2).
The study consisted of three dense measurement
Period 1: Before using the new care bundle based sepsis
protocol (July 1, 2006–November 6, 2006).
Period 2: After the sepsis protocol was put to use
(November 6, 2006–June 25, 2007) and before training
and performance feedback.
Period 3: After training and performance feedback (June
25, 2007–October 1, 2007).
In most implementation programs, it is not possible to
disentangle the separate effects of the various implementation
activities (Grimshaw et al., 2004). The two
consecutive interventions were followed by measurement
periods, so that we could measure the effects of introducing
a protocol and the additional effects of training and
2.1. Study setting and population
Every year, approximately 20,000 patients visit the ED
of a 953-bed university hospital in the Netherlands, where
35 registered nurses are employed. The study inclusion
criteria were: adult patients (16 years old) visiting the ED
because of the presence of a known or suspected infection,
to whom at least two of the following diagnostic criteria for
systemic inflammation apply: temperature greater than
38.3 8C, temperature less than 36 8C, heart rate greater than
90/min, respiratory rate greater than 20/min, cold chills,
altered mental status, systolic blood pressure less than
90 mm Hg, mean arterial pressure less than 65 mm Hg, and
hyperglycaemia in the absence of diabetes mellitus (Levy
et al., 2003; Nguyen et al., 2006). Patient data were
collected from July 1, 2006 until October 1, 2007.
2.2. Implementation program
The ED manager and three ED nurses (our ‘‘contact
nurses’’) were involved in the process of developing the
2.2.1. Development of a care bundle based sepsis protocol
A sepsis protocol (hereafter referred to as ‘‘protocol’’)
for nurses and physicians in the ED was developed by a
multidisciplinary team including an intensivist, ED internist,
a surgeon, a medical microbiologist, a clinical
pharmacist, ED nurses, and a nurse practitioner. Everybody
involved was familiar with the hospital organization,
organization of the ED, and the physicians and nurses
working in the ED (Grol et al., 2005; Wensing et al., 2006).
They developed a protocol, based on the SSC care bundle
mechanism (Burgers et al., 2003; Shapiro et al., 2005a,
2008). For the selection of the required bundle elements,
two different levels of evidence were used: evidence-based
practices described in the present sepsis guidelines (Green
et al., 2008; Robson and Daniel, 2008; Shapiro et al.,
2005b), and expert opinion.
The content of the protocol was discussed with the ED
manager and the three contact nurses. The nurses
suggested including the hospitalization or discharge of
the patient from the ED within 3 h as an additional bundle
element. The final protocol consisted of two parts: a sepsis
screening list for nurses and a sepsis performance list,
including seven bundle elements.
22.214.171.124. Sepsis screening list. The screening list was developed
to help the nurses identify patients with sepsis. The
nurses had to note any focus suspected of being infectious
and the two or more systemic inflammatory response
syndrome (SIRS) criteria on the screening list. Then the
physician had to be informed of the identification of a
patient with sepsis.
126.96.36.199. Sepsis performance list. To guide the nurses and
physicians in the ED, we developed a list with seven
relevant bundle elements. They were:
1. Measure the serum lactate concentration within 6 h
2. Obtain two blood cultures before starting antibiotics
3. Make a chest radiograph
4. Take a urine sample for urinalysis and culture
5. Start antibiotics within 3 h
6. Volume resuscitation in case of serum lactate
>4.0 mmol/L or hypotension
7. Hospitalize or discharge the patient within 3 h.
The nurses and physicians were expected to take
elements 1–5 and 7 for all patients included in the
protocol. Element 6 (volume resuscitation) was only
necessary in case the included patient had a serum lactate
>4.0 mmol/L or hypotension.
1466 M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473
It was agreed that, after identifying a patient with
sepsis, the responsible nurse should start immediately
with obtaining blood for chemistry tests and culture, and
urine for urinalysis and culture. Furthermore, prior to the
implementation of the protocol, we agreed with our
radiologists that, in patients included in the protocol, a
chest radiograph would be performed without a physicians’
prescription. Finally, the nurses played an important
role in timely obtaining the physician’s prescription for
To collect all data and for the general necessity of
accurate registration of the performed elements, the
nurses had to sign off the performed elements and note
the time they were done on the performance list.
After it was fully developed and accepted by all those
involved in sepsis care, the protocol was placed on the
University Medical Centre (UMC) Intranet website, available
to all UMC employees, to facilitate access to it.
2.2.2. Initiation of the sepsis protocol (intervention 1)
The new protocol was formally introduced during the
change of duty in the ED on November 6, 2006. From that
moment on, the protocol was available to the ED. In
addition to the formal introduction, all the ED nurses
received an e-mail message with instructions about how to
use the screening and performance lists. They were
emphatically asked to use the lists each time a patient
met the inclusion criteria. If there were any questions, the
nurse practitioner in the implementation team could be
reached during office hours or by e-mail.
