Essay: Evaluating compliance to Surviving Sepsis Campaign (SSC) resuscitation bundles in hospitals across the UK and implications for nursing practice: An Extended Literature Review

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This literature review aims to evaluate hospitals’, and more particularly nurses’ capacity to comply with Surviving Sepsis Campaign (SSC) sepsis resuscitation bundles across the UK, as SSC guidelines have proven to increase sepsis survival rates when implemented properly.
Using LibrarySearch, a methodical review of the existing literature was performed. A variety of health related databases and journals were searched and Boolean logic was applied to specific search terms (Lobiondo-Wood and Haber, 2014). Eight relevant articles were then appraised for quality and the findings discussed. A lack of resources such as equipment and supplies, lack of appropriate referrals due to poor SSC education of medical and nursing staff, and the inconsistent use of SSC guidelines are all associated to with generally poor compliance with SSC sepsis resuscitation bundles in the UK. Overall, the extent of hospitals’ compliance to SSC sepsis resuscitation bundles depends on the availability of the resources and equipment, education of medical and nursing staff, and consistent use of the SSC guidelines. Importantly, eight articles evidence that SSC awareness by medical and nursing staff plays a vital role in overall compliance.
Chapter 1: Introduction
Hart (1998, p. 26) defines a literature review as a summary and ‘critical analysis of relevant available’ studies related to the chosen topic being reviewed. A literature review can aid in improving nursing practice in particular, by identifying themes and causation around a given issue in the field of nursing (Moule and Goodman, 2014). Hence, it is critical to gather evidence-based information through a literature review of the latest available research to help improve one’s practice and make decisions that is based on the best available evidence (Aveyard, 2014).
Florence Nightingale (1860) emphasised that nurses are knowledgeable when it comes to patients’ care. Therefore, in the nursing profession there is no way to stop learning, but instead there are ways to update what has been learned from the past according to present conditions, and to gain new insights in order to provide the best available evidence-based practice to patients’ care (NMC, 2010; CRD, 2007). Moreover, it is the responsibility of a nurse to learn new information concerning his or her patients and the environment he or she directly works in, in order to be prepared for new challenges and changes in delivering evidence-based nursing care to patients (Spencer, 2011).
The next chapter will briefly discuss the background and rationale of the focus question of this literature review, which is: ‘To what extent can hospitals in the UK comply with SSC resuscitation bundles, and what are the implications for nursing practice’? The following chapter will outline the methodology of research, including how relevant literature was searched, tabulated, and analysed, and how the three themes emerged from the chosen articles (Parahoo, 2006). This is followed by the discussion and analysis of themes that arose from the chosen articles, and the implications and recommendations for nursing practice. Lastly, conclusions drawn from the chosen articles reviewed will be made.
Chapter 2: Background and Rationale
2.1 What is Sepsis?
Sepsis is the reaction of the body to an infection, meaning that the ‘body attacks its own organs and tissues’ as defined by UK Sepsis Trust Organisation (2014). Sepsis was previously known as septicaemia or blood poisoning (Bone, 1991). It starts from an uncomplicated infection that develops into severe sepsis, wherein the infection becomes associated with organ dysfunction and leads to an increased risk of death (Mackenzie and Lever, 2007).
According to the UK Sepsis Trust Organization (2014), sepsis can quickly lead to shock, multi-organ dysfunction and eventually results in death if the sepsis is not detected immediately and not treated promptly. Sepsis is one of the primary reasons of death worldwide. This is why Surviving Sepsis Campaign guidelines have been introduced worldwide.
2.2 Surviving Sepsis Campaign (SSC) sepsis resuscitation bundles
In 2004, Dellinger et al. launched Surviving Sepsis Campaign (SSC) international guidelines in the United States for the management of severe sepsis as an effort to reduce the mortality rate associated with sepsis (Dellinger et al., 2004a). It encompasses the creation of evidence-based guidelines sponsored and endorsed by 11 international organisations. It was revised in 2008 and the latest revision was in 2013. Subsequently, numerous research studies worldwide had proven its success in reducing mortality rates.
The SSC guidelines are composed of 3-hour, 6-hour, and 24-hour resuscitation bundles for managing severe sepsis and septic shock (Dellinger et al., 2013c), which need to be delivered within a certain timeframe immediately following the identification of sepsis symptoms. These bundles are a group of three or more elements of care specifically related to the disease, that when implemented together will improve patient outcomes (Surviving Sepsis Organization, 2014b; Institute for Healthcare Improvement, 2014; Dellinger et al., 2013c; Daniels et al., 2011).
2.3 SSC guidelines and United Kingdom
In 2005, the United Kingdom launched the SSC guidelines in an attempt to reduce the sepsis mortality rate in the UK (Bray and Murphy, 2006). The National Institute for Health and Clinical Excellence (NICE) (2007) recommended to carry out a set of observations or vital signs systematically using the Early Warning Score (EWS) and the SSC resuscitation bundles (Dellinger et al., 2013c) for management of severe sepsis and septic shock. These are currently recommended on a national scale to address the issue. However, despite of the introduction of the campaign a decade ago, the mortality rate in UK remains unacceptably high, ‘There are 102,000 cases of sepsis arise annually, 36,800 deaths every year as a result of severe sepsis’ (Daniels et al., 2011, p. 508). ‘Putting this into perspective, lung cancer (the biggest killer after cardiovascular disease) claims just fewer than 35,000 lives per year, bowel cancer 15,000 and breast cancer 9,000′ (Richards, 2013, p. 3). Hence, it is important to identify the limitations to compliance and determine how medical and nursing staff can best help patients survive sepsis (NPSA, 2007). In any hospital setting, there are different patients with many different kinds of illnesses, and nurses play a vital role in ensuring that patients receive the best and most appropriate possible care, thus preventing patients’ deterioration (Aitken et al., 2011). Moreover, rapid diagnosis and treatment saves lives when done as quickly as possible (Parliamentary and Health Service Ombudsman, 2013). Thus, the aim of this literature review is to evaluate hospitals’ compliance to SSC sepsis resuscitation bundles across the UK as well as to identify the role of the nurse in helping to improve overall SSC compliance (Surviving Sepsis Organization, 2014a).
The following focus question was formulated to address the abovementioned concerns and to guide the literature search of this review: ‘To what extent can hospitals in the UK comply with SSC resuscitation bundles, and what are the implications for nursing practice’? The next chapter will discuss in further detail the methodology used for conducting research in order to address the most appropriately respond to this question.
