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Emergency nurses’ experiences of the implementation of early goal directed fluid resuscitation therapy in the management of sepsis: a qualitative study

Authors:

Abstract

Background Severe sepsis can lead to organ failure and death if immediate treatment, such as intravenous fluids and antibiotics, are not commenced within the first hour. Time - critical initiation of intravenous fluids which in other words is early goal directed fluid resuscitation has not always been given its clinical priority. This qualitative study aimed at exploring the experiences of emergency nurses initiating early goal directed fluid resuscitation in patients with sepsis. Methods Using an exploratory approach, face - to - face semi - structured interviews were conducted with ten registered nurses working in emergency departments across New South Wales, Australia. Thematic analysis was used for data analysis. Findings Participants described various factors that inhibited the timely initiation of early goal directed fluid resuscitation, some clinical practice challenges, and strategies to improve nursing practice. Most participants, particularly those practicing as Clinical Initiatives Nurses suggested the incorporation of nurse initiated early goal directed fluid resuscitation for patients with sepsis as part of their scope of practice. Conclusion Our findings identified several barriers that inhibit effective nurse - initiated early goal directed fluid resuscitation. It is anticipated that these findings will provide validation for the re-evaluation of the existing protocols and practice guidelines to increase the scope of practice of emergency nurses initiating early goal directed fluid resuscitation.
Please
cite
this
article
in
press
as:
Kabil
G,
et
al.
Emergency
nurses’
experiences
of
the
implementation
of
early
goal
directed
fluid
resuscitation
therapy
in
the
management
of
sepsis:
a
qualitative
study.
Australasian
Emergency
Care
(2020),
https://doi.org/10.1016/j.auec.2020.07.002
ARTICLE IN PRESS
G Model
AUEC-483;
No.
of
Pages
6
Australasian
Emergency
Care
xxx
(2020)
xxx–xxx
Contents
lists
available
at
ScienceDirect
Australasian
Emergency
Care
jo
u
r
nal
home
page:
www.elsevier.com/locate/auec
Research
paper
Emergency
nurses’
experiences
of
the
implementation
of
early
goal
directed
fluid
resuscitation
therapy
in
the
management
of
sepsis:
a
qualitative
study
Gladis
Kabil,
Deborah
Hatcher,
Evan
Alexandrou,
Stephen
McNally
School
of
Nursing
and
Midwifery,
Western
Sydney
University,
Locked
Bag
1797,
Penrith,
NSW,
2751,
Australia
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
16
April
2020
Received
in
revised
form
9
July
2020
Accepted
10
July
2020
Keywords:
sepsis
fluid
therapy
Early
Goal
Directed
Therapy
barriers
emergency
department
nurses
a
b
s
t
r
a
c
t
Background:
Severe
sepsis
can
lead
to
organ
failure
and
death
if
immediate
treatment,
such
as
intravenous
fluids
and
antibiotics,
are
not
commenced
within
the
first
hour.
Time
-
critical
initiation
of
intravenous
fluids
which
in
other
words
is
early
goal
directed
fluid
resuscitation
has
not
always
been
given
its
clinical
priority.
This
qualitative
study
aimed
at
exploring
the
experiences
of
emergency
nurses
initiating
early
goal
directed
fluid
resuscitation
in
patients
with
sepsis.
Methods:
Using
an
exploratory
approach,
face
-
to
-
face
semi
-
structured
interviews
were
conducted
with
ten
registered
nurses
working
in
emergency
departments
across
New
South
Wales,
Australia.
Thematic
analysis
was
used
for
data
analysis.
Findings:
Participants
described
various
factors
that
inhibited
the
timely
initiation
of
early
goal
directed
fluid
resuscitation,
some
clinical
practice
challenges,
and
strategies
to
improve
nursing
practice.
Most
participants,
particularly
those
practicing
as
Clinical
Initiatives
Nurses
suggested
the
incorporation
of
nurse
initiated
early
goal
directed
fluid
resuscitation
for
patients
with
sepsis
as
part
of
their
scope
of
practice.
Conclusion:
Our
findings
identified
several
barriers
that
inhibit
effective
nurse
-
initiated
early
goal
directed
fluid
resuscitation.
It
is
anticipated
that
these
findings
will
provide
validation
for
the
re-
evaluation
of
the
existing
protocols
and
practice
guidelines
to
increase
the
scope
of
practice
of
emergency
nurses
initiating
early
goal
directed
fluid
resuscitation.
©
2020
College
of
Emergency
Nursing
Australasia.
Published
by
Elsevier
Ltd.
All
rights
reserved.
Introduction
Sepsis
is
a
leading
cause
of
death
in
healthcare
settings
world-
wide.
Globally,
nearly
30
million
people
develop
sepsis
every
year
and
has
an
attributable
mortality
rate
of
up
to
50%
which
equates
to
one
death
every
3.5
seconds
[1].
In
Australia,
more
than
5000
peo-
ple
die
of
sepsis
each
year,
three
times
the
number
of
deaths
caused
by
road
traffic
accident
and
is
greater
than
deaths
due
to
prostate,
breast,
colorectal
cancers
and
HIV/AIDS
combined
together
[2].
Sepsis
is
a
time
-
critical
emergency
that
requires
early
recog-
nition
and
prompt
management.
