Canadian Association of Emergency Physicians sepsis treatment checklist: optimizing sepsis care in Canadian emergency departments

Abstract

Objective: The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines created by the CAEP Critical Care Practice Committee (C4) and published in the Canadian Journal of Emergency Medicine (CJEM) form the most definitive publication on Canadian emergency department (ED) sepsis care to date. Our intention was to identify which of the care items in this document are specifically necessary in the ED and then to provide these items in a tiered checklist that can be used by any Canadian ED practitioner. Methods: Practice points from the CJEM sepsis publication were identified to create a practice point list. Members of C4 then used a Delphi technique consensus process over May to October 2009 via e-mail to create a tiered checklist of sepsis care items that can or could be completed in a Canadian ED when caring for the septic shock patient. This checklist was then assessed for use by a survey of ED practitioners from varying backgrounds (rural ED, community ED, tertiary ED) from July to October 2010. Results: Twenty sepsis care items were identified in the CAEP sepsis guidelines. Fifteen items were felt to be necessary for ED care. Two levels of checklists were then created that can be used in a Canadian ED. Most ED physicians in community and tertiary care centres could complete all parts of the level I sepsis checklist. Rural centres often struggle with the ability to obtain lactate values and central venous access. Many items of the level II sepsis checklist could not be completed outside the tertiary care centre ED. Conclusion: Sepsis care continues to be an integral and major part of the ED domain. Practice points for sepsis care that require specialized monitoring and invasive techniques are often limited to larger tertiary care EDs and, although heavily emphasized by many medical bodies, cannot be reasonably expected in all centres. When the resources of a centre limit patient care, transfer may be required.

Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock

“…Our transfer patients experienced significant delays in resuscitation therapy, likely secondary to the administrative and care burdens of transfer itself. Even though treatment guidelines support the completion of resuscitation bundles while in the ED (13), patients presenting to rural EDs often fail to receive guideline-adherent sepsis care (23,24).…”

The Effect of Hospital Volume on Mortality in Patients Admitted with Severe Sepsis

“…Given the fact that most high volume EDs were in teaching hospitals, the authors hypothesized that the difference in mortality was likely due to better resuscitation at larger EDs. The converse also has been demonstrated in that rural EDs rarely meet complete Surviving Sepsis Campaign guidelines due to the absence of technical and administrative expertise [20] . Recognition of inadequate therapy due to a lack of technical expertise and appropriate infrastructure has prompted some hospital systems to create tiered sepsis checklists that target basic stabilization before transfer [20] .…”

A Survey on Critical Care Resources and Practices in Low- and Middle-Income Countries

“…Data exist showing that the worldwide implementation of a simple World Health Organization surgical safety checklist improves outcomes, even in LMIC [20]. Checklist use in operating rooms [8,21], ICU [9,22,23], emergency departments [24,25], and other acute settings [12,26] have also led to substantial improvement in efficiency of the daily plan of care and were associated with decreased complications. Similarly, best practices in critical care include implementation of bundled care, such as the "ventilatory bundle" [27].…”