Our study is a foundational analysis of the sepsis quality of care improvement project at LUH for the strategic development plan of the 2019-2023 period. We identified significant deficiencies in sepsis awareness amongst nurses and physicians of our university tertiary care center and local paramedics. A minority of healthcare professionals in our institution are aware Sepsis-3 consensus definitions for sepsis. Similarly, a minority of staff are aware SOFA and qSOFA scores. Correspondingly, a minority of paramedics, nurses, and physicians self-evaluated as good or very good for sepsis knowledge and management. Importantly, these findings are associated with a lack of continuing education.
Despite the fact that Sepsis-3 consensus was released more than four years ago,1 despite its incorporation in the core of the Lausanne medical school curriculum or in institutional tools such as the LUH’s guide for empirical antimicrobial therapy, our results show a lack of penetrance of the latest sepsis definition.26,27 The lack of specific continuing education accounts primarily for this. Only 18.5% of participants reported having attended sepsis-specific training in the previous three years. Thus, the vast majority of participants have not been exposed to training on the new sepsis definitions and are not familiar with the qSOFA score. This was striking for both paramedics and nurses that are at the front line of sepsis recognition. Nurses spend comparatively more time than physicians at the patient bedside28 and early recognition of nosocomial sepsis by nurses increases 30-days survival.29
Similarly, only one-third of physicians are aware of the current sepsis definition. One-fifth of physicians using the definition of hemodynamic instability in addition to infection, may lead to delays in the recognition of septic patients. Furthermore, the low rate of calculation of a SOFA score by physicians implies that documentation of sepsis in discharge summaries and electronic medical records is also compromised. We are accumulating evidence in the context of our quality of care project (data not shown). As a consequence, sepsis epidemiology at the institutional level may be severely affected.
These observations support further - and regular - training incorporating Sepsis-3 consensus definitions in our institution as studies support continuous training to improve sepsis awareness amongst participants.30,31 Because a minority of participants, whether nurses, paramedics or physicians rated their knowledge and management skills as good or very good, there is a major opportunity for continuing education.
To the best of our knowledge, the present study is the first assessing sepsis-3 knowledge surveying large sample size, multiple professions across all adult departments of a tertiary care center, thus representing all persons implicated in adult sepsis care. Multiple studies have assessed sepsis awareness,8,10,12−18 however, only three probed Sepsis-3, all of which were limited in scope: Nucera and coworkers assessed Sepsis-3 awareness among nurses and physicians and found similar deficiencies, however the study was limited to 181 persons and excluded oncology wards. Consistent with our study, they identified major deficiencies in awareness particularly pertaining to scores and definitions. However, the large sampling in our study enables a better resolution of deficiencies. As an example, the capacity to define sepsis according to sepsis significantly better in ICU, ED and internal medicine compared to surgery and psychiatry. Mulders and co-workers assessed a very different setting, interviewing general practitioners, but found similar observations with very low penetrance of SOFA score-based sepsis definitions and qSOFA score-based assessment. Finally, a survey limited to ICU physicians in China revealed a limited familiarity with only 16% of 366 physicians using Sepsis-3 consensus definitions.11 Studies relating to Sepsis-2 definitions had already identified significant deficiencies: Seymour and co-workers found paramedical staff struggling to define sepsis.8 Abdul Rahman and colleagues identified deficiencies among nurses and physicians in the ED.12 However, sepsis-specific training is associated with significant improvement in such deficiencies.18
This study’s strengths include the number of participants, the participation rate, the combined assessment of nurses, physicians and paramedics and the breadth departments of adult medicine assessed. Furthermore, methodology with direct supervision of participants taking the survey ensures high-quality data collection. It also has limitations: The survey was built on knowledge, attitude and practice of health care professionals towards sepsis based on literature review and focus groups of experts clinicians.32 It was tested in iterative pilots and revisions among intended respondents. However, we did not perform subsequent reliability (internal consistency, test-retest reliability, or inter-rater reliability) or construct validity assessment through a Crohnbach’s alpha test due to the various formats of questions. Second, it is limited to a single center and results may not be generalizable, although they are consistent with previous studies. Third, we have a slight imbalance towards younger age for participants and male sex for nurses. The exclusion of staff not having daily contact with patients likely accounts in part for the age bias. The propensity of male nurses to take the test is more difficult to explain; it might reflect a more prevalent part-time activity amongst females compared to males (average full time equivalent 0.73 vs. 0.82). Fourth, we had significant discrepancies in the various hospital departments. This was strongly influenced by differences in availability (seminars, availability on the ward).