To
improve
the
recognition
and
outcomes
of
sepsis,
evidenced
-
based
practices
were
incorporated
collectively
by
the
‘Surviving
Sepsis
Campaign’
in
2002
to
form
the
Corresponding
author.
E-mail
addresses:
g.kabil@westernsydney.edu.au
(G.
Kabil),
d.hatcher@westernsydney.edu.au
(D.
Hatcher),
E.Alexandrou@westernsydney.edu.au
(E.
Alexandrou),
s.mcnally@westernsydney.edu.au
(S.
McNally).
sepsis
management
guidelines.
An
integral
part
of
the
sepsis
guide-
lines
is
the
‘Sepsis
Pathway’
[4].
The
Pathway
is
used
widely
across
the
world
and
in
Australia
and
was
introduced
in
NSW
in
2011as
part
of
the
‘Sepsis
Kills’
program.
The
Pathway
recommends
the
use
of
a
care
bundle
known
as
Early
Goal
Directed
Therapy
(EGDT),
a
group
of
evidence
-
based
interventions
which
when
implemented
together
have
proven
to
be
more
effective
than
when
implemented
as
individual
therapies.
EGDT
has
significantly
improved
patient
outcomes
with
a
16%
reduction
in
mortality
[5].
The
interventions
include
(i)
obtaining
lactate
level
and
blood
cultures,
(ii)
admin-
istering
empirical
antibiotics
(iii)
administering
30
ml/kg
IV
fluids
to
correct
hypotension
or
lactate
>4
mmol/L
(iv)
commencing
vaso-
pressors
in
life
-
threatening
situations.
The
Pathway
maintains
that
all
of
these
interventions
should
be
initiated
immediately
and
col-
lectively
from
the
time
of
presentation
with
the
primary
aim
of
optimising
vital
organ
perfusion
and
haemodynamic
stability
[6].
The
New
South
Wales
Clinical
Excellence
Commission
(NSW
CEC)
has
modified
the
Sepsis
Pathway
and
recommends
initiating
20
ml/kg
as
an
initial
IV
fluids
bolus
instead
of
30
ml/kg
and
repeat-
https://doi.org/10.1016/j.auec.2020.07.002
2588-994X/©
2020
College
of
Emergency
Nursing
Australasia.
Published
by
Elsevier
Ltd.
All
rights
reserved.
Please
cite
this
article
in
press
as:
Kabil
G,
et
al.
Emergency
nurses’
experiences
of
the
implementation
of
early
goal
directed
fluid
resuscitation
therapy
in
the
management
of
sepsis:
a
qualitative
study.
Australasian
Emergency
Care
(2020),
https://doi.org/10.1016/j.auec.2020.07.002
ARTICLE IN PRESS
G Model
AUEC-483;
No.
of
Pages
6
2
G.
Kabil
et
al.
/
Australasian
Emergency
Care
xxx
(2020)
xxx–xxx
ing
further
20
ml/kg
IV
fluids
bolus
if
haemodynamic
stability
is
not
returned
[7].
Despite
evidence
of
its
significance,
compliance
with
timely
initiation
of
Early
Goal
Directed
Fluid
Resuscitation
(EGDFR)
is
suboptimal.
Studies
have
shown
that
the
time
to
initiation
of
EGDFR
can
be
delayed
by
up
to
over
an
hour
after
presentation
and
nearly
half
do
not
receive
adequate
IV
fluids
resuscitation
[8,9].
Although
a
number
of
studies
have
analysed
factors
contributing
to
the
delay
in
first
antibiotic
dose
administration
[10,11],
there
is
limited
data
investigating,
specifically,
the
individual
element
of
fluid
resuscitation.
The
aim
of
this
study
was
to
explore
the
experi-
ences
and
the
factors
that
emergency
nurses
considered
inhibiting
the
initiation
of
EGDFR
for
patients
identified
with
sepsis.
Method
An
exploratory
approach
using
face
to
face
semi
-
structured
interviews
was
used.
The
purpose
was
to
describe
inhibiting
factors
expressed
by
emergency
nurses
that
impacted
the
timely
initia-
tion
of
EGDFR.
Participants
were
ten
registered
nurses
from
both
metropolitan
and
regional
emergency
departments
(EDs)
across
NSW.
Sampling
To
facilitate
diverse
participation,
two
purposive
sampling
tech-
niques
were
used,
maximum
variation
and
snowball
sampling.
The
maximum
variation
technique
involved
inviting
participants
with
various
levels
of
emergency
nursing
experience
and
working
across
various
emergency
settings,
such
as
metropolitan,
tertiary
trauma
centres,
rural
and
non
-
tertiary
hospitals
[12].
The
snowball
sam-
pling
method
allowed
for
new
participants
to
be
enrolled
through
referrals
from
existing
participants
[13].
Ethics
Ethics
approval
was
obtained
from
the
Western
Sydney
Uni-
versity
Human
Research
Ethics
Committee
(approval
number:
H13030)
prior
to
commencing
the
study.
Participant
recruitment
The
study
population
included
registered
nurses
currently
prac-
ticing
full
or
part
-
time
in
an
emergency
department
in
either
metropolitan
or
rural
NSW,
and
who
provide
informed
consent
to
participate.