As part of this implementation strategy, the contact
nurses were repeatedly requested to motivate and assist
the other ED nurses in using the protocol. In the meantime,
data collection was started. One of the contact nurses (LP)
was frequently consulted about implementation issues,
such as incomplete filled out screening and performance
lists. The ED nurses’ questions were answered personally
or by e-mail.
2.2.3. Training and performance feedback (intervention 2)
Six months after initiation of the protocol, training
began. Training about sepsis, and the presentation of
feedback on performance data of periods 1 and 2, took
place during a department meeting for all ED nurses on
June 25, 2007. The training focused on sepsis, severe sepsis,
septic shock, and the clinical importance of early recognition
and treatment. Although they could not provide data
to support this, the nurses presumed that their compliance
to the bundle was already optimal at baseline. Therefore,
the training also included performance feedback. Feedback
about the group performance of the bundle elements in the
first two periods was presented, as were changes in the
performance of each element from the first to the second
period. Feedback focused on the elements which the
nurses and physicians were generally completing adequately
and those that needed more attention. The aim of
the presentation was to give the nurses a clear overview of
their own practice and to encourage them to improve the
diagnosis and management of sepsis. Further, the nurses’
experience with applying the protocol in daily practice was
evaluated by means of short interviews. Finally, to reach
the whole group of nurses in the ED, all of them received
the presentation by e-mail, and a poster was presented in
the ED. Besides the group training and performance
feedback intervention, the contact nurses and nurse
practitioner gave regular feedback to the individual ED
nurses on their use of the protocol.
To improve the physicians’ knowledge about sepsis and
the use of the protocol in the ED, the intensivist instructed
every new group of ED residents every 2 months. This
training started at the end of February 2007. A training
program and a conference for medical residents were
organized (Tromp et al., 2009).
2.3. Data collection and processing
Data collection included patient data and performance
data. The data collection team consisted of a nurse
practitioner, an undergraduate, and an internist.
2.3.1. Patient data
The relevant patient characteristics included gender,
age, suspected focus of infection, and final documented
diagnosis at the time of discharge from hospital. Information
about the clinical end points included the length of the
hospital stay and the in-hospital mortality rate. The
baseline data were collected by retrospectively checking
the diagnoses on the ED admission list for patients with
sepsis. The required data (including the two or more
diagnostic criteria for systemic inflammation) were
collected from the clinical patient databases, medical
records, and nursing records. The final documented
diagnoses were obtained from medical discharge records.
After use of the protocol was started, the data were
prospectively collected from the screening and performance
lists. Missing data were collected from the clinical
patient databases, medical records, and nursing records. If,
during the study period, a patient with sepsis was
registered at the ED more than once, he/she was included
in the study each time.
Although most of the patients with sepsis were triaged
and included in the protocol by the nurses, some patients
were erroneously not included in the protocol by them: the
nurse did not recognize a patient with sepsis or forgot to fill
out the screening and performance list. To compare the
differences in the performance of the bundle elements
between those patients included in the protocol by the
nurses and those who were not, the patients who were not
included in the protocol were still included in the study. To
recover patients who were undeservedly not included in
the protocol, we retrospectively checked the diagnoses
against the ED admission list for patients with sepsis.
2.3.2. Performance data
The goal of the protocol was to improve and evaluate
the care of the total group of patients with sepsis, and not
only those with severe sepsis or septic shock. Since high
serum lactate concentrations and/or hypotension only
occurs in a small proportion of the patients with sepsis
who present themselves at the ED, early goal-directed
therapy was included as a bundle element in the protocol
(element 6) but not included as a measure of protocol
M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1467
adherence for this study. Therefore, completion of six
bundle elements and compliance with them were measured.
Baseline performance data were collected from
clinical patient databases, medical records, and nursing
records. After use of the protocol was started, all data were
collected from the performance lists. Missing data were
collected from the clinical patient databases, medical
records, and nursing records.
2.4. Data analysis
The primary outcome measure was compliance with
the bundle of six elements and the completion of the
individual elements. The theory behind care bundles is that
when several evidence-based interventions are grouped
together in a single protocol, it will improve patient
outcome. Although the study was not powered to
demonstrate a statistically significant effect on the clinical
end points, we included the length of the hospital stay and
the in-hospital mortality rate as secondary outcome
Descriptive statistics regarding the performance of the
bundle of six elements, the performance of the individual
elements, length of hospital stay, and mortality rate
included frequencies, percentages, medians, and means.
The compliance was expressed as a percentage, and the
compliance to the bundle was also expressed as the total
number of elements that were correctly performed (on a
scale of 0–6).
