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Our June 6, 2017 Patient Safety Tip of the
Week NYS
Mandate for Sepsis Protocol Works
reported on the successful reduction in sepsis mortality in New York State
after the New York State Department of
Health mandated that hospitals begin using protocols to help with early
identification and treatment of sepsis. Hospitals began implementing these protocols in 2014. By the third
quarter of 2016, 84.7% of adult patients and 85.3% of pediatric patients with
severe sepsis or septic shock were treated using protocols (NYSDOH 2017).
Adult in-hospital mortality fell from 30.2% in early 2014 to 25.4% by late
2016. Pediatric mortality rates were more variable without a clearcut trend. After
adjusting for patient factors, the NYSDOH analysis of the data showed that the
odds of dying were 21% less for adult patients who received protocol-driven
treatments compared to patients who do not receive protocol-driven treatments.
The time frame for management was also critical. After adjustment, the NYSDOH
analysis showed that the odds of dying were 27% less for adult patients who
received all of the recommended treatments within
three hours compared to patients who did not receive all of the recommended
treatments.
Seymour et al. dove deeper into the data (Seymour
2017). Supporting the
importance of early treatment, they found that each hour of time to the
completion of the 3-hour bundle was associated with higher mortality (odds
ratio of death until completion of 3-hour bundle, 1.04 per hour). Patients who
had the bundle completed during hours 3 through 12 had 14% higher odds of dying
in the hospital than those whose bundle was completed by 3 hours. Those same
odds (1.04 per hour) were seen for time to administration of antibiotics and
in-hospital mortality and patients who received first dose of antibiotics
during hours 3 through 12 had 14% higher odds of dying in the hospital than
those receiving antibiotics by 3 hours.
But there may be more
to the story of the New York State experience. Lasater et al. (Lasater 2020) looked at New York State hospital data from
2017 and found a significant relationship between sepsis mortality and hospital
nurse-to-patient staffing ratios. They found that each additional patient per
nurse was associated with 12% higher odds of in-hospital mortality, 7% higher
odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer
lengths of stay, even after accounting for patient and hospital covariates
including hospital adherence to SEP-1 bundles. And, while adherence to SEP-1
bundles was associated with lower in-hospital mortality and shorter lengths of
stay, the effects were markedly smaller than those observed for nursing
staffing. Each additional patient per nurse is associated with 12% higher odds
of in-hospital mortality compared with a 10% change in SEP-1 adherence
associated with only a 5% change in in-hospital mortality. Higher SEP-1 scores
were also associated with shorter lengths of stay, but staffing had more than
twice as large an effect on shorter lengths of stay, even when accounting for
hospitals SEP-1 scores. Moreover, the effect of staffing was large and
significant in terms of 60-day mortality and readmissions, while the SEP-1 scores
revealed no association.
So, how does this relate to the prior NYS
studies? They emphasized that adherence to the sepsis protocols in the first 3
hours was important. So how does that relate to nursing staffing? Our June 6,
2017 Patient Safety Tip of the Week NYS
Mandate for Sepsis Protocol Works
also noted a study (Peltan 2017)
that showed a relationship between adherence to protocols and how busy the emergency departments are. They
found that patients received antibiotics within three hours in 83 percent of
cases in uncrowded ERs, but only 72 percent of the time when the ER was crowded
(exceeded the ERs licensed beds). Such might reflect nursing staffing ratios
in the ER.
But the Lasater study used nursing staffing
ratios on med/surg units, not the ER. Nurses on the med/surg units would be
more likely to be involved in the 6-hour
bundle, which included fluid administration, vasopressors for refractory
hypotension, and reassessment of serum lactate levels. But there is another
important consideration. The original New York State studies reported
only the relationship of mortality to the timing of the first dose of
antibiotics. But it turns out that the subsequent administration of antibiotics
may also be important. Another study (Leisman 2017)
found that major second antibiotic dose
delays were common. They observed an association
between major second dose delay and increased mortality, length of stay, and
mechanical ventilation requirement. In fact, in their multivariable
analysis, major delay was associated with a 61% increased odds of hospital mortality. Interestingly, they found
that major delays in second doses were paradoxically more frequent for patients
receiving compliant initial care. Its quite
conceivable that better nurse:patient ratios on the
med/surg units might reduce such delays in administration of the second
antibiotic dose.
Whatever the actual reasons, the Lasater
study suggests that better nurse:patient ratios are
beneficial for outcomes in patients with sepsis. That shouldnt
be surprising, since there have been a number of studies showing reduced
patient mortality, in general, when there are fewer patients per nurse (see the
list of our prior columns on nursing staffing below). However, well reiterate a point we make in almost each of those
columns the nurse:patient ratio is likely less
important that the actual nurse workload, which is more difficult to quantitate.
The Lasater study is a valuable addition to
the growing body of evidence linking patient outcomes to nursing staffing.
Some of our other columns on nursing
workload and missed nursing care/care left undone:
November
26, 2013 Missed Care: New Opportunities?
May
9, 2017 Missed
Nursing Care and Mortality Risk
March
6, 2018 Nurse
Workload and Mortality
May
29, 2018 More
on Nursing Workload and Patient Safety
October
2018 Nurse
Staffing Legislative Efforts
February
2019 Nurse
Staffing, Workload, Missed Care, Mortality
July 2019 HAIs
and Nurse Staffing
September 1, 2020 NY State and Nurse Staffing
Issues
February 9, 2021 Nursing Burnout
Our
other columns on sepsis:
References:
NYSDOH (New York State Department of Health).
New York State report on sepsis care improvement initiative: hospital quality
performance. March 2017 https://www.health.ny.gov/press/reports/docs/2015_sepsis_care_improvement_initiative.pdf
Seymour CW, Gesten
F, Prescott HC, et al. Time to Treatment and Mortality during Mandated
Emergency Care for Sepsis. NEJM 2017; Online First May 23, 2017
http://www.nejm.org/doi/full/10.1056/NEJMoa1703058?query=featured_home
Lasater KB, Sloane DM, McHughMD,
et al. Evaluation of hospital nurse-to-patient staffing ratios and sepsis
bundles on patient outcomes. American Journal of Infection Control 2020;
Published online December 10, 2020
https://www.sciencedirect.com/science/article/pii/S0196655320310385
Peltan ID, Bledsoe
JR, Oniki TA, et al. Increasing ED Workload Is Associated with Delayed Antibiotic Initiation
for Sepsis. Abstract 5505. 2017 American Thoracic Society International
Conference. Presented May 21, 2017
http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A1155
Leisman D, Huang V,
Zhou Q, et al. Delayed Second Dose Antibiotics for Patients Admitted From the Emergency Department With Sepsis: Prevalence, Risk
Factors, and Outcomes. Critical Care Medicine 2017; 45(6): 956-965, June 2017
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