Chapter 3: Methodology
This chapter will discuss the selection criteria, search strategy, and the search outcome of the literature search. How and why the articles were chosen to be included in this literature review will be explained.
3.1 Selection Criteria
The inclusion and exclusion criteria were determined using the Population, Intervention, Comparison or Comparator and Outcome (PICO) tool. The PICO acronym is used to articulate the research question and structure the search strategy (CRD, 2007; Higgins and Green, 2008; Whitlock et al., 2010).
3.1.1 Population
Studies evaluating compliance to the Surviving Sepsis Campaign (SSC) sepsis resuscitation bundles across hospitals in the United Kingdom (UK) were considered. Hospital settings allow for a wider sample in evaluating nursing and medical staff’s adherence to the guidelines of the SSC rather than in specialist clinics or GPs settings. Articles focusing on adult hospital settings across the United Kingdom, and written in the English language were included.
Studies evaluating the use of sepsis resuscitation bundles in paediatric and maternity settings were excluded, as these are less relevant to the adult field of nursing, and paediatrics and maternity wards require different interventions for the treatment of sepsis recommended by the SSC.
Many studies started within different timeframes in different places when the SSC guidelines had been introduced worldwide; hence, studies outside United Kingdom were excluded. The literature review focuses solely on the UK, since it is easier to recognise the limitations of the sepsis care bundles when evaluating sample populations in one country rather than across many countries.
3.1.2 Intervention
Studies assessing the compliance to the Surviving Sepsis Campaign guidelines (Dellinger et al., 2013c) comprising severe sepsis, septic shock resuscitation care bundles and early goal directed therapy (EGDT) were included, as these are elements of the established bundles and interventions used to manage patients with severe sepsis and septic shock in the UK (Surviving Sepsis Organization, 2014b).
Studies assessing severe sepsis and septic shock cases without using the recommendation of SSC guidelines were excluded, as this paper aims to identify issues and determine possible reasons as to why and how non-compliance is occurring despite the proven effectiveness of sepsis resuscitation bundles under the Surviving Sepsis Campaign (Daniels et al., 2011). As the United Kingdom launched its Surviving Sepsis Campaign in 2005 (Bray and Murphy, 2006), only studies assessing compliance to the SSC guidelines to address severe sepsis and septic shock in the UK from 2005 onward were included in this literature review.
3.1.3 Outcome
Studies evaluating the relationships between awareness, resources, and compliance to the SSC sepsis resuscitation bundles, as well as correlative evidence of decreasing mortality rates associated with compliance in sepsis were included.
3.1.4 Study Design
Due to the nature of the focus question, which is to evaluate the compliance to the SSC sepsis resuscitation bundles, quantitative studies were included that include prospective observational studies, retrospective cohort studies, questionnaires, and surveys. The focus of this paper is across the United Kingdom in order to establish general determining factors regarding the limitations, barriers, and solutions for successful implementation of SSC sepsis resuscitation bundles (Surviving Sepsis Organization, 2014a). Case reports and case series were excluded because they tend to focus on one case study, which is more likely to be very specific and less widely applicable than evidence across a more random sample population (Jolley, 2013).
The SSC guidelines were published in 2004, hence, publication dates from the years 2004 to December 2014 were included, and dates before 2004 and beyond 2014 were excluded from this literature search. In terms of hospital studies in the UK, only articles published between 2005 and 2014 were included, since the SSC guidelines were launched in the UK in 2005.
3.2 Search Strategy
After establishing the focus question this paper aims to answer, the first step was to identify the necessary databases for accessing a wide range of data sources in the Internet (Younger, 2004). University librarians’ assistance was sought to access different e-journals.
Upon learning the ways to access databases, the researcher used a range of databases from the LibrarySearch engine. LibrarySearch is the University’s search and retrieval tool designed to search for databases and e-journals. This search was performed to reduce bias of the review, and to retrieve articles containing the search terms used. Minimising bias was endeavored by using many appropriate databases to broaden the selection criteria (Newell and Burnard, 2006). A worldwide search was not included, as only the population of the United Kingdom was relevant to the research question and only articles written or translated in English were considered for review in the study. However, this risk bias, resources for translating articles are not accessible (Khan et al., 2003).
Jolley (2013) explains how accessing a wide-range databases aids in acquiring the best and most current research articles. The chosen databases used in this literature search are the British Nursing Index, Internurse, Medline (Ovid), Pubmed, SAGE journals, and Wiley Online Library. The British Nursing Index was chosen because this database covers all aspects of nursing from 1994 to present, which meets the inclusion criteria for articles from 2004 to 2014. Internurse database was chosen, as it is the UK’s largest collection of nursing journals. Furthermore, as the UK is home of the British Journal of Nursing, the journal was used for its main focus on research conducted in UK. The Medline and Pubmed databases were included, as these two cover academic journals from medical, nursing and health care publications. Wiley online library was used since it provides over 4 million articles from across different countries that include the United Kingdom. Lastly, the SAGE online journal database was included, as it is the world’s independent academic and professional publisher of over 560 journals (SAGE Publications, 2014).
After selecting databases, the next step was to decide which search terms were to be used in accessing literature that would provide the most appropriate evidence for the research question. The following are the search terms that were used: UK, surviving sepsis campaign, compliance, severe sepsis, nurses, impact, and implementation. To increase the search sensitivity, Boolean logic was applied using the words ‘AND,’ ‘OR’ and ‘NOT’ (Khan et al., 2003).
3.3 Search Outcome
This section will describe which databases successfully produced relevant results based on the search terms and selection criteria. It will further illustrate the number of articles retrieved, and of the articles retrieved, which were identified as the most relevant to the focus question.
This literature search took place between October and December 2014. Using the Search Scope in LibrarySearch engine, six databases were selected to gather articles by applying various search terms relevant to the focus question of this paper. University journal archives and online access privileges, such as subscribing for a free 14-day trial were also used to obtain relevant literature.
Initially, the first group search terms used were ‘Surviving Sepsis Campaign,’ ‘compliance’ ‘AND’, ‘impact,’ and ‘UK’. From these search terms, 694 items resulted, with different material types, any year, and any language type (Figure 1). This was then narrowed down from 694 to 3 items by applying the selection criteria wherein the publication date range of the retrievable articles was limited to filter inclusion of only literature relevant for the review, given that Surviving Sepsis Campaign guidelines were first published in 2004. Therefore, only articles published between 1st January 2004 and 31st December 2014 were considered in order to filter the most current available evidence. Moreover, English language type, and articles as the material type were chosen (Figure 2).