To analyze the differences in compliance between the
measurements, both overall and for each of the six
separate elements, we used a generalized linear model
with a logarithmic link and Bernoulli distribution function.
In our secondary, subgroup analysis, we added the impact
of the nurses’ triage in periods 2 and 3 as a cofactor.
In a similar way, analysis of variance was used to
compare the mean of the total number of times that the
elements were correctly taken between baseline and the
two post-intervention measurements. Each of many
nurses treated several patients, which had to be accounted
for in the statistical analysis. Therefore, we estimated the
intraclass correlation coefficient, based on a mixed model
analysis of the cases in which the nurse was known, and we
used this coefficient to adjust the results of the analysis of
variance of all data.
3.1. Patient population
The study included 825 patients presenting with sepsis
at the ED (Fig. 1). There were no statistically significant
differences in patient characteristics per period (Table 1).
Eighty-nine percent of the participants were admitted to a
nursing ward or intensive care unit. The ED nurses
registered pneumonia and urogenital infection as the
most commonly suspected infections. In 680 of the 825
cases (82%), the final diagnosis was a bacterial infection,
most commonly in the lungs (33%), followed by urinary
tract and/or genitalia infections (21%).
3.2. Effects on performance of the bundle and the bundle
In 731 of 825 cases, information about all six elements
was available. In 3.5% of the cases in period 1, all six
elements were performed and improved significantly to
10.8% after period 2, and 12.4% after period 3 (Table 2).
When analyzing the completion of the individual
elements, there was a significant improvement in
completing three of six elements after period 2
(Table 2), and there was a significant improvement in
completing four of the six elements after period 3: measure
serum lactate (improved from 23% to 80%), take a chest
radiograph (from 67% to 83%), take urine for urinalysis and
culture (from 49% to 67%), and start antibiotics within 3 h
(from 38% to 56%).
The mean number of performed bundle elements
improved significantly in period 2 versus period 1 (from
3.0 to 3.9, 95% CI = 0.7–1.2) and further increased after
period 3 (from 3.9 to 4.2, 95% CI = 0.03–0.5), as Fig. 2 shows.
The outcome of the analysis of variance of all cases
(n = 825) is comparable to the outcomes of cases with
complete data. Furthermore, no differences between the
analysis of variance of all data and the analysis of only the
cases for which the nurse was known were found.
3.3. Recognition of patients with sepsis
We examined whether patients were erroneously not
included in the protocol by the nurses, and it turned out
that in period 2, 71% of the cases were included in the
protocol by the ED nurses and this percentage further
improved to the inclusion of 82% patients with sepsis in
period 3 (p = 0.005).
In the patients with sepsis that were erroneously not
included in the protocol by the nurses, we also examined
whether the compliance with the bundle elements was
different. For 589 of the 666 cases included in periods 2 and
3, information about the completion of all six elements was
available (88%). The subgroup analysis of the impact of the
nurses’ inclusion showed that the completion of the six
elements in the cases that were included by the nurses was
significantly better (1.2 elements more; 95% CI = 1.0–1.4)
Fig. 1. Overall number of patients presenting to the ED during the study
and patients with sepsis included per study period.
1468 M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473
than the completion of the six elements in the cases that
were afterwards included by the study team (Table 3).
3.4. Effects on the hospital mortality rate and length of
The in-hospital mortality rate decreased from 6.3% in
period 1 to 5.5% in period 3, which was not significant. The
median (interquartile range) length of hospital stay did not
change (6 (2–12) to 6 (3–11) days).
Our study demonstrates that using a nurse-driven, care
bundle based, sepsis protocol followed by training and
performance feedback results in improved early recognition
and treatment of patients with sepsis who present to
the ED. The implementation program resulted in signifi-
cant improvement of the compliance with the bundle
(from 3.5% to 12.4%) and significant changes in four of the
six individual elements. The process of obtaining two
blood cultures before starting antibiotics did not improve
significantly, probably because of the already good
compliance at baseline. Further, the median time of
hospitalization or discharge of the patient did not improve
We can improve the quality of care for patients with
sepsis by using a relatively simple and inexpensive
implementation program. Although care bundles can be
a powerful stimulus to focusing the multidisciplinary
team on working together to deliver reliable care, the
development of a bundle is only one component in an
overall improvement strategy (Marwick and Davey,
2009). To further improve the recognition of patients
with sepsis and the performance of SSC-based recommendations
in our ED, additional improvement activities
Interestingly, subgroup analysis showed that compliance
with the six bundle elements was significantly better
in the cases that the nurses included than in the cases that
they did not. This shows that recognizing sepsis with the
use of the sepsis screening list alone resulted in better
compliance with completion of the six elements. Without
the list, some patients with sepsis were initially missed in
the nurses’ triage, but the attending physicians ultimately
identified and treated them.
