BMC Emerg Med. 2022 Jan 11;22(1):3. doi: 10.1186/s12873-021-00558-5.
Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis.
BMC emergency medicine
Gladis Kabil, Steven A Frost, Deborah Hatcher, Amith Shetty, Jann Foster, Stephen McNally
Affiliations
Affiliations
- Western Sydney University, School of Nursing and Midwifery, Locked bag 1797, Penrith, NSW, 2751, Australia. [email protected].
- Department of Emergency, Westmead Hospital, Sydney, Australia. [email protected].
- Western Sydney University, School of Nursing and Midwifery, Locked bag 1797, Penrith, NSW, 2751, Australia.
- South Western Sydney Nursing and Midwifery Research, Ingham Institute of Applied Medical Research, Sydney, Australia.
- University of New South Wales, Sydney, Australia.
- Westmead Institute for Medical Research, Westmead, Australia.
- NSW Ministry of Health, New South Wales, Australia.
PMID: 35016638
PMCID: PMC8753824 DOI: 10.1186/s12873-021-00558-5
Abstract
BACKGROUND: Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood.
METHODS: We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors.
RESULTS: We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25-1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = - 24.11(95% CI - 14.09 to - 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28-1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24-0.72)].
CONCLUSION: Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects.
PROSPERO REGISTRATION ID: CRD42021225417.
© 2021. The Author(s).
Keywords: Barriers; Compliance; Facilitators; Fluid therapy; Sepsis
References
- Am J Emerg Med. 2016 Jan;34(1):1-9 - PubMed
- BMC Emerg Med. 2017 Aug 30;17(1):27 - PubMed
- Implement Sci. 2009 Aug 07;4:50 - PubMed
- Crit Care. 2013 Oct 06;17(5):R224 - PubMed
- BMJ. 2009 Jul 21;339:b2535 - PubMed
- Intensive Care Med. 2017 May;43(5):625-632 - PubMed
- J Telemed Telecare. 2018 Apr;24(3):202-208 - PubMed
- Shock. 2012 May;37(5):463-7 - PubMed
- N Engl J Med. 2001 Nov 8;345(19):1368-77 - PubMed
- Med J Aust. 2016 Feb 1;204(2):73 - PubMed
- J Crit Care. 2019 Jun;51:94-98 - PubMed
- J Crit Care. 2017 Apr;38:35-40 - PubMed
- Intensive Crit Care Nurs. 2017 Aug;41:90-97 - PubMed
- Res Synth Methods. 2020 Sep;11(5):641-654 - PubMed
- Ann Pharmacother. 2018 Mar;52(3):240-245 - PubMed
- J Intensive Care Med. 2018 Feb;33(2):111-115 - PubMed
- J Emerg Nurs. 2018 Nov;44(6):552-562 - PubMed
- Int J Qual Health Care. 2018 Dec 1;30(10):802-809 - PubMed
- JAMA. 2016 Feb 23;315(8):801-10 - PubMed
- Evid Based Ment Health. 2019 Nov;22(4):153-160 - PubMed
- Chest. 2018 Jan;153(1):39-45 - PubMed
- Stat Methods Med Res. 2018 Jun;27(6):1785-1805 - PubMed
- JAMA. 2014 Apr 2;311(13):1308-16 - PubMed
- Lancet Psychiatry. 2019 Dec;6(12):1039-1053 - PubMed
- Am J Med Qual. 2017 Sep/Oct;32(5):500-507 - PubMed
- N Engl J Med. 2017 Aug 3;377(5):414-417 - PubMed
- Scand J Trauma Resusc Emerg Med. 2017 Sep 19;25(1):96 - PubMed
- J Emerg Nurs. 2020 Jan;46(1):91-98 - PubMed
- PLoS One. 2015 May 06;10(5):e0125827 - PubMed
- BMC Med Res Methodol. 2014 Dec 19;14:135 - PubMed
- Crit Care. 2020 Apr 7;24(1):137 - PubMed
- JAMA. 2017 Oct 3;318(13):1233-1240 - PubMed
- Am J Emerg Med. 2017 Jul;35(7):953-960 - PubMed
- J Emerg Med. 2013 Mar;44(3):698-708 - PubMed
- Ann Acad Med Singap. 2020 Sep;49(9):661-668 - PubMed
- J Crit Care. 2013 Apr;28(2):148-51 - PubMed
- Patient Educ Couns. 2019 May;102(5):817-841 - PubMed
- Int Emerg Nurs. 2008 Oct;16(4):250-6 - PubMed
- BMJ. 1997 Sep 13;315(7109):629-34 - PubMed
- Ann Emerg Med. 2016 Sep;68(3):298-311 - PubMed
- Shock. 2012 Nov;38(5):474-9 - PubMed
- Intensive Care Med. 2021 Nov;47(11):1181-1247 - PubMed
- Emerg Med J. 2017 Sep;34(9):578-585 - PubMed
- Am J Emerg Med. 2019 Apr;37(4):762-763 - PubMed
- Lung. 2011 Feb;189(1):11-9 - PubMed
- Emerg Med J. 2013 May;30(5):397-401 - PubMed
- Int J Clin Pract. 2012 Jul;66(7):705-10 - PubMed
- Intensive Care Med. 2017 Mar;43(3):304-377 - PubMed
- Am J Emerg Med. 2020 May;38(5):879-882 - PubMed
- J Emerg Nurs. 2015 Mar;41(2):130-7 - PubMed
- J Emerg Med. 2013 Apr;44(4):735-41 - PubMed
- Am J Emerg Med. 2014 Sep;32(9):1120-4 - PubMed
- Crit Care Med. 2015 Dec;43(12):2589-96 - PubMed
- BMC Emerg Med. 2017 Mar 23;17(1):11 - PubMed
- Clin Infect Dis. 2017 Oct 15;65(8):1253-1259 - PubMed
- CJEM. 2017 Mar;19(2):112-121 - PubMed
- Australas Emerg Care. 2021 Mar;24(1):67-72 - PubMed
- J Thorac Dis. 2020 Feb;12(Suppl 1):S37-S47 - PubMed
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