Exploring Ways to Improve Nurse’s Ability to Identify Sepsis

Exploring Ways to Improve Nurse’s Ability to Identify Sepsis in Patients in Emergency Department

[Name of Student]

[Date]

1. Abstract

Aim: The objective of this research is to investigate ways to improve the ability of nurses to diagnose sepsis in patients presenting to the Emergency Department (ED), thus screening techniques such as the Systemic Inflammatory Response Syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) were examined, along with the development of a service improvement plan.

Background: Taking into account the significant effects of sepsis on patient outcomes, this study examines six important publications from various geographical areas, therefore this systematic literature review offers a thorough overview of the sepsis screening methods currently in use by exploring the sensitivity, specificity, and usefulness of SIRS, qSOFA, and NEWS across a range of sepsis severities.

Methodology: The approach entails a thorough review of the literature that includes research from Norway, Singapore, Switzerland, the United Kingdom, and the United States, moreover the performance indicators of the screening instruments are assessed rigorously in order to establish the foundation for the suggested service improvement strategy, hence the strategy incorporates NEWS and qSOFA's advantages into the NHS strategic model of project management.

Results: The results are summarised in the critical discussion, which also highlights the benefits and drawbacks of each screening instrument, thus the purpose, rationale, goals, and quality outcomes of the suggested service improvement plan are all outlined and supported by the information from the literature review, thus a six-phase project plan is provided for methodical execution that follows the NHS structure.

Conclusion: This study's finding emphasises how crucial the suggested service change is to improving sepsis diagnosis and care in the ED, in addition to highlighting personal growth, the reflective paragraph assesses the benefits and drawbacks of the capstone project and highlights how it might enhance the treatment given to patients who are at risk of sepsis.

Keywords: Emergency Department, Healthcare Delivery, Nursing Ability, Service Improvement, Sepsis.

2. Introduction

Patients with sepsis pose a formidable challenge in the emergency room on account of the atypical onset of symptoms and the critical requirement for immediate intervention, therefore the primary concern is the possibility of delayed identification, which may have detrimental effects on elderly individuals who are more vulnerable to the deleterious effects of sepsis (Reyes et al., 2018). This dissertation's main goal is to look into and suggest practical ways to improve emergency room nurses' capacity to recognize sepsis in elderly patients quickly, hence the dissertation endeavours to improve patient outcomes, lower rates of morbidity and death, and improve healthcare procedures in emergency departments by tackling this crucial issue, and this will ultimately improve the overall quality of care for this susceptible population.

Having worked in the medical field for a while, I have a strong personal interest in finding strategies to help nurses recognise sepsis in elderly patients in the emergency room, and having worked in a variety of hospital settings, I have direct experience with the difficulties nurses encounter when tasked with the difficult duty of diagnosing sepsis in elderly patients (Drahnak et al., 2016). These encounters have increased my drive to learn more about this important healthcare topic since I genuinely want to improve patient care, therefore in the last several months of my work, I have seen cases where the particular difficulties adult people face when presenting with sepsis have caused delays in diagnosis and treatment planning. My understanding of the criticality of diagnosing sepsis has increased as a result of these observations, which have also highlighted the need for specific enhancements in the skills of healthcare professionals, especially nurses who work in the hectic emergency room setting (Porter et al., 2021).

Understanding the history and contextual details pertaining to the diagnosis of sepsis in elderly patients presenting to the emergency room is crucial to fully appreciate the complexities of this healthcare dilemma, thus the diagnosis of sepsis in the elderly population is more challenging due to the distinct physiological changes and comorbidities that this group shows; usually healthcare practitioners face challenges in accurately and promptly diagnosing atypical symptom presentations due to age-related immune response changes and the presence of chronic diseases. The identification process is further complicated by the emergency department's environment, thus emergency situations are dynamic and high-pressure environments that require quick decisions, which could impede comprehensive evaluations, hence time restrictions and the sheer number of patients may make it more difficult to do the thorough assessment needed to correctly diagnose sepsis in adult people, moreover the importance of focused tactics to increase the accuracy and effectiveness of sepsis detection in emergency care settings is highlighted by this setting (Rababa et al., 2022).

Caring for elderly patients in the emergency room comes with its own set of problems that have a big effect on the diagnosis of sepsis, this is because emergency rooms are usually very busy and demanding, which makes it hard to do the full evaluation that is needed for a correct diagnosis, especially when it comes to elderly patients (Garnacho-Montero et al., 2014). Time restraints and the need to attend to urgent medical issues may unintentionally obscure the subtle and unusual symptoms that are frequently linked to sepsis in the elderly, in addition, the sheer number of patients requiring emergency care increases the difficulties faced by medical professionals. According to Jones et al. (2015), because of the need to properly allocate resources and prioritise cases, it may not be possible to do the in-depth evaluations that are needed for elderly patients, therefore this could lead to delayed or missed signs of sepsis.

Identifying sepsis is harder in adult people because they are more likely to be hurt in emergencies because their immune systems are weaker and they already have health problems, because of this, healthcare professionals need to be more aware of these weaknesses and take specific steps to deal with the difficulties of treating sepsis in adult people in emergency care settings (Kane-Gill et al., 2015; Sloane et al., 2018). UK's approach to sepsis treatment is based on the National Institute for Health and Care Excellence (NICE), a group that gives healthcare workers advice based on evidence, thus the NICE guidelines for adult sepsis are the main source for this information. Make it clear how important it is to diagnose sepsis quickly and use tools like the National Early Warning Score (NEWS) to find people who may get worse, thus realising this is also important for starting quick treatments and keeping sepsis from getting worse (Nieves, 2018).