Characteristics of the patients (n = 825).
Variable Period 1 Period 2 Period 3
Cases included (n) 159 447 219
Cases included by nurses – 317 179
Cases with complete data set – 269 162
Cases included by the researcher 159 130 40
Cases with complete data set 142 119 39
Gender (female)a 74 (47) 172 (39) 95 (43)
Age (years)b 55 (43–71) 60 (45–71) 59 (43–70)
Patients admitted to nursing ward or ICUa 135 (85) 405 (91) 189 (88)
Septic shocka 8 (5.0) 18 (4.0) 4 (1.8)
Length of hospital stay (days)b 6 (2–12) 7 (3–12) 6 (3–11)
In-hospital mortality ratea 10 (6.3) 27 (6.0) 12 (5.5)
Triage nurse’s diagnosis in emergency departmenta
Pneumonia 96 (21.5) 60 (27.4)
Urogenital infection 55 (12.3) 43 (19.6)
Wound infection 19 (4.3) 13 (5.9)
Abdominal infection 18 (4.0) 13 (5.9)
Circulatory system/catheter infection 9 (2.0) 5 (2.3)
Skin/soft tissue 7 (1.6) 6 (2.7)
Bone/joint 8 (1.8) 3 (1.4)
Implant/prosthesis infection 3 (.7) 3 (1.4)
Meningitis 3 (.7) 2 (.9)
Endocarditis 1 (.2) –
Other/unknown focus 73 (16.3) 38 (17.4)
No clear diagnosis 208 (46.5) 64 (29.2)
Final confirmed diagnosis at dischargea
Pulmonary 34 (21.4) 169 (37.8) 65 (29.7)
Urinary tract/genital 37 (23.3) 81 (18.1) 51 (23.3)
Skin/soft tissue 21 (13.2) 26 (5.8) 24 (11.0)
Abdominal 18 (11.3) 45 (10.1) 25 (11.4)
Circulatory system 7 (4.4) 16 (3.6) 9 (4.1)
Bone/joint 3 (1.9) 11 (2.5) –
Cerebral 2 (1.3) 7 (1.6) 1 (.5)
Ear/nose/throat 4 (2.5) 6 (1.3) 5 (2.3)
Other focus – 7 (1.6) 6 (2.7)
Diagnosis not related to infection 14 (8.8) 43 (9.6) 23 (10.5)
No final diagnosis reached 19 (11.9) 36 (8.1) 10 (4.6)
ICU = intensive care unit.
a Results expressed as number and (percentage). b Results expressed as median and (interquartile range).
M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1469
As nurses are often the first to see and triage a patient,
in our view their position in the current organization
structure should be exploited to a greater extent.
Therefore, the role of the nurses in the development and
implementation of the protocol was emphasized in our
study. By giving the nurses a greater responsibility in the
recognition and treatment of patients with sepsis, the care
for these patients obtained a more multidisciplinary
character and our study demonstrates that this was
associated with an improvement of the quality of care.
In our study, the six bundle elements focused on all
patients with sepsis. Most studies about implementation
of the SSC bundles specifically focus on patients with
severe sepsis and septic shock (Carter, 2007; Nguyen et al.,
2007b; Shorr et al., 2007). In our patient group, 3.6% had
septic shock. We deliberately included all patients with
sepsis because the bundle should be performed in all
patients so that we can identify the most affected ones. In
addition, the first step to reduce the mortality due to severe
sepsis or septic shock is to prevent the progression of
sepsis to severe sepsis and septic shock (Annane et al.,
2005). The early recognition and treatment of patients
with sepsis will help achieve this prevention. Our study
was not powered to identify a positive effect on patient
outcome. However, hospital mortality was low in our
patient group and tended to decrease during our study.
Previous studies describe the effects of implementation
activities to improve sepsis diagnosis and treatment in the
ED. Our results confirm those of a smaller study evaluating
the effectiveness of a standardized, SSC-based, set of
elements for managing sepsis in the ED of a university
medical centre (Micek et al., 2006). In this study, 60
patients with septic shock were included before implementation
of the standardized set of elements and 60
patients afterwards, and ten process-of-care variables
were evaluated. As in our study, formal clinical training
was part of the implementation activities. Similarly to our
study, several improvements were reached, e.g., measurement
of serum lactate improved from 17% to 78%. Contrary
to Micek et al.s’ study (2006), our study focused on all
patients with sepsis, not only on those with septic shock.
Our study is limited in being an uncontrolled study in
only a single centre. Our implementation program was
tailor-made to the situation of our hospital, so the results
cannot be extrapolated. Theoretically it is possible that, in
the course of time and based on the last evidence,
diagnostic and therapeutic procedures change. Therefore,
the possibility of a time effect, independently of our
performed implementation strategies, cannot be excluded.