(Figure 1)
(Figure 2)
The next group of search terms used were ‘Surviving Sepsis Campaign,’ ‘AND’, ‘nurses’ and ‘UK.’ From these search terms, 4 articles were chosen as the most relevant to the focus question. Furthermore, from these 4 articles retrieved using the selection criteria as shown in Figure 3, these were narrowed down from 4 to 1 article, as the other 3 were not research articles.
(Figure 3)
‘Severe sepsis,’ ‘guidelines,’ ‘AND’, ‘nurses’ and ‘UK’ were the third group of search terms used in the LibrarySearch engine that resulted in 69 articles (Table 4). To filter results to match the most relevant criteria of the focus question of this review, the subject was refined to ‘Great Britain,’ hence the search was narrowed down from 69 to 2 articles (Table 5).
(Figure 4)
(Figure 5)
Finally, the following search terms: ‘Surviving Sepsis Campaign,’ ‘AND’, and ‘UK’ were used to find further literature, which resulted in 1,295 items (Figure 6). A collection of journals ‘ namely: Intensive Critical Care Journal, Journal of Clinical Nursing, and Nursing Critical Care Journal ‘ were chosen to narrow down the search from 1,295 to 6 articles (Figure 7).
(Figure 6)
(Figure 7)
In total, 12 articles were retrieved utilizing the search terms relevant to the focus question. These were then evaluated for relevant titles and abstracts. Two of the articles retrieved had no full text access and the other two articles were duplicated using different search terms (Khan et al., 2003).
The eight articles were tabulated that met the selection criteria. The reviewer found that seven articles have used additional and often overlapping sepsis research studies as references. For example, 6 articles referenced Gao et al. (2005), 1 referenced Simmond et al. (2007), and 1 referenced Robson et al. (2007) which were also helpful in determining the academic legitimacy and relevance of the articles (Polit and Beck, 2006; Whittaker and Williamson, 2011).
In order to minimise bias, Glasziou et al. (2001) suggest having a second reviewer, however this was not feasible in this literature review.
Finally, quantitative research was included as it relates to the focus question of the review, which is to evaluate the compliance to the SSC sepsis resuscitation bundles as recommended by Dellinger et al. (2013c). Evaluation is primarily conducted with the use of quantitative targets and measurements (Coughlan, Cronin and Ryan, 2007).
Ultimately, eight articles were included in this literature review. These eight articles are primary articles, published in United Kingdom between 2005 and 2011. All of these studies concern hospitals’ implementation and compliance to the ‘sepsis resuscitation bundles adapted from the Surviving Sepsis Campaign’ (Dellinger et al., 2013c; Surviving Sepsis Organization, 2014a; Surviving Sepsis Organization, 2014b), particularly for adult patients identified as having sepsis in the UK.
3.4 Critical Appraisal Skills Programme (CASP) and Hierarchy of Evidence
Reviewing research is a ‘mechanism used to provide feedback for improvement’ as noted by Polit and Beck (2006). After articles were selected, a CASP framework was chosen to critically appraise each article according to its validity, credibility, and implication to practice by following the Case-control and Cohort Studies Appraisal Checklists (CASP, 2013). This helped the reviewer to scrutinise the individual work and to underline the strengths and weaknesses of each article in order to identify the best examples of evidence-based practice (Coughlan, Cronin and Ryan, 2007).
The Canadian Task Force on Periodic Health Examination in late 1979 was the first to disseminate the Hierarchy of Evidence, until which point different, hierarchies had been established and used (The Canadian Task Force on the Periodic Health Examination, 1979; Evans, 2003). Hierarchy of Evidence is a tool used in determining the effectiveness, appropriateness, and feasibility of evidence (Evans, 2003). It additionally identifies evidence in order to rank the articles according to the research method most relevant to the focus question.
Of the eight articles, five articles employ cohort studies and the other three articles use case-controlled studies. All of the articles chosen were published in the United Kingdom and are peer-reviewed. The Systematic Review is the highest level of hierarchy, followed by the Random Controlled Trial (RCT) as the second level of evidence. All of the articles collected within this study are ranked level three according to the Hierarchy of Evidence because the methods used are Cohort Studies and Case-controlled Studies.
3.5 Themes for analysis
The next step after determining the appropriate literature for this review was an analysis of the literature. Upon undertaking the analysis, three themes have been identified: equipment and supply limitations, a lack of appropriate referrals due to poor education of medical staff and nurses on SSC sepsis resuscitation bundles, and the inconsistent use of SSC sepsis resuscitation bundles from hospital to hospital.
The following chapter critically discusses the three themes that emerged from the literature analysis of the eight selected articles, as well as the implications for the field of nursing as related to the SSC.
Chapter 4: Literature Analysis
This literature analysis will critically consider the eight articles in order to judge the strengths, weaknesses, and the significance of each study (Burns and Grove, 2009) in addressing the research question: ‘To what extent can hospitals in the UK comply with SSC resuscitation bundles, and what are the implications for nursing practice’? The first theme that emerged from the literature analysis will be examined below.
4.1 Resource limitations
Compliance with the SSC sepsis resuscitation bundles requires that serum lactate be obtained and that this is measured using an Arterial Blood Gas (ABG) machine (Dellinger et al., 2013c). Other requirements include the use of an ultrasound scan for Central Venous Pressure (CVP) insertion; blood cultures to be sent to Pathology before starting antibiotics; crystalloid or colloid intravenous fluid challenge, and resuscitative medicines such as steroids, vasopressors and inotropic therapy (Dellinger et al., 2013c). However, five of the articles reviewed evidence that this necessary equipment is lacking in a number of hospitals in the UK.
4.1.1 Equipment and medication
Three of the research articles specify that in some cases there has been lack of necessary resources that are used to meet compliance to the SSC sepsis resuscitation bundles. This not only limits the ability of medical and nursing staff to manage sepsis, but it also limits the reviewer’s ability to evaluate compliance with the SSC sepsis resuscitation bundles.