The
study
excluded
registered
nurses
who
are
currently
not
practicing
in
an
emergency
department
in
metropolitan
or
rural
NSW
or
those
who
are
on
a
casual
contract
with
only
some
alloca-
tions
to
work
as
a
registered
nurse
in
the
emergency
department,
as
well
as
those
unwilling
to
consent
to
participate
in
the
study
(Figs.
1
and
2).
Flyers
promoting
the
study
were
posted
on
social
media
sites
of
professional
organisations
such
as
the
Australian
College
of
Emergency
Nursing.
The
participants
recruited
through
social
media
then
assisted
in
further
recruitment
through
snowball
sam-
pling.
Participant
information
sheets
and
consent
forms
were
provided
prior
to
the
interview.
Health
settings
of
participants
included
major
trauma
hospitals
to
smaller
district
hospitals
and
regional
centres
from
metropolitan
Sydney,
Greater
Western
Syd-
ney,
North
Sydney,
and
the
Illawarra
region.
Twelve
registered
nurses
expressed
willingness
to
participate
in
the
study.
Two
were
excluded
as
they
were
not
currently
practising
in
the
ED.
The
par-
ticipants
ranged
from
25
to
68
years
in
age
with
an
average
age
of
39.9
years.
Eight
participants
were
female
and
two
were
male.
The
participants
had
on
average
15.5
years
of
nursing
experience
as
registered
nurses
with
an
average
of
11years
of
experience
work-
ing
in
the
emergency
department.
Six
out
of
the
ten
participants
Potenti
al participants con
tacted
(social media and snowball s
ampli
ng)
Responses
rece
ived(via email)
n=12 Ineligible parti
cipant s as
they were curr
entl
y not
practising in t
he emergency
department
n=2
Eli
gible parti
cipants
n=10
Fig.
1.
Flowchart
of
participant
recruitment.
Manually read and re - read interview transcripts
486 initi
al codes
developed
Initial codes colour coded using
Quirkos, group ed under 35 titl
es
Re
- reading and review
to identi
fy
simil
arities
4 common themes & 18
subthemes evolved
3 major themes & 17
sub
themes emerged
Fig.
2.
Flowchart
of
data
analysis.
were
from
metropolitan
trauma
hospitals,
three
were
from
smaller
district
hospitals
and
one
was
from
a
regional
hospital.
Data
Collection
Semi
-
structured
face
-
to
-
face
interviews
were
conducted.
All
interviews
were
conducted
in
neutral
settings
that
were
mutu-
ally
agreeable
for
both
participants
and
the
interviewer.
Participant
demographics
were
collected
as
part
of
the
study
protocol.
An
inter-
view
guide
with
12
questions
was
used
during
the
interview,
the
approach,
however,
remained
flexible
to
facilitate
participation.
The
questions
and
prompts
used
in
the
guide
were
constructed
through
the
emergency
nursing
experience
of
the
researcher
as
well
as
through
relevant
literature
and
piloted
by
three
clinical
experts
in
emergency
nursing.
The
data
analysis
began
concur-
rently
during
data
collection
and
continued
until
data
saturation
was
achieved
and
determined
after
the
tenth
interview
as
no
new
patterns
evolved.
All
interviews
were
digitally
audio
-
recorded
using
a
digital
voice
recorder
and
transcribed
verbatim
with
the
participant’s
consent
(Table
1).
Please
cite
this
article
in
press
as:
Kabil
G,
et
al.
Emergency
nurses’
experiences
of
the
implementation
of
early
goal
directed
fluid
resuscitation
therapy
in
the
management
of
sepsis:
a
qualitative
study.
Australasian
Emergency
Care
(2020),
https://doi.org/10.1016/j.auec.2020.07.002
ARTICLE IN PRESS
G Model
AUEC-483;
No.
of
Pages
6
G.
Kabil
et
al.
/
Australasian
Emergency
Care
xxx
(2020)
xxx–xxx
3
Table
1
Demographic
details
of
participants.
Participant
Age
Gender
Job
title
ED
Beds
Years
of
nursing
experience
Years
of
ED
experience
68
Female
RN,
CNE
24
48
25
30
Male
RN
55
6
5
47
Female
RN,
CNE
16
23
23
35
Female
RN
23
10
5
47
Female
RN,
Nurse
Unit
Manager
55
22
10
31
Female
RN
56
10
8
36
Female
RN
30
12
12
39
Female
RN
56
1
1
25
Male
RN,
CNE
22
4
3.5
41
Female
RN,
Sepsis
Champion
56
19
18
Job
Title
Key:
RN
=
Registered
Nurse
CNE
=
Clinical
Nurse
Educator:
provides
clinical
nurse
education
within
the
emergency
department
NUM
=
Nurse
Unit
Manager:
manages
and
provides
nursing
leadership
within
the
emergency
department.
Sepsis
Champion:
provides
training,
strategies
to
optimise
timely
recognition
and
management
of
sepsis
and
monitor
effectiveness.
Data
Analysis
Data
transcription
was
undertaken
by
external
professionals.
All
transcripts
were
manually
audited
to
check
against
original
recording
for
accuracy.
The
final
version
of
the
transcripts
were
imported
into
the
Quirkos
software
program
(version
2.0.1,
Edin-
burgh,
UK)
for
coding
which
enabled
the
researcher
to
file,
code,
and
retrieve
data.
