Nursing Staff Capacity Plays a Crucial Role in Compliance to Empiric Antibiotic Treatment Within the First Hour in Patients with Septic Shock
Sepsis and septic shock are among the leading causes of intensive care unit (ICU) admissions and are associated with significant morbidity and mortality. Early administration of appropriate antibiotics has been shown to significantly improve survival rates in patients with sepsis and septic shock, as recommended by international guidelines. However, compliance with sepsis protocols remains alarmingly low. Nurses, who play a vital role in executing physician orders, are likely key contributors to the compliance of empiric antibiotic administration. Previous studies have highlighted the essential role of nurses as brokers of doctors’ antibiotic decisions and have demonstrated that nurse-led protocols can be effective, safe, and sustainable methods for achieving early antibiotic administration in patients with suspected febrile neutropenia. To further investigate this relationship, a retrospective cohort study was conducted to examine the effect of nursing staff capacity on compliance with empiric antibiotic treatment in patients with septic shock.
The study was approved by the Independent Ethics Committee for Clinical Research of Zhongda Hospital, affiliated with Southeast University. It included all adult patients aged 18 years or older who were admitted to the ICU due to septic shock between January 1, 2015, and February 29, 2016. Patients were diagnosed with septic shock by ICU physicians upon consultation and subsequent transfer to the ICU. Exclusion criteria included pregnancy, patients diagnosed with septic shock by clinicians from other departments, and those who had already received antimicrobials before ICU admission. The study defined the time of sepsis diagnosis as the time of ICU admission and evaluated whether patients received antimicrobials within one hour of admission.
Nursing staff capacity was categorized based on educational background and work experience. Nurses were classified into four levels: N0 (nurses with a college degree or above, a nurse qualification certificate, and less than one year of work experience), N1 (nurses with a nurse qualification certificate and one to three years of work experience), N2 (nurses with a nurse practitioner qualification and more than three years of work experience), and N3 (nurses with nurse-in-charge qualifications or professional critical care nurse qualifications at the provincial level for more than one year). Nursing shifts were structured as follows: day shift (08:00 to 16:00), afternoon shift (16:00 to 22:30), and night shift (22:30 to 08:00 the next day). Shift changes occurred from 07:00 to 09:00, 15:00 to 17:00, and 21:30 to 23:30.
The study recorded the time of initial empiric antibiotic treatment for all patients, along with details of nursing staff capacity and shifts. Demographic characteristics, clinical variables, and other medical information potentially associated with compliance were also collected. Patients were grouped based on the capacity of nursing staff and shifts, and compliance rates for empiric antibiotic treatment within one hour were calculated for each group.
Additionally, a questionnaire was designed to evaluate nurses’ subjective assessment of the importance of empiric antibiotic treatment within one hour after the diagnosis of septic shock. The questionnaire used a scale ranging from 1 to 10, with higher scores indicating greater perceived importance.
A total of 1458 patients were admitted to the ICU during the study period, of which 255 were diagnosed with septic shock. After exclusions, 214 patients were included in the analysis. Among these, 110 (51.4%) received empiric antibiotic treatment within one hour. Baseline characteristics and outcomes did not differ significantly between patients who received timely and delayed empiric antibiotic treatment.
Analysis of nursing staff capacity and shifts revealed significant differences in compliance rates. Compliance was lowest during shift changes (42.4%) compared to the night shift (63.9%). Furthermore, compliance rates varied based on nursing staff capacity: 44.8% for N0, 48.7% for N1, and 78.3% for N2 and N3. Compared to N0 and N1, compliance rates were significantly higher for N2 and N3 (N2 and N3 vs. N0, P=0.015; N2 and N3 vs. N1, P=0.008). However, after multivariate analysis, only N2 was associated with increased compliance to antibiotic management.
The type of antibiotic also significantly affected compliance. Carbapenems were more commonly used in the timely empiric antibiotic treatment group, while enzyme inhibitor compounds were less common. Multivariate analysis confirmed that carbapenems were significantly associated with increased compliance to antibiotic management.
The questionnaire was completed by 113 nurses. Scores varied based on nursing staff capacity, with N0 scoring 6.91, N1 scoring 8.90, and N2 and N3 scoring 9.79. Nurses with higher levels of capacity were more likely to recognize the importance of empiric antibiotic treatment within one hour (N0 vs. N1, P=0.002; N1 vs. N2 and N3, P<0.001; N0 vs. N2 and N3, P<0.001).
The study concluded that compliance with empiric antibiotic treatment within one hour in patients with septic shock was suboptimal in the ICU, with a compliance rate of 51.4%. Nursing staff capacity was identified as a significant factor influencing compliance. Compliance was lowest during shift changes, likely due to the increased workload and communication demands during these periods. However, after adjusting for confounders, shift changes were not independently associated with compliance.
The findings suggest that improving the training of nursing staff, particularly for lower-grade nurses, could enhance compliance with empiric antibiotic treatment. Strengthening professional training during shift changes may be particularly effective. Additionally, the study highlighted the importance of the type of antibiotic used, with carbapenems being associated with higher compliance rates.
The study had several limitations, including its single-center, retrospective design, small sample size, and potential confounding factors not included in the final analysis. The hospital’s workload during the study period was also not considered, which could have introduced bias. To confirm the findings, a larger, prospective clinical trial is needed.
In summary, the study underscores the critical role of nursing staff capacity in ensuring timely empiric antibiotic treatment for patients with septic shock. Improving nurse training and optimizing antibiotic selection could significantly enhance compliance rates and, ultimately, patient outcomes.
doi.org/10.1097/CM9.0000000000000073
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