Crossing the handover chasm: Clinicians' perceptions of barriers to the early detection and timely management of severe sepsis and septic shock

Abstract

Purpose

The purpose was to identify barriers to the early detection and timely management of severe sepsis throughout the emergency department (ED), general ward (GW), intermediate care unit (IMC), and the intensive care unit (ICU).

Materials and methods

Five multicenter focus group discussions with 29 clinicians were conducted. Discussions were based on a moderation guide were recorded and transcribed. Qualitative analysis was performed according to the principles of the concept mapping method and the framework approach.

Results

The major causes of the delayed detection and treatment could be summarized in a framework of communication errors and handover difficulties throughout patients' course of treatment, which can be divided into 5 core areas: inadequate histories before hospital admission; poorly coordinated handovers between the ambulance service and the ED; delayed patient transfer between the ED and the GW as well as delays in patient transfers between the GW and the ICU by, for example, a lack of bed capacity and a shortage of staff. Generally, participants from all wards mentioned that the urgency with which septic patients needed to be treated was not communicated.

Conclusions

Our study shows the need to improve intra- and interunit handover processes in hospital care, which would ensure a holistic treatment concept, thereby improving patient care.

Introduction

Severe sepsis and septic shock are serious medical conditions and are associated with a high risk of mortality [1]. Over the past years, the annual incidence of sepsis rose steadily [2], [3]. Early recognition and prompt therapy are associated with improved outcomes [4], [5], [6], [7]. The Surviving Sepsis Campaign guidelines recommend aiming for an effective antimicrobial therapy within the first hour after recognition of sepsis [8]. A number of studies have reported delays in antimicrobial therapy, with median times to an antimicrobial therapy in the range of 115 to 186 minutes after diagnosis [6], [9], [10], [11], [12], [13], [14]. In a Spanish multicenter trial, Ferrer et al [5] observed that only 18.4% of patients received their antimicrobial therapy within the first hour after diagnosis. Likewise, only 22.5% of patients received their antimicrobial therapy in the first hour after onset of organ dysfunction in a German study [14].

In light of these troubling findings, Burney et al [15] delivered insights into the barriers to sepsis guideline implementation in emergency departments (EDs): The authors identified knowledge gaps and procedural hurdles in sepsis identification and treatment, and concluded that both educational and process components are core elements in improving sepsis care in the ED. Data on nursing barriers to implementation are lacking and represent a large area of need regarding knowledge translation. Adding to this, Mearelli et al [16] reported that there is particular need for more awareness of the signs and symptoms of sepsis if septic patients are treated in general medical wards, as patients in these wards are mostly older and have higher rates of morbidity than patients in intensive care units (ICUs), making the identification of the typical signs and symptoms of sepsis difficult.

Different departments are responsible for diagnosis and treatment; patients will encounter a large number of staff, with teams changing several times each day. Prior studies have emphasized the need for effective collaboration between the ED and critical care services, as well as between administrators and health care providers; this is particularly true with regard to improving the detection and treatment of severe sepsis and septic shock [17], [18], [19], [20]. Nevertheless, research in this area is insufficient and has mostly presented how isolated instances of problematic handovers have resulted in the fragmentation of care [21].

The present study aims to identify barriers to the early identification and timely management of severe sepsis and septic shock throughout the ED, general wards (GWs), intermediate care units (IMCs), and ICUs, as well as their crossing points, using an interdisciplinary approach. A further goal is to develop solutions to improve the early detection and timely treatment of these medical conditions.