Periodic Health Examination in late 1979

AbstractThis literature review aims to evaluate hospitals’, and more particularly nurses’ capacity to comply with Surviving Sepsis Campaign (SSC) sepsis resuscitation bundles across the UK, as SSC guidelines have proven to increase sepsis survival rates when implemented properly.Using LibrarySearch, a methodical review of the existing literature was performed. A variety of health related databases and journals were searched and Boolean logic was applied to specific search terms (Lobiondo-Wood and Haber, 2014). Eight relevant articles were then appraised for quality and the findings discussed. A lack of resources such as equipment and supplies, lack of appropriate referrals due to poor SSC education of medical and nursing staff, and the inconsistent use of SSC guidelines are all associated to with generally poor compliance with SSC sepsis resuscitation bundles in the UK. Overall, the extent of hospitals’ compliance to SSC sepsis resuscitation bundles depends on the availability of the resources and equipment, education of medical and nursing staff, and consistent use of the SSC guidelines. Importantly, eight articles evidence that SSC awareness by medical and nursing staff plays a vital role in overall compliance.Chapter 1: IntroductionHart (1998, p. 26) defines a literature review as a summary and ‘critical analysis of relevant available’ studies related to the chosen topic being reviewed. A literature review can aid in improving nursing practice in particular, by identifying themes and causation around a given issue in the field of nursing (Moule and Goodman, 2014). Hence, it is critical to gather evidence-based information through a literature review of the latest available research to help improve one’s practice and make decisions that is based on the best available evidence (Aveyard, 2014).Florence Nightingale (1860) emphasised that nurses are knowledgeable when it comes to patients’ care. Therefore, in the nursing profession there is no way to stop learning, but instead there are ways to update what has been learned from the past according to present conditions, and to gain new insights in order to provide the best available evidence-based practice to patients’ care (NMC, 2010; CRD, 2007). Moreover, it is the responsibility of a nurse to learn new information concerning his or her patients and the environment he or she directly works in, in order to be prepared for new challenges and changes in delivering evidence-based nursing care to patients (Spencer, 2011).The next chapter will briefly discuss the background and rationale of the focus question of this literature review, which is: ‘To what extent can hospitals in the UK comply with SSC resuscitation bundles, and what are the implications for nursing practice’? The following chapter will outline the methodology of research, including how relevant literature was searched, tabulated, and analysed, and how the three themes emerged from the chosen articles (Parahoo, 2006). This is followed by the discussion and analysis of themes that arose from the chosen articles, and the implications and recommendations for nursing practice. Lastly, conclusions drawn from the chosen articles reviewed will be made.Chapter 2: Background and Rationale2.1 What is Sepsis?Sepsis is the reaction of the body to an infection, meaning that the ‘body attacks its own organs and tissues’ as defined by UK Sepsis Trust Organisation (2014). Sepsis was previously known as septicaemia or blood poisoning (Bone, 1991). It starts from an uncomplicated infection that develops into severe sepsis, wherein the infection becomes associated with organ dysfunction and leads to an increased risk of death (Mackenzie and Lever, 2007).According to the UK Sepsis Trust Organization (2014), sepsis can quickly lead to shock, multi-organ dysfunction and eventually results in death if the sepsis is not detected immediately and not treated promptly. Sepsis is one of the primary reasons of death worldwide. This is why Surviving Sepsis Campaign guidelines have been introduced worldwide.2.2 Surviving Sepsis Campaign (SSC) sepsis resuscitation bundlesIn 2004, Dellinger et al. launched Surviving Sepsis Campaign (SSC) international guidelines in the United States for the management of severe sepsis as an effort to reduce the mortality rate associated with sepsis (Dellinger et al., 2004a). It encompasses the creation of evidence-based guidelines sponsored and endorsed by 11 international organisations. It was revised in 2008 and the latest revision was in 2013. Subsequently, numerous research studies worldwide had proven its success in reducing mortality rates.The SSC guidelines are composed of 3-hour, 6-hour, and 24-hour resuscitation bundles for managing severe sepsis and septic shock (Dellinger et al., 2013c), which need to be delivered within a certain timeframe immediately following