The
thematic
analysis
of
the
interview
transcripts
was
informed
by
Braun
and
Clarke’s
2006
six
-
step
framework
[14].
The
researcher
manually
read
and
re
-
read
all
ten
interview
transcripts
to
become
familiar
with
the
concepts
and
identify
similarities
in
the
data.
The
codes
initially
developed
were
then
grouped
to
iden-
tify
similar
texts,
grouping
texts
with
related
content.
The
initial
coding
report
was
reviewed
by
the
study
authors.
During
thematic
analysis,
codes
evolved
into
common
patterns.
The
initial
codes
were
analysed
under
three
themes
and
seventeen
subthemes.
Sub-
themes
were
also
grouped
under
the
parent
themes.
Findings
Among
the
ten
participants,
three
themes
were
identified
as
being
most
relevant
to
their
experiences:
(i)
nurses’
perceptions
and
experiences;
(ii)
clinical
practice
challenges;
and
(iii)
strategies
to
improve
compliance.
Nurses’
perceptions
and
experiences
Controversies
regarding
the
importance
of
IV
fluids
was
seen
among
the
participants
with
the
less
experienced
participants
giving
less
importance
to
EGDFR.
Participants
recognised
the
signif-
icance
of
IV
fluids
bolus
and
attributed
it
to
the
positive
outcomes
they
have
seen
in
their
patients.
“The
fluid
challenge
is
a
huge
one.
We
tend
to
get
onto
that
pretty
quickly
“Macey
(EDRN
-
23)
“I
just
see
a
big
response
to
it
(IV
fluids).
It
seems
to
work
better
than
anything.
.
.,
100%”
Jackie
(EDRN
-10)
However,
less
experienced
participants
indicated
that
initiating
IV
fluids
is
not
a
priority.
They
felt
that
treating
the
infection
with
antibiotics
should
take
precedence
over
EGDFR.
“The
fluids
will
only
help
with
tachycardia
and
temperature,
but
won’t
treat
the
infection
.
.
.We
don’t
try
to
push
the
fluids;
we
try
to
push
antibiotics”
Jill
(EDRN
-
1)
Participants
highlighted
the
negative
patient
outcomes
when
IV
fluids
was
not
initiated
early.
They
recalled
real
patient
stories
of
deterioration.
“With
the
delay
of
treatment,
they
became
more
unwell.
They
end
up
in
resuscitation
area
with
inotropes,
arterial
lines
and
in
High
Dependency
Unit”
Annie
(EDRN
-5)
Participants
also
described
poor
patient
outcomes,
prolonged
hospitalisation,
complications,
and
critical
care
admissions
asso-
ciated
with
delayed
initiation
of
EGDFR.
Incorrect
allocation
of
a
triage
category
plays
an
important
role
in
delayed
IV
fluids
initia-
tion
where
sepsis
has
been
overlooked,
particularly
during
after
-
hours.
“They
came
in,
they
were
not
picked
up
as
a
category
2,
given
a
category
3,
so
.
.
.
a
lot
of
time
to
work
them
up:
30–40–60
minutes.
And
by
the
time
you
get
the
patient,
blood
pressure
was
drop-
ping
.
.
.
She
didn’t
have
a
cannula
so
we
couldn’t
give
fluids
.
.
.
we
talked
to
the
doctor
.
.
.
they
were
not
concerned
.
.
.
“She’s
just
(got)
abdominal
pain
.
.
.
when
the
scan
comes,
we’ll
discuss
.
.
.
in
the
morning,
the
blood
pressure
dropped,
.
.
.
(she)
became
febrile
.
.
.
she
had
sepsis
.
.
.ended
up
going
to
HDU
[High
Dependency
Unit]”
Jill
(EDRN
-
1)
It
was
also
suggested
that
the
ideal
quantity
of
IV
fluids
to
be
administered
would
depend
on
the
individual
health
status
of
the
presenting
patients.
“It
depends
on
the
morbidities,
renal,
heart
function,
whether
they’ve
got
fluid
restrictions
and
their
age.
Let’s
say,
a
20
year
-
old
male
with
sepsis
that’s
got
no
comorbidities.
I
think,
immediately,
one
to
two
litres
and
review
every
litre
after
that”
Sean
(EDRN
-
3.5)
Compliance
with
the
Sepsis
Pathway
was
reported
as
poor
and
adherence
to
the
Sepsis
Pathway
was
related
to
busyness
and
acu-
ity.
The
actual
time
of
intervention
ranges
from
two
to
three
hours,
while
the
recommendation
is
to
commence
treatment
immedi-
ately.
“Two
hours.
That’s
the
worst
I’ve
seen.
Previously,
it
was
like
68
minutes”
Diana
(EDRN
-
18)
However,
participants,
from
a
non
-
tertiary
hospital
and
a
rural
setting,
stated
that
medical
officers
were
available
in
their
depart-
ments
to
review
sepsis
patients
within
the
first
ten
minutes
of
arrival.
“Yeah,
everything
in
10
minutes.
The
doctor
has
to
come
over.
We
get
fluid
ready
and,
by
the
time
the
doctor
comes
over,
we
can
actually
say
they’ll
have
fluids”
Judy
(EDRN
-
12)
On
further
exploring
the
clinical
practice
to
overcome
limita-
tions,
participants
stated
that
they
step
out
of
their
scope
of
practice
when
they
see
the
need
for
initiating
IV
fluids
in
sepsis
patients.
