2019-01-23T12:31:12+00:00
Topic: Quantitative and Qualitative Health Articles Review
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Topic: Quantitative and Qualitative Health Articles Review Instructions:
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.) Problem Statement Statement of Purpose Research Question(s)/Hypothesis Study Methods Key Findings Citation 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.) Problem Statement Statement of Purpose Research Question(s) Method Key Findings Citation Please use the two attached articles for the analysis, that is required for the assignment. http://www.medscape.com/viewarticle/839734- the article is titled: A Qualitative Investigation of Patients` and Caregivers` Experiences of Severe Sepsis Qualitative article ..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 article file:///C:/Users/sherri/Downloads/1001391_The%20role%20of%20nurses%20in%20the%20recognition%20and%20treatment%20of%20patients%20with%20sepsis.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 intervention study 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 f Dept of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, The Netherlands International Journal of Nursing Studies 47 (2010) 1464–1473 ARTICLE INFO Article history: Received 4 September 2009 Received in revised form 16 March 2010 Accepted 24 April 2010 Keywords: Care bundle Emergency department Nursing interventions Protocol compliance Quality of health care Sepsis ABSTRACT 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. doi:10.1016/j.ijnurstu.2010.04.007 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 remains troublesome. Care bundles can be used for the implementation of evidence-based practice. 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. 1. Introduction 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:// www.mrw.interscience.wiley.com/cochrane/cochrane_clsysrev_crglist_fs.html). 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 recommendations. 2. Method 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 periods: 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 performance feedback. 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 implementation program. 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. 2.2.1.1. 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. 2.2.1.2. 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 antibiotic treatment. 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 measures. 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. Results 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 elements 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 hospital stay 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). 4. Discussion 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 significantly. 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 are required. 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. Table 1 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. 4.1. Limitations 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 Table 2 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) Relative incidence (95% CI)a of period 2 versus period 1 Usage in period 3 (n = 201) Relative incidence (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 of antibioticsb 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 appropriate work-up. 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. Table 3 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. 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Here is a copy of my paper to show the articles chosen: Quantitative 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) Qualitative 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) References Gallop, K. H., Kerr, C. E., Nixon, A., Verdian, L., Barney, J. B., & Beale, R. J. (2015). A Qualitative Investigation of Patients&rsq
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Quantitative and Qualitative Health Articles Review Name: Institutional Affiliation: Date: Article 1. Quantitative Review on the Study of the Role of Nurses in the recognition and treatment of Patients with Sepsis. The article was written by a group of ten and the published in the year 2009 in the International Journal of Nursing Studies. The writers included Miram Tromp, Marlies Hulscher and the others. The article was chosen since it contains a good analysis and experimentation on the role that the nurses play in recognizing the patients with sepsis and the treatment they give them. Statement of purpose It is aimed at looking at the effects of a multifaceted implementation program that will help in the improvement of the services that are given to the sepsis patients when they visit the healthy facilities. The program will ensure th
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