the identification of sepsis symptoms. These bundles are a group of three or more elements of care specifically related to the disease, that when implemented together will improve patient outcomes (Surviving Sepsis Organization, 2014b; Institute for Healthcare Improvement, 2014; Dellinger et al., 2013c; Daniels et al., 2011).2.3 SSC guidelines and United KingdomIn 2005, the United Kingdom launched the SSC guidelines in an attempt to reduce the sepsis mortality rate in the UK (Bray and Murphy, 2006). The National Institute for Health and Clinical Excellence (NICE) (2007) recommended to carry out a set of observations or vital signs systematically using the Early Warning Score (EWS) and the SSC resuscitation bundles (Dellinger et al., 2013c) for management of severe sepsis and septic shock. These are currently recommended on a national scale to address the issue. However, despite of the introduction of the campaign a decade ago, the mortality rate in UK remains unacceptably high, ‘There are 102,000 cases of sepsis arise annually, 36,800 deaths every year as a result of severe sepsis’ (Daniels et al., 2011, p. 508). ‘Putting this into perspective, lung cancer (the biggest killer after cardiovascular disease) claims just fewer than 35,000 lives per year, bowel cancer 15,000 and breast cancer 9,000′ (Richards, 2013, p. 3). Hence, it is important to identify the limitations to compliance and determine how medical and nursing staff can best help patients survive sepsis (NPSA, 2007). In any hospital setting, there are different patients with many different kinds of illnesses, and nurses play a vital role in ensuring that patients receive the best and most appropriate possible care, thus preventing patients’ deterioration (Aitken et al., 2011). Moreover, rapid diagnosis and treatment saves lives when done as quickly as possible (Parliamentary and Health Service Ombudsman, 2013). Thus, the aim of this literature review is to evaluate hospitals’ compliance to SSC sepsis resuscitation bundles across the UK as well as to identify the role of the nurse in helping to improve overall SSC compliance (Surviving Sepsis Organization, 2014a).The following focus question was formulated to address the abovementioned concerns and to guide the literature search of this review: ‘To what extent can hospitals in the UK comply with SSC resuscitation bundles, and what are the implications for nursing practice’? The next chapter will discuss in further detail the methodology used for conducting research in order to address the most appropriately respond to this question.Chapter 3: MethodologyThis chapter will discuss the selection criteria, search strategy, and the search outcome of the literature search. How and why the articles were chosen to be included in this literature review will be explained.3.1 Selection CriteriaThe inclusion and exclusion criteria were determined using the Population, Intervention, Comparison or Comparator and Outcome (PICO) tool. The PICO acronym is used to articulate the research question and structure the search strategy (CRD, 2007; Higgins and Green, 2008; Whitlock et al., 2010).3.1.1 PopulationStudies evaluating compliance to the Surviving Sepsis Campaign (SSC) sepsis resuscitation bundles across hospitals in the United Kingdom (UK) were considered. Hospital settings allow for a wider sample in evaluating nursing and medical staff’s adherence to the guidelines of the SSC rather than in specialist clinics or GPs settings. Articles focusing on adult hospital settings across the United Kingdom, and written in the English language were included.Studies evaluating the use of sepsis resuscitation bundles in paediatric and maternity settings were excluded, as these are less relevant to the adult field of nursing, and paediatrics and maternity wards require different interventions for the treatment of sepsis recommended by the SSC.Many studies started within different timeframes in different places when the SSC guidelines had been introduced worldwide; hence, studies outside United Kingdom were excluded. The literature review focuses solely on the UK, since it is easier to recognise the limitations of the sepsis care bundles when evaluating sample populations in one country rather than across many countries.3.1.2 InterventionStudies assessing the compliance to the Surviving Sepsis Campaign guidelines (Dellinger et al., 2013c) comprising severe sepsis, septic shock resuscitation care bundles and early goal directed therapy (EGDT) were included, as these are elements of the established bundles and interventions used to manage patients with severe sepsis and septic shock in the UK (Surviving Sepsis Organization, 2014b).Studies assessing severe sepsis and septic shock cases without using the recommendation of SSC guidelines were excluded, as this paper aims to identify issues and determine possible reasons as to why and how