Sepsis has traditionally been defined as a systemic inflammatory response syndrome (SIRS) with a suspected source of infection, which can be life threatening and lead to organ dysfunction when it is not recognised and treated early (Daniels, 2010). In 2016 an international consensus redefined sepsis as a ‘life-threatening organ dysfunction caused by a dysregulated host response’ (Singer et al, 2016). This new definition of sepsis identified patients who have evidence of organ dysfunction, previously recognised as severe sepsis, and abandoned SIRS as a definition. The use of two or more SIRS criteria to identify sepsis was no longer recommended, since most patients in hospital have changes in white cell count, temperature and heart rate, but may never develop infection; these parameters reflect the signs of inflammation in the form of infection, but do not necessarily indicate a dysregulated, life-threatening response (Singer et al, 2016). However, the Sepsis Trust has acknowledged that the SIRS criteria are still relevant in the identification of infection (also known as uncomplicated sepsis prior to 2016), and individuals who are at risk of developing sepsis (Daniels and Nutbeam, 2017), which explains why the SIRS criteria are still used in clinical practice.
There are more than 250 000 episodes of sepsis in the UK annually, resulting in approximately 44 000 deaths (Daniels and Nutbeam, 2017). Improving the recognition and treatment of sepsis is a national priority in the UK, and the focus of a range of national initiatives (National Institute for Health and Care Excellence (NICE), 2017; NHS England, 2018).
In an effort to improve understanding, recognition and management of sepsis, a global approach has been taken, with the launch of the Surviving Sepsis Campaign (SSC) in 2002 by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (https://tinyurl.com/tczv7zrz). The campaign aimed to increase health professionals' knowledge about identifying and treating sepsis through the implementation of bundles to provide a standardised approach.
The sepsis bundle known as the ‘Sepsis Six’ was introduced by the UK Sepsis Trust in 2006 and consists of three therapeutic and three diagnostic interventions: delivery of antibiotics, oxygen and intravenous fluid, and obtaining blood cultures, measuring lactate and monitoring of urine output (Daniels and Nutbeam, 2017). Mortality from sepsis can be reduced by early recognition and treatment with antibiotics. The delivery of the Sepsis Six bundle within 1 hour has been shown to reduce mortality by 47% (Daniels et al, 2011).
Screening for sepsis allows for early detection of patients with potential sepsis. Nurses are in a prime position to carry out sepsis screening and initiate the Sepsis Six bundle as part of their daily routine (McCaffery et al, 2016; Torsvik et al, 2016). In Wales, there is a standardised approach to sepsis screening known as the ‘triple trigger tool’ (Jones and Hancock, 2017). Patients are identified as septic positive with a National Early Warning Score 2 (NEWS2) (Royal College of Physicians, 2017) of 3 or more; two or more SIRS criteria; and suspicion of new infection (Hancock, 2015; Daniels and Nutbeam, 2017). The SIRS criteria are:
- Temperature >38.3°C or <36.0°C
- Pulse >90/minute
- Respiratory rate >20/minute
- White cell count >12x109/L or <4.0x109/L
- New confusion/drowsiness
- Blood glucose >7.7 mmol/L) (in non-diabetic patients) (Daniels and Nutbeam, 2017).
Early recognition and treatment of sepsis can make all the difference in preventing organ failure. A delay in screening for sepsis leads to a delay in identifying the condition, which results in delayed treatment and management (Walters, 2018). Nurses are in a prime position to identify patients who are unwell or deteriorating since they spend most of their working hours with patients. Sepsis screening should be integrated into a nurse's daily routine (McCaffery et al, 2016). Therefore, nurses need to be educated to screen patients to identify sepsis and begin treatment to ensure compliance with the sepsis bundle within 1 hour.
Undertaking all the steps required to complete the Sepsis Six within 1 hour is challenging. Barriers include nurses' skills, staff shortages, distractions, poor communication and delay in the prescribing of antibiotics (Matthaeus-Kraemer et al, 2016; Tarrant et al, 2016; Roberts et al, 2017a; 2017b; Breen and Rees, 2018). Although a lack of training has been identified as a barrier to implementation of the sepsis bundle (Roberts et al, 2017a), few studies have evaluated the effects of sepsis training.
Most studies on the implementation of the Sepsis Six bundle have been undertaken in the emergency department (ED). However, patients who are already in hospital are vulnerable to deteriorating and developing sepsis. In a multicentre study of the prevalence of patients with sepsis or severe sepsis on general wards and emergency departments in Wales, Szakmany et al (2016) found that 5.5% of all inpatients outside critical care settings had sepsis or severe sepsis. Compliance with the sepsis bundle was found to be low, with only 3% of septic patients and 9% of patients with severe sepsis having the bundle completed (Szakmany et al, 2016).