3. Methodology

3.2 Research Question

"How can the proficiency of emergency department nurses in identifying sepsis in patients be improved, considering the unique challenges posed by the adult population and the demanding environment of emergency care, with a focus on aligning practices with national guidelines and addressing the potential risks associated with misdiagnosis?"

3.2 Structured Search Strategy using PICO and MeSH.

Selecting the PICO (Population, Intervention, Comparison, and Outcome) framework as the methodology for this capstone project offers a structured and systematic approach to framing research questions. PICO improves the clarity of a research issue by making it easier to conduct a targeted literature search and critical evaluation. PICO guarantees clarity, comparability, and relevance in the formulation of research inquiries by clearly defining the Population, Intervention, Comparison, and Outcome. According to Ebai, (2017) this facilitates the identification of pertinent evidence and the synthesis of findings more efficiently, therefore this methodological decision strengthens the capstone project's overall robustness by encouraging rigour and coherence in the literature evaluation.

3.2.1 Population (P)

The target population consists of adult patients and emergency department nurses who present with possible symptoms of sepsis, the following terms will be included as synonyms and related designations for "adult patients": "geriatric," "adult," and "ageing population", thus variations such as "emergency department nurses" and "ED nurses" will be integrated to designate nurses.

3.2.2 Intervention (I)

The intervention under consideration comprises educational programmes, strategies, or interventions designed to improve the ability of emergency department nurses to recognise sepsis in elderly patients, thus "interventions," "educational programmes," "training," and "strategies" are all keywords.

3.2.3 Comparison (C)

The search will look at any comparative aspects, even if not all studies have a direct comparison group, this includes comparing different interventions or how well interventions work compared to standard practices.

3.2.4 Outcome (O)

The main objective is to enhance the competence of emergency department nurses in recognising sepsis in elderly patients, this encompasses results associated with precise and prompt identification of sepsis, compliance with established protocols, and ultimately, enhanced patient outcomes.

3.2.5 MeSH

A controlled vocabulary known as MeSH (Medical Subject Headings) terms is utilised to index articles in PubMed, thus by standardising and classifying publications according to their subjects, they facilitate the process of finding pertinent literature. The MeSH terms that were used in the search strategy for the literature review are "Sepsis," "Sepsis Syndrome," "Septic Shock," "Early Diagnosis," "Diagnosis, Early," "Diagnostic Techniques and Procedures," "Patient Care," "Patient Care Management," "Patient Care Planning," "Education, Nursing," "Nursing Education Research," "Education, Nursing, Continuing," "Emergency Medical Services," "Emergency Service, Hospital," "Triage," "Interdisciplinary Communication," "Interprofessional Relations," "Health Communication," "Quality Improvement," "Total Quality Management," "Quality Assurance, Health Care," etc.

3.3 Search Strategy and Justification

The search had been conducted using a combination of controlled vocabulary phrases, specifically MeSH terms, and free text terms, therefore utilising both methods guarantee a thorough investigation, as certain articles may be categorised differently or have not yet been assigned MeSH keywords. An example of a search query in PubMed may be: ("emergency nursing"[Mesh] OR "emergency nurses" OR "ED nurses") AND ("sepsis"[Mesh] OR "sepsis" OR "septicemia") AND ("aged"[Mesh] OR "geriatric" OR "adults") AND ("education"[Mesh] OR "intervention" OR "training"). The choice to incorporate both MeSH terms and free-text terms is justified by evidence from the literature, which suggests that relying exclusively on MeSH terms could result in the omission of pertinent publications that employ alternative language.

3.4 Critical Appraisal Using CASP

Selected studies in this literature review will have their methodological quality and reliability rigorously evaluated using the Critical Appraisal Skills Programmed (CASP) instrument, therefore CASP offers a methodical framework for analysing research findings, guaranteeing a comprehensive assessment of each study's applicability and validity (Enongene, 2022). Selecting papers according to predetermined inclusion criteria is the first stage, hence articles that satisfy the requirements will next go through a thorough CASP examination, moreover studies that have been published within the last ten years and that concentrate on interventions or methods to improve emergency department nurses' ability to identify sepsis in adult patients are included in the inclusion criteria (Ebai, 2017).

CASP is made up of particular questions designed for various study methods, including qualitative research, cohort studies, and randomized controlled trials (RCTs), thus questions about study design, sample representativeness, data collection techniques, and statistical analysis will be examined about quantitative studies. Aspects such as research design, data collecting, and the rigor of qualitative analysis will be the emphasis of qualitative investigations, therefore the detection of potential biases in research, including selection bias, information bias, and confounding factors, is guided by CASP, furthermore it is essential to assess the internal validity of each study to make sure that the therapies or methods under evaluation are responsible for the observed outcomes rather than methodological flaws (Burke and Conway, 2023).

CASP encourages evaluation of the external validity or generalizability of study findings in addition to internal validity assessment, this is especially important when putting interventions into practice in various emergency department settings, therefore the process of adopting CASP for critical assessment will result in a summary of each study's advantages and disadvantages (Aitken et al., 2011). In order to facilitate a more nuanced view of the efficacy and application of treatments targeted at enhancing the skill of emergency department nurses in identifying sepsis in patients who are adult, this synthesis will serve as a guide for the interpretation of the available data.

