Challenges of implementing the hour-1 sepsis bundle: a qualitative study from a secondary hospital in Indonesia

Priyo Sasmito; Satriya Pranata; Rian Adi Pamungkas; Etika Emaliyawati; Nisa Arifani

doi:10.4266/acc.2023.01473

Articles

Page Path: HOME > Acute Crit Care > Volume 39(4); 2024 > Article

Original Article Infection Challenges of implementing the hour-1 sepsis bundle: a qualitative study from a secondary hospital in Indonesia: Priyo Sasmito^1,2,#, Satriya Pranata³, Rian Adi Pamungkas⁴, Etika Emaliyawati⁵, Nisa Arifani⁶; Acute and Critical Care 2024;39(4):545-553.
DOI: https://doi.org/10.4266/acc.2023.01473
Published online: November 27, 2024

¹Department of Anesthesiology Nursing, Faculty of Vocation, Universitas Medika Suherman, Cikarang, Indonesia

²Department of Nursing, Faculty of Health Sciences, Universitas Ichsan Satya, Tangerang Selatan, Indonesia

³Department of Nursing, Faculty of Nursing and Health Sciences, Muhammadiyah University of Semarang, Semarang, Indonesia

⁴Department of Nursing, Faculty of Nursing, Esa Unggul University, Jakarta Barat, Indonesia

⁵Department Emergency and Critical Care Nursing, Faculty of Nursing, Padjadjaran University, Bandung, Indonesia

⁶Department of Emergency Medicine, Medical Faculty, Brawijaya University, Malang, Indonesia

Corresponding author: Priyo Sasmito Medical Faculty, Padjadjaran University, Prof Eyckman St 38, Bandung City, West Java 40161, Indonesia Tel: +62-821-5768-5388, E-mail: priothegreat2@gmail.com

#Current affiliation: Medical Faculty, Padjadjaran University, Bandung, Indonesia

• Received: November 6, 2023 • Revised: October 2, 2024 • Accepted: October 14, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

192 Views
22 Download

prev next

Full Article

Download PDF

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
KEY MESSAGES
NOTES
REFERENCES

Abstract

Background
Good sepsis management is key to successful sepsis therapy and optimal patient outcomes. Objectives: This study aimed to determine obstacles among nurses and doctors to implementing the hour-1 sepsis bundle in a secondary hospital in Indonesia.
Methods
This was a qualitative study with a phenomenological approach. Data were obtained from one-on-one in-depth interviews with 13 doctors and nurses in the intensive care unit and emergency department who were purposively sampled. Data were analyzed using content analysis.
Results
Five main themes were revealed in the analysis: incomplete implementation of the hour-1 sepsis bundle, lack of knowledge about the hour-1 sepsis bundle, cost issues, lack of supporting facilities, and lack of coordination among health workers.
Conclusions
Optimizing regional health laboratories, optimizing the use of quick Sequential Organ Failure Assessment (qSOFA) and SOFA, and creating a series of sepsis protocols within the hospital are some solutions that secondary hospitals can implement to ensure appropriate management of sepsis cases. Involvement of health policyholders and hospital management is needed to address these challenges.
Keywords: emergency department; hospitals; intensive care unit; sepsis

INTRODUCTION

Sepsis is one of the leading causes of hospitalizations and deaths worldwide [1,2]. This condition is responsible for more than one-third of hospital visits, and about 50% of sepsis patients who are hospitalized require treatment in the intensive care unit (ICU) [1]. Sepsis is also associated with a mortality rate of more than 40%, and about one-third of patients die within 48 hours after being admitted to the ICU [3,4]. Sepsis is also associated with a heavy health cost burden for both patients and their families as well as for hospitals and the state in the current era of social health insurance [1,3]. Early diagnosis and appropriate early management of sepsis are key to successful treatment [1,5-8].

Low-resource health facilities such as those in low- and middle-income countries are less likely to be able to perform sepsis management as fully mandated in the sepsis hour-1 bundle, a simplification of the 3- and 6-hour bundles [7]. This bundle was introduced to facilitate early management of sepsis. Not all health facilities, especially primary and secondary hospitals, have complete screening and care facilities [9,10]. The high costs of treatment and examination are another obstacle to sepsis management in this setting [11]. Inappropriate sepsis management in primary and secondary healthcare settings can result in suboptimal sepsis management in tertiary referral hospitals. Previous studies in tertiary referral hospitals have shown that the administration of broad-spectrum antibiotics before obtaining blood cultures at the referring hospital (primary and secondary hospital) is inappropriate and can skew blood culture findings [6,8,10].