non-compliance is occurring despite the proven effectiveness of sepsis resuscitation bundles under the Surviving Sepsis Campaign (Daniels et al., 2011). As the United Kingdom launched its Surviving Sepsis Campaign in 2005 (Bray and Murphy, 2006), only studies assessing compliance to the SSC guidelines to address severe sepsis and septic shock in the UK from 2005 onward were included in this literature review.3.1.3 OutcomeStudies evaluating the relationships between awareness, resources, and compliance to the SSC sepsis resuscitation bundles, as well as correlative evidence of decreasing mortality rates associated with compliance in sepsis were included.3.1.4 Study DesignDue to the nature of the focus question, which is to evaluate the compliance to the SSC sepsis resuscitation bundles, quantitative studies were included that include prospective observational studies, retrospective cohort studies, questionnaires, and surveys. The focus of this paper is across the United Kingdom in order to establish general determining factors regarding the limitations, barriers, and solutions for successful implementation of SSC sepsis resuscitation bundles (Surviving Sepsis Organization, 2014a). Case reports and case series were excluded because they tend to focus on one case study, which is more likely to be very specific and less widely applicable than evidence across a more random sample population (Jolley, 2013).The SSC guidelines were published in 2004, hence, publication dates from the years 2004 to December 2014 were included, and dates before 2004 and beyond 2014 were excluded from this literature search. In terms of hospital studies in the UK, only articles published between 2005 and 2014 were included, since the SSC guidelines were launched in the UK in 2005.3.2 Search StrategyAfter establishing the focus question this paper aims to answer, the first step was to identify the necessary databases for accessing a wide range of data sources in the Internet (Younger, 2004). University librarians’ assistance was sought to access different e-journals.Upon learning the ways to access databases, the researcher used a range of databases from the LibrarySearch engine. LibrarySearch is the University’s search and retrieval tool designed to search for databases and e-journals. This search was performed to reduce bias of the review, and to retrieve articles containing the search terms used. Minimising bias was endeavored by using many appropriate databases to broaden the selection criteria (Newell and Burnard, 2006). A worldwide search was not included, as only the population of the United Kingdom was relevant to the research question and only articles written or translated in English were considered for review in the study. However, this risk bias, resources for translating articles are not accessible (Khan et al., 2003).Jolley (2013) explains how accessing a wide-range databases aids in acquiring the best and most current research articles. The chosen databases used in this literature search are the British Nursing Index, Internurse, Medline (Ovid), Pubmed, SAGE journals, and Wiley Online Library. The British Nursing Index was chosen because this database covers all aspects of nursing from 1994 to present, which meets the inclusion criteria for articles from 2004 to 2014. Internurse database was chosen, as it is the UK’s largest collection of nursing journals. Furthermore, as the UK is home of the British Journal of Nursing, the journal was used for its main focus on research conducted in UK. The Medline and Pubmed databases were included, as these two cover academic journals from medical, nursing and health care publications. Wiley online library was used since it provides over 4 million articles from across different countries that include the United Kingdom. Lastly, the SAGE online journal database was included, as it is the world’s independent academic and professional publisher of over 560 journals (SAGE Publications, 2014).After selecting databases, the next step was to decide which search terms were to be used in accessing literature that would provide the most appropriate evidence for the research question. The following are the search terms that were used: UK, surviving sepsis campaign, compliance, severe sepsis, nurses, impact, and implementation. To increase the search sensitivity, Boolean logic was applied using the words ‘AND,’ ‘OR’ and ‘NOT’ (Khan et al., 2003).3.3 Search OutcomeThis section will describe which databases successfully produced relevant results based on the search terms and selection criteria. It will further illustrate the number of articles retrieved, and of the articles retrieved, which were identified as the most relevant to the focus question.This literature search took place between October and December 2014. Using the Search Scope in LibrarySearch engine, six databases were selected to gather articles by applying