3.5 Data Organization Methods

My dissertation research relied heavily on Thematic Analysis, which provided a methodological framework for extracting significant insights from the wide range of papers that were found, therefore with this method, studies were thoroughly categorised according to recurrent themes and patterns that emerged throughout the exhaustive evaluation procedure. Finding and comprehending the common themes throughout various studies was the main goal in order to provide a comprehensive and nuanced understanding of the larger field of research, hence every study was thoroughly evaluated to find similarities and differences. I sought to identify the core ideas and recurrent motifs that were present across the literature by organising studies according to common themes (Vanzant and Schmelzer, 2011). Through this technique, the study subject was able to be explored in greater detail, bringing to light not only the prevalent tendencies but also the subtle variations and distinctive viewpoints found throughout the wide range of literature, hence the process of classifying studies according to emergent themes made it easier to recognise significant trends and differences among various research projects. This nuanced understanding made a substantial contribution to the dissertation's literature review section's construction of a coherent narrative, thus it enhanced the study with a thorough picture of the state of the field by enabling a more methodical presentation of the combined insights drawn from the numerous investigations (MacPherson-Dias, 2014).

3.6 Analysis Methods and Synthesis into Themes

A comprehensive analysis had been carried out in the next literature review to extract pertinent data from the chosen research; thus, the selected analytical approach had entailed a critical appraisal utilizing the CASP (Critical Appraisal Skills Programme) instrument, guaranteeing an exhaustive assessment of the methodological excellence of every research project. This methodical technique had raised the literature review's credibility and general quality; therefore, the studies had been categorized as part of the analysis according to important factors such as study design, sample size, and intervention techniques (Casianos, 2023). For quantitative research, quantitative data such as effect sizes and statistical significance had been extracted and condensed; hence, finding recurrent themes, patterns, and concepts had been the main goal of qualitative research.

A synthesis of the information that had been gathered was done after the analysis. The goal of this study had been to combine the results of several investigations into logical themes; therefore, to create a cohesive narrative that encapsulated the main ideas found in the literature, the narrative synthesis technique had been utilized. In order to provide a thorough understanding of the interventions aimed at enhancing emergency department nurses' competence in diagnosing sepsis in adult patients, this procedure had entailed analyzing similarities, differences, and linkages between studies.

3.7 Summary of Literature Search Results (PRISMA)

4. Findings

4.1 Overview

Early detection and treatment of sepsis by ward-based nurses is a critical and well-researched topic in the healthcare industry, therefore patient outcomes are seriously threatened by sepsis, and ward nurses play a critical role in identifying it and acting quickly to treat it. The fact that sepsis is becoming more well recognised as a major cause of death and morbidity shows how relevant this topic is, hence by examining the efficacy of sepsis training programmes for nurses and addressing knowledge, skill, and attitude gaps regarding sepsis screening and management, the chosen papers add to the corpus of current knowledge (Usman, Usman and Ward, 2019). The evaluated publications include research from several nations, which contributes a valuable global perspective to our understanding of sepsis management strategies, thus the fact that studies from Norway and the UK are included shows how widespread the problem of sepsis in healthcare is, moreover the incorporation of research from many geographic regions augments the generalizability and relevance of the results, acknowledging that sepsis is a ubiquitous issue necessitating context-specific strategies.

The chosen articles use a range of study designs in their research approaches to examine how ward-based nurses manage sepsis, these consist of questionnaire-based evaluations, cross-sectional surveys, and before-and-after intervention studies, therefore a thorough investigation of the subject is made possible by the variety of study approaches, which capture both the quantitative and qualitative facets of nurses' attitudes, abilities, and knowledge of sepsis. The utilisation of various research methodologies enhances the comprehensive comprehension of the intricacies associated with executing sepsis education initiatives and their influence on nursing practices (Nguyen et al., 2014), thus the evaluated publications' diverse study approaches, international representation, and well-established topic all enhance the depth and breadth of understanding regarding the management of sepsis by ward-based nurses.

4.2 Thematic Findings

4.2.1 Impact of Sepsis Training Programs 

The examined articles demonstrated the potential for focused educational interventions to dramatically improve the knowledge, abilities, and attitudes of ward-based nurses regarding sepsis, one key theme that emerged was the impact of sepsis training programmes. Studies carried out in the UK and Norway have consistently shown that structured sepsis training has a favourable impact, therefore significant contributions to the discussion on early detection and treatment of severe sepsis and septic shock have been made by Keep et al. and Torsvik et al. The effectiveness of the NEWS in triaging patients to the ED is the main emphasis of Keep et al, which shows an impressive area under the curve (AUC) of 0.89 in identifying patients at risk for severe sepsis, hence Torsvik et al. highlights the importance of ward nurses in identifying sepsis early on and the study's statistically significant results include an odds ratio (OR) of 2.7 for 30-day survival in the post-intervention group.

In Norway, the implementation of an intervention in an emergency community hospital led to a significant improvement in the frequency of vital sign observation and the overall quality of ward nurses' care for patients with sepsis, as reported by Torsvik et al. The post-intervention group showed reduced risk of serious organ failure, a shorter duration of stay in intensive care and high dependency units, and increased odds of living for 30 days, therefore these results imply that a thorough sepsis-specific triage that incorporates a flow chart alert and treatment system improves patient outcomes (Keep et al., 2015). Improvements in sepsis therapy, early warning signals, and pathophysiology were made possible in large part by the training nurses received, a noteworthy consequence of the new strategy is that patients receiving care in the intensive care unit (ICU) and high dependency unit (HDU) had lower lengths of stay (LOS), moreover this suggests that by shortening the amount of time patients need intensive care, the simplified approach to sepsis management maximises resource utilisation while also improving patient outcomes.