Sepsis management should span the continuum from primary health facilities to secondary and tertiary hospitals. However, few studies have explored gaps in sepsis management at the intra- and inter-health facilities levels. Our aim in this study was to explore the barriers faced by health workers in secondary hospitals in limited resource settings in implementing the hour-1 sepsis bundle. Our findings can be used as a basis for further research into the sepsis management chain, especially in health systems with tiered referral systems in limited-resource areas.

MATERIALS AND METHODS

This study was a qualitative research design with a phenomenological approach. The study was conducted in the ICU and emergency department (ED) of a secondary private hospital in Bekasi Regency, West Java, Indonesia. This study was reviewed and approved by an independent Ethics Committee of Universitas Medika Suherman (No. 164/V/B/UMS/XI/2021). All participants provided informed consent, and interviews and data collection were anonymous. Transcriptions and recordings were secured and coded in a protected file. Refusal to participate in the study did not have any consequences and entailed no penalties.

This study involved 13 key informants selected by purposive sampling. This study focused on a specific population, namely health professionals in acute and critical care responsible for implementing sepsis patient management. Inclusion criteria were doctors and nurses who were responsible for patient management in the ICU and ED and had been working for at least 5 years at the hospital for doctors or at least as an advanced beginner-level nurse. Participants who were outside the area at the time of data collection were excluded (Table 1). Strict criteria were used to ensure the accuracy of the information obtained for the study. Two ICU doctors, two senior ED doctors, and nine ED and ICU nurses who met the criteria were enrolled in this study (Figure 1). These participants were asked the following questions: Based on your experience, are sepsis patients managed based on the hour-1 sepsis bundle and what are obstacles to its implementation?

Data Collection

The data in this study were primary data obtained from key informants. Participants were questioned about implementation of the hour-1 sepsis bundle in the ICU and/or ED and barriers faced by doctors and nurses in the implementation of this bundle. Data were obtained using one-on-one, in-depth interviews conducted using semi-structured open-ended questions until data saturation was achieved. Participants were informed about the study and how the information would be coded to protect participant confidentiality via phone and the WhatsApp (WA) application. Participants who agreed to be involved in the study completed informed consent and demographic forms and sent these back via WA. Each participant was then scheduled for a 30–60-minute interview with voice recording. After the interview, recordings were played back to the participants to confirm they were satisfied with the information they had provided. In this research, the “precede proceed” framework was used by emphasizing themes and sub-themes, as shown in Table 2.

In more detail, data were obtained through voice recordings and transcriptions. Data analysis followed the stages of Miles and Huberman [12] as follows. Data collection was the initial step in the qualitative data analysis process, and data were collected using in-depth interviews. Next, data reduction was conducted by selecting and simplifying the data obtained into notes or transcriptions. Data were processed and sorted to address the research question. In the third stage, the data were formatted for presentation in the forms of charts, matrices, and brief descriptions. Conclusions were drawn and data were verified in the fourth stage.

RESULTS

Four doctors and nine nurses in the ED or ICU participated in this study. The majority of respondents was female (61.5%), had been working for 5–10 years (61.5%), and was aged 31–45 years (61.5%). Mean participant age was 39 years (standard deviation [SD], 9), and mean length of work was 9 years (SD, 6) (Table 3). Five themes emerged from content analysis: (1) incomplete implementation of the hour-1 sepsis bundle, (2) lack of knowledge about the hour-1 sepsis bundle, (3) cost issues, (4) lack of supporting facilities, and (5) lack of coordination among health workers (Table 2).

Theme 1: Incomplete Implementation of the Hour-1 Sepsis Bundle

Even though some of the actions in the bundle were implemented, such as adequate fluid resuscitation, administration of antibiotics, and administration of vasopressors, not all recommendations were followed.

The most important step in the management of sepsis is the administration of antibiotics. We use antibiotics according to the germ map. Other therapies are applied as in other critical patients, such as resuscitation fluids, vasopressors if needed, and ventilators if patients have respiratory failure, while other therapies are supportive, depending on the source of infection. (P2)

Lactate level measurements and collection of blood culture samples before administering antibiotics were not mentioned as routine components of the sepsis management bundle by either doctors or nurses.

With regard to blood cultures, we do not have a blood culture facility. For lactate levels, I don't know whether or not our lab can do this, because as far as I can remember I was never asked by the doctor to order this examination. (P6)
You see… we don't do culture checks. There is rarely an order to check lactate in the ED. (P3)

Theme 2: Lack of Knowledge about the Hour-1 Sepsis Bundle

Six nurses stated that they had never heard about the hour-1 bundle sepsis, two doctors said that it was still being studied, and the other two doctors did not mention anything about it.

Hmmm... I've never heard of it. (P6)
I've heard about it (hour-1 sepsis bundle), but we still need to learn about it. (P2)

These statements reflect a general awareness of the hour-1 sepsis bundle among some participants, yet highlight a gap in comprehensive knowledge and readiness for implementation.

Theme 3: Cost Issues

Most participants reported cost as one of the largest barriers faced by most health facilities in treating sepsis. The large costs associated with treatment have different impacts on patients who have insurance and those who do not.

Patients who have insurance

Most participants stated that sepsis patients who have national insurance are referred to a higher-level hospital, and that the burden of patient financing becomes the burden of the state and the higher-level hospitals.

BPJS (insured) patients must be smart when setting a budget. If the cost of treatment exceeds the claim…we are forced to refer the patient to a higher hospital. (P1)
The burden of health costs is borne by national health insurance and sometimes even has to be borne by the hospital if the claim value is less than the costs already incurred by the hospital. (P5)

Patients who do not have insurance

Non-insured patients are generally unable to receive optimal care and treatment and may decide to discontinue their treatment.

Generally, the obstacle faced by general patients (non-insured patients) and their families is that the cost is too high, so not all available examinations and medicines are offered. (P5)
If the patient does not have enough money, they usually just ask to go home. (P4)

Theme 4: Lack of Supporting Facilities

Most participants said that there were no blood culture facilities in their hospitals. Participants also said that there was never a request for lactate testing for sepsis patients and did not know whether this laboratory test was available in their hospital.

We don't have blood culture tests. (P3)
For lactate examination, I don't know whether or not our lab can run this test, because as far as I remember, I was never asked by the doctor to order this examination. (P6)

Theme 5: Lack of Coordination among Health Care Workers

Absence of a sepsis protocol in the hospital

Our data analysis revealed a difference in the expectations of health care workers in the ED and the ICU. A clear implication was that the hospital does not have a mutually agreed-upon protocol for sepsis patients.

In my opinion, the sepsis bundle should be performed in the ED, and in the ICU, we should just have to continue therapy. (P1)
Tests ordered for sepsis patient should be agreed upon and explicitly defined. If the specialist (doctor) feels that the test doesn't matter but we have ordered it, we are the ones who are reprimanded. Agreement on the tests to be conducted would be much better for us and the patient. Everything that a patient needs should be able to be performed without the need for a consultation first. (P3)

Lack of nurse involvement in sepsis management

Most participants also said that the management of sepsis in the ICU and ED was based on the advice of doctors.

Management of sepsis in the ICU follows the advice of the attending doctor and an anesthesiologist as a companion doctor. (P6)
It (sepsis treatment) depends on the orders of the ED doctor and consultant doctor. (P8)

DISCUSSION

Incomplete Implementation of the Hour-1 Sepsis Bundle

Sepsis management using the hour-1 sepsis bundle in a secondary hospital in Indonesia was incompletely implemented. In particular, lactate levels were not assessed and blood samples were not collected for culture. This is because the health care workers do not understand the importance of these tests, and the hospital facilities are limited [9].

Lack of Supporting Facilities

Serum lactate test for septic patients

Serum lactate is a marker of tissue hypoxia due to increased aerobic glycolysis triggered by increased beta-adrenergic simulation or other causes associated with poor outcomes. Measurement of initial lactate levels can be used to assess the efficacy of resuscitation. If the initial lactate level is greater than 2 mmol/L, a repeat lactate measurement should be performed in 2–4 hours [13]. A previous study found that a type A referral teaching hospital took 1–6 hours to collect the first lactate sample in the ED in cases of shock [14]. A lactate level greater than 2 mmol/L is one predictor of septic shock besides the patient's ability to maintain their mean arterial pressure [15]. The longer it takes to diagnose septic shock, the longer is the time to vasopressor administration. This is concerning as the initiation of a vasopressor 6 hours or more after recognition of shock is associated with a significant increase in 30-day mortality [16].

Blood cultures

Blood culture samples should be collected before administration of antibiotics to optimize the identification of the causative pathogen and improve outcomes [17]. This is because biased culture results can occur within minutes of administering the first dose of an appropriate antibiotic. Nevertheless, the administration of broad-spectrum antibiotics should not be delayed for blood cultures [18,19]. Most of the sepsis patients who are admitted to referral hospitals in Indonesia have received prior treatment at a health facility in addition to antibiotic therapy [19]. This is also true for government referral hospitals (type A hospitals), which also do not require blood culture examinations because their clinical meaning does not balance the high cost of the procedure [14,18,20]. Most hospitals in low-resource areas do not have the ability to perform blood culture testing and must send blood samples to other facilities for such examination [9]. This adds to the financial burden for both the patient and the hospital.

Optimizing regional health laboratories

Government presence is needed to overcome the lack of hospital laboratories. Optimizing the use of regional health laboratories in each district/city as a joint laboratory system is one potential solution. The joint laboratory could perform supporting tests related to sepsis such as lactate serum measurements and blood cultures. This strategy was adopted by the government during the coronavirus disease 2019 (COVID-19) pandemic to provide basic diagnostic examinations for primary health facilities.

Cost Issues

The high cost of caring for sepsis patients, especially those receiving intensive therapy, is an obstacle both for patients and their families, as well as for hospitals and countries. In developed countries, the median hospital cost of sepsis per patient is $32,421, and the median ICU cost of sepsis per patient is $27,461 [21,22]. These costs are approximately five-fold higher than Indonesian insurance claims for one episode of severe sepsis.

Patients who have insurance

For patients with insurance, health costs are not an issue, but the amount the government reimburses for a single episode of care for a sepsis patient is often insufficient to cover the cost of care already incurred by hospitals. Therefore, primary and secondary hospitals tend to refer patients who have exceeded the government-provided claim fee limit to higher-level hospitals, such as tertiary referral hospitals. As a result, health costs borne by the state are increasing. To cope with these cost overruns due to sepsis, stabilized patients can be referred to step-down centers [23].

Patients who do not have insurance

Patients who do not have insurance are responsible for their own health care costs. This makes it easier for health workers to perform the necessary measures based on available resources. However, for patients with limited funds, healthcare costs are often the reason for incomplete therapy.

Optimizing the use of qSOFA and SOFA

A sepsis management protocol called the hour-1 sepsis bundle is a simplification of the 3- and 6-hour bundles [7]. This bundle was introduced to facilitate early management of sepsis, which is key to successful treatment [7,18]. Effective implementation of the sepsis bundle is expected to reduce treatment costs [2,7]. Hospitals can optimize the use of quick Sequential Organ Failure Assessment (qSOFA) and SOFA to reduce costs [8]. In a multicenter study in China in 2017, the SOFA score had a higher specificity in detecting sepsis based on the 2016 definition of Surviving Sepsis Campaign than the old definition of sepsis using two systemic inflammatory response syndrome signs with a source of infection [4,5,11]. SOFA also can be used to assess the severity of sepsis and the effectiveness of clinical management of sepsis and can be used to allocate existing resources in the ICU [8].

qSOFA and SOFA can be used as screening tools for early recognition of sepsis in triage and the ED. qSOFA alone is considered to have low sensitivity for sepsis screening but is a simple tool for triage. Furthermore, specific screening in the ED can continue with SOFA [2,5,8]. SOFA can be used for a good initial screening in the ED or ward before deciding to treat patients in the ICU. SOFA can also be used to manage patients who have been treated in the ICU. An improvement in SOFA score along with the patient's clinical condition can be used to make a clinical judgment to transfer the patient to a lower care unit or even to a lower tier of health care [23].

Lack of Knowledge about the Hour-1 Sepsis Bundle

Another obstacle in the management of sepsis using the hour-1 sepsis bundle was a lack of staff knowledge about this protocol [24]. Good knowledge of sepsis can improve confidence in early recognition and management of patients [25]. Sepsis education and training are important to increase knowledge. Application of sepsis screening tools and care bundles is necessary to increase practitioners' confidence in recognizing and managing patients with sepsis [25,26]. Hospital stakeholder involvement is needed to improve the knowledge of doctors and nurses either through formal means such as training or non-formal means such as case discussions or morning reports [25].

Lack of Coordination among Health Workers

The absence of sepsis protocols in the hospital

Our data imply the lack of sepsis protocols in hospitals. Although national sepsis guidelines exist, doctors tend to manage sepsis according to experience, knowledge, and availability of medical equipment [25]. The existence of sepsis protocols can improve patient outcomes [27]. This, however, requires support from hospital policymakers to create protocols that are mutually agreed upon among the various disciplines involved. There should be protocols that cover the period from patient admission to discharge to ensure unbroken care among the units [4,7,11].

Lack of nurse involvement in sepsis management

In this study, there were differences in attitudes between doctors and nurses about the management of sepsis in the ICU. Nurses tend to be passive in sepsis management in Indonesia. ICU patient therapy relies heavily on doctors. Nurses can play a more important role in managing sepsis patients [28]. The evidence shows that nurses have fundamental roles in the early identification, control, and prevention of sepsis, which can halt disease progression and decrease morbidity and mortality [29,30]. Good knowledge and use of sepsis protocols and screening tools can reduce patient mortality. Nurse familiarity with qSOFA, completion of SOFA, or the use of an initiated sepsis implementation tool can help facilitate earlier recognition and time-critical interventions [28,30]. Application of the hour-1 sepsis bundle for suspected sepsis patients can save lives [28].

Hospital sepsis protocol

Hospital sepsis protocols can be used as tools to control the cost and quality of care for sepsis patients [31]. We recommend a series of sepsis protocols within the hospital to improve patient outcomes and reduce the cost [27,32]. These protocols should specify the flow of services and the roles of all practitioners involved in sepsis management. The ED doctor is responsible for screening for sepsis using qSOFA and SOFA; when the patient is assigned to a specific doctor, the hour-1 sepsis bundle should immediately be carried out according to the agreed-upon protocol. When deciding whether to hospitalize the patient in the ICU, the ICU doctor should be responsible for determining the feasibility of treatment based on SOFA scores and clinical findings. There is great need for a national sepsis protocol that can be used to manage sepsis within a hospital (at various hospital levels) and that can also be used as a guide to manage case among hospitals [32,33].

Limitations

This was a one-center study with a small sample size; however, we believe that the results of this study are relevant to primary and secondary hospitals around Bekasi. We hope to conduct a multicenter study with a larger sample size to obtain more varied data and avoid bias.

Conclusions

We found that the hour-1 sepsis bundle was incompletely implemented in a secondary hospital in Indonesia. Barriers included lack of knowledge about the hour-1 sepsis bundle, cost issues, lack of supporting facilities, and lack of coordination among health workers. Optimizing regional health laboratories, increasing the use of qSOFA and SOFA, and developing a series of sepsis protocols within the hospital are some solutions to these issues. The involvement of health policyholders and hospital management is needed to address these challenges.

KEY MESSAGES

▪ Hour-1 sepsis bundle was incompletely implemented in a secondary hospital in Indonesia.

▪ Barriers included a lack of knowledge about the hour-1 sepsis bundle, cost issues, lack of supporting facilities, and lack of coordination among healthcare workers.

▪ Optimizing regional health laboratories, optimizing the use of quick Sequential Organ Failure Assessment (qSOFA) and SOFA as sepsis screening and management tools, and creating a series of sepsis protocols within the hospital are some solutions that can be implemented.

▪ Health policyholder and hospital management involvement is needed to address these challenges.

NOTES

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

We gratefully acknowledge the support provided by Universitas Medika Suherman and Sentra Medika Hospital. Their commitment to advancing healthcare research has been invaluable to the development and completion of this work. We deeply appreciate their contributions, which were instrumental in facilitating this study.