These
participants
were
more
experienced
with
up
to
48
years
Please
cite
this
article
in
press
as:
Kabil
G,
et
al.
Emergency
nurses’
experiences
of
the
implementation
of
early
goal
directed
fluid
resuscitation
therapy
in
the
management
of
sepsis:
a
qualitative
study.
Australasian
Emergency
Care
(2020),
https://doi.org/10.1016/j.auec.2020.07.002
ARTICLE IN PRESS
G Model
AUEC-483;
No.
of
Pages
6
4
G.
Kabil
et
al.
/
Australasian
Emergency
Care
xxx
(2020)
xxx–xxx
of
nursing
experience,
and
those
who
have
been
in
roles
such
as
clinical
nurse
unit
managers,
clinical
educators,
and
sepsis
project
champions.
Experienced
participants
were
more
likely
to
practice
intuitive
decision
-
making
when
faced
with
clinical
challenges.
“Because
we
actually
do
it
anyway,
which
is
how
we
just
chart
it
illegally,
but
we
know
that
they
need
their
fluids”
Jackie
(EDRN
-10)
“So,
I
know,
based
off
experience
some
of
us
will
.
.
.
I
would
cannulate.
I
would
start
a
bag
of
saline
and
say
to
a
doctor,
“Hey,
I’ve
done
this.
Can
you
sign
off?”
And
it
will
always
be
okay.
I’ve
gone
through
the
checklist
with
a
patient
to
make
sure
they
don’t
have
any
risk
factors”
Sean
(EDRN
-
3.5)
However,
participants
with
limited
experience
stated
that
they
would
not
initiate
IV
fluids
because
they
would
not
step
out
of
their
scope
of
practice.
“I
don’t
personally
initiate
IV
fluids;
I
have
to
put
a
doctor’s
order
for
that.
Just
because
I
like
to
keep
my
registration.”
Jill
(EDRN
-
1)
Clinical
Practice
Challenges
Participants
indicated
that
early
recognition
of
sepsis
is
a
chal-
lenge.
The
presentation
may
not
be
congruent
with
sepsis
on
arrival,
yet
later
progresses
to
severe
sepsis
when
the
patient
dete-
riorates.
“I
think
there’s
a
real
focus
now
on
febrile
tachycardia.
If
you’re
missing
particularly
the
temperature.
.
.
if
they
present
with
a
tem-
perature
of
35.5
.
.
.
that’s
where
it
gets
missed”
Macey
(EDRN
-
23)
Busy
workloads
were
identified
as
the
primary
factor
leading
to
delays
in
initiating
treatment,
describing
EDs
as
constantly
busy,
overcrowded,
and
understaffed.
Several
unwell
patients
presenting
at
the
same
time
was
suggested
as
resulting
in
competing
priorities.
“The
only
people
that
are
being
seen,
often
especially
after
10
o’clock
at
night
are
the
ones
that
the
waiting
room
nurses
see,
oth-
erwise
they
would
wait
in
the
waiting
room
for
eight
hours”
Jackie
(EDRN
-
10)
and
“The
staffing
shortages
and
the
cutback
on
staff
.
.
.
That’s
got
danger
written
all
over
it
for
our
septic
patients”
Macey
(EDRN
-
23)
Participants
conveyed
that
the
complexity
of
patients’
presenta-
tions
and
comorbidities
influenced
the
commencement
of
IV
fluids
immediately.
Concerns
were
also
expressed
about
unwell
patients
with
difficult
veins
to
cannulate.
“The
only
other
thing
that
would
stop
me
from
being
able
to
intervene
was
somebody
who
had
very,
very
difficult
veins.
I
have
no
choice
but
to
put
them
back
into
the
waiting
room,
therefore,
nothing
is
done
for
them
until
they’re
seen
medically.
That
is
a
really
big
barrier”
Jackie
(EDRN
-
10)
There
was
a
discussion
about
the
interdisciplinary
conflicts
that
exist
in
the
ED.
Participants
conveyed
that
interprofessional
issues;
such
as
attitudes,
behaviour,
and
communications
between
nurses
and
medical
officers
were
at
times
inhibiting.
Other
associated
fac-
tors
were
the
experience
level
of
nurses,
their
clinical
skill
set,
and
assertiveness.
It’s
also,
to
not
blur
the
lines
within
what
nurses
and
doctors
can
do.
There’s
that
very
much
about:
“I’m
a
doctor,
you’re
a
nurse.
You
can
do
this
within
this
parameter,
but
we
can
do
this,
we
have
powers
above
that.”
Jackie
(EDRN
-
10)
and
“As
a
junior
nurse,
you
can’t
do
a
couple
of
stuff
like
cannulate
or
escalate”
Annie
(EDRN
-
5)
Getting
a
medical
officer’s
order
to
initiate
IV
fluids
can
be
a
significant
cause
of
delay
because
the
current
NSW
Sepsis
Pathway
does
permit
nurses
to
initiate
the
recommended
amount
of
IV
fluids
in
sepsis.
Participants
stated
they
felt
as
if
“their
hands
were
tied”
due
to
the
limited
scope
of
practice.