Gao et al.’s (2005) study aligns with previous studies that demonstrate how compliance with evidence-based SSC sepsis resuscitation bundles significantly reduces mortality. The study comprises ‘101 consecutive adult patients with severe sepsis and septic shock on medical or surgical wards, or in accident and emergency areas at two acute National Health Service (NHS) Trust Teaching hospitals in England’ (Gao et al., 2005, p. R764). The findings evidence poor ward care in critically ill patients, evidencing that eight percent of patients had no oxygen administrated, fourteen percent had no IV access, and fourteen percent of patients ‘had no observation monitoring of blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, urine output, or conscious level’ (Gao et al., 2005, p. R766).
Since the aim of Gao et al.’s (2005) study is to assess the relationship between compliance with SSC guidelines and a decreased sepsis mortality rate, reasons for non-compliance are beyond the scope of this study. However, the authors importantly note that the hospital’s resource limitation led to a deviation from the SSC sepsis resuscitation bundle ‘in the short term’ (Gao et al., 2005, p. R764). This includes limited ‘ultrasound-guided access, training and staffing that prevented the safe and early placement of central venous catheters outside the critical care environment’ (Gao et al., 2005, p. R766). The ultrasound-guided access is essential to insert the CVP, therefore even if the staff has the knowledge to comply with SSC guidelines, with limited resources available, compliance is not possible. In hospitals such as these two NHS Trust Teaching hospitals, resource limitations forced the staff to deviate from ‘the benchmark for persistent hypotension despite fluid resuscitation, adapting a target haemoglobin of 7 to 9 g/dl and/or vasopressors but exluding the requirement to achieve a target of >8mmHg and ScVO2 of’ >70% central venous pressure’ (Gao et al., 2005, p. R768).
Similarly, McNeill, Dixon and Jenkins’ (2008) study highlights the issue of resource limitations. McNeill, Dixon and Jenkins, (2008) investigates the implementation of the 6-hour resuscitation care bundle as advocated by Dellinger et al. (2004) in 265 Acute Medicine Units (AMUs) in the United Kingdom. The research methodology is a questionnaire with 10 questions about the delivery of the 6-hour SSC sepsis resuscitation bundle, sent to each of the participating AMUs. The data was collected and tabulated per percentage by region. Thirty-five percent of the 162 respondents claimed to have implemented the 6-hour sepsis resuscitation bundle in their own hospital, although seventy-one percent had access to outreach teams, and only forty percent had enhanced care beds. Moreover, ‘the minimum facilities to comply with the 6-hour resuscitation bundle were the availability of enhanced care beds, ability to measure arterial blood gas lactate, measure CVP and to administer inotropes’ (McNeill, Dixon and Jenkins, 2008, p. 164). These minimum facilities varied in different regions in UK.
The findings of McNeill, Dixon and Jenkins’, (2008) study identified that only six hospitals had successfully implemented the complete sepsis resuscitation bundle and that thirty-five percent AMUs claimed to have implemented the SSC guidelines despite eighty-eight percent of AMUs lacking the minimum facilities to comply. Although resource availability is not the main focus of either of the abovementioned studies, this emphasis on limitations indicates that the extent to which a hospital can comply with the SSC sepsis resuscitation bundles depends largely on the resources available.
McNeill, Dixon and Jenkins, (2008) results indicate that in contrast to the evidence of resources limitations presented by Gao et al.’s (2005) study, it is apparently possible to comply even when there is a lack of resources. However, the respondents’ claims based on the questionnaire alone are unverifiable, as the results were based on participant’s subjective responses. McNeill, Dixon and Jenkins (2008) have no way of proving that the participants responses are honest, although they do suggest that clinical audits to be conducted for future studies. Nevertheless, McNeill, Dixon and Jenkins’ (2008) study identifies the importance of the facilities needed to effectively deliver the 6-hour sepsis resuscitation bundle across AMUs in UK, and finds that resources are lacking overall. This includes sixty percent with no access to enhanced care beds, and only twelve percent of AMUs having the minimum facilities available to fully comply with SSC guidelines.
Baldwin et al.’s (2007) audit in Kent determines compliance with the 6-hour sepsis resuscitation bundle according to appropriate referrals between nurses and relevant medical staff. It finds that even where communication was adequate between nurses and doctors, ‘there were instances when the appropriate antibiotics was out of stock in A&E’ (Baldwin et al., 2007, p. 255) particularly with a shortage of the antibiotic Tazocin. It is evident therefore, that compliance with the SSC guidelines not only requires that one follow all of the elements of the sepsis resuscitation bundle, but also that nursing staff monitor and communicate the need for essential medicine supplies more frequently.
4.1.2 Financial resources
Another significant resource limitation relating to SSC compliance is the financial capacity of a given hospital. Gao et al. (2005, p. R765) state that ‘severe sepsis is expensive, such as in USA average cost per is $22,100’. Even ‘in an age of financial austerity,’ Page et al. (2011, p. 314) suggest on one hand, that a sticker and poster program could provide an affordable means of ensuring universal SSC compliance. Robson, Beavis and Spittle (2007) on the other hand, suggest that there should be funds for nurse education and training as solutions to ensure compliance. Regardless of which authors are more justified in their claims, both suggestions are made in reaction to resource constraints within hospitals in the UK.
Page et al.’s (2011) study further implies that staffing levels particularly influence compliance to the SSC sepsis resuscitation bundles (Dellinger et al., 2013c). The study notes that ‘compliance was better in Accident & Emergency (A&E) than in the Clinical Decisions Unit (CDU) due to a sixty-three percent staffing level in A&E as compared to the low staffing level of thirty percent in CDU’ (Page et al., 2011). A&E doctors moreover had ‘continuous support of their nurse’ (Page et al., 2011, p. 314). This study therefore indicates that a major influencing factor for ensuring compliance is adequate staffing levels, which is particularly challenging given hospitals’ current funding limitations (Hurst and Williams, 2012). Furthermore, findings suggest that compliance to the SSC sepsis resuscitation bundles depends on the nurse’s role in performing the initial triage for patients.
4.1.3 Implications for nursing practice
The level of effectiveness of compliance to SSC sepsis resuscitation bundles in the UK is partially, but also significantly contingent on levels of resource availability. This integrates into nursing practice, as it is important for nurses to know how limited resources can impact compliance to the sepsis resuscitation care bundles for the management of severe sepsis and septic shock. Additionally, it is the nurse’s responsibility to ensure that ‘medication ordering systems are in place to minimize dose omissions and delay; utilize staff resource efficiently’ (NHS Greater Glasgow and Clyde Prescribing Organisation, 2008). Assuring that there is proper inventory of medical supplies and medication, and that the proper equipment is in working order and within easy access for use by medical staff are all within the scope of responsibilities and duties of a nurse. In essence, nursing is an act of utilising the environment to assist patient’s recovery (Nightingale, 1860), and compliance with SSC guidelines to decrease patient mortality rates is no exception to this duty.