various search terms relevant to the focus question of this paper. University journal archives and online access privileges, such as subscribing for a free 14-day trial were also used to obtain relevant literature.Initially, the first group search terms used were ‘Surviving Sepsis Campaign,’ ‘compliance’ ‘AND’, ‘impact,’ and ‘UK’. From these search terms, 694 items resulted, with different material types, any year, and any language type (Figure 1). This was then narrowed down from 694 to 3 items by applying the selection criteria wherein the publication date range of the retrievable articles was limited to filter inclusion of only literature relevant for the review, given that Surviving Sepsis Campaign guidelines were first published in 2004. Therefore, only articles published between 1st January 2004 and 31st December 2014 were considered in order to filter the most current available evidence. Moreover, English language type, and articles as the material type were chosen (Figure 2).(Figure 1)(Figure 2)The next group of search terms used were ‘Surviving Sepsis Campaign,’ ‘AND’, ‘nurses’ and ‘UK.’ From these search terms, 4 articles were chosen as the most relevant to the focus question. Furthermore, from these 4 articles retrieved using the selection criteria as shown in Figure 3, these were narrowed down from 4 to 1 article, as the other 3 were not research articles.(Figure 3)‘Severe sepsis,’ ‘guidelines,’ ‘AND’, ‘nurses’ and ‘UK’ were the third group of search terms used in the LibrarySearch engine that resulted in 69 articles (Table 4). To filter results to match the most relevant criteria of the focus question of this review, the subject was refined to ‘Great Britain,’ hence the search was narrowed down from 69 to 2 articles (Table 5).(Figure 4)(Figure 5)Finally, the following search terms: ‘Surviving Sepsis Campaign,’ ‘AND’, and ‘UK’ were used to find further literature, which resulted in 1,295 items (Figure 6). A collection of journals ‘ namely: Intensive Critical Care Journal, Journal of Clinical Nursing, and Nursing Critical Care Journal ‘ were chosen to narrow down the search from 1,295 to 6 articles (Figure 7).(Figure 6)(Figure 7)In total, 12 articles were retrieved utilizing the search terms relevant to the focus question. These were then evaluated for relevant titles and abstracts. Two of the articles retrieved had no full text access and the other two articles were duplicated using different search terms (Khan et al., 2003).The eight articles were tabulated that met the selection criteria. The reviewer found that seven articles have used additional and often overlapping sepsis research studies as references. For example, 6 articles referenced Gao et al. (2005), 1 referenced Simmond et al. (2007), and 1 referenced Robson et al. (2007) which were also helpful in determining the academic legitimacy and relevance of the articles (Polit and Beck, 2006; Whittaker and Williamson, 2011).In order to minimise bias, Glasziou et al. (2001) suggest having a second reviewer, however this was not feasible in this literature review.Finally, quantitative research was included as it relates to the focus question of the review, which is to evaluate the compliance to the SSC sepsis resuscitation bundles as recommended by Dellinger et al. (2013c). Evaluation is primarily conducted with the use of quantitative targets and measurements (Coughlan, Cronin and Ryan, 2007).Ultimately, eight articles were included in this literature review. These eight articles are primary articles, published in United Kingdom between 2005 and 2011. All of these studies concern hospitals’ implementation and compliance to the ‘sepsis resuscitation bundles adapted from the Surviving Sepsis Campaign’ (Dellinger et al., 2013c; Surviving Sepsis Organization, 2014a; Surviving Sepsis Organization, 2014b), particularly for adult patients identified as having sepsis in the UK.3.4 Critical Appraisal Skills Programme (CASP) and Hierarchy of EvidenceReviewing research is a ‘mechanism used to provide feedback for improvement’ as noted by Polit and Beck (2006). After articles were selected, a CASP framework was chosen to critically appraise each article according to its validity, credibility, and implication to practice by following the Case-control and Cohort Studies Appraisal Checklists (CASP, 2013). This helped the reviewer to scrutinise the individual work and to underline the strengths and weaknesses of each article in order to identify the best examples of evidence-based practice (Coughlan, Cronin and Ryan, 2007).The Canadian Task Force on Periodic Health Examination in late 1979 was the first to disseminate the Hierarchy of Evidence, until which point different, hierarchies had been established and used (The Canadian Task Force on the Periodic Health Examination, 1979; Evans, 2003). Hierarchy of Evidence is a tool used in determining the effectiveness, appropriateness, and