Barriers of Implementing Early Goal-Directed Therapy Among Critically Ill Patients with Sepsis

Although early goal-directed therapy (EGDT) has been found to improve mortality in critically ill patients with severe sepsis/septic shock, its implementation in the emergency department (ED) can be challenging. objectives. to identify barriers of implementing early goal-directed therapy among critically ill patients with sepsis . setting . This study was conducted in the emergency department units of Alexandria Main University Hospital (AMUH), namely the reception unit and resuscitation unit. Semoha University Hospital (SUH) namely the reception unit. Subjects: All nurses of both gender (60) who are assigned to the direct care of the newly admitted patients with sepsis at the previously mentioned units were included in the study. Tool. One tool was utilized for data collection in this study. "Barriers of implementing early goal-directed therapy among critically ill patients with sepsis questionnaire. Result .: The study showed that there was a significant relationship between pt related barriers and the implementation of early goal-directed therapy p= (0.041 * ), also, there was a significant relationship between ECNs barriers and the implementation of early goal-directed therapy, p= (0.034 * ), there was a significant relationship between organizational barriers and the implementation of early goal-directed therapy, p=(0.049 * ). Conclusion: The most common barriers according to emergency care nurses related barriers regarding patients were the presence of relatives at the time of admission, barriers related to nurses as a Shortage of staff, barriers related to the organization including lack of collaboration and communication between different departments, furthermore, other health team barriers such as delay in diagnosis.


Introduction
Sepsis is thought to impact around 30 million people worldwide each year, causing 6 to 11 million fatalities.Between 780,000 and 970,000 cases of sepsis are thought to occur annually throughout the Middle East and North Africa.One-fourth of sepsis patients pass away while they are hospitalized.The most fatal conditions have death rates that are close to 50% (Paoli et al., 2018, Dugar et al., 2020).The Surviving Sepsis Campaign (2021) states that sepsis is an organ failure that may be fatal and is brought on by an improperly controlled host response to infection.Additionally, as sepsis is a systemic reaction to an infection, a patient must also exhibit two or more Systemics inflammatory response syndrome (SIRS) criteria in addition to a suspected infection.Early goaldirected therapy is a three-hour protocolized resuscitation approach to certain objectives in the treatment of sepsis.EGDT has significantly enhanced patient outcomes, including a 16% decrease in mortality.Among the interventions are taking blood cultures and lactate levels, giving empirical antibiotics, giving 30 ml/kg IV fluids to treat hypotension or lactate >4 mmol/L, and starting vasopressors in life-threatening situations.Following these guidelines has continued to be essential for improving clinical outcomes and quality of care for sepsis patients (Jahangiri et al., 2023,You et al., 2022,Nadeem et al., 2022).
There are many difficulties associated with early Goal Directed Therapy (EGDT), but the two biggest obstacles that nurses face are a lack of knowledge regarding the presentation and care of sepsis and septic shock, and a lack of resources in the ED to fully implement the protocol.Early EGDT is beneficial in reducing morbidity and mortality associated with severe sepsis and septic shock.(Salameh & Aboamash, 2022).
By identifying physiological changes that may signal the onset of sepsis, enhancing adherence to the implementation of early goal-directed therapy, and educating staff about sepsis management through the translation of best practices, nurses play a critical role in identifying early sepsisrelated manifestations.All of these factors are crucial in improving sepsis-related outcomes.(Harley et al., 2021;Mims, 2022).

Aims of the Study
This study aimed to identify the barriers of implementing early goal directed therapy among critically ill patients with sepsis.

Research Question:
What are the barriers of implementing early goal directed therapy among critically ill patients with sepsis?

Research Design:
Exploratory research design was used in this study.

Settings:
This study was conducted in the emergency department units of: Alexandria Main University Hospital (AMUH) namely reception unit and resuscitation unit & Semoha University Hospital (SUH) namely reception unit Subjects: All nurses of both sex (60) who are assigned in the direct care of the newly admitted patients with sepsis to the previously mentioned units was included in study.

Tools:
One tool was used in the current study namely "Barriers of implementing early goal directed therapy among critically ill patients with sepsis questionnaire.
This tool was adapted from The Surviving Sepsis Campaign 2021 by the researcher after reviewing the related literatures (Gripp et al., 2021) (Lester et al., 2018) (Pruinelli et al., 2018)(Shock et al., 2022) to identify barriers of implementing early goal directed therapy among critically ill patients with sepsis.This tool was included five parts: This part included time of admission, diagnosis, severity of disease, comorbidity conditions which are complicating initial management, presence of relatives at the time of admission, etc.These items will be rated on a dichotomous scale of (yes or no) and the score will be assigned for each item as follow: Yes (for correct answer) and equal one, While No (for incorrect answer) and equal zero.

Part III: Nurses related barriers:
It was used to assess nurse related barriers as job/ skill related data as skill competencies, lack of awareness about early goal directed therapy protocol, lack of supervision, lack of training program.

Part IV: Organization related barriers:
It was used to assess organization related barriers as lack of resources, lack of collaboration and communications.

Part V: Health care team related barriers:
This part included shortage of staff members, difficult in recognition of the patient condition, delay in diagnosis, delay in prescription of medications, delay in insertion of central venous catheter, etc.

Method
Approval of the ethics committee of the faculty of nursing was obtained.An official approval to conduct this study was obtained after providing explanation of the aim of the study.An informed consent was obtained from the patients.The study tools were tested for content validity by 7 experts in the field of the study.The necessary modifications were done accordingly.A pilot study was carried out on 10% of the study sample to test the clarity and applicability of the research tools.Reliability of the tools was tested using Cronbach's Alpha test.
The reliability coefficient was for tool 0.87% which is accepted.