Experienced
emergency
nurses
have
a
broad
range
of
experience
working
in
various
roles
within
the
emergency
department
and
have
generally
completed
the
Tran-
sition
to
Emergency
Nursing
Program
offered
by
NSW
Health.
These
experienced
nurses
then
progress
to
become
advanced
prac-
tice
emergency
nurses
such
as
Clinical
Initiatives
Nurse
(CIN).
CIN
nurses
are
authorised
by
the
NSW
Health
Department
to
pre-
scribe
treatment
initiatives
such
as
analgesia
and
intravenous
fluids
within
the
scope
of
standing
orders.
This
includes
prescribing
intra-
venous
Hartmanns
at
the
rate
of
1
litre
over
8
hours.
However,
this
is
incongruent
with
the
Sepsis
Pathway
as
it
recommends
com-
mencing
intravenous
fluids
as
a
20
ml/kg
intravenous
fluid
bolus.
“CIN
can
prescribe
fluids,
but
we
can
only
prescribe
slow
Hart-
manns”
Sean
(EDRN
-
3.5)
and
“The
problem
is
we
still
want
the
doctor
to
come.
It’s
getting
that
doctor
to
come
to
order
that
fluids
because
the
sepsis
pathway
doesn’t
allow
us
to
nurse-
initiate
IV
fluids,
does
it?
It
has
to
be
sighted
by
the
doctor
.
.
.
even
though
they
are
advanced
emergency
trained,
sepsis
does
not
fall
into
that
standing
order
for
initiating
fluids”
Diana
(EDRN
-
18)
Strategies
to
Improve
Compliance
Participants
suggested
that
supporting
nurse
-
initiated
IV
fluids
for
patients
with
sepsis
would
significantly
improve
the
timeliness
of
EGDFR
and
questioned
the
authenticity
of
the
constraints
cur-
rently
on
nurses,
citing
that
they
have
standing
orders
to
nurse
-
initiate
opioid
medication,
which
requires
a
similar
level
of
clinical
judgement
to
be
exercised.
“We
can
give
morphine
and
fentanyl;
I
don’t
see
why
we
can’t
give
fluids”
Jill
(EDRN
-
1)
and
“If
it
states
that
nurse
can
initiate
fluids
.
.
.
if
that
gave
us
that
power,
that
standing
order
to
initi-
ate
fluids
without
the
doctor
sighting
it,
yes,
I
think
that’s
what’s
holding
us
up”
Diana
(EDRN
-
18)
Participants
felt
that
the
current
Sepsis
Pathway
is
complex,
overloaded
with
information
and
is
non
-clinician
-
friendly
and
suggested
redesigning
it
“It’s
a
little
bit
complex.
It’s
a
bit
busy.
.
.
For
a
junior
nurse
to
read
that
pathway,
there’s
no
way”
Macey
(EDRN
-
23)
They
suggested
that
positive
strategies
included
education,
training,
and
constant
re-enforcement
regarding
the
Sepsis
Path-
way.
I
think
everybody
knows
about
the
pathway
.
.
.
it
is
having
that
persistent
training
because
people
would
forget.”
Diana
(EDRN
-
18)
It
was
also
suggested
that
more
nurses
could
be
taught
ultra-
sound
guided
IV
cannulation
as
that
would
speed
up
IV
access
for
patients
with
difficult
access
“We’re
trying
to
run
education
for
the
nurses
to
start
learning
ultrasound
cannulation”
Cathy
(EDRN
25)
Discussion
Each
year,
more
than
5000
Australians
die
from
sepsis.
Severe
sepsis
leading
to
organ
failure
causes
death
in
almost
one
in
three
patients
hospitalised
with
sepsis
[2].
EGDFR
optimises
organ
tissue
perfusion
during
sepsis
and,
in
doing
so,
reduces
the
complica-
tions
related
to
organ
failure
and
death
[15].
The
findings
from
this
study
provide
key
insights
regarding
emergency
nurses’
experi-
ences;
challenges
around
timely
initiation
of
EGDFR
and
strategies
to
improve
its
timeliness.
Throughout
the
data,
the
concept
of
patient
deterioration
associated
with
delayed
initiation
of
EGDFR
was
repeated.
It
is
evident
that
the
factors
causing
delays
in
initi-
ating
EGDFR
are
common
across
various
EDs.
While
some
of
the
discussions
are
comparable
to
what
is
known
from
the
literature
review,
several
new
insights
have
been
revealed
by
the
participants.
Most
participants
confirmed
the
positive
effects
of
EGDFR.
Their
clinical
decision
to
initiate
intravenous
fluids
early
is
a
result
of
the
impact
they
see
on
their
patients,
such
as
improved
tissue
perfu-
sion.
Several
experimental
studies,
including
the
landmark
study
Please
cite
this
article
in
press
as:
Kabil
G,
et
al.
Emergency
nurses’
experiences
of
the
implementation
of
early
goal
directed
fluid
resuscitation
therapy
in
the
management
of
sepsis:
a
qualitative
study.
Australasian
Emergency
Care
(2020),
https://doi.org/10.1016/j.auec.2020.07.002
ARTICLE IN PRESS
G Model
AUEC-483;
No.
of
Pages
6
G.
Kabil
et
al.
