This study evaluated the implementation of a state-wide PSP by assessing the variables and factors contributing to ED nurse’s knowledge of paediatric sepsis recognition, escalation and management. The study captured data from a broad range of nurses and varying health care settings participating in a sepsis QI initiative. Respondents were from 14 metropolitan and regional EDs, of which four were dedicated paediatric departments and ten were mixed adult-paediatric EDs in QLD, Australia.
This is the first study to explore and evaluate knowledge and factors contributing to implementation of a sepsis pathway, providing insight into the complex phenomena of knowledge translation (33). The survey tool, designed from the TDF, was validated by an EFA and can serve future sepsis QI initiatives in other states and countries to assess implementation and KT. The study provided the following key findings: First, nurses predominately agreed or strongly agreed with statements contained in four of the five factors that reflect elements indicative of utilisation of the sepsis pathway. Second, variation in knowledge of paediatric sepsis existed across hospitals, despite participation in a state-wide QI project and the provision and supported implementation of a standardised sepsis pathway; variation in knowledge scores could be explained by the final two key findings. Third, the experience in paediatrics and dedicated ‘sepsis QI nurse funding’ focused on supporting the sepsis QI initiative, were key respondent and hospital site characteristics associated with improved uptake of the pathway as measured by the knowledge score. Finally, the factors (i) knowledge and beliefs, (ii) beliefs about capability and skills and (iii) environmental context and resources emerged as the strongest factors associated with the primary outcome, knowledge score.
Translation of knowledge as a measure of sepsis pathway implementation
We used a knowledge assessment, composed of 15 questions targeting specific knowledge relevant for sepsis recognition, escalation, and management, formulated from the PSP. Time to initiation of sepsis treatment represents one of the strongest determinants of sepsis mortality in children (34, 35), yet studies have revealed major differences in compliance with sepsis bundles between sites using similar pathways, even when considering patient severity. Inter-institution variability in sepsis pathway knowledge and application can jeopardise the achievement of key performance indicators (8, 9, 36), and contribute to suboptimal pathway compliance and patient care (37–39). Paediatric sepsis is particularly challenging because of the non-specific manifestation of sepsis and the relative rarity of sepsis compared to large numbers of febrile children being assessed in EDs, resulting in limited exposure for individual staff members (7). In addition, a large proportion of children present to hospitals caring for adult and paediatric patients, staffed by a mixed, or primarily adult-experienced workforce. Hence, there is a need for evidence to guide improved strategies for the successful and sustainable implementation of sepsis pathways in children.
Our findings identified variability in sepsis knowledge, within and between sites (11, 12, 16), despite provision of a standardised, state-wide pathway and the related targeted education. These findings echo previous studies where average to low knowledge scores have been reported despite having a sepsis pathway and associated education in place (40–43). Our study has identified that years of paediatric experience, ‘sepsis QI nurse funding’ and three identified factors associated with KT could explain a large proportion of variation in knowledge scores between sites, which can inform future sepsis initiatives.
Factors associated with improved knowledge translation and implementation
Successful QI initiatives within emergency medicine require consideration of the variety of elements influencing clinician behaviour that may affect KT and subsequent implementation and practice change (44). We explored a range of factors and identified three key factors which were significantly associated with improved KT of the PSP, as measured by nurses’ knowledge score. Knowledge and beliefs, capability and skills, and environmental context and resources, emerged as the key predictors of nurse’s knowledge scores. KT is an underutilised phenomena in EDs (44), and focus on these three factors can inform future sepsis QI initiatives, campaigns and sepsis education to impact care globally, where previous efforts have reported limited success (15, 28, 45, 46).
Nurses in our study identified predominately positive agreement statements across four of the five factors indicating PSP utilisation, and 96% of nurses identified the pathway as a management resource, providing insight into implementation in clinical practice (Table 2; Supplementary Material 8). One factor, centred around the beliefs about capability and skills required to deliver treatment for paediatric sepsis, had comparatively lower ratings indicating that nurses need additional development to enhance confidence in skills required for managing paediatric sepsis. Similar findings have been identified in previous studies (43, 47), highlighting the importance of education initiatives focusing on kinaesthetic skill acquisition (and so, enhanced belief in capability) in training, especially where exposure to critically unwell children may otherwise be infrequent. In our study, only 35% of nurses reported caring for a child with sepsis as a weekly or fortnightly occurrence, highlighting the relatively low exposure to paediatric sepsis. The identified positive link between beliefs in capability and skills to sepsis knowledge should inform future QI and education initiatives to focus on increasing confidence in capability (43, 47–49) as a mechanism for enhancing knowledge translation and subsequent care for children.