However, no changes in hospital practice during the study
that may have led to confounding were present, as local
and national protocols and guidelines on the treatment of
pneumonia, urinary tract infections, and sepsis remained
unchanged during the study period.
The sepsis screening and performance list itself may
have limitations. The clinical signs included in the sepsis
screening list are very sensitive, but not very specific
The performance of the complete sepsis bundle and the six individual bundle elements at baseline (period 1), after introduction of the sepsis protoco
(Robson and Daniel, 2008; Talan, 2006; Talan et al., 2008),
l (period 2), and after training and performance feedback (period
3) (n = 731).
Variable Usage in period
1 (n = 142)
Usage in period
2 (n = 388)
(95% CI)a of period
2 versus period 1
Usage in period
3 (n = 201)
(95% CI)a of period
3 versus period 1
Performance of the complete sepsis bundle
(all six elements)
3.5% 10.8% 3.1 (1.2–7.6)* 12.4% 3.6 (1.4–9.0)*
Measure lactate within 6 h 22.6% 73.5% 2.9 (2.5–3.5)* 80.3% 3.9 (3.0–5.2)*
Take two blood cultures before start antibiotics 83.1% 78.6% 0.8 (0.5–1.2) 86.3% 1.2 (0.7–2.0)
Take a chest radiograph 67.3% 88.1% 2.8 (2.0–3.9)* 82.7% 1.9 (1.3–2.7)*
Take urine for urinalysis and culture 49.0% 54.6% 1.1 (0.9–1.3) 66.7% 1.5 (1.2–1.9)*
Start antibiotics within 3 h 37.7% 49.6% 1.2 (1.1–1.4)* 55.9% 1.4 (1.2–1.7)*
Time from ED admission till administration
2 h 25 min
(1 h 35 min–3 h 0 )
2 h 5 min
(1 h 20 min–3 h 0 min)
1 h 45 min
(1 h 15 min–2 h 25 min)
Admit or discharge patient within 3 h 44.0% 46.2% 1.0 (0.9–1.2) 48.9% 1.1 (0.9–1.3)
Time from ED admission till admission
to a nursing ward or dischargeb
3 h 12 min
(2 h 25 min–4 h 20 min)
3 h 15 min
(2 h 25 min–4 h 10 min)
3 h 5 min
(2 h 15 min–4 h 5 min)
a Relative incidence (95% confidence interval) i.e. the ratio of the percentages (cases with complete data set). b Results expressed as median (interquartile range). * Significant differences.
1470 M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473
which may have led to overdiagnosis and overtreatment.
Of course this results in unnecessary treatment costs.
However, unnecessary costs for a chest radiograph or a
urine examination is probably outweighed by the high
costs of treatment of patients with severe sepsis or septic
shock or the consequences of missing a diagnosis of severe
sepsis or septic shock. The fact that 82% of the patients
were ultimately diagnosed with an infection indicates that
not many patients who were false-positively found to have
sepsis were unnecessarily treated with antibiotics. As only
the physicians can prescribe antibiotic therapy, it remains
the responsibility of the treating physician to decide
whether to treat a patient with antibiotics, but better
compliance with the bundle led to a more complete and
5. Conclusions and future research
Our data suggest that the use of a predominantly nursedriven,
care bundle based, sepsis protocol combined with
training and performance feedback can significantly
improve the recognition of patients with sepsis at the
ED and the taking of elements based on SSC recommendations
for these patients. More attention should be given to
the role of nurses in quality improvement of sepsis care.
Our pilot study turned out to be both effective and feasible
Fig. 2. Nurses’ compliance (%) in the performance of the protocol elements (0–6 elements correctly performed), every 3 months.
Differences between cases included by the ED nurses and cases initially not included by ED nurses, at the level of the performance of the complete sepsis
bundle and the six individual bundle elements (n = 589).
Variable Cases included by
ED nurses (n = 431) n (%)
Cases initially not included by
ED nurses (n = 158) n (%)
Performance of the complete sepsis bundle (all six elements) 56 (13.0) 11 (7.0)
Measure lactate within 6 h 374 (86.8) 75 (47.5)
Take two blood cultures before starting antibiotics 385 (89.3) 99 (62.7)
Take a chest radiograph 375 (87.0) 136 (86.1)
Take a urine sample for urinalysis and culture 280 (65.0) 62 (39.2)
Start antibiotics within 3 h 241 (55.9) 56 (35.4)
Admit or discharge the patient within 3 h 207 (48.0) 68 (43.0)
Patients with sepsis and complete data set noted after the start of the sepsis protocol. ED = emergency department.