Ethical considerations:
Written informed consent was obtained from patient after explaining the aim of the study and the right to refuse to participate in the study and/ or withdraw at any time.Patient's privacy was respected.Data confidentiality was during implementation of the study.

Statistical Analysis
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp) Qualitative data were described using number and percent.The Kolmogorov-Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation and median.Significance of the obtained results was judged at the 5% level.

Table (1)
denotes the relationship between socio-demographic data of the studied emergency nurses and mean score of the patient related barriers It can be noted that there was a statistical significant relationship between age of ECNs and patient related barriers p=(0.030* )As regard education level, there was a statistically significant relationship between education level and patient related barriers (p= 0.037*)As regard years of experiences, there was a statistically significant relationship between years of experiences and patient related barriers (P= 0.009 * ).As regard implementation of early goal directed therapy, there was a statistically significant relationship between implementation of early goal directed therapy and patient related barriers (P= 0.041 * ).

Table (2)
represents the relationship between socio-demographic data of the ECNs and mean percentage score of EGDT implementation barriers regarding nurses.It can be noted that there was a statistically significant relationship between age of ECNs and nurses related barriers p= (0.005 * ).Similarly, education level p= (0.004 *) , years of experiences p= (<0.001 * ), and implementation of early goal directed therapy p= (0.034 *) .

Table (3)
shows the relationship between socio-demographic data of the ECNs and mean percentage score of EGDT implementation barriers regarding organization.It can be noted that there was a statistically significant relationship between age of ECNs and organizational barriers p = (0.016 *) .As regard education level, there was a statistically significant relationship between education level and organizational barriers (p=0.047* ).As regard years of experiences, there was a statistically significant relationship between years of experiences and organizational barriers (P= 0.011 * ).As regard implementation of early goal directed therapy, there was a statistically significant relationship between implementation of early goal directed therapy and organization related barriers (P= 0.049 * ).Tables (4) denotes the relationship between socio-demographic data of the ECNs and percent score mean score of EGDT implementation barriers regarding other health team.It can be noted that there was a statistically significant relationship between age of ECNs and health team related barriers p= (0.019 *) .As regard education level, there was a statistically significant relationship between education level and health team related barriers (P=0.045* ).As regard years of experiences, there was a statistically significant relationship between years of experiences and health team related barriers (P=0.014* ).As regard implementation of early goal directed therapy, there was a statistically significant relationship between implementation of early goal directed therapy and health team related barriers (P=0.013* ).

Discussion
The main conclusions of the current study identified the major obstacles to initiating early goal-directed therapy in critically sick sepsis patients.Patient-related obstacles include diagnosis, comorbidities, and the presence of family at the time of admission.In addition, obstacles specific to nurses exist, such as a staffing shortage and the stress of caring for multiple patients (which increases the workload of nurses).Additionally, there are organizational obstacles such poor departmental coordination and communication, lengthy admissions processes, and extended turnaround times in laboratories.Additional health team-related obstacles include the lack of healthcare teams and delays in sepsis patients' diagnoses.These results can be attributed to a lack of EGDT knowledge and expertise, a staffing shortfall, or a lack of early goal-directed treatment training programs.
One study (Salameh & Aboamash, 2022;Castro 2015;Mikkelsen et al., 2010) explored the challenges faced in implementing early goal-directed therapy.(Salameh & Aboamash, 2022) sought to identify the emergency nurses' and doctors' knowledge, attitudes, practices, and barriers regarding the management of sepsis.It is clear that both emergency nurses and physicians, the largest obstacle to giving effective care to patients with sepsis is the lack of monitoring equipment given that both emergency nurses and physicians had poor-to-moderate levels of sepsis knowledge.They also discovered that programs for ongoing education are necessary to give nurses and doctors with consistent knowledge on sepsis management.The creation of a recognized procedure can enhance nurses' expertise, outlooks, and methods.
Another study (Castro 2015) aimed to synthesize current research findings regarding nursing barriers associated with EGDT.The results showed that there were two main obstacles that prevented the EGDT from being implemented: a lack of resources in the ED and a lack of information about how to present and treat sepsis and septic shock.These findings may be related to funding issues and a lack of training opportunities.(Mikkelsen et al., 2010) state as such.The study sought to discover the variables linked to not starting EGDT in the ED.At the levels of the patient, doctor, and organization, they identified potential obstacles to starting EGDT.At the patient level, sex and the seriousness of the condition seemed to affect whether EGDT was started.At the organizational level, they discovered that EGDT was much less likely to be started and less likely to be finished in individuals in whom EGDT was started while the Severe Sepsis Service was not active.Additionally, there are numerous obstacles to successfully integrating evidence into clinical practice.

Conclusion
Regarding EGDT implementation barriers among studied emergency care nurses, it was clear that the majority of EGDT implementation barriers were Health care team related barriers in nature, followed by patient related barriers and nurses related barriers in nature.Barriers related to health team such as shortage of health care team, delay in diagnosis is a barrier to them, lack of multidisciplinary collaboration, resistance to change to the new guidelines of EGDT (doesn't participate in training programs and delay prescription, ordering and delivery of fluids, medications, and vasopressors.Furthermore, patient related barriers such as the presence of relatives at the time of admission, age of the patients (greater than 60 years) diagnosis and comorbidity, severity of the illness( SOFA score) and immