Search

Bachelor i Prehospitalt arbeid - Paramedic Hensikt: Etter egne erfaringer, samtaler med kollegaer i tjenesten, og leste fagartikler, har vi fått inntrykket av at qSOFA virker dårligere enn ønsket. Hensikten med dette studiet er å sammenligne et annet verktøy for identifisering av sepsis, Prehospital Early Sepsis Detection Score (PRESEP-score), med det nåværende qSOFA. Vurderingene blir gjort ut i fra sensitivitet, spesifisitet, PPV og NPV. Samt blir de vurdert ut i fra prevalens av symptomer og tegn hos sepsispasienter. Metode: Vi har valgt å gjøre denne oppgaven som et litteraturstudie. Det vil si at den baserer seg på teori og forskning som finnes fra tidligere Resultat/konklusjon: Resultatene viser at qSOFA har en lav sensitivitet (26%), men en høy spesifisitet (98%). PRESEP-score har høy sensitivitet (85%), men en noe lavere spesifisitet (86%) enn qSOFA. Ettersom vi har konkludert med at sensitivitet er noe som skal vektlegges mer, mener vi at PRESEP-score kan potensielt være noe bedre. Utfordringen med PRESEP-score er at det finnes lite forskning om dette verktøyet, og det bør derfor forskes mer på, og eventuelt prøve det ut i den prehospitale tjeneste.

Introduksjon: For å sikre tryggere behandling av sepsispasienter og unngå avvik, er det blitt innført et nytt screeningverktøy for å fange opp pasientene. QSOFA-kriteriene er ment til å brukes i akuttmottak, men implementering av et nytt verktøy foregår ikke alltid problemfritt. For å lykkes kan det derfor være nyttig å belyse hvilke barrierer en kan møte i implementeringsprosessen. Hensikt: Hensikten med oppgaven er å kartlegge hvilke barrierer som kan påvirke implementeringen av QSOFA i akuttmottak. Metode: Oppgaven er en litteraturstudie. Strukturerte- og ustrukturerte søk har resultert i fem relevante forskningsartikler. Disse er blitt nøye kritisk analysert. Søkeord som ble benyttet i prosessen var: QSOFA, sepsis, nurse, education, ED, emergency department, screening tools, implementation og SIRS. Resultat: Litteraturstudien har funnet frem til barrierer blant helsepersonell og organisatoriske faktorer kan påvirke implementeringen av QSOFA i akuttmottaket. Disse går hovedsakelig ut på kunnskap- og erfaringsvariasjoner, sviktende samarbeid og mangel på ressurser. Konklusjon: Kunnskapshull blant sykepleiere om sepsis kan ses på som en barriere i implementeringen av screeningverktøyet QSOFA. For å forhindre at barrieren oppstår må sykepleiere selv ta initiativ til å heve sin egen kunnskap og kompetanse. Sykepleiere i akuttmottaket har et ulikt syn på hva det vil si å opptre profesjonelt, og de prioriterer arbeidsoppgaver forskjellig. Disse barrierene kan bidra til å vanskeliggjøre implementeringsprosessen, da slike faktorer kan medføre til et dårlig arbeidsmiljø. Dersom implementeringen ikke følges opp fra alle i avdelingen, kan det føre til at sykepleiere mister motivasjonen til å gjennomføre. Et anspent forhold mellom profesjonene, dårlig oppfølging og samhandling med leder kan ses på som avgjørende barrierer for implementeringen. Det er viktig at ansatte ser på QSOFA som et screeningverktøy som er nyttig og som vil skape flyt i akuttmottaket. Dette er avgjørende faktorer som fort kan utvikle seg til å bli barrierer i implementeringen. Introduction: To secure safer treatment and avoid deviations around sepsis patients, a new screening tool is introduced to easier identify patients with sepsis. The QSOFA-criteria is intended for use in the emergency department, but implementation of a new tool doesn’t always go smoothly. To succeed, it may prove useful to investigate potential barriers in the implementation process. Purpose: The purpose of this literature review is to investigate which barriers can affect the implementation of QSOFA as a new screening tool in the emergency department. Method: This bachelor thesis is a literature review. Structured and unstructured searches resulted in five relevant articles. The articles were critically analyzed. Keywords: QSOFA, sepsis, nurse, education, ED, emergency department, screening tools, implementation and SIRS. Results: The bachelor thesis found barriers among healthcare professionals and organizational factors which may affect the implementation of QSOFA in the emergency department. These barriers are mainly variations in knowledge and experience, failing collaboration and lack of resources. Conclusion: Gaps in knowledge about sepsis among nurses can be seen as a barrier in the implementation of the QSOFA screening tool. To prevent the barrier from occurring, nurses themselves must take initiative to raise their own knowledge and competence. Nurses in the ED have different views on what it means to be a professional and prioritize their work tasks differently. These barriers can contribute to complicate the implementation process, as such factors can lead to a poor working environment. The nurses can lose motivation to carry out the implementation if it’s not followed up by everyone in the department. A tense relationship between professions, poor follow-up and interaction with managers can be seen as crucial barriers for implementation. It is important that employees look at QSOFA as a screening tool that is useful and will create flow in the ED. These are key factors and can quickly develop into barriers for implementation.

BACKGROUND: Sepsis is known to be a prevalent and severe condition associated with high morbidity and mortality, and as such these patients pose a major burden on intensive care units (ICU) worldwide. However, despite the relative importance of sepsis, there has never once existed full consensus regarding the definition and clinical criteria making up this condition. The concept of sepsis as a condition of systemic inflammation – with the SIRS criteria as its clinical manifestation – has long been the widespread opinion. Nonetheless, this definition has raised great amounts of criticism due to its highly unspecific nature, in addition to not contributing to further insights into the underlying pathophysiology of sepsis. In February 2016 the European Society of Intensive Care Medicine og Society of Critical Care Medicine responded by publishing new definitions of sepsis and septic shock together with newly derived and validated clinical criteria. The already in-use Sequential Organ Failure Assesment (SOFA) score is intended to replace SIRS in the diagnostic work-up of sepsis, though as a screening tool SIRS is replaced by the new quick SOFA (qSOFA). These new clinical criteria supposedly better reflect the underlying pathophysiology of sepsis as a “life- threatening organ dysfunction caused by a dysregulated host response to infection”, and the qSOFA should identify high-risk patients in a more specific and timely manner. The authors urge further external validations of their recommendations. Thus, the goal of this systematic literature review is firstly to uncover all the relevant studies externally validating the new Sepsis-3 recommendations, and secondly to survey articles and statements addressing the implications of Sepsis-3 as well as the criticisms raised against it. METHOD: A systematic review of the literature available from PubMed was accomplished using the following keywords: “qSOFA OR quick SOFA OR quick Sepsis-related Organ Failure Assessment score OR quick Sequential Organ Failure Assessment score”. The search was conducted on two occasions in order to capture the latest publications considering that the external validation of Sepsis-3 is to date an ongoing joint project. RESULTS: In total, 29 articles were included, whereas a large proportion of these reported on a small patient group. Owing to differing inclusion criteria and variations in study design, primary outcomes and methods of data extraction, none of the reported results were directly applicable to be compared. However, the articles individually add value to the joint external validation of Sepsis-3. There are great variations in reported sensitivity, specificity and diagnostic accuracy (AUROC). However, trending in the largest studies, qSOFA displays good diagnostic accuracy, although comparable to or weaker than other well-established EWS and screening tools, and unacceptably low sensitivity in the general ward and ED. This was especially true for older patients. The value of adding serum lactate as a variable to qSOFA is still uncertain, as the included articles reports conflicting results. In the prehospital setting, qSOFA exhibits unacceptably low sensitivity. The sensitivity is in some studies shown to increase at arrival to the ED and during the ED stay. In two small studies validating qSOFA in resource limited settings, qSOFA displayed good diagnostic accuracy and well preserved sensitivity. CONCLUSION: High specificity at the cost of unacceptably insufficient sensitivity makes qSOFA less suitable as a screening tool for sepsis. Adding to this, test properties comparable to other well-established EWS suggests that hospitals might draw less benefit from the rapid acceptance and implementation of the Sepsis-3 recommendations. Before the latter becomes widespread, additional large prospective multicenter studies ought to demonstrate the superiority of Sepsis-3 and also improved outcomes in the current patient group.