The present study investigated the outcomes of sepsis training on ward-based nurses in relation to screening and initiation of sepsis treatment, since this is a neglected area. The authors also explored the perceived barriers to screening patients and completing the sepsis bundle among ward nurses.
Aim
The aim of this study was to explore the effects of sepsis training on knowledge, skills and attitudes among ward-based nurses in one hospital in relation to sepsis screening and the delivery of the sepsis bundle within 1 hour.
Methods
The study used a cross-sectional survey design. An anonymous questionnaire was developed, which was based on a review of the literature. The survey contained 22 closed questions with a mixture of Yes/No, rating scale, and multiple-choice response options and two open-ended questions to capture staff views and experience. Age, length of service, band, area of work, and sepsis training status were collected (Figure 1). The questionnaire was piloted with five nurses who were attending sepsis training and two advanced nurse practitioners (ANPs) working within the critical care outreach team, which provided assurance that the questions were understood and provided appropriate data for analysis, which contributed to the reliability and validity of the questionnaire.
Figure 1. Sepsis questionnaire
The study was carried out in an acute NHS teaching hospital in Wales that serves a population of 240 000 over a large geographical area. Registered nurses from 16 acute surgical and medical wards were invited to anonymously take part in the study over a 4-week period between February and March 2019. In total, there were 250 potential participants who fitted the inclusion criteria for this study (registered nurses working as a band 5 or 6 with a permanent or temporary contract, working on an acute medical or surgical ward). Questionnaires were returned anonymously in a sealed postal box.
Analysis
Data from the questionnaires were coded and entered into the Statistical Package for Social Sciences (SPSS) for analysis. Descriptive statistics were produced for demographics. The internal consistency of the attitude questionnaire was explored using Cronbach's alpha. The Mann-Whitney U test (U) was used to explore the difference between attitudes towards sepsis screening and management for nurses who had received training and those who had not. The relationship between receiving training in sepsis and screening a patient for sepsis was tested using the chi-square test of independence (χ2). Experience of training was also explored in relation to confidence in screening and knowledge of screening criteria and procedure (NEWS2 and SIRS). A coding scheme was developed from the free text by inputting the data into Excel initially where themes were identified and coded.
Ethical considerations
The authors obtained ethical approval from the School of Health Sciences, as well as the NHS board's research and development approval process via the Integrated Research Application System (IRAS). Since this research study was being carried out at a single NHS site, local permission was granted to undertake it.
Results
In total, 250 questionnaires were distributed and 98 returned, which gave a response rate of 39%. Of the 98 respondents, 83 (85%) had two or more years' experience post-qualification, 59 (60%) worked on a medical ward and 39 (40%) worked on a surgical ward. The majority of the respondents, 88 (90%) were working at band 5, with only 10 (10%) working at band 6. Of the 98 respondents, 72 (73%) had received sepsis training and 26 (27%) had not. Sepsis training within the acute hospital where the study was undertaken is not mandatory. The ANPs working in the critical care outreach team offer a one-day course, held each month in the hospital, on recognising and managing deteriorating patients, which includes sepsis training. This training is available for both registered nurses and healthcare assistants. The sepsis training consists of SIRS criteria, recognising sepsis using the sepsis screening tool and the Sepsis Six bundle.
NEWS sepsis screening knowledge
Respondents were asked to indicate at what NEWS2 score patients should be screened for sepsis, on a scale of 1 to 9+. Of the 98 respondents, 68 (69%) answered correctly and selected to start sepsis screening with a NEWS2 score of 3. Most respondents (80, 82%) had screened a patient for sepsis, 15 (15%) had not screened a patient for sepsis and 3 (3%) were not sure.
SIRS knowledge
The survey was designed to assess the respondents' knowledge on the correct SIRS criteria elements on which to screen patients for sepsis (Table 1). Knowledge was lowest with regards to biochemical markers. The majority or respondents, 66 (67%), incorrectly selected that systolic blood pressure of <90 and a new need for oxygen to maintain saturation at >90% were elements of the SIRS screening criteria. A similar number, 60 (61%), incorrectly selected lactate >4. These elements are an indication of organ dysfunction and hypoperfusion and not elements of the SIRS screening criteria (Daniels, 2010).