M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473 1471
in a university hospital. Future research should aim at
testing this promising implementation strategy in a
multicenter controlled trial.
Conflict of interest
There are no financial or commercial conflicts of
interest concerning this study.
No financial support was received.
The local medical ethics committee waived the need for
written informed consent before this study began.
We thank the nurses from the ED of the Radboud
University Nijmegen Medical Centre for including the
patients in the sepsis protocol, and for registration of the
recommendations they performed in case of hospitalizing
a patient with sepsis.
Angus, D.C., Linde-Zwirble, W.T., Lidicker, J., Clermont, G., Carcillo, J.,
Pinsky, M.R., 2001. Epidemiology of severe sepsis in the United States:
analysis of incidence, outcome, and associated costs of care. Critical
Care Medicine 29, 1303–1310.
Annane, D., Bellissant, E., Cavaillon, J.M., 2005. Septic shock. Lancet 365,
Baldwin, L.N., Smith, S.A., Fender, V., Gisby, S., Fraser, J., 2008. An audit of
compliance with the sepsis resuscitation care bundle in patients
admitted to A&E with severe sepsis or septic shock. International
Emergency Nursing 16, 250–256.
Bero, L.A., Grilli, R., Grimshaw, J.M., Harvey, E., Oxman, A.D., Thomson,
M.A., On Behalf of the Cochrane Effective Practice and Organisation of
Care Review Group, 1998. Closing the gap between research and
practice: an overview of systematic reviews of interventions to
promote the implementation of research findings. British Medical
Journal 317, 465–468.
Burgers, J.S., Grol, R.P., Zaat, J.O., Spies, T.H., van der Bij, A.K., Mokkink,
H.G.A., 2003. Characteristics of effective clinical guidelines for general
practice. The British Journal of General Practice 53, 15–19.
Carter, C., 2007. Implementing the severe sepsis care bundles outside the
ICU by outreach. Nursing in Critical Care 12, 225–230.
Carlbom, D.J., Rubenfeld, G.D., 2007. Barriers to implementing protocolbased
sepsis resuscitation in the emergency department—results of a
national survey. Critical Care Medicine 35, 2525–2532.
Dellinger, R.P., Carlet, J.M., Masur, H., Gerlach, H., Calandra, T., Cohen, J.,
Gea-Banacloche, J., Keh, D., Marshall, J.C., Parker, M.M., Ramsay, G.,
Zimmerman, J.L., Vincent, J.L., Levy, M.M., 2004. Surviving Sepsis
Campaign guidelines for management of severe sepsis and septic
shock. Critical Care Medicine 32, 858–873.
Dellinger, R.P., Levy, M.M., Carlet, J.M., Bion, J., Parker, M.M., Jaeschke, R.,
Reinhart, K., Angus, D.C., Brun-Buisson, C., Beale, R., Calandra, T.,
Dhainaut, J.F., Gerlach, H., Harvey, M., Marini, J.J., Marshall, J., Ranieri,
M., Ramsay, G., Sevransky, J., Thompson, T., Townsend, S., Vender, J.S.,
Zimmerman, J.L., Vincent, J.L., 2008. Surviving Sepsis Campaign:
international guidelines for management of severe sepsis and septic
shock: 2008. Critical Care Medicine 36, 296–327.
De Miguel-Yanes, J.M., Andueza-Lillo, J.A., Gonza´lez-Ramallo, V.J., Pastor,
L., Mun˜oz, J., 2006. Failure to implement evidence-based clinical
guidelines for sepsis at the ED. The American Journal of Emergency
Medicine 24, 553–559.
Ferrer, R., Artigas, A., Levy, M.M., Blanco, J., Gonza´lez-Dı´az, G., GarnachoMontero,
J., Iba´n˜ez, J., Palencia, E., Quintana, M., de la Torre-Prados,
M.V., 2008. Improvement in process of care and outcome after a
multicenter severe sepsis educational program in Spain. JAMA 299,
Fulbrook, P., Mooney, S., 2003. Care bundles in critical care; a practical
approach to evidence-based practice. Intensive Critical Care Nursing
Funk, D., Sebat, F., Kumar, A., 2009. A systems approach to the early
recognition and rapid administration of best practice therapy in
sepsis and septic shock. Current Opinion in Critical Care 15, 301–307.
Gao, F., Melody, T., Daniels, D.F., Giles, S., Fox, S., 2005. The impact of
compliance with 6-hour and 24-hour sepsis bundles on hospital
mortality in patients with severe sepsis: a prospective observational
study. Critical Care 9, R764–770.