/
Australasian
Emergency
Care
xxx
(2020)
xxx–xxx
5
of
the
Early
Goal
Directed
Therapy
Collaborative
Group
[15]
have
confirmed
that
administering
intravenous
fluids,
particularly
in
the
early
phases
of
sepsis,
improves
microcirculation
and
decreases
mortality
by
16%
[16],
reduces
intensive
care
admissions
and
length
of
stay
in
hospitals
[17].
However,
a
few
less
experienced
participants
in
this
study
questioned
the
need
for
intravenous
fluids
and
stated
they
would
administer
antibiotics
to
treat
the
infection
and
not
intravenous
fluids.
An
explanation
for
this
may
be
that
their
inexperience
in
treating
patients
with
sepsis,
and
the
associated
fear
of
fluid
overload,
may
have
influenced
their
perceptions
regarding
EGDFR
resulting
in
adhering
to
the
rules
with
no
sense
of
intuition.
This
is
in
congruence
with
studies
[18]
that
argue
that
excessive
fluid
administration
in
sepsis
may
lead
to
adverse
effects,
such
as
acute
respiratory
distress
syndrome
resulting
from
fluid
overload.
Nonetheless,
these
studies
do
not
analyse
the
time
of
administra-
tion,
but
rather
consider
the
total
cumulative
fluids
administered
and
warn
against
injudicious
use
of
intravenous
fluids
beyond
the
early
resuscitation
phase.
Several
participants
confirmed
that
delayed
intravenous
fluids
initiation
in
sepsis
results
in
patient
deterioration
with
patients
then
requiring
more
aggressive
management
such
as
the
use
of
inotropes,
invasive
arterial
lines,
and
ICU
admissions.
This
is
further
supported
by
the
findings
from
a
recent
observational
cohort
study,
where
patient
outcomes
were
measured
in
terms
of
end
organ
failure.
Of
the
patients
with
sepsis
who
did
not
receive
early
intra-
venous
fluids
initiated
by
the
ambulance,
more
than
half
showed
signs
of
organ
failure
in
ED.
Conversely,
of
those
who
received
intravenous
fluids
in
their
pre
-
hospital
treatment,
40%
showed
improved
outcomes
[19].
The
volume
of
intravenous
fluids
administered
during
the
initial
resuscitation
phase
plays
a
crucial
role
in
patient
outcomes.
Partic-
ipants
described
that
the
ideal
volume
of
fluid
that
they
prefer
to
administer
is
dependent
on
the
patient’s
comorbidities.
Concerns
related
to
the
development
of
pulmonary
oedema
associated
with
excessive
intravenous
fluid
therapy,
particularly
in
patients
with
pre
-
existing
comorbidities
are
contradicted,
in
the
findings
from
a
2014
retrospective
cohort
study
which
suggested
that
there
is
no
significant
association
between
the
volume
of
fluid
administered
within
the
first
6-24
hours
and
acute
respiratory
distress
syndrome
[20].
Most
participants
affirmed
anecdotally
that
their
department’s
compliance
with
EGDFR
would
be
poor
with
times
ranging
from
two
to
eight
hours
and
attributed
several
factors
discussed
below
that
contribute
to
extended
delays.
This
finding
supports
those
of
previous
studies
analysing
the
time
to
EGDT
[8,9].
Diagnostic
dif-
ficulties
relating
to
sepsis,
for
example,
differentiating
between
a
patient
with
pneumonia
with
sepsis
and
acute
heart
failure,
in
the
absence
of
fever,
is
almost
an
impossibility.
This
may
result
in
uncertainty
and
misdiagnosis;
therefore,
delaying
the
initiation
of
treatment
for
sepsis
[21].
Several
participants
conveyed
that
timely
recognition
of
sepsis
is
a
huge
challenge.
Patients
present
with
diverse
medical
symptoms
but
no
concrete
diagnostic
evidence
of
sepsis.
The
busy
workload
of
ED
with
a
high
patient
-
nurse
ratio,
partic-
ularly
during
after
-
hours,
has
routinely
caused
significant
delays
in
initiating
EGDFR.
This
concurs
with
the
findings
from
a
retrospec-
tive
analysis
revealing
that
increased
ED
occupancy
and
patient
hours
significantly
decreased
the
likelihood
of
patients
with
sepsis
receiving
intravenous
fluids
within
the
first
hour
[22].
Many
par-
ticipants
in
this
study
described
that
the
time
it
takes
for
the
first
medical
officer
to
review
the
patient
after
triage
can
cause
signif-
icant
delays
in
initiating
EGDFR
which
is
similar
to
findings
from
previous
studies
[8].
They
reported
that
it
can
take
up
to
eight
hours
during
night
shifts,
with
patients
remaining
in
the
waiting
room
with
no
EGDFR
commenced.
Critically
ill
patients
with
poor
peripheral
circulation
on
pre-
sentation
tend
to
deteriorate
rapidly.
This
is
compounded
by
less
experienced
nurses
without
cannulation
competency,
leading
to
delays
in
initiating
intravenous
fluids.
These
findings
are
similar
to
that
of
a
recent
study,
where
Australia
is
identified
as
a
nation
with
one
of
the
lowest
numbers
of
nurses
who
can
cannulate.
Unde-
niably,
this
skill
gap
can
contribute
to
delays
in
initiating
EGDFR
[3].