Institutional variables associated with improved knowledge translation and implementation
The variation we observed in knowledge scores between the 14 hospital sites was largely explained by dedicated ‘sepsis QI nurse funding’, irrespective of site, geographic and facility differences (Fig. 3C). A lack of provision of dedicated human resources has been identified as the greatest challenge in caring for critically ill paediatric patients, impacting nurse’s confidence in their capability (47). Our identified link between confidence and knowledge informs future models, aiming to justify resources dedicated to paediatric sepsis QI initiatives. Our results emphasise the importance of specific training, education, tools and resources to increase nurse’s confidence about their capabilities around managing challenging presentations, (50, 51) such as paediatric sepsis. National and international sepsis guidelines have often achieved implementation success through use of sepsis leads and champions to advocate for education uptake and broad awareness (52, 53), with higher performing sites containing these components (54). Challenges with healthcare include reduced funding sources, involving balancing cost efficiency for such initiatives, however if sepsis care is suboptimal, the costs and other burdens imposed on health systems are significant (41).
Respondent characteristics associated with improved knowledge translation and implementation
We identified, years of paediatric experience as a significant predictor of increased knowledge. Previous study findings have also identified years of paediatric experience contributes to increased capability and confidence caring for paediatric patients (47). While years of clinical experience cannot be replaced we argue, based on our findings, there is a need for dedicated and ongoing resources targeting specialised paediatric sepsis education to enhance exposure; to supplement years of experience. These findings are supported in previous literature identifying that paediatric training and resources enhanced clinician’s exposure to and subsequent confidence in delivering care to critically unwell paediatrics (43, 55).
Importantly, surveys of students, and of the healthcare workforce have revealed relatively low levels of agreement and knowledge about sepsis, which contrasts with the fact that sepsis represents one of the leading diseases associated with preventable deaths across all age groups (41, 56). In Australia, despite the fact that national sepsis standards are being developed, currently there are no standards or mandates for under-graduate, post-graduate, or facility specific training for ED nurses on sepsis (47). In Australia, a generalist model in undergraduate nursing curriculum (25) contrasts with that in the United Kingdom, which offers specialised paediatric nursing degrees. This may pose Australian nurses with a challenge as they are required to provide care across the lifespan, however children have significant differences in pathophysiology that requires specialist knowledge and training which is currently limited (47). Indeed, a recent university study concluded knowledge of paediatric sepsis was as low as 8% in graduating nurses in Queensland, Australia (56). The importance of specified paediatric training, including post-graduate qualifications, facility mandated courses and certification, requires exploration in the future development of health services and education (47, 55).
Knowledge was the main measure assessed and the contributing factors, however we did not assess whether increased knowledge was associated with improved treatment and outcomes in sepsis. Participating hospitals may have chosen to consider the sepsis QI initiative as part of regular business, resulting in-kind support which was not included in our calculations. We calculated ‘sepsis nurse funding’ as dedicated resourcing to lead the project and the predictive relationship of funding on knowledge score suggests that providing dedicated funding is of value. Two additional hospital sites were not included, as they had no sepsis-lead to run the survey. Independent data collection occurred locally, which may have contributed to response bias, unknown site confounding variables, and inconsistent instructions for completion alongside the biases that exist with self-reporting data (57). We mitigated this risk by educating nurse leads at each site and providing an instruction script for consistent, supportive messaging. Each site was sent weekly response rates and reminders, the survey was available offline, and a strict inclusion criterion was created. A broad range of nurses were surveyed to include multiple perspectives and responses (29). A sensitivity analysis of demographic details for partial responses that were excluded from analysis was undertaken to ensure no significant differences existed (Supplementary Material 6). Some sites had low response rates. We could not measure ‘improved’ knowledge to demonstrate successful implementation, as no baseline survey was conducted. As such, the cross-sectional design does not enable demonstration of sustainable knowledge or predict future implementation success, rather we explored the contributing factors and variables, which may inform future QI initiatives. Our sample was, however, heterogenous in nature with a large, combined site sample size and is the largest paediatric sepsis implementation study conducted that assesses PSP implementation through KT, resulting in a greater chance of generalisability.