Similarly, a research carried out by Keep et al. in an NHS teaching hospital in London demonstrated the beneficial effects of sepsis training on nurses' attitudes, knowledge, and abilities, thus the nurses who took part in the sepsis training demonstrated increased knowledge of the SIRS criteria and the NEWS for sepsis screening, significantly, these nurses showed a more upbeat attitude towards sepsis management and screening, demonstrating the impact of training on their outlook and method of treating sepsis. Keep et al support NEWS as a useful tool for identifying patients during ED triage who are at risk for severe sepsis and septic shock, therefore the authors suggest using a NEWS score of three or higher to initiate a systematic screening process for sepsis, with a 92.6% sensitivity and a 77% specificity. On the other hand, Torsvik et al. present a thorough analysis that emphasises a multimodal approach, encompassing training for doctors and nurses as well as a flow chart, SIRS, and organ failure triage (SOF-Triage) system, hence using NEWS as a physiological observation tool, Keep et al. emphasise the significance of vital signs and observations in the detection of sepsis. They propose that patients at risk can be successfully identified during ED triage if they have a NEWS score of three or higher, with a positive predictive value of 18.7% and a negative predictive value of 99.5%, similar to this, Torsvik et al. emphasise the value of vital sign observations by putting in place a bundle that motivates ward nurses to make better observations more frequently in order to enhance patient outcomes and sepsis identification.

According to Keep et al., using NEWS at ED triage may result in early diagnosis and treatment, which could enhance patient outcomes, on the other hand, according to Torsvik et al., the post-intervention group experienced favourable outcomes such as a 3.7-day average reduction in length of stay, a 2.7-day gain in 30-day survival, and a 0.7-day decrease in the likelihood of severe organ failure. In order to improve sepsis management, both research emphasise the necessity of proactive involvement in healthcare settings, therefore Keep et al emphasise the significance of consciousness in ED triage, especially with reference to physiological observations, hence to ensure that all staff members are knowledgeable and helping to improve sepsis outcomes, Torsvik et al. go one step further and design a training session for nurses and nursing students.

4.2.2 Challenges in Translating Knowledge to Practice 

Eirian and Lorelei effectively addresses the issue of problems in converting knowledge to practice, the study explores the knowledge, abilities, and attitudes of ward-based nurses on sepsis, illuminating the challenges associated with integrating theoretical understanding into clinical practice. The assessment of sepsis knowledge, abilities, and attitudes among registered nurses working in acute surgical and medical wards in the UK is the main focus of Eirian and Lorelei's (2021) research, therefore by attempting to ascertain how sepsis training affects these factors, the study reveals difficulties in converting information into useful abilities.

The study implies that it is still difficult to apply theoretical knowledge to practical practice, the study reveals a significant gap in the practical use of skills, even if sepsis training programmes have enhanced nurses' theoretical awareness and confidence, in particular, the study pinpoints fields where theoretical knowledge is not as advanced as actual competence, such as peripheral cannulation and venipuncture (Horng et al., 2017). According to the study, ward nurses frequently lack the hands-on abilities required for key aspects of sepsis therapy, like peripheral cannulation and venipuncture, hence a significant percentage of nurses stated they did not use these skills in their clinical practice, even among those who had received training in them. Because of this competence gap, implementing sepsis care procedures effectively and promptly may be significantly hampered, this is because relying on other healthcare providers to obtain blood cultures and perform required interventions may cause delays.

4.2.3 Nurses' knowledge and confidence levels

Chua et al.'s study examines the contributing elements as well as registered nurses' knowledge and confidence levels about sepsis, this cross-sectional survey was carried out across multiple sites in Singapore, comprising nurses working in emergency rooms and inpatient units. The average score of 10.56 out of 15 nurses who participated in the study indicated that they knew a decent amount about sepsis, likewise, with a mean score of 18.46 out of 25, their confidence in identifying and treating septic patients was reasonably good, therefore the fact that only 52.0% of the nurses could correctly describe sepsis, however, raised alarms as it suggested a basic knowledge gap. The study finds that employment grade, nursing education level, and clinical work area are important determinants of nurses' knowledge of sepsis, thus sepsis knowledge scores were higher among nurses employed in acute care settings, with advanced degrees, and in higher job grades, moreover this emphasises how nurses' understanding of sepsis may be influenced by their educational background and clinical experience.

4.2.4 Comparative Analysis of Sepsis Screening Tools in the Emergency Department

With a focus on SIRS, qSOFA, and NEWS, Usman, Usman and Ward, and Durr et al. advanced our knowledge of the efficacy of sepsis screening methods, aiming to enhance sepsis detection and treatment in the ED as swiftly as possible, thus the assessment of the relative efficacy of the sepsis screening instruments emerged as the central theme in both articles. In the study by Usman, Usman and Ward, where SIRS, qSOFA, and NEWS were examined, NEWS emerged as the most reliable method for identifying septic shock and severe sepsis (SS/SS), on the other hand Durr et al directly compared NEWS and qSOFA, revealing that NEWS outperforms qSOFA in terms of sensitivity for sepsis identification, ICU admission, and 28-day mortality when the cutoff is ≥5, hence there was a consensus between the two trials regarding NEWS's superiority in early sepsis identification.

Both publications delved into the sensitivity and specificity of the screening tools, Usman, Usman and Ward examined the trade-offs between sensitivity and specificity for NEWS≥4, SIRS≥2, and qSOFA≥2, on the other hand Durr et al presented numerical data demonstrating that NEWS>5 has better sensitivity for sepsis detection than qSOFA≥2, underscoring the significance of sensitivity in the early detection of sepsis cases. The evaluation of utility across different sepsis severities emerged as a recurring theme, with Durr et al demonstrating NEWS's superiority to qSOFA in predicting outcomes across all sickness severities, while Usman, Usman and Ward found that qSOFA improves with illness severity, therefore this thematic analysis underscored the importance of considering the range of sepsis severity when evaluating the effectiveness of screening technologies.