AUTHOR CONTRIBUTIONS

Conceptualization: PS. Data curation: NA. Formal analysis: NA, NL. Methodology: RAP, SP. Project administration: PS. Visualization: PS, NA. Writing – original draft: PS, NA. Writing – review & editing: RAP, SP, EE, FIP, NL. All authors read and agreed to the published version of the manuscript.

Figure 1.

Participant recruitment process flowchart for intensive care unit (ICU) and emergency department (ED) staff. a) Advanced beginner level nurse: defined as either a Diploma-level nurse with more than 4 years of work experience or a registered nurse (RN) with over 3 years of experience.

Table 1.

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Doctor or nurse who is responsible for the management of patients in the intensive care unit or emergency department	Being outside the area at the time of data collection
Have worked at least 5 years at the hospital for doctors or at least at an advanced beginner level nurses

Table 2.

Themes, subthemes, and category

Precede-proceed element	Main findings	Findings
Predisposing	Hour-1 bundle sepsis is not properly implemented	- Blood culture samples before administering antibiotics were not mentioned as routine examinations.
	Hour-1 bundle sepsis is not properly implemented	- Sepsis management does not comply with the hour-1 sepsis bundle.
	Health professional knowledge	- Lack of knowledge about hour-1 bundle sepsis
		- Nurses, doctors, and laboratory staff do not receive regular training.
		- Health workers forget the procedure because it has not been done for a long time.
	Lack of coordination among health workers	- Lack of nurses’ role in sepsis management
Enabling	Lack of supporting facilities	- No blood culture examination facilities
Enabling	Lack of supporting facilities	- There are no laboratory personnel continuously trained to perform blood culture examinations.
Reinforcing	Hospital cost policy	- There is no policy for funding laboratory tests and intensive care unit rooms to support the implementation of the 1-hour bundle sepsis.
	Hospital cost policy	- The absence of sepsis protocol in the hospital
	Government coverage (universal health coverage policy)	- The government does not cover laboratory tests and procedures for hour-1 bundle sepsis.
		- There is no memorandum of understanding between the government and hospitals regarding procedures.
		- Most patients rely on universal health coverage.

Table 3.

Characteristics of participants

Participants characteristics		No. (%)	Mean±SD
Professional background	Doctor	4 (30.8)	-
Professional background	Nurse	9 (69.2)
Age	<31 yr	2 (15.4)	39±9
	31–45 yr	8 (61.5)
	>45 yr	3 (23.1)
Sex	Male	5 (38.5)	-
Sex	Female	8 (61.5)
Length of work	5–10 yr	8 (61.5)	8.9±5.6
	10–15 yr	3 (23.1)
	>15 yr	2 (15.4)

SD: standard deviation.

REFERENCES

1. Paoli CJ, Reynolds MA, Sinha M, Gitlin M, Crouser E. Epidemiology and costs of sepsis in the United States: an analysis based on timing of diagnosis and severity level. Crit Care Med 2018;46:1889-97.Article PubMed PMC
2. Dugar S, Choudhary C, Duggal A. Sepsis and septic shock: guideline-based management. Cleve Clin J Med 2020;87:53-64.Article PubMed
3. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence 2014;5:4-11.Article PubMed
4. Teles F, Rodrigues WG, Alves MG, Albuquerque CF, Bastos SM, Mota MF, et al. Impact of a sepsis bundle in wards of a tertiary hospital. J Intensive Care 2017;5:45. Article PubMed PMC PDF
5. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021;47:1181-247.Article PubMed PMC
6. Liang XU, Zhiwei GA, Weiqin WU, Yadong YU, Weijun GU, Qi LI, et al. Compliance of sepsis hour-1 bundle strategy for patients with septic shock in emergency department. Chin J Gen Pract 2022;21:42-7.
7. Milano PK, Desai SA, Eiting EA, Hofmann EF, Lam CN, Menchine M. Sepsis bundle adherence is associated with improved survival in severe sepsis or septic shock. West J Emerg Med 2018;19:774-81.Article PubMed PMC
8. Umemura Y, Abe T, Ogura H, Fujishima S, Kushimoto S, Shiraishi A, et al. Hour-1 bundle adherence was associated with reduction of in-hospital mortality among patients with sepsis in Japan. PLoS One 2022;17:e0263936. Article PubMed PMC
9. Ye Lynn KL, Hanson J, Mon NC, Yin KN, Nyein ML, Thant KZ, et al. The clinical characteristics of patients with sepsis in a tertiary referral hospital in Yangon, Myanmar. Trans R Soc Trop Med Hyg 2019;113:81-90.Article PubMed
10. Rudd K, Hantrakun V, Boonsri C, Somayaji R, Fitzpatrick A, Day N, et al. Sepsis management in adults admitted to a Thai regional referral hospital. Chest 2019;155:120A. Article
11. Chan JK, Leung YL. A retrospective study on the compliance with surviving sepsis campaign guideline in patients with sepsis admitted to intensive care unit in Hong Kong. J Intensive Crit Care 2017;3:1-10.
12. Miles MB, Huberman AM. An expanded sourcebook: qualitative data analysis. 2nd ed. Sage; 1994.
13. Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc 2013;88:1127-40.Article PubMed
14. Kruse O, Grunnet N, Barfod C. Blood lactate as a predictor for in-hospital mortality in patients admitted acutely to hospital: a systematic review. Scand J Trauma Resusc Emerg Med 2011;19:74. Article PubMed PMC PDF
15. Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med 2018;44:925-8.Article PubMed PDF
16. Colon Hidalgo D, Patel J, Masic D, Park D, Rech MA. Delayed vasopressor initiation is associated with increased mortality in patients with septic shock. J Crit Care 2020;55:145-8.Article PubMed
17. Syaputra A, Wijaya DW, Hanafie A. Patterns of antibiotic use in the one hour bundle treatment of sepsis. J Soc Med 2022;1:108-14.Article PDF
18. Mizrahi A, Jaureguy F, Petit H, Péan de Ponfilly G, Carbonnelle E, Le Monnier A, et al. Early empirical antibiotic therapy modification in sepsis using Beta-Lacta test directly on blood cultures. Int J Transl Med 2022;2:448-55.Article
19. Walker SV, Steffens B, Sander D, Wetsch WA. Implementation of antibiotic stewardship improves the quality of blood culture diagnostics at an intensive care unit of a university hospital. J Clin Med 2022;11:3675. Article PubMed PMC
20. Nisa A, Dradjat Respati S, Ari P, Antonius F, Suryanto EA, Nanik S, et al. Emergency room overcrowding factors affecting treatment management of sepsis patients in Dr. Saiful Anwar Public Hospital. Biotika 2021;1:3-11.
21. Arefian H, Heublein S, Scherag A, Brunkhorst FM, Younis MZ, Moerer O, et al. Hospital-related cost of sepsis: a systematic review. J Infect 2017;74:107-17.Article PubMed
22. Hajj J, Blaine N, Salavaci J, Jacoby D. The “centrality of sepsis”: a review on incidence, mortality, and cost of care. Healthcare (Basel) 2018;6:90. Article PubMed PMC
23. Jeon K, Na SJ, Oh DK, Park S, Choi EY, Kim SC, et al. Characteristics, management and clinical outcomes of patients with sepsis: a multicenter cohort study in Korea. Acute Crit Care 2019;34:179-91.Article PubMed PMC PDF
24. Shakeel S, Iffat W, Nesar S, Shayan S, Ali A, Gajdács M, et al. Prompt identification of sepsis on hospital floors: are healthcare professionals ready for the implementation of the hour-1 bundle? Trop Med Infect Dis 2022;7:291. Article PubMed PMC
25. Adegbite BR, Edoa JR, Rylance J, Jacob ST, Kawale P, Adegnika AA, et al. Knowledge of health workers relating to sepsis awareness and management in Lambaréné, Gabon. Acta Trop 2021;219:105914. Article PubMed
26. Chua WL, Teh CS, Basri MA, Ong ST, Phang NQ, Goh EL. Nurses’ knowledge and confidence in recognizing and managing patients with sepsis: a multi-site cross-sectional study. J Adv Nurs 2023;79:616-29.Article PubMed
27. Moore WR, Vermuelen A, Taylor R, Kihara D, Wahome E. Improving 3-hour sepsis bundled care outcomes: implementation of a nurse-driven sepsis protocol in the emergency department. J Emerg Nurs 2019;45:690-8.Article PubMed
28. Bleakley G, Cole M. Recognition and management of sepsis: the nurse’s role. Br J Nurs 2020;29:1248-51.Article PubMed
29. Branco MJ, Lucas AP, Marques RM, Sousa PP. The role of the nurse in caring for the critical patient with sepsis. Rev Bras Enferm 2020;73:e20190031.Article PubMed
30. Gripp L, Raffoul M, Milner KA. Implementation of the Surviving Sepsis Campaign one-hour bundle in a short stay unit: a quality improvement project. Intensive Crit Care Nurs 2021;63:103004. Article PubMed
31. Walsh D, Gekle R, Bramante R, Decena E, Raio C, Levy D. Emergency department sepsis huddles: achieving excellence for sepsis benchmarks in New York State. Am J Emerg Med 2020;38:222-4.Article PubMed
32. Rogers P, Boussina AE, Shashikumar SP, Wardi G, Longhurst CA, Nemati S. Optimizing the implementation of clinical predictive models to minimize national costs: sepsis case study. J Med Internet Res 2023;25:e43486.Article PubMed PMC
33. Thompson K, Venkatesh B, Finfer S. Sepsis and septic shock: current approaches to management. Intern Med J 2019;49:160-70.Article PubMed PDF

