A Scoping Review of Sepsis Management in Prehospital and Emergency Department Settings: Barriers, Facilitators and Strategies to Improve Care

A scoping review of sepsis management in prehospital and emergency Department settings: barriers, facilitators and strategies to improve care:

Jennifer Greene ACP MSc (cand)^1,2, Deborah Ocholi MD¹, Judah Goldstein PCP PhD^1,2, Alix Carter MD MPH FRCPC^1,2, Blair L. Bigham MD FRCPC^3,4
1.  Dalhousie University
2.  Emergency Health Services Nova Scotia
3.  Dalla Lana School of Public Health, University of Toronto
4.  Scarborough Health Network Research Institute

Introduction: Despite high-quality guidelines, barriers to timely evidence-based sepsis care persist, worsening morbidity and mortality. This scoping review describes barriers and facilitators to providing sepsis care in the prehospital and emergency department (ED) settings and strategies that support better sepsis care.

Methods: Employing the Briggs scoping review method and PRISMA-ScR reporting standards, we systematically searched MEDLINE, Embase, CINAHL, and Scopus for studies on the quality of sepsis care in prehospital and ED settings. Study selection was performed in duplicate and data extraction and quality assessment, using the PEP Program Levels of Evidence scale, was performed by one reviewer and verified by a second.

Results: After screening 7840 titles, 363 articles were included. Most (59.5%; n=216) studies were from the United States. ED (81.8%; n=297), prehospital (11.8%; n=43) or both (n=23; 6.3%) settings were studied. Nurses (33.9% n=222), physicians (33.8% n=221) and paramedics (9.3% n=61) were the most studied personnel. Most studies (62.3% n=226) were of moderate quality however 18 studies (5.0%; 7 RCTs and 11 SRs) were high quality. Half of studies reported on adult populations (50.7%; n=184), though pediatrics and older adults were represented at 11.6% and 1.4% of the literature respectively. Antibiotic delivery was the most reported on interventional aspect of care (14.0%; n=51)

Improvement strategies included educational interventions (16.8%; n=66), sepsis bundles (14.0%; n=55), and using novel screening methods (11.5%; n=45). Most strategies improved care (81.8%; n=193). Barriers to care were difficult recognition, (23.3%n=120), low awareness of guidelines (17.3%; n=89) and inadequate staffing (9.3%; n=48). Facilitators for implementing strategies were education (29.5%; n=145), communication (12.2%; n=60) and visual tools/checklists (10.2%; n=50).

Conclusion: This is the largest review of strategies to improve sepsis outcomes in the prehospital and ED settings. There is an abundance of moderate quality literature that can guide improved awareness, early recognition and systems-based care.