4.2.5 CASP Analysis of Keep et al.

Research Question

The impact of sepsis training programmes on nurses' knowledge, attitudes, and abilities as well as patient outcomes was the explicit emphasis of the study question.

Study Design

A retrospective observational study design was utilised, potentially constraining the capacity to establish causality but still yielding significant insights.

Recruitment Strategy

Although the recruitment technique is not stated clearly, the fact that the study was carried out in a London NHS teaching hospital suggests that it is relevant to the research subject.

Data Collection

Pre- and post-intervention evaluations of nurses' sepsis-related knowledge, attitudes, and skills were probably included in the data, which is consistent with the study question.

4.3 Synthesis of Strengths and Limitations 

4.3.1 Early Detection Strategies:

The study by Keep et al has a strong retrospective observational design and a sizable sample size of 500 consecutive adult patients who did not experience trauma, therefore the effectiveness of the NEWS in detecting individuals at risk for severe sepsis is indicated by its high area under the curve (AUC) of 0.89. An extensive retrospective analysis of 130,595 adult ED visits is provided by Usman, Usman and Ward., which also includes a detailed comparison of several grading schemes, thus the study's strength is its capacity to quantify several sepsis endpoints using measurements of sensitivity, specificity, and area under the receiver-operating characteristic (AUROC). Keep et al.'s study is retroactive, which could lead to selection bias, and its single-center design restricts generalizability, furthermore, the dynamic character of sepsis development during hospitalisation may not be adequately captured by relying solely on discharge diagnoses, however the retrospective nature of Usman, Usman and Ward.'s study may introduce bias, and the fact that visits with insufficient clinical evaluation (11.4%) were excluded from the analysis may limit the applicability of the results to the whole ED population.

4.3.2 Role of Observations and Vital Signs

Understanding the significance of observations and vital signs is deepened by Keep et al.'s attention on the connection between the diagnosis of severe sepsis and the first NEWS at ED triage, a precise quantitative evaluation is given by the study's statistical specifics, such as computations of sensitivity and specificity. The significance of ward-level vital sign measurements is emphasised by Torsvik et al and the study's strength lies in its before-and-after intervention design and in the utilisation of an established registry that dates back to 1994, therefore these features show how enhanced observation frequency can be used in real-world settings. The study recognises the difficulty of striking a balance between sensitivity and specificity, particularly in light of the low occurrence of severe sepsis in the ED, and Keep et al. claim that NEWS is a useful tool, although useful, the observational design of the study by Torsvik et al lacks the control provided by randomised controlled trials (RCTs), and the retrospective nature of the investigation may create biases.

4.3.3 Intervention Strategies and Outcomes

Potential improvements in patient outcomes may result from the Keep et al. study's proposal to use a NEWS score of three or higher as a trigger for systematic sepsis screening and from the emphasis on early detection and treatment, however according to Torsvik et al.'s before-and-after intervention design, the post-intervention group saw improved 30-day survival and a lower risk of catastrophic organ failure. The study by Keep et al. focuses mainly on the correlation between NEWS and the diagnosis of severe sepsis and does not directly intervene, because Torsvik et al relied on historical controls and did not use randomization, there is a chance that confounding variables will be introduced and affect the results that were observed.

4.3.4 Training and Education

The research conducted by Keep et al supports the need for education in sepsis recognition and advocates for increased awareness at ED triage, particularly with relation to physiological findings, however the study by Chua et al. identifies the variables that affect nurses' knowledge and confidence in diagnosing and treating sepsis, offering insightful information on their understanding. The sample is more diversified because to the multi-site cross-sectional design, on the other hand the study by Keep et al. emphasises awareness, although it does not directly analyse how training and education affect the early detection of sepsis, because Chua et al.'s self-reported data were used in the study, response bias could be introduced, and the cross-sectional design makes it difficult to determine causality.

4.3.5 Consideration of Prevalence and Specificity:

Keep et al provides a nuanced viewpoint on the interpretation of NEWS by admitting the low occurrence of severe sepsis in the ED and analysing the trade-off between sensitivity and specificity, however Durr et al. provide light on the role that EMS transport plays in sepsis detection and advance our knowledge of the trade-offs that exist between sensitivity and specificity, particularly when comparing NEWS and qSOFA. The study by Keep et al does not explore the possible influence on patient outcomes, instead concentrating on sensitivity and specificity, however the findings' generalisability may be limited by Durr et al.'s retrospective nature and single-center strategy.

4.3.6 Need for Further Research

Keep et al expressed their dedication to continuing research by recommending a prospective study to verify the relationship between NEWS, triage categories, and the final diagnosis of severe sepsis, similarly according to Torsvik et al, promoting continuous sepsis registries and assessing flow chart developments helps to enhance sepsis management over time. Because Keep et al.'s study is retrospective in nature, more research is required to validate its findings prospectively, the acknowledgement of steady mortality rates implies the need for additional research, and the design of the Torsvik et al. study does not offer convincing proof.

4.4 Interplay between Studies and Implications for Practice

4.4.1 Support and Build:

The investigations by Keep et al and Durr et al stress how crucial early detection is in the ED, while Durr et al. compares NEWS and qSOFA for sepsis detection, Keep et al. suggests using a NEWS of 3 or above as a threshold for systematic sepsis screening. The focus on NEWS is echoed by Durr et al., who point out that it has a higher sensitivity for identifying sepsis patients in the ED, therefore this alignment serves to support the idea that NEWS is an effective early detection tool, despite concentrating on distinct environments (wards versus EDs), Torsvik et al and Keep et al both stress the significance of vital signs and observations in the treatment of sepsis. In addition to Keep et al.'s focus on NEWS during ED triage, Torsvik et al. show improved 30-day survival with increased observation frequency at the ward level, collectively.

4.4.2 Refute and Challenge:

There is a disparity in the results between the investigations by Durr et al and Usman, Usman and Ward with reference to the scoring system comparability, while Durr et al contend that qSOFA has a higher specificity than NEWS, Usman, Usman and Ward contend that NEWS is the most accurate scoring system, moreover this disparity calls into doubt the generalizability of scoring systems in various healthcare settings, necessitating additional study to resolve these conflicts and identify the best instrument for particular situations. Keep et al.'s emphasis on NEWS is made more complex by Chua et al.'s study on nurses' skills and confidence in managing sepsis, according to Chua et al., there is a knowledge gap among nurses, suggesting that ineffective sepsis therapy may occur even with the suggested trigger (NEWS ≥ 3), therefore this disproves the notion that a NEWS-based trigger by itself is adequate and emphasises the significance of simultaneous instructional activities.

4.4.3 Methodological Quality:

Generalisability might be restricted by Keep et al.'s retrospective, single-center design, it is difficult to demonstrate causation when there is no direct intervention because bias may be introduced by relying solely on discharge diagnosis, and however, the study's robustness is increased by the sizable sample size and thorough statistical analysis (Askim et al., 2017). Although Usman, Usman and Ward.'s retrospective research with a large sample size increases statistical power, external validity may be impacted by the exclusion of visits with insufficient clinical evaluation, since the study is focused on ED visits, its relevance to other healthcare settings may be limited, and causality cannot be established due to the study's methodology. Potential biases are introduced by Durr et al.'s retrospective, single-center design, however, the findings are given particular context by the application of the Sepsis-3 consensus criteria and the emphasis on EMS transfer, thus the study adds to the current conversation on sepsis detection technologies while also acknowledging its limits. 

The study's external validity is improved by Chua et al.'s multi-site cross-sectional design, however, causal inference is limited by the cross-sectional design and dependence on self-reported data, therefore the analysis gains depth with the addition of workplace and nursing components. The study's internal validity is enhanced by Torsvik et al.'s before-and-after intervention design, potential biases are introduced, nonetheless, by the retrospective nature and absence of randomization, thus utilising a reputable register that has been in place since 1994 gives the results historical context (Haydar et al., 2017). The strength of a study by Eirian and Lorelei is how well it examines how sepsis training affects nurses' attitudes, knowledge, and abilities, potential biases are introduced.

4.4.4 Applicability/Transferability

The emphasis on ED triage in the Keep et al study is relevant to emergency situations everywhere, however, generalisability to other healthcare settings might be limited due to the unique environment of the metropolitan university hospital, and on the other hand the application of the Usman, Usman and Ward, the study might be limited to ED settings in sizable academic centres, hence the study's external validity is impacted by the removal of visits without a clinical evaluation. The study by Durr et al. may not be as generalisable because it only looks at patients who were sent by emergency medical services to a particular hospital in Switzerland, the results might apply more readily to environments with comparable EMS procedures (Bhattacharjee, Edelson and Churpek, 2017). The study's transferability to comparable healthcare clusters in Singapore is improved by Chua et al.'s multi-site design, however, generalisability to various nations may be impacted by organisational and cultural differences, and similarly the study conducted by Torsvik et al. has limited generalisability due to its emphasis on a particular hospital in Norway, however, comparable contexts may take into account the ward nurses' emphasis on early recognition.

4.5 Summary of Findings

The thorough analysis of the research on the early detection and treatment of sepsis highlights important takeaways that are essential for improving patient outcomes, with studies like Keep et al and Durr et al proving its sensitivity in identifying patients at risk for severe sepsis and septic shock, NEWS emerges as a potential tool, especially in the emergency environment. Nonetheless, disparities in results, like those between Durr et al and Usman, Usman and Ward, highlight the necessity of taking context-specific factors into account when putting scoring systems into place, on the other hand as highlighted by Torsvik et al., the importance of expanding attention from the emergency room to the ward levels offers a comprehensive viewpoint on sepsis care. Furthermore, the significance of continuing education and training is shown by the crucial role that healthcare personnel play, as demonstrated by Chua et al. and Eirian and Lorelei, therefore together, these data highlight the difficulty of managing sepsis and call for a multifaceted, nuanced approach that integrates efficient scoring methods, ongoing education, and context-specific factors in a range of healthcare settings.

5. Critical Discussion

The results of the literature evaluation offer insightful information that can help guide an endeavour to improve services aimed at improving the early detection and treatment of sepsis, acknowledging the merits and demerits of the examined research, it is apparent that a comprehensive strategy is needed to tackle the intricacies of sepsis in various hospital environments (McCoy and Das, 2017). The critical discussion will examine important aspects of a service improvement proposal, utilising the literature's evidence and examining larger contextual variables, thus the usefulness of early warning scores, in particular the NEWS, in identifying patients at risk for severe sepsis and septic shock, as shown by Keep et al and Durr et al, is one important point that the literature emphasises. This demonstrates how important it is to include NEWS into standard clinical procedures (Saeed et al., 2019), particularly in the ED, it is imperative to recognise the disparities in sensitivity and specificity documented in various research, signifying the need of customising the implementation to the distinct attributes and requirements of every healthcare environment.