feasibility of evidence (Evans, 2003). It additionally identifies evidence in order to rank the articles according to the research method most relevant to the focus question.Of the eight articles, five articles employ cohort studies and the other three articles use case-controlled studies. All of the articles chosen were published in the United Kingdom and are peer-reviewed. The Systematic Review is the highest level of hierarchy, followed by the Random Controlled Trial (RCT) as the second level of evidence. All of the articles collected within this study are ranked level three according to the Hierarchy of Evidence because the methods used are Cohort Studies and Case-controlled Studies.3.5 Themes for analysisThe next step after determining the appropriate literature for this review was an analysis of the literature. Upon undertaking the analysis, three themes have been identified: equipment and supply limitations, a lack of appropriate referrals due to poor education of medical staff and nurses on SSC sepsis resuscitation bundles, and the inconsistent use of SSC sepsis resuscitation bundles from hospital to hospital.The following chapter critically discusses the three themes that emerged from the literature analysis of the eight selected articles, as well as the implications for the field of nursing as related to the SSC.Chapter 4: Literature AnalysisThis literature analysis will critically consider the eight articles in order to judge the strengths, weaknesses, and the significance of each study (Burns and Grove, 2009) in addressing the research question: ‘To what extent can hospitals in the UK comply with SSC resuscitation bundles, and what are the implications for nursing practice’? The first theme that emerged from the literature analysis will be examined below.4.1 Resource limitationsCompliance with the SSC sepsis resuscitation bundles requires that serum lactate be obtained and that this is measured using an Arterial Blood Gas (ABG) machine (Dellinger et al., 2013c). Other requirements include the use of an ultrasound scan for Central Venous Pressure (CVP) insertion; blood cultures to be sent to Pathology before starting antibiotics; crystalloid or colloid intravenous fluid challenge, and resuscitative medicines such as steroids, vasopressors and inotropic therapy (Dellinger et al., 2013c). However, five of the articles reviewed evidence that this necessary equipment is lacking in a number of hospitals in the UK.4.1.1 Equipment and medicationThree of the research articles specify that in some cases there has been lack of necessary resources that are used to meet compliance to the SSC sepsis resuscitation bundles. This not only limits the ability of medical and nursing staff to manage sepsis, but it also limits the reviewer’s ability to evaluate compliance with the SSC sepsis resuscitation bundles.Gao et al.’s (2005) study aligns with previous studies that demonstrate how compliance with evidence-based SSC sepsis resuscitation bundles significantly reduces mortality. The study comprises ‘101 consecutive adult patients with severe sepsis and septic shock on medical or surgical wards, or in accident and emergency areas at two acute National Health Service (NHS) Trust Teaching hospitals in England’ (Gao et al., 2005, p. R764). The findings evidence poor ward care in critically ill patients, evidencing that eight percent of patients had no oxygen administrated, fourteen percent had no IV access, and fourteen percent of patients ‘had no observation monitoring of blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, urine output, or conscious level’ (Gao et al., 2005, p. R766).Since the aim of Gao et al.’s (2005) study is to assess the relationship between compliance with SSC guidelines and a decreased sepsis mortality rate, reasons for non-compliance are beyond the scope of this study. However, the authors importantly note that the hospital’s resource limitation led to a deviation from the SSC sepsis resuscitation bundle ‘in the short term’ (Gao et al., 2005, p. R764). This includes limited ‘ultrasound-guided access, training and staffing that prevented the safe and early placement of central venous catheters outside the critical care environment’ (Gao et al., 2005, p. R766). The ultrasound-guided access is essential to insert the CVP, therefore even if the staff has the knowledge to comply with SSC guidelines, with limited resources available, compliance is not possible. In hospitals such as these two NHS Trust Teaching hospitals, resource limitations forced the staff to deviate from ‘the benchmark for persistent hypotension despite fluid resuscitation, adapting a target haemoglobin of 7 to 9 g/dl and/or vasopressors but exluding the requirement to achieve a target of >8mmHg and ScVO2 of’ >70% central venous pressure’ (Gao et al., 2005, p. R768).

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