4.1.4 Recommendations
McNeill, Dixon and Jenkins’ (2008) study highlights the issue of resource limitations in addressing sepsis. However, further investigation is recommended to determine the reasons for the lack of resources and solutions as to how resource availability could be improved to ensure that compliance is feasible not only with the 6-hour resuscitation bundle, but also to identify sepsis in the first place. Additionally, an audit of the 265 AMUs surveyed is recommended in order to increase accuracy of results. This would also help to explain the reasons why despite having limited resources, some hospitals have found it possible to comply with the SSC sepsis resuscitation bundles.
The next section will discuss the second theme identified in addressing the research question, which is a lack of appropriate referrals due to poor education of medical and nursing staff on the implementation of SSC sepsis resuscitation bundles.
4.2 Lack of appropriate referrals due to poor SSC education of medical and nursing staff
One of the evident reasons for general poor compliance with SSC sepsis resuscitation bundles across the UK is a lack of referrals for patients displaying symptoms of sepsis. Seven of the eight articles reviewed evaluated compliance of the medical and nursing staff’s implementation of the sepsis resuscitation bundles as related to SSC education. Only one article evaluated the compliance of the medical staff alone. The articles under review evidence that better compliance outcomes of SSC sepsis resuscitation bundles relies largely on medical and nursing staff having a proper awareness of the SSC guidelines for the management of severe sepsis and septic shock, particularly in terms of identifying sepsis, and subsequently in providing appropriate referrals.
4.2.1 Identifying sepsis
Robson, Beavis and Spittle (2007) audited seventy-three registered nurses in ‘medical, surgical and orthopaedic wards’ in Chesterfield Royal Hospital. The audit took place in 2005 over the three-month period and identifies the extent to which nurses understand ‘definitions of sepsis, and the recommendations for its initial management’ (Robson, Beavis and Spittle, 2007, p. 86). It was reported as an audit because the nurses were tested against the ‘standard definitions and evidence-based management guidelines’ of the SSC (Robson, Beavis and Spittle, 2007, p. 87). Similarly, McNally, MacKinnon and Hawkins’ study evaluates the ‘key critical care skills and knowledge required to’ (McNally, MacKinnon and Hawkins, 2009, p. 22) implement the early goal directed therapy (EGDT) as recommended by the Surviving Sepsis Organization (2014b) in Specialist Registrars (SpRs) in anaesthetics, ‘general surgery and general medicine throughout Scotland’ (McNally, MacKinnon and Hawkins, 2009, p. 22). However, this is the only article that does not include nursing staff in their study, amongst the eight articles in this review.
Seventy-three nurses from junior to senior grades completed the questionnaire created by Robson, Beavis and Spittle (2007) in the form of test. The questions included diagnosing patients with sepsis or severe sepsis based on the signs and symptoms, five case studies to explain management plans, and ten ‘true or false’ statements (Robson, Beavis and Spittle, 2007, p. 86). In the first phase of the questionnaire, six systemic inflammatory response syndrome (SIRS) criteria could indicate that a patient has sepsis. Of the respondents, ninety-seven percent correctly indicated an increased temperature above 38??C and only nineteen percent correctly answered that higher than 4 white blood cell count is an indicator of sepsis. Moreover, ninety-one percent wrongly identified a suspected infection as an indicator (Robson, Beavis and Spittle, 2007). This study shows that ward nurses appears to have ‘general lack of awareness that low temperature, low white blood cells are signs of sepsis’ (Robson, Beavis and Spittle, 2007, p. 87).
McNally, MacKinnon and Hawkins’ (2007, p. 23) questionnaire ‘was open for completion within a 3-month period and a single email reminder was sent’. This study aimed to ‘survey at least fifty percent of general surgical trainees and an equivalent number from other specialities, and a statistical analysis was performed with SPSS 13 using the Chi-squared test’ (McNally, MacKinnon and Hawkins, 2009, p. 23). The respondents were asked about the years of training, previous critical care experience, their attitudes towards the awareness of EGDT and the SSC guidelines. ‘A power calculation ‘indicated that 30 replies per specialty would’ (McNally, MacKinnon and Hawkins, 2007, p. 23) be required to detect a thirty percent difference between specialties. Overall, although McNally, MacKinnon and Hawkins (2007) did not focus on nurse’s SSC protocol knowledge, they similarly found that medical staff in Specialist Registrars lacked knowledge of EGDT elements.
A number of nurses surveyed by Robson, Beavis and Spittle (2007) had reportedly taken some life-support courses such as the Acute Life-threatening Events Recognition and Treatment (ALERT) course by Smith, Osgood and Crane (2012) where any patient with low BP should receive 500-1000ml of fluid, and may be repeated as necessary. However, there is no specification on to the length of courses or the extent, which sepsis was studied. In the ALERT book, sepsis is discussed in a separate chapter, which means that nurses may not have been educated on sepsis. According to McClelland and Moxon (2014), the nurse’s role is vital in early detection and recognition of sepsis, hence nurses ought to possess a full awareness of identifying sepsis and managing it beyond identification. Since grade doctors provide immediate care and resuscitation to patients with severe sepsis or septic shock, McNally, MacKinnon and Hawkins (2007) focused only on Specialist Registrars (SpRs) in anaesthetics, general surgery and general medicine.
Although McNally, MacKinnon and Hawkins (2007) suggest the development of working relationships amongst anaesthetic staff, trainee physicians and surgeons in order to ensure proper referrals and compliance with the SSC sepsis resuscitation bundes, nursing staff are absent from the study. This inaccurately assumes that only grade doctors can give provision of immediate care and resuscitation to patients with severe sepsis or septic shock, despite the researchers’ admittance that nurses are the first to identify a deteriorating patient and inform the doctors to come and see the patient.
Page et al.’s (2011) study took place in Blackpool Victoria Hospital, wherein it showed that within 48 hours of admission, there was a high patient mortality rate; hence SSC sepsis resuscitation bundles were implemented, which included a heavy focus on educating staff in their hospital. During the study, they introduced an education campaign to motivate the staff in implementing the sepsis resuscitation bundles. Activities within the education campaign included lectures for all the junior doctors, pocket cards detailing the SSC sepsis resuscitation bundles and small group tutorials to all nurses. In addition, posters were placed in every department.
Page et al. (2011) proved the effectiveness of this ‘sticker campaign’ in improving the identification and treatment of sepsis by comparing the hospital’s sepsis compliance with nearby Preston Royal Hospital that did not implement the same campaign, and where compliance with all the elements ‘was not achieved in any patient’ (Page et al., 2011). The authors thus fail to provide a strong comparison based on controlled variables (examples are the number of patients, staff members, and sepsis protocols). Nevertheless, they propose that the sticker programme should be transferrable to almost any acute hospital and that the SSC sepsis resuscitation bundles could be achieved in a district general hospital.
Page et al. (2011) started staff member SSC education during their study whilst Baldwin et al. (2007) indicated that there was education across their Trust, particularly for the critical care outreach nurses and ICU consultants where educational sessions outlining the surviving sepsis campaign and its components were conducted. Robson, Beavis and Spittle (2007); Simmonds et al. (2008); McNally, MacKinnon and Hawkins (2009); McNeill, Dixon and Jenkins (2008) do not state if there were education campaigns occurring in the UK hospitals studied, despite the fact that they all suggest better staff education about sepsis and its management. Lack of staff education on sepsis is evident across all articles reviewed; however, the reason for this lack is not clearly explained, and requires further research.
4.2.2 Critical care referral
None of the eight articles evidence a hospital that achieved 100% compliance with the SSC guidelines, and all reviewed articles mention the importance of education and awareness of the sepsis care bundle across all disciplines in terms of appropriate and timely patient management and referral.
Simmonds et al.’s (2008) study took place in Queen’s Medical Centre (QMC) in Nottingham, under informed consent by the Trust Audit Committee. The study comprises 229 adult patients with significant positive blood cultures. Simmond et al. (2008, p. 124) used an expanded version called the QMC Sepsis Measurement Tool, which includes: the ‘timing of sepsis resuscitation bundles interventions, seniority of doctors and the level at which care was given.’ The findings were that patients experiencing severe sepsis were only seen by any doctor after a median of 1.1 hours. Similarly, Cronshaw et al.’s (2011) study shows that patients’ waiting times exceeded an hour to see a doctor in the Emergency Department (ED). Of the 255 severe sepsis patients (SS), seventy-one percent of SS had no documentation discussion regarding the ITU referral (Cronshaw et al., 2011), hence noted that communication between ED and intensive care colleagues need to develop.
‘[D]espite severely abnormal physiology’ (Simmonds et al., 2008, p. 125), only sixty-one percent were referred for critical care opinions and only sixty percent of those patients were reviewed by a specialist in critical care within 12 hours of meeting severe sepsis criteria according to the SSC. Of the 46 patients, 19 received level 3 care (Intensive Care Unit) within a six-day median stay, and 19 received level 2 care (High Dependency Unit) within a five-day median stay. Thirty-three percent of the sepsis patients died within 90 days and thirty-five percent within a year (Simmonds et al., 2008, p. 126).
This analysis of different levels of care indicate that mortality is higher outside of critical care and this correlates to the authors’ findings that there is a lack of sepsis resuscitation bundle compliance outside of critical care areas. Cronshaw et al.’s research study evidences that only twenty-nine percent of the patients were referred to ITU staff, and were considered not suitable or were labeled ‘do-not attempt resuscitate’ and seventy-one percent of severe sepsis patients had no documented discussions for referrals to the ITU (2011, p. 671). Simmonds et al.’s (2008) and Cronshaw et al.’s (2011) findings therefore, demonstrate that a lack of referrals is one of the factors that contribute to poor SSC sepsis resuscitation bundle compliance.
Simmond et al. (2008) suggest that SSC sepsis resuscitation bundles are to be investigated beyond the intensive care in order to improve the capacity of the entire hospital system to address sepsis. McNeill, Dixon and Jenkins, (2008) study supports Simmond et al.’s (2008, p. 165) suggestion, because the findings of McNeill, Dixon and Jenkins, indicate that only ‘few AMUs across the UK hospitals can comply with the sepsis care bundle that have systems in place to resuscitate a patient with sepsis’. AMU is categorised as first level of care; therefore, it is essential to survey the compliance of the SSC sepsis resuscitation bundles at this level.
Although SSC sepsis resuscitation bundles ought to theoretically be implemented in any level of care in the hospital setting, implementation at different levels of care does not guarantee overall compliance with SSC sepsis resuscitation bundles, as proven by Cronshaw et al. (2011); Simmonds et al. (2008); McNeill, Dixon and Jenkins (2008); Robson, Beavis and Spittle (2007); Page et al. (2011). Nevertheless, one essential factor for ensuring compliance with the SSC sepsis resuscitation bundles is the awareness of staff members on how and when to refer the patient as quickly as possible from the point at which the patient is diagnosed as having sepsis.
4.2.3 Communication between levels of care
Baldwin et al. (2007) argue that the reason fifty percent compliance to the administration of the antibiotics is due to poor communication between the prescribing doctor and the nurse who is meant to administer the antibiotics. The study claims that some elements of the SSC sepsis resuscitation bundles were not implemented due to issues around the doctors wherein junior medical staff were primarily attending to the patients’ treatment (Baldwin et al., 2007, p. 255).
4.2.4 Implications for nursing practice
Robson, Beavis and Spittle’s (2007) questionnaire particularly affirms that ward nurses generally fail to recognise patients as having severe sepsis or septic shock and are not confident to give intravenous fluid to those patients with lowered systolic BP or urine output as they may have fears of causing fluid overload for the patient. Simmonds et al. (2008, p. 127) recommend that this lack of awareness could be addressed through the recent advent of course initiatives such as the ‘Ill Medical Patients Acute Care and Acute Care Undergraduate Teaching needs to be routinely part of postgraduate medical and nursing education.’ Equally, McNeill, Dixon and Jenkins, (2008) suggest that education of nursing staff is needed, and similarly, Robson, Beavis and Spittle’s (2007, p. 89) study identifies that a ‘deficit in knowledge of nurses could lead’ to poor compliance to SSC sepsis resuscitation bundles.