Green, R.S., Djogovic, D., Gray, S., Howes, D., Brindley, P.G., Stenstrom, R.,
Patterson, E., Easton, D., Davidow, J.S., 2008. Canadian Association of
Emergency Physicians Sepsis Guidelines: the optimal management of
severe sepsis in Canadian emergency departments. Canadian Journal
of Emergency Medical care 10, 443–459.
Grimshaw, J.M., Shirran, L., Thomas, R., Mowatt, G., Fraser, C., Bero, L.,
Grilli, R., Harvey, E., Oxman, A., O’Brien, M.A., 2001. Changing provider
behavior: an overview of systematic reviews of interventions. Medical
Care 39, II2–45.
Grimshaw, J.M., Thomas, R.E., MacLennan, G., Fraser, C., Ramsay, C.R., Vale,
L., Whitty, P., Eccles, M.P., Matowe, L., Shirran, L., Wensing, M.,
Dijkstra, R., Donaldson, C., 2004. Effectiveness and efficiency of
guideline dissemination and implementation strategies. Health Technology
Assessment 8, 1–72.
Grol, R., Wensing, M., Eccles, M.P., 2005. Improving Patient Care. The
Implementation of Change in Clinical Practice. Elsevier, Oxford.
Institute for Healthcare Improvement (IHI) (2006a) Critical Care:
Bundle Up for Safety. http://www.ihi.org/IHI/Topics/CriticalCare/
Institute for Healthcare Improvement (IHI) (2006b) Critical Care: What is
a Bundle?. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/
ImprovementStories/WhatIsaBundle.htm (accessed January 18,
Jones, A.E., Shapiro, N.I., Roshon, M., 2007. Implementing early goaldirected
therapy in the emergency setting: the challenges and experiences
of translating research innovations into clinical reality in
academic and community settings. Academic Emergency Medicine
Kumar, A., Roberts, D., Wood, K.E., Light, B., Parrillo, J.E., Sharma, S.,
Suppes, R., Feinstein, D., Zanotti, S., Taiberg, L., Gurka, D., Kumar,
A., Cheang, M., 2006. Duration of hypotension before initiation of
effective antimicrobial therapy is the critical determinant of survival
in human septic shock. Critical Care Medicine 34, 1589–1596.
Levy, M.M., Dellinger, R.P., Townsend, S.R., Linde-Zwirble, W.T., Marshall,
J.C., Bion, J., Schorr, C., Artigas, A., Ramsay, G., Beale, R., Parker, M.M.,
Gerlach, H., Reinhart, K., Silva, E., Harvey, M., Regan, S., Angus, D.C.,
2010. The surviving Sepsis Campaign: results of an international
guideline-based performance improvement program targeting severe
sepsis. Critical Care Medicine 38, 367–374.
Levy, M.M., Fink, M.P., Marshall, J.C., Abraham, E., Angus, D., Cook, D.,
Cohen, J., Opal, S.M., Vincent, J.L., Ramsay, G., 2003. 2001 SCCM/
ESICM/ACCP/ATS/SIS international sepsis definitions conference. Critical
Care Medicine 31, 1250–1256.
Marwick, C., Davey, P., 2009. Care bundles: the holy grail of infectious risk
management in hospital? Current Opinion in Infectious Diseases 22,
Micek, S.T., Roubinian, N., Heuring, T., Bode, M., Williams, J., Harrison, C.,
Murphy, T., Prentice, D., Ruoff, B.E., Kollef, M.H., 2006. Before–after
study of a standardized hospital order set for the management of
septic shock. Critical Care Medicine 34, 2707–2713.
Nguyen, H.B., Lynch, E.L., Mou, J.A., Lyon, K., Wittlake, W.A., Corbett, S.W.,
2007a. The utility of a quality improvement bundle in bridging the
gap between research and standard care in the management of severe
sepsis and septic shock in the emergency department. Academic
Emergency Medicine 14, 1079–1086.
Nguyen, H.B., Corbett, S.W., Steele, R., Banta, J., Clark, R.T., Hayes, S.R.,
Edwards, J., Cho, T.W., Wittlake, W.A., 2007b. Implementation of a
bundle of quality indicators for the early management of severe sepsis
and septic shock is associated with decreased mortality. Critical Care
Medicine 35, 1105–1112.
Nguyen, H.B., Rivers, E.P., Abrahamian, F.M., Moran, G.J., Abraham, E.,
Trzeciak, S., Huang, D.T., Osborn, T., Stevens, D., Talan, D.A., 2006.
Severe sepsis and septic shock: review of the literature and emergency
department management guidelines. Annals of Emergency Medicine
Osborn, T.M., Nguyen, H.B., Rivers, E.P., 2005. Emergency medicine and
the surviving sepsis campaign: an international approach to managing
severe sepsis and septic shock. Annals of Emergency Medicine 46,
Rivers, E.P., McIntyre, L., Morro, D.C., Rivers, K.K., 2005. Early and innovative
interventions for severe sepsis and septic shock: taking advantage
of a window of opportunity. Canadian Medical Association
Journal 173, 1054–1065.