Figure & Data

References

Citations

Citations to this article as recorded by

PubReader
ePub Link

Cite

CITE: export Copy Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Challenges of implementing the hour-1 sepsis bundle: a qualitative study from a secondary hospital in Indonesia

Acute Crit Care. 2024;39(4):545-553. Published online November 27, 2024

DOI: https://doi.org/10.4266/acc.2023.01473

XML Download

Figure

Challenges of implementing the hour-1 sepsis bundle: a qualitative study from a secondary hospital in Indonesia

Figure 1. Participant recruitment process flowchart for intensive care unit (ICU) and emergency department (ED) staff. a) Advanced beginner level nurse: defined as either a Diploma-level nurse with more than 4 years of work experience or a registered nurse (RN) with over 3 years of experience.

Figure 1.

Challenges of implementing the hour-1 sepsis bundle: a qualitative study from a secondary hospital in Indonesia

Inclusion criteria	Exclusion criteria
Doctor or nurse who is responsible for the management of patients in the intensive care unit or emergency department	Being outside the area at the time of data collection
Have worked at least 5 years at the hospital for doctors or at least at an advanced beginner level nurses

Precede-proceed element	Main findings	Findings
Predisposing	Hour-1 bundle sepsis is not properly implemented	- Blood culture samples before administering antibiotics were not mentioned as routine examinations.
	Hour-1 bundle sepsis is not properly implemented	- Sepsis management does not comply with the hour-1 sepsis bundle.
	Health professional knowledge	- Lack of knowledge about hour-1 bundle sepsis
		- Nurses, doctors, and laboratory staff do not receive regular training.
		- Health workers forget the procedure because it has not been done for a long time.
	Lack of coordination among health workers	- Lack of nurses’ role in sepsis management
Enabling	Lack of supporting facilities	- No blood culture examination facilities
Enabling	Lack of supporting facilities	- There are no laboratory personnel continuously trained to perform blood culture examinations.
Reinforcing	Hospital cost policy	- There is no policy for funding laboratory tests and intensive care unit rooms to support the implementation of the 1-hour bundle sepsis.
	Hospital cost policy	- The absence of sepsis protocol in the hospital
	Government coverage (universal health coverage policy)	- The government does not cover laboratory tests and procedures for hour-1 bundle sepsis.
		- There is no memorandum of understanding between the government and hospitals regarding procedures.
		- Most patients rely on universal health coverage.

Participants characteristics		No. (%)	Mean±SD
Professional background	Doctor	4 (30.8)	-
Professional background	Nurse	9 (69.2)
Age	<31 yr	2 (15.4)	39±9
	31–45 yr	8 (61.5)
	>45 yr	3 (23.1)
Sex	Male	5 (38.5)	-
Sex	Female	8 (61.5)
Length of work	5–10 yr	8 (61.5)	8.9±5.6
	10–15 yr	3 (23.1)
	>15 yr	2 (15.4)

Table 1. Inclusion and exclusion criteria

Table 2. Themes, subthemes, and category

Table 3. Characteristics of participants

SD: standard deviation.