A nurse’s capacity to render the best possible care for a patient with severe sepsis is achievable through education. This is a key to implementing the SSC sepsis resuscitation bundles, and patients’ survival relies on the healthcare professionals who will accurately execute the SSC sepsis resuscitation bundles. Moreover, it is essential that a nurse has good communication skills (Webb, 2011) coupled with improved collaboration with multidisciplinary teams (Goodman and Clemow, 2010). Good communication skills and collaboration are the result of staff education and awareness on compliance to SSC sepsis resuscitation bundles, and are essential in ensuring the patient’s continuity of care.
4.2.5 Recommendations
Robson, Beavis and Spittle’s (2007) evidence implies that nurses’ awareness of sepsis management demonstrated limited awareness, with less than half of respondents knowing each of the sepsis symptoms, however there is a lack of confidence on implementing the interventions specified in the SSC guidelines. Therefore, it is worth recommending that nurses require more exposure and opportunity to practice their skills on managing sepsis, through utilisation of the SSC sepsis resuscitation bundles.
Page et al. (2011) state that their sticker programme and posters may be an efficient alternative to costly education and training programmes as these are affordable and consistent means of educating staff. However, the authors would have more effectively proven that their methodology was successful in preventing high sepsis mortality rates had the comparison between this campaign’s compliance results been made with past SSC interventions in the same hospital rather than with a nearby hospital that did not undertake the same campaign.
Whichever hospitals endeavour to implement the sticker programme should evaluate SSC compliance by comparing the present sepsis related mortality rate with the sepsis related mortality rate achieved through said programme in order to achieve more accurate measurements of compliance. Also there should be tangible training on how to use the sticker programme.
McNally, MacKinnon and Hawkins (2009) suggest that a minimum education on how to initiate EGDT is important, however what exactly covers a ‘minimum education’ ought to be clarified. Hence this cannot be recommended. Awareness and education without good communication and collaboration will affect the effectivity of compliance to the SSC sepsis resuscitation bundles, therefore, further study to evaluate the multidisciplinary team collaboration in relation to SSC sepsis resuscitation bundles is recommended.
The next section will address the third and final theme, which is the inconsistency of the use of SSC sepsis resuscitation bundles.
4.3 Inconsistent use of Surviving Sepsis Campaign guidelines
The SSC sepsis resuscitation bundles compliance is evident when there is consistency on the use and implementation of the standard guidelines. Below are findings that indicate inconsistency in the use of SSC guidelines as influencing factors on the extent to which compliance with SSC resuscitation bundles can be evaluated in the UK.
4.3.1 Management in addition to SSC sepsis resuscitation bundles
Three of the articles reviewed that took place in hospitals across the UK have added different forms of management to the existing SSC guidelines, which creates difficulty challenge in evaluating overall compliance.
Simmond et al. (2008, p. 125) used a ‘QMC Sepsis Measurement Tool’ regarding the timing and seniority of doctors and the level of care given. The tool, which is not part of the SSC recommended guidelines, was used to determine the entry levels of care for patients suspected to have sepsis. Gao et al. (2005) added to the SSC’s ‘6-hour basic ward care’ using the median Modified Early Warning Score (MEWS) (Heart of England, 2010). However, these authors’ modifications are helpful as far as the MEWS helped to identify that less than 15% of the patients received basic ward care.
Cronshaw et al. (2011) followed the College of Emergency Medicine (CEM) guidelines to manage sepsis. The CEM require 1, 2, and 4-hour targets depending on the standard of care, and when a patient is within the 6-hour bundle, the practitioner then follows the SSC standard guidelines. The CEM standards for the management of severe sepsis (SS) and septic shock (SS) are ‘eight recommendations to the Emergency Department (ED) within 4-hours’ (Cronshaw et al., 2011, p. 670). Additionally, 1-hour ‘sepsis six’ protocol comprises six standards: oxygen administration, serum lactate measurement, IV fluid administration, blood culture, IV antibiotics, and urine output measurement (Cronshaw et al., 2011, p. 671).
Even if the CEM guidelines and sepsis six protocol add incongruity to to the SSC sepsis resuscitation bundles, there is still consistency on implementation of the six-hour sepsis care bundle under the Surviving Sepsis Campaign (SSC). Nevertheless, none of the aforementioned studies are easily transferable across a range of hospitals in the UK, as they have all altered the SSC guidelines in some way.
4.3.2 Modified elements under the SSC guidelines
Two articles were found to have changed particular elements within the SSC sepsis resuscitation bundles.
Gao et al. (2005, p. R765) used ‘haemoglobin target instead of haematocrit and used remaining hypotension after fluid resuscitation for threshold of inotropes instead of central venous oxygen saturation’, which is the standard for the sepsis care bundle. Likewise, Page et al. (2011) mention that there were some doctors who opted not to apply certain elements of the SSC sepsis resuscitation bundles, such as giving the full 20 ml/kg bolus to the patient, and documented the reason for not giving it as professional discretion. Gao et al. (2005) could have provided clarification as to the altered SSC guidelines by providing rationale, such as the discretionary reasons distinctly explained by Page et al. (2011).
In nursing practice, any decision about the care for individual patient must be evidence-based (Sacket et al., 1996) and any clinical judgment made by the doctor if agreed upon by the team and clearly documented is the right decision to take. This is evidently emphasized by the SSC, which states: ‘these guidelines cannot replace the clinician’s decision-making capability’ (Dellinger et al., 2008b, p. 19) hence, clinician can use own discretion. However, the extent to which a clinician alters the SSC care bundles either in writing or in practice will still have a significant impact on researchers’ capacity to evaluate SSC compliance across hospitals in the UK, as is the discrepancy in this particular literature review.
While three studies have used different formats of the SSC sepsis resuscitation bundles and two studies modified the elements, five of the articles reviewed found overall consistency in the use of the SSC guidelines and have positive implications for compliance. Cronshaw et al. (2011); Baldwin et al. (2007); Page et al. (2011) adhere to the SSC’s 6-hour sepsis bundle guidelines, and McNally, MacKinnon and Hawkins’ (2009) study follows each element of Early-goal Directed Therapy (EGDT) (Rivers et al., 2001) through the SSC. Finally, Robson, Beavis and Spittle (2007) test the ‘ward nurses’ knowledge of standard sepsis definitions according to the Surviving Sepsis Campaign management guidelines.