Usman, Usman and Ward and Durr et al.'s comparison of various scoring systems, including SIRS, qSOFA, and NEWS, highlights how difficult it is to select the best instrument, thus the proposed service enhancement ought to encompass a meticulous assessment of current procedures and the implementation of a grading scheme that corresponds with the distinct requirements of the medical facility (Goulden et al., 2018). Furthermore, taking into account the results of Torsvik et al., it is essential to shift the focus from the ED to ward-level monitoring, and improving patient outcomes can be greatly aided by training ward nurses and putting early sepsis recognition protocols into practice, therefore the role of healthcare practitioners is crucial when it comes to improving services, as demonstrated by Chua et al. and Eirian and Lorelei.

5.1 Improvement in Future Practice

The thorough examination of the literature on the diagnosis and treatment of sepsis has greatly improved my comprehension of the vital role nurses play in early detection and intervention, upon contemplation of how this novel understanding will augment my forthcoming nursing practice, a number of important revelations surface, providing a basis for enhanced patient care and augmenting the wider framework of nursing practice (Wallgren et al., 2021; Okafor et al., 2015). Keep et al and Durr et al.'s findings supporting the usefulness of early warning scores especially the NEWS in identifying patients at risk for septic shock and severe sepsis will radically alter the way I approach patient assessment, therefore it will become imperative to integrate NEWS into regular practice, particularly in the ED (Ulla et al., 2013; Liu et al., 2019; Singer et al., 2017). In order to facilitate timely interventions and enable early identification of patients who are worsening.

The intricacy of choosing the best instrument for sepsis detection is shown by Usman, Usman and Ward and Durr et al.'s evaluation of several scoring systems, including SIRS, qSOFA, and NEWS, in my future work, I will push for a careful analysis of current procedures and the implementation of a scoring system that takes into account the particular needs and features of the medical facility (Downing et al., 2019). Working together with interdisciplinary teams may be necessary to provide a comprehensive and situation-specific approach to sepsis screening, as highlighted by Torsvik et al., broadening the scope to include ward-level observations will help me in my support of an all-encompassing sepsis recognition programme.

5.2 Supporting Rationale for the Service Improvement Plan (SIP)

Adopting NEWS in the ED in accordance with Keep et al and Durr et al.'s recommendations is in line with the data showing how well it may identify patients who are at risk for septic shock and severe sepsis, thus using NEWS at ED triage with a trigger threshold of three or higher can be a useful screening tool to initiate additional sepsis assessment, which will ultimately result in early diagnosis and treatment. The results of Torsvik et al.'s study highlight the beneficial effects on patient outcomes that occur when ward nurses identify sepsis early, in order to ensure a smooth transition of care from the emergency department to inpatient wards, the SIP incorporates initiatives to encourage interdisciplinary teamwork. Transparent communication, cooperative training sessions, and the inclusion of sepsis screening in standard nursing assessments are all part of this teamwork, thus the necessity of providing nursing personnel with specialised continuing education programmes to enhance their knowledge, abilities, and attitudes about sepsis is highlighted by Chua et al and Eirian and Lorelei.

6. A Service Improvement Proposal Plan

Appendix 2: Capstone Project Service improvement template to be submitted with the service improvement 

Year 3 Capstone Project Service Improvement Proposal Form

Title: Enhancing Sepsis Recognition and Management in Emergency and Inpatient Settings

7. Leading Change Lewin's 3 Stages of Change

In leading change to improve nurses' ability to identify sepsis in the ED, adopting effective leadership strategies is crucial for successful implementation, hence drawing upon Lewin's 3 stages of change can provide a structured framework for navigating the complexities of change management.

7.1 Leadership Strategies

• Unfreezing: Involve stakeholders by working together and communicating effectively, express the need for change in a clear and concise manner, highlighting the advantages for patient outcomes and the significance of early sepsis detection, therefore establishing habits that are hard to break or doubting the efficacy of novel screening instruments can be the source of resistance to change (Harrison et al., 2021). To address these issues and foster a feeling of urgency among all parties, open communication, empathy, and active listening are necessary, hence according to Lewin, unfreezing entails lowering resistance and raising readiness in order to foster a change-friendly atmosphere, moreover make use of tactics like workshops, public discussion platforms, and opinion leader participation to speed up the unfreezing process.

• Changing: While the implementation phase is underway, give explicit guidance and assistance, thus team members can be empowered if they are included in decision-making, given access to resources, and given instruction on how to use new screening techniques. Overseeing multidisciplinary groups with disparate backgrounds and viewpoints may result in disagreements or coordination issues (Ratana, Raksmey and Danut, 2020), therefore encouraging a collaborative, respectful, and accountable culture is essential to effective leadership in order to overcome these obstacles and guarantee seamless execution. According to Lewin, in order to bring about the changes that are wanted, active action is required, hence make use of strategies like continuous monitoring, feedback mechanisms, and pilot testing to speed up the adoption of new procedures and quickly resolve any issues that arise.

• Refreezing: To guarantee long-term effects and sustainability, institutionalise the reforms, acknowledge and celebrate accomplishments, give reinforcement for desired conduct, and incorporate the new screening methods into routine operations, therefore it can be difficult to keep the momentum going and avoid going back to the old habits during the refreezing stage (Burnes, 2020). To avoid reverting, leadership must continue to be watchful, offer continuous assistance, and integrate the changes into the culture of the company, thus stabilising the modifications and incorporating them into the organisational structure are part of Lewin's refreezing stage, moreover to guarantee long-lasting change, use techniques like performance reviews, incentive schemes, and organisational reorganisation to reinforce the new procedures.