Table 1. Frequency of systemic inflammatory response syndrome (SIRS) criteria correct and incorrect answers (n=98)
| SIRS criteria (correct) | Selected n (%) | Not selected n (%) |
|---|---|---|
| Temperature: <36°C | 67 (68%) | 31 (32%) |
| Temperature: >38.3°C | 94 (96%) | 4 (4%) |
| Heart rate >90 bpm | 85 (87%) | 13 (13%) |
| Respiratory rate: >20 bpm | 85 (87%) | 13 (13%) |
| WCC: >12 | 65 (66%) | 33 (34%) |
| WCC: <4 | 43 (44%) | 55 (56%) |
| BG: >7.7 in non-diabetic | 48 (49%) | 50 (51%) |
| Acutely altered mental state | 73 (75%) | 25 (25%) |
| Sign of a new infection | 71 (72%) | 27 (28%) |
Key: BG=capillary blood glucose; BP=blood pressure; bpm=beats/breaths per minute; WCC=white cell count
Skills required to carry out the Sepsis Six
Patients identified as positive on the septic screen need to have the Sepsis Six bundle implemented within 1 hour. Possessing skills such as venepuncture and cannulation means that nurses are able to perform elements of the Sepsis Six bundle, such as obtaining blood cultures and lactate and inserting a cannula without having to rely on other members of the multidisciplinary team, which improves bundle compliance within the hour. Having to wait for other members of the multidisciplinary team to undertake these tasks on ward patients leads to delay (Tarrant et al, 2016). Respondents were asked to select their competency level for the various skills required to carry out the Sepsis Six within 1 hour. The majority of ward nurses lack skills such as venepuncture, peripheral cannulation and male catheterisation. It is interesting to note that 21% of the respondents stated that they had received venepuncture training but did not carry out the skill. There was a similar finding with regards to peripheral cannulation (18%). There was a high interest in receiving training in the areas where skills were lacking, such as venepuncture, peripheral cannulation and male catheterisation (Figure 2).
Figure 2. Skills required to carry out the Sepsis Six
Behaviour and attitude statements
The answers to the attitude statements are given in Table 2.
Table 2. Sepsis screening: attitudes of ward nurses (n=98)
| Statements | Strongly disagree n (%) | Disagree n (%) | Neither agree or disagree n (%) | Agree n (%) | Strongly agree n (%) |
|---|---|---|---|---|---|
| Q12. There is adequate training on sepsis | 1 (1) | 12 (12) | 15 (15) | 58 (59) | 12 (12) |
| Q13. Screening patients for sepsis is part of my role | 0 (0) | 0 (0) | 2 (2) | 37 (38) | 59 (60) |
| Q14. I am confident in screening patients for sepsis | 0 (0) | 8 (8) | 11 (11) | 51 (52) | 28 (29) |
| Q15. If I had a sick patient I would escalate to a doctor or critical care outreach team (CCOT) to perform sepsis screen | 0 (0) | 5 (5) | 3 (3) | 26 (27) | 64 (65) |
| Q16. It is part of my role to decide when to initiate the Sepsis Six bundle | 0 (0) | 1 (1) | 12 (12) | 34 (35) | 51 (52) |
| Q17. I would only initiate the Sepsis Six bundle following instruction from a doctor or CCOT | 14 (14) | 47 (48) | 15 (15) | 17 (17) | 5 (5) |
| Q18. There is adequate staffing for me to carry out Sepsis Six on septic patients within 1 hour | 8 (8) | 26 (27) | 25 (26) | 31 (32) | 8 (8) |
| Q19. I often feel I do not have enough time to perform Sepsis Six within an hour | 3 (3) | 29 (30) | 22 (22) | 36 (37) | 8 (8) |
| Q20. I prioritise carrying out Sepsis Six on a septic patient over other tasks | 0 (0) | 0 (0) | 10 (10) | 45 (46) | 43 (44) |
| Q21. There is often a delay in prescribing when patients are septic | 0 (0) | 18 (18) | 29 (30) | 41 (42) | 10 (10) |
| Q22. It is part of my role to complete the Sepsis Six compliance bundle | 0 (0) | 1 (1) | 4 (4) | 51 (52) | 42 (43) |
The total attitude score was computed by adding the scores from the attitude statements (numbers 13, 14, 16, 17, 20 and 22 in Table 2). A higher score indicates a positive attitude, whereas a lower score indicates a negative attitude. The range of the attitude score was from 18 to 30 with a mean of 25 (standard deviation (SD)=2.97), a median of 25, and a mode of 28. The total attitude scores were reasonably normally distributed. The Cronbach's alpha for the attitude scale was 0.713, which is in the acceptable range.
One of the primary objectives of the study was to explore ward-based nurses' attitudes towards the implementation of the Sepsis Six bundle. Nurses who had received training had a more positive attitude (M=25.74, SD=2.54) compared to nurses who had not (M=23.58, SD=3.51) (U=611.5, P=0.009). There were no significant differences according to specialty, age or length of service.