4.3.3 Implications for nursing practice
In nursing practice, a systematic approach that comprises evidence-based management for patients suffering from severe sepsis or septic shock, or critically ill patients, that is universal and can be transferrable from one hospital to another is desirable (Gerrish, 2010). But given the apparent inconsistency of SSC care bundles due to different formats used and implemented beyond the SSC guidelines, nurses and medical staff will encounter difficulty in complying with SSC recommended sepsis resuscitation bundles from hospital to hospital. Moreover, the continuity of care for the patient will not be consistent, especially in cases where a patient must be transferred from one hospital to another.
An updating of skills and fostering nursing knowledge about SSC guidelines, sepsis recognition, assessment, interventions and management, is essential because most of the time nurses are the bedside clinicians of the patients. It is therefore fundamental for nurses to be given initiatives to update and enhance their knowledge and skills regarding the SSC guidelines.
4.3.4 Recommendations:
One hospital might have different sepsis management from another hospital as demonstrated by the studies of Gao et al. (2005); Cronshaw et al. (2011); Simmonds et al. (2008). Hence the health outcomes will vary from one hospital’s version of the SSC guidelines to another’s. If the SSC sepsis resuscitation bundles were implemented universally then it would be much easier to identify evidence and determine trends pertaining to compliance.
Seven articles in this literature review have rated their study compliance with the SSC sepsis resuscitation bundles by the use of percentage, whereas Gao et al. (2005) rated compliance by the use of ‘all’ or ‘none’ as pass-fail for the elements of the sepsis care bundle. Had Gao et al. (2005) rated compliance by the use of percentage, it would be easier to discern which criterion of the SSC sepsis resuscitation bundles needs to be implemented or may not work for patients with sepsis. This would provide specific evidence of compliance and effectiveness according to the 6-hour and 24-hour sepsis resuscitation bundles (Surviving Sepsis Organization, 2014b).
Despite adding inconsistency to the SSC guidelines, Gao et al.’s (2005, p. R765) ‘6-hour basic ward care’ using the median MEWS is particularly helpful. Because basic ward care is a crucial obligation that every nurse must undertake, and these include the ability to recognise and prevent delay in intervention or transfer of critically ill patient to an appropriate place for patient’s safety (NPSA, 2007). Moreover, the one-hour sepsis six protocol in Cronshaw et al. (2011) study, which was originally formed by Daniels et al. (2011) is worth recommending to include in the SSC sepsis resuscitation bundles internationally as this protocol has already been implemented in some hospitals across the UK. The sepsis six management for patients is also being taught in the ALERT course (Smith, Osgood and Crane, 2012) as part of the nursing degree final year curriculum in some universities across the UK, hence a newly qualified nurse is expected to be knowledgeable on the sepsis management, particularly of sepsis six. Therefore, it is worth suggesting to conduct further enquiry into student nurses’ knowledge towards SSC sepsis resuscitation bundles across the UK.
Chapter 5: Strengths and limitations of this extended literature review
5.1 Strengths
The reviewer included articles measuring compliance of SSC sepsis resuscitation bundles across the UK. The publications are recent articles and hence provide good evidence and insights of clinical practice regarding SSC sepsis resuscitation bundles in hospitals across the UK (Aveyard, 2014).
All articles included in the review are primary articles and represent a variety of hospitals across the UK with larger sample sizes (Burns and Grove, 2009). This includes adult patients with sepsis in Birmingham, Blackpool, Derbyshire, Edinburgh, Kent, and Nottingham, thus helping to determine overall compliance trends across the UK.
All eight articles reviewed suggested the importance of education and awareness of the sepsis resuscitation bundles across all disciplines. The overall strength of the findings from this review is that the evidence from the articles helped to determine that nurses play a critical role in improving the ‘golden hour’ in the delivery of sepsis care bundles, in terms of identifying, prioritising, and rapidly referring the patient diagnosed with sepsis (Lovick, 2009).
5.2 Limitations
Four articles have added some interventions aside from the SSC guidelines.
Furthermore, studies by Robson, Beavis and Spittle (2007); Simmonds et al. (2008); McNeill, Dixon and Jenkins (2008) stress that education is needed, but do not elaborate upon any specific training that the nursing and medical staff have undergone before the study, or what kind of education the authors are recommending. Page et al. (2011) claim that a sticker education program is equal to greater compliance; however, the authors’ fails to compare with past SSC compliance ratings within the same hospital, which weakens their argument and how responses to questionnaires regarding compliance cannot be verified, whereas an audit provides a more thorough indication of compliance in a given hospital.
Chapter 6: Conclusions
The aim of this literature review was to evaluate hospitals’ compliance to the SSC sepsis resuscitation bundles across the UK as well as to identify implications for the role of the nurse in complying with the SSC guidelines.
Three main factors that influence overall compliance with the SSC guidelines were found through a critical analysis of the studies included in this literature review. Firstly, the availability of resources and equipment such as enhanced care beds and medicinal supplies within the hospital appears to be limited in Baldwin et al., (2007); McNeill, Dixon and Jenkins, (2008). Secondly, at the very least, the lack of SSC awareness by hospital nursing staff is a significant concern, because nurses are the first point of contact for patients, and are therefore largely responsible for identifying sepsis. Trainee doctors and medical staff also need proper SSC education, as McNally, MacKinnon and Hawkins’ (2009) evidence that only anaesthetic staff are sufficiently knowledgeable about sepsis resuscitation bundles. Lastly, inconsistency in the use and subsequently in the implementation of the SSC guidelines ‘ such as a change or elimination of certain SSC elements, whether due to lack of resources or practitioner discretion ‘ significantly limit researchers’ capacity to evaluate SSC compliance across the UK.
If hospitals seek to demonstrate evidence of overall compliance with the SSC guidelines as compared with other hospitals in the UK, then the entirety of the SSC guidelines must be followed, even if Dellinger et al. (2008b) have only highly recommended it. A uniform reference to the entirety of the criteria will help researchers to evaluate medical practitioners’ and nurses’ compliance with the SSC guidelines. Moreover, adherence with the SSC guidelines will help hospitals to determine the relevance of each element for sepsis management, and therefore provide a rationale as to whether an element may be appropriate or not, rather than modifying the guidelines from the outset.
Nevertheless, since the SSC guidelines were published in 2004 and has been revised every two years, there is still time and opportunity to gather all current evidence-based data regarding the implementation of the SSC guidelines. Even in a time of economic austerity recommendations for sepsis management could be replicated in hospitals across the UK through the appropriate and more consistent use of SSC guidelines by nursing and medical staff in order to both benefit patients’ health conditions and decrease mortality rates.

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