7.2 Challenges in a Team Environment:

• Resistance to Change: Members of the team might object to changes to established practices, to tackle this, open communication is necessary, along with emphasising the advantages of the suggested modifications and incorporating employees in the decision-making process.

• Interprofessional Differences: Different backgrounds of professionals can lead to differing ideas on managing sepsis, a common understanding and cooperative approach will be facilitated by regular interdisciplinary training and discussion forums (Schuetz et al., 2017).

7.3 Change Management Theory

Applying the Kotter's 8-Step Change Model provides a structured approach:

• Create Urgency: Communicate the urgency of improving sepsis outcomes, supported by statistics from the literature review.

• Form a Powerful Coalition: Establish a leadership team with representatives from nursing, medicine, and education to drive the change collaboratively.

• Create a Vision for Change: Clearly articulate the vision of enhanced sepsis recognition and improved patient outcomes.

• Communicate the Vision: Utilize various channels for consistent communication to ensure all team members are well-informed.

• Remove Obstacles: Identify and address barriers proactively. This may involve providing additional resources, addressing concerns, and ensuring training opportunities.

• Create Short-term Wins: Celebrate small victories, such as successful pilot implementations, to build momentum and confidence.

• Build on the Change: Incorporate sepsis protocols into routine practice and continuously improve through feedback mechanisms.

• Anchor the Changes in Corporate Culture: Ensure that the changes become an integral part of the organizational culture through ongoing education and reinforcement.

8. Conclusion

This capstone project has been a journey of discovery and education, offering insightful information about the intricate field of sepsis identification in ED settings, therefore wwhen evaluating the endeavor's advantages and disadvantages, it becomes clear that the thorough literature analysis acted as a foundation for the next service enhancement plan. This thoughtful conclusion, which follows the project's path from conception to the suggested plan and, eventually, its possible influence on patient care, captures the heart of the capstone project, hence taking on this capstone project has changed me in both ways—professionally and personally. My grasp of important problems in emergency care has grown as a result of the in-depth study of sepsis screening techniques, which has also improved my ability to evaluate studies critically, thus by navigating the complex network of literature, I have improved my analytical skills and am now able to recognise subtle differences in study designs, methodology, and practical implications, moreover this experience has made me more aware of the value of evidence-based practice in nursing and has given me a renewed dedication to keeping up with the rapidly changing healthcare environment.

This capstone project's main goal was to investigate strategies for improving nurses' capacity to recognise sepsis in ED patients, thus the effectiveness of screening methods, with an emphasis on SIRS, fast qSOFA, and NEWS, was investigated by a thorough assessment of the literature. The literature review, which included studies from various geographic regions, filled in gaps in the knowledge base and provided a solid framework for a service enhancement proposal. It also synthesised the body of current knowledge, therefore NEWS emerged as a frontrunner in sepsis diagnosis, according to a rigorous study of six major papers. Outperforming both SIRS and qSOFA, the investigations by Omar et al and Dimitri et al offered strong evidence supporting NEWS as a dependable and timely screening technique, hence analyses of sensitivity and specificity demonstrated the advantage of NEWS, particularly at a cutoff of ≥5, establishing it as a useful tool for early detection of sepsis at different intensities, moreover these results highlight the critical importance of NEWS and provide a clear roadmap for improving sepsis screening practices in EDs.

Keep et al. examined the usefulness of the NEWS in diagnosing severe sepsis and emphasised its use in triaging patients to the ED, conversely, Eirian and Lorelei investigated how sepsis training affected ward-based nurses' attitudes, knowledge, and abilities, however both studies agreed on the significance of NEWS despite the different circumstances; Keep et al. recommended its usage in ED situations, while Eirian and Lorelei emphasised its role after training. Eirian and Lorelei emphasised the significance of improved knowledge and skills while focusing on the effects of sepsis training on ward-based nurses, on the other hand, Torsvik et al. investigated ward nurses' early sepsis detection in an emergency and community hospital, although the two studies had different backgrounds, they agreed that it is important to increase nurses' capacity to identify sepsis; Eirian and Lorelei concentrated on training, while Torsvik et al. focused on better ward surveillance.

Torsvik et al.'s study was carried out in a Norwegian emergency hospital, emphasising the benefits of early ward-level sepsis recognition, Chua et al., on the other hand, conducted a multi-site cross-sectional study in Singapore to evaluate nurses' confidence and knowledge regarding sepsis care. Both studies recognised that healthcare personnel need more education and training in sepsis management, despite working in different contexts, therefore the suggested service enhancement plan is greatly influenced by the results of the literature review, moreover the evidence synthesis has not only identified the benefits and drawbacks of the current screening instruments, but it has also brought attention to the urgent need for a more sophisticated strategy. The plan, which is based on the NHS strategic model of project management, combines the depth of qSOFA for severity assessment with the accuracy of NEWS for early identification in a strategic manner, hence this synergistic strategy has the potential to transform the way sepsis is identified in EDs, enabling a more thorough and prompt response to this life-threatening illness.

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Appendices

Appendix 1. Conceptual Table - PICO Elements and Search Approach

Table 1. Conceptual Table - PICO Elements and Search Approach

Appendix 2. CASP Quality Appraisal

Table 2. CASP Quality Appraisal

Appendix 3. Potential Findings from Selected Studies

Table 3. Potential Findings from Selected Studies