1472 M. Tromp et al. / International Journal of Nursing Studies 47 (2010) 1464–1473
Robson, W., Beavis, S., Spittle, N., 2007. An audit of ward nurses’ knowledge
of sepsis. Nursing in Critical Care 12, 86–92.
Robson, W.P., Daniel, R., 2008. The sepsis six: helping patients to survive
sepsis. British Journal of Nursing 17, 16–21.
Shapiro, N., Howell, M.D., Bates, D.W., Angus, D.C., Ngo, L., Talmor, D.,
2006. The association of sepsis syndrome and organ dysfunction
with mortality in emergency department patients with
suspected infection. Annals of Emergency Medicine 48, 583–
Shapiro, N.I., Howell, M., Talmor, D., 2005a. A blueprint for a sepsis
protocol. Academic Emergency Medicine 12, 352–359.
Shapiro, N.I., Howell, M.D., Talmor, D., Nathason, L.A., Lisbon, A., Wolfe,
R.E., Woodrow Weiss, J., 2005b. Serum lactate as a predictor of
mortality in emergency department patients with infection. Annals
of Emergency Medicine 45, 524–528.
Shapiro, N.I., Wolfe, R.E., Wright, S.B., Moore, R., Bates, D.W., 2008. Who
needs a blood culture? A prospectively derived and validated prediction
rule. Journal of Emergency Medicine 35, 255–264.
Shorr, A.F., Micek, S.T., Jackson Jr., W.L., Kollef, M.H., 2007. Economic
implications of an evidence-based sepsis protocol: can we improve
outcomes and lower costs? Critical Care Medicine 35, 1257–1262.
Talan, D.A., 2006. Dear SIRS: it’s time to return to sepsis as we have known
it. Annals of Emergency Medicine 48, 591–592.
Talan, D.A., Moran, G.J., Abrahamian, F.M., 2008. Severe sepsis and septic
shock in the emergency department. Infectious Disease Clinics of
North America 22, 1–31.
Tromp, M., Bleeker-Rovers, C.P., van Achterberg, T., Kullberg, B.J., Hulscher,
M., Pickkers, P., 2009. Internal medicine residents’ knowledge about
sepsis: effects of a teaching intervention. The Netherlands Journal of
Medicine 10, 312–315.
Wang, H.E., Shapiro, N.I., Angus, D.C., Yealy, D.M., 2007. National estimates
of severe sepsis in United States emergency departments.
Critical Care Medicine 35, 1928–1936.
Wensing, M., Wollersheim, H., Grol, R., 2006. Organizational interventions
to implement improvements in patient care: a structured review of
reviews. Implementation Science 1, 2.
Here is a copy of my paper to show the articles chosen:
The first article I choose is a quantitative research review of the nurses role in recognizing and treating patients with sepsis in an emergency department, the article describes a before and after study of interventions implemented to help reduce sepsis mortality. The research study evaluated two consecutive interventions and provided data to show the before intervention and after intervention implementation of a nurse driven care bundle set and education with performance feedback. The research starts with data collected before a new care bundle was initiated, continues with data collection for the implementation, and finishes with the third phase of data collection to include the effects of training and performance feedback. This study is based on an emergency room with 35 registered nurses with a patient population of 20,000 visits per year. The study criteria involved adult patients 16 years and older, presentation of a known or suspected infection and at least two abnormal vital signs. The research study presents quantitative data relating to 825 patients with statistical findings for a multi facade implemented process showing the before and after effects of a nurse driven process. I choose this journal because it is an international nursing journal related to my field of nursing. (Tromp et al., 2010, p. 1464)
The second article I choose is a qualitative research review of the patients and caregivers experience related to sepsis. This study used a method of face to face or telephone interviews to gather information. The research was based on patient’s age 18 and older and diagnosed with sepsis within a 12 month time frame. The caregivers were defined as family members or friends that provided care to the patient during or after their diagnosis of sepsis. This study was an explorative review with a small sample size of 22 patients, 17 caregivers and a total of 39 interviews. The objective of the research was to understand, explore the patient’s awareness, knowledge and understanding of their experience after they were affected with a hospitalization of sepsis. The study also focused on the impact of this illness related to the caregiver’s experience. I had a very hard time finding a qualitative study related to sepsis, the article I found was in a critical care medicine journal still relating to my field of nursing. (Gallop et al., 2015, para. 3)
Gallop, K. H., Kerr, C. E., Nixon, A., Verdian, L., Barney, J. B., & Beale, R. J. (2015). A Qualitative Investigation of Patients&rsq