Sepsis training
Nurses who had attended sepsis training were more likely to have screened a patient for sepsis (χ2 (2, n=98)=12.17, P=0.002). Among the nurses who had received training, 90% (65/72) had screened patients for sepsis compared to 58% (15/26) in the non-trained group. Nurses who had attended training on sepsis were more confident in screening patients for sepsis (χ2 (3, n=98)=24.90, P<0.001). Nurses who had attended sepsis training had better knowledge on the correct NEWS2 score to start screening for sepsis (χ2 (1, n=98)=15.94, P<0.001). Among the nurses who had received sepsis training, 81% (58/72) knew the correct NEWS2 to start sepsis screening compared to only 38% (10/26) in the non-trained group. Nurses who had attended sepsis training demonstrated a higher knowledge with regards to SIRS criteria (M=53.24, SD=24.52) compared to nurses who had not received training (M=40.17, SD=23.32), (U=649, P=0.019).
Barriers and facilitating factors to implementing the Sepsis Six bundle within 1 hour
Respondents were asked to identify barriers that prevented them from completing the delivery of the Sepsis Six within an hour and factors that assist them. In total, 80 of the respondents left comments on perceived barriers and facilitators, with many identifying more than one, and some leaving a lengthy response. Examples of comments are given in Table 3. Themes were identified and coded and frequency analysis was carried out for barriers (Figure 3) and facilitating factors (Figure 4).
Table 3. Barriers and facilitators for implementing the sepsis 6 bundle in 1 hour: perceptions of ward nurses (illustrative data from open-ended questions)
| Barriers |
|---|
|
Key: ANP=advanced nurse practitioner; CCOT=critical care outreach team; HCA=healthcare assistant; NEWS= National Early Warning Score; PGD=patient group directive
Figure 3. Number of staff who reported different barriers to implementing the Sepsis Six bundle within 1 hour 
Figure 4. Number of staff who reported different factors that facilitate implementation of the Sepsis Six bundle in 1 hour
The top two barriers identified were workload and staffing levels, followed by skills, availability of doctors, and prescribing. Heavy workload and low staffing levels on the wards made it difficult to complete the Sepsis Six within 1 hour. Some comments were made with regards to having unfamiliar staff working on the wards (illustrated in Table 3), such as agency staff and healthcare assistants, which could be a barrier at times when abnormal observations were not escalated appropriately. The lack of skills such as venepuncture and cannulation were also identified by many as causing a delay. Waiting for patients to be reviewed by a doctor, especially out of hours, was recognised as a barrier. This also resulted in prescribing delays.
The top three facilitating factors were tools, training and support. Several respondents said that tools such as the sepsis screening tool, sepsis bundle and having a patient group directive (PGD) for first dose antibiotics aided them in the delivery of the Sepsis Six within 1 hour. Training to improve knowledge was also important. It was apparent from the comments that having peer support from colleagues on the ward was essential to implementing Sepsis Six within an hour.
Discussion
Nurses who had received sepsis training had a higher level of knowledge on NEWS2 screening and SIRS criteria. Nurses who had received sepsis training were more likely to have a positive attitude towards early recognition and initial management of sepsis and were more confident in carrying out sepsis screening. They were therefore more likely to screen patients, resulting in early identification and management. Early recognition and management of sepsis with the delivery of Sepsis Six within 1 hour is important to prevent patients deteriorating on the wards (Daniels et al, 2011; Dellinger et al, 2013; McCaffery et al, 2016). This study adds to the evidence on education and training interventions, a neglected topic in healthcare improvement research (Dixon-Woods, 2019).
Not having the appropriate skills to carry out the Sepsis Six within 1 hour was identified as a key barrier by respondents. Certain practical skills are required, such as venepuncture and peripheral cannulation skills as a priority. However, the authors' study found that a majority of ward nurses lack these skills. Even among those who had received training in these skills, many did not use them. Another study by Breen and Rees (2018) found that ward nurses were significantly more likely to lack these skills compared to ED nurses. A lack of the necessary skills, or a reluctance to use them, places patients at risk of deteriorating if there is a delay in obtaining intravenous access to administer appropriate antibiotics and fluids.
