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Proposal of a sepsis rapid response team (RRT) for the emergency room of the University Hospital of Vassouras (UHV).
IFMSA Denem - Universidade de Vassouras, Vassouras
Professional Master’s Degree in Applied Health Sciences / Intensive Care
Prof. Dr. Marco Aurélio dos Santos Silva
Prof. Dr. Marco Aurélio dos Santos Silva
Type of Research Project
- Clinical Project without Laboratory work
What is the background of the project?
Sepsis is defined by the presence of life-threatening organ dysfunction due to the body's unregulated response to an infection. It is extremely prevalent, with high morbidity and mortality and high costs to the health system. Early diagnosis and treatment are key to reducing the mortality rate. The implementation of managed clinical protocols is a useful tool that helps institutions standardize septic patient care, reducing negative outcomes and providing better treatment effectiveness. The Rapid Response Team (RRT) is recognized as a coherent and integrated system of strategic actions aimed at the care of patients with clinical conditions outside a prepared environment previously prepared to meet urgent situations. The service has the following sequence: 1) Rapid identification of the clinical deterioration of the patient, focused on effective and efficient communication in triggering the RRT; 2) Organized documentation of the results, resulting from the operationalization of the care instituted by the RRT; 3) Continuous improvement of care assessed through auxiliary indicators to prevent adverse events and contribute to the formulation of strategies that prevent the worsening of the clinical picture; 4) Team coordination, evaluation of material resources for care, follow-up with continuing education and updating of RRT. The mortality of sepsis in the University Hospital of Vassouras (HUV) has not decreased, despite the release of the Sepsis 3 protocols in 2016, which lead to the hypotesis that the Quick Sequential Organ Failure Assessment (qSOFA) protocol was not being correctly applied. The aim of the development of the RRT is to improve the usage of the qSOFA protocol in the hospital’s emergency room, targeting the quicker recognition of septic patients and decrease in mortality.
What is the aim of the project?
The aim of the study is to develop a Rapid Response Team (RRT) to patients with Sepsis / Septic Shock treated at the emergency room of the University Hospital of Vassouras (HUV), as well as compare the outcome of patients before and after the implementation of RRT in the HUV Emergency.
What techniques and methods are used?
This is an interventional, comparative, longitudinal and prospective study in the HUV Emergency. The proposal to implement a RRT for early initiation of the protocol of care for patients with sepsis and / or septic shock assumes that systematic screening is the basis for early diagnosis of these patients. Therefore, in order to achieve the goal of reducing the time between patient admission to the emergency and diagnosis / treatment, a) a RRT will be created and enabled for patients with sepsis and / or septic shock to act on the emergence of HUV; b) a managed clinical protocol will be elaborated and implemented for the care of adult patients with sepsis and / or septic shock; c) a protocol-based flowchart will be inserted for the RRT to quickly identify and act upon patients with sepsis and / or septic shock with the Quick Sequential Organ Failure Assessment (qSOFA), enabling the RRT to identify the potentially serious patient early in the emergence of HUV, thus reducing the time between admission and the initiation of appropriate treatment and consequent referral to the Intensive Care Unit; Finally, a smartphone application will be developed to trigger and promote interactivity of RRT members. Subsequently the implementation of the RRT will be conducted a study comparing the outcome of these patients before and after the adoption of the protocol. In order to investigate the effects of implementing TRR on HUV Emergency, data will be evaluated for normality using the Komolgorov-Smirnov test. Then parametric data will be tested by Student's t-test or Analysis of variance (ANOVA) and non-parametric data by Mann-Whitney or Kruskal-Wallis being considered significant p <0.05. The sepsis protocol will be opened whenever there is a patient with an infection installed or suspected at the time of emergency screening and at least two of the 3 clinical criteria measured by qSOFA are present. Upon identification of one or more parameters of the patient's qSOFA clinical criteria, the emergency screening nurse will immediately report the presence of a potentially serious patient to one of the emergency room physicians at that time. After the evaluation of the doctor on duty, he will trigger the RRT and provide therapeutic resources and monitoring to the patient in question, always obeying the availability of beds in the red and yellow rooms. The RRT will consist of an emergency doctor and nurse and an ICU doctor and nurse. Once the RRT has been triggered, the emergency physician will request an intensive care bed for the patient in question, as well as inform the Internal Regulation Center (NIR) about the patient with suspected sepsis in the emergency of the HUV and, after this, the NIR checks the availability of ICU beds, always complying with the ICU admission criteria and priorities recommended by the Federal Council of Medicine (CFM). Meanwhile, the emergency nursing team, if medically indicated, will provide monitoring, necessary medications and laboratory tests including the first-hour approach, following the new Sepsis Protocol (2018): I. Lactate dosage and blood culture collection (2 samples); II. Broad spectrum antibiotic therapy according to the site of possible infection and indication; III. Immediate onset of volume replacement with 30mL / kg crystalloid solution in case of hypotension or lactate ≥ 4 mmol / L or 18 mg / dL; Administration of vasoactive drugs if the patient is hypotensive during or after volume replacement to maintain mean arterial pressure (MAP) ≥ 65mmHg.
What is the role of the student?
- The student will observe the practical experiments but will be highly involved in the analysis of the results
- The tasks will be done under supervision
What are the tasks expected to be accomplished by the student?
The student will, along with other healthcare professionals from HUV, be responsible for prompt assessment, screening and treatment of patients with signs of clinical deterioration outside the ICU environment, as well as application of the quick SOFA during patient admission at the HUV emergency room with suspected sepsis or septic shock. The student will also partake in a training, that will be carried out through in-service training. During training, the new concepts of sepsis, septic shock, and the clinical criteria used in quick SOFA will be addressed. The respective roles and timing of action in the potentially serious patient care chain will be defined when admitted to the emergency room and meet the inclusion criteria for opening the sepsis protocol. Lastly, the student will be envolved in an application development using the Appy Pie Application Builder which requires no design or coding skills, aiming to trigger the rapid response and promote interactivity between the TRR members. The student will partake in all phases of the study, which will consist on: • Create and train a RRT for patients with sepsis and / or septic shock to act on the emergence of HUV; • Develop and implement a managed clinical care protocol for adult patients with sepsis and / or septic shock; • Insert a protocol-based flowchart for RRT to quickly identify and act upon patients with sepsis and / or septic shock from qSOFA; • Enable the RRT to identify the potentially serious patient early in the emergence of HUV, thus reducing the time between admission and the initiation of appropriate treatment and consequent referral to the Intensive Care Unit; • Develop a smartphone app to trigger the RRT and promote interactivity of RRT members. • Compare the outcome of patients before and after the implementation of RRT in the HUV Emergency, with data collection from the students’ experience in observing and partaking in the RRT. The student will be a part of the data analysis (oriented by the tutors), using the following statistical tests: Komolgorov-Smirnov, T-Student Test, ANOVA, Mann-Whitney and Kruskal-Wallis. The statistical program used will be Microsoft Excel.
Will there be any theoretical teaching provided (preliminary readings, lectures, courses, seminars etc)
Yes. There will be preliminary readings and seminars provided by the project tutor on introduction to scientific research and clinical trials.
What is expected from the student at the end of the research exchange? What will be the general outcome of the student?
- The student will prepare a poster - The student will prepare a scientific report
What skills are required of the student? Is there any special knowledge or a certain level of studies needed?
The student is expected to have basic digital tools knowledge (such as word processing documents, slide presentation software, electronic reference materials and tablet and cellphone applications), since the project involves the development of an application.
Are there any legal limitations in the student’s involvement
Type of students accepted
This project accepts: - Medical students - Graduated students (less than 6 months)
- Seymour CW; Liu VX; Iwashyna TJ; Brunkhorst FM; Rea TD; Scherag A; et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama. 2016;315(8):762-74. Epub 2016/02/24.
- Shankar-Hari M; Phillips GS; Levy ML; Seymour CW; Liu VX; Deutschman CS; et al. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama. 2016;315(8):775-87. Epub 2016/02/24.
- Singer M; Deutschman CS; Seymour CW; Shankar-Hari M; Annane D; Bauer M; et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama. 2016;315(8):801-10. Epub 2016/02/24.
- Angus DC; Linde-Zwirble WT; Lidicker J; Clermont G; Carcillo J; Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence; outcome; and associated costs of care. Critical care medicine. 2001;29(7):1303-10. Epub 2001/07/11.
- Dellinger RP. Cardiovascular management of septic shock. Critical care medicine. 2003;31(3):946-55. Epub 2003/03/11.
- Rhodes A; Evans LE; Alhazzani W; Levy MM; Antonelli M; Ferrer R; et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive care medicine. 2017;43(3):304-77. Epub 2017/01/20.
- Rhodes A; Evans LE; Alhazzani W; Levy MM; Antonelli M; Ferrer R; et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical care medicine. 2017;45(3):486-552. Epub 2017/01/19.
- Machado FR CA; Carrara FS; Bozza FA; Lubarino J; Azevedo LC; et al. Prevalência e mortalidade por sepse grave e choque séptico em unidades de terapia intensiva brasileiras. Rev Bras Terapia Intensiva. 2014;Supl 1(S13).
- Hotchkiss RS; Karl IE. The pathophysiology and treatment of sepsis. The New England journal of medicine. 2003;348(2):138-50. Epub 2003/01/10.
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