This
study
reveals
several
new
findings
that
are
not
previously
reported
in
the
literature
including
(i)
interprofessional
communi-
cation
barriers
(ii)
limitations
in
the
scope
of
practice
for
emergency
nurses,
and
(iii)
Intuitive
clinical
decision
making
and
practising
outside
the
scope
of
practice.
Participants
acknowledged
that
inter-
professional
communication
difficulties
can
exist
between
medical
officers
and
nurses,
that
were
associated
with
poor
communication
skills
and
knowledge
limitations
of
inexperienced
nurses.
How-
ever,
there
was
agreement
that
senior
medical
officers
do
trust
the
clinical
decision
making
abilities
of
experienced
nurses.
This
study
has
identified
a
clear
disparity
between
advanced
clinical
practices.
Clinical
Initiatives
Nurses
have
well
developed
advanced
practice
skills
and
are
authorised
to
nurse
-
initiate
intra-
venous
Hartmann’s
over
eight
hours.
While
a
Clinical
Initiatives
Nurse
can
initiate
intravenous
fluids
for
other
medical
presenta-
tions,
they
are
not
authorised
by
the
Sepsis
Pathway
2018
to
initiate
an
intravenous
bolus
in
patients
with
sepsis
who
require
it
urgently.
In
comparison,
NSW
Ambulance
services
authorise
all
paramedics
to
initiate
intravenous
fluids
in
accordance
with
the
Sepsis
Path-
way
on
the
scene
and
therefore,
raises
the
question
and
validity
of
this
restriction
placed
on
emergency
nurse
practice.
As
a
conse-
quence,
participants
in
this
study
revealed
that
they
are
intuitively
practicing
outside
of
their
scope
of
practice
in
order
to
decrease
the
time
to
EGDFR.
Participants
justified
this
due
to
the
patient’s
pressing
need
for
intravenous
fluids
and
the
nurses’
deep
concern
regarding
the
delay
in
treatment
and
the
potential
for
patient
dete-
rioration.
A
significant
recommendation
arising
from
this
study
relates
to
the
authorisation
of
nurse
-
initiated
bolus
intravenous
sodium
chloride
0.9%
in
accordance
with
the
Sepsis
Pathway.
Participants
stated
that
nurses
at
the
Clinical
Initiatives
Nurses
level,
who
can
otherwise
initiate
intravenous
fluids
in
other
presentations,
would
be
the
most
appropriate
level
of
nurses
because
they
have
the
required
skills
and
knowledge
to
make
judicious
clinical
decisions.
This
recommendation
would
benefit
as
a
“faster,
cheaper,
better”
approach
to
clinical
practice
because
it
implies
no
additional
cost
on
the
existing
models
of
care
and
infrastructure,
building
workforce
capacity.
Other
concurrent
recommendations
for
practice
include
(i)
redesigning
the
existing
NSW
Sepsis
Pathway;
(ii)
ongoing
edu-
cation,
(iii)
more
staffing
and
resources,
and
(iv)
advanced
skill
training
of
emergency
nurses.
Conclusions
The
findings
from
this
study
can
inform
a
review
and
the
devel-
opment
of
policies
and
protocols
such
as
the
NSW
Sepsis
Pathway.
These
findings
have
key
implications
for
current
clinical
practice
associated
with
EGDFR
and
for
future
research.
However,
it
is
important
to
consider
that
managing
patients
with
sepsis
is
com-
plex
and
the
challenges
associated
are
multifactorial.
The
ultimate
beneficiaries
of
the
findings
of
this
study
are
the
patients
pre-
senting
to
ED
with
sepsis.
Empowering
nurses
to
articulate
their
perceptions
and
providing
an
opportunity
for
nurses
to
expand
their
scope
of
practice
will
lead
to
significant
improvements
in
patient
outcomes,
reduction
in
attributable
mortality
and
mor-
bidity,
and
positive
cost
-
benefit
for
healthcare
expenditure
in
Australia.
Please
cite
this
article
in
press
as:
Kabil
G,
et
al.
Emergency
nurses’
experiences
of
the
implementation
of
early
goal
directed
fluid
resuscitation
therapy
in
the
management
of
sepsis:
a
qualitative
study.
Australasian
Emergency
Care
(2020),
https://doi.org/10.1016/j.auec.2020.07.002
ARTICLE IN PRESS
G Model
AUEC-483;
No.
of
Pages
6
6
G.
Kabil
et
al.
/
Australasian
Emergency
Care
xxx
(2020)
xxx–xxx
Limitations
Like
any
other
data
collection
tool,
interviews
are
susceptible
to
subjective
interpretation.
The
perceptions
of
the
participants
are
subjective
and
are,
therefore,
subject
to
change
with
time.
In
rela-
tion
to
their
experiences,
the
participants
may
only
give
what
they
are
prepared
to
reveal
which
may
not
reflect
their
actual
practice.
Gender
balance
comprised
mostly
of
women
which
could
influence
the
data;
however,
this
is
reflective
of
the
gender
distribution
in
the
Australian
nursing
workforce.
Additionally,
because
the
interviews
were
limited
to
emergency
nurses
in
NSW,
the
transferability
of
these
findings
is
limited
to
similar
groups.
Funding
This
research
received
no
external
funding.
Conflicts
of
interest
The
authors
would
like
to
report
no
conflicts
of
interest.
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