Exploring facilitators and barriers of appropriate and timely initiation of intravenous fluids for adults with sepsis in emergency departments

Abstract

Sepsis is defined as life-threatening organ dysfunction caused by dysregulated host response to infection. Global estimates suggest about 51 million cases of sepsis annually, with 11 million sepsis related deaths accounting for approximately 20% of all annual deaths. Early recognition of sepsis and resuscitation are key to ensuring the best outcomes. This includes patients with sepsis-induced hypotension requiring adequate and timely intravenous fluids to restore tissue perfusion and prevent irreversible multi-organ failure and death. Most patients with sepsis are admitted to the hospital via the emergency department, therefore appropriate and timely initiation of the initial intravenous fluids is vital to reduce mortality rate in this setting. However, intravenous fluid administration has been a challenging aspect of clinical sepsis management in emergency departments with research demonstrating poor compliance. Although there have been several studies on sepsis management, evidence is scarce regarding the factors that specifically influence the initiation of intravenous fluids when patients arrive in emergency departments. To develop effective interventions to improve clinical practice, a comprehensive understanding of these facilitators and barriers is essential. Therefore, this program of research was undertaken to address this current gap. The aims of this program of research were to: (1) identify facilitators and barriers to appropriate and timely administration of initial intravenous fluids in adults presenting with sepsis in the emergency department; and (2) provide evidence regarding the optimal approach and supporting strategies to improve appropriate and timely initiation of intravenous fluids in sepsis. This thesis is presented as a series of six papers (five peer-reviewed publications and one manuscript currently under review). Successful implementation of interventions to improve intravenous fluids in sepsis requires a thorough understanding of the facilitators, barriers, and strategies to improve practice that is relevant, accepted and supported by the emergency clinicians in the specific setting. This program of research has identified and provided a comprehensive understanding of these factors and in addition established consensus among key stakeholders in the four emergency departments regarding the identified factors and strategies. This research also supports direct benefits to patients with improvement in mortality specific to the target population. Actionable and contextual findings such as making provision for nurse-initiated fluids in sepsis, intelligent and integrated electronic alerts, and customisable Sepsis Pathway are a few of the outcomes of this research. These findings will inform the development of structured interventions to improve appropriate and timely administration of intravenous fluids subsequently improving outcomes for Western Sydney patients with sepsis.

Date of Thesis submission	2024
Original language	English
Awarding Institution	Western Sydney University
Supervisor	Stephen McNally (Supervisor), Deborah Hatcher (Supervisor), Steve Frost (Supervisor) & Amith Shetty (Supervisor)