Providing nurses with training in venepuncture and cannulation will be beneficial; however, there remains the need to wait for a doctor or an ANP to prescribe the necessary treatment. Delay in prescribing, and waiting for patients to be reviewed by doctors, were identified by the respondents as a barrier to implementing the Sepsis Six within 1 hour. This supports the finding by Matthaeus-Kraemer et al (2016). For every hour delay in the administration of antibiotics there is a 7.6% increase in mortality (Kumar et al, 2006; Barochia et al, 2010; Castellanos-Ortega et al, 2010; Kumar et al, 2015). Having a PGD to enable nurses to administer the first dose of antibiotics was identified as facilitating the implementation of the Sepsis Six bundle in 1 hour. Having a nurse-initiated sepsis protocol has been found to significantly reduce the median time to initial antibiotics (Bruce et al, 2015). Mattison et al (2016) found that having a PGD can result in timely antibiotic administration, with 96% of patients receiving antibiotics within 1 hour. Having a PGD protocol overcomes some of the barriers associated with the delay in the administration of antibiotics within 1 hour.
Workload and staffing levels were the most frequently mentioned barrier to implementing the Sepsis Six bundle in 1 hour. Similar findings have been reported elsewhere (Burney et al, 2012; Tarrant et al, 2016; Roberts et al, 2017a; 2017b; Breen and Rees, 2018). However, it was not simply a question of having adequate numbers of staff on the ward, respondents also valued the support of colleagues and good teamwork in implementing the Sepsis Six bundle. Respondents reported problems with inexperienced and unfamiliar staff (for example temporary agency staff), who carry out observations on patients but may not recognise or know when to report abnormal observations. Not reporting high NEWS2 scores and deteriorating observations to a staff nurse delays the identification of a potential septic patient, which puts that patient at risk of deteriorating. This supports a finding by Breen and Rees (2018), who found that one of the biggest barriers to identifying sepsis was the lack of sepsis recognition during observation rounds.
The ‘hollowing out’ of the NHS workforce through an overreliance on unregistered and temporary nursing staff is currently an important public policy concern (Buchan et al, 2019). This study contributes to the evidence for the effects of such workforce policies on patient care. It also raises questions about the education and training needs of agency staff, and whether or not they have access and support to attend the same training as staff employed by trusts and health boards.
Tools were the most frequently mentioned factor that nurses found helped them in completing the Sepsis Six within 1 hour. In the authors' hospital these tools consist of the Sepsis Six screening tool and bundle, the screening tool on the observation chart and the NEWS2. These tools provide a nurse-initiated approach to sepsis, which empowers nurses. Previous research, mainly in emergency departments, has found that providing nurses with training and education, paired with appropriate tools, can improve sepsis care (Tromp et al, 2010; Bruce et al, 2015; Drahnak et al, 2016; McCaffery et al, 2016; Torsvik et al, 2016; Shah et al, 2018).
Limitations
The overall response rate for this study was 39%. Although this may seem low, it corresponds with similar studies (Roberts et al, 2017a; Breen and Rees, 2018). The respondents' self-selected into the study, and this may have produced bias. Staff who have an interest in sepsis may have been more inclined to take part in the survey compared to those with less interest.
Conclusion
Sepsis training improves nurses' attitude, knowledge and confidence with regards to sepsis screening and initiating the Sepsis Six within 1 hour. Therefore, the recommendation from this study is that sepsis training should become mandatory for all clinical staff, including all nurses, healthcare assistants and doctors. The widespread use of unregistered and temporary staff on acute wards reduces the support available for ward staff to screen for sepsis, and the teamwork and peer support required for decision-making and use of clinical skills. A lack of practical skills was also identified as a barrier. Despite having received training on skills such as venepuncture and cannulation, the majority of nurses did not use these skills. The study has identified this as an area that requires further research to explore the underlying causes. Consideration should also be given to the impact that temporary nurse staffing has on the availability of knowledge and skills for sepsis screening.
KEY POINTS
- This study used a questionnaire to investigate the effects of sepsis training for ward-based nurses on knowledge, skills and attitudes to sepsis screening and initiation of the sepsis bundle, and also explored barriers and facilitating factors faced by ward nurses
- Nurses with sepsis training had better sepsis screening knowledge, were more confident and demonstrated a more positive attitude towards sepsis screening and management, and were more likely to have screened a patient for sepsis
- Ward-based nurses identified tools such as the sepsis screening tool, training and peer support as facilitating factors to sepsis screening and initiation of the sepsis bundle, whereas workload, staffing levels and lack of skills such as venepuncture and cannulation were identified as barriers
- The findings from this study strengthen the argument that sepsis training should become mandatory for all ward staff
CPD reflective questions
- What improvements could be implemented in your clinical area to overcome some of the barriers to sepsis screening and bundle compliance?
- Think about how to improve staff knowledge on sepsis screening in your clinical area, and how this could be embedded into the daily routine as a norm
- How can you ensure that staff in your clinical area have the necessary skills required to deliver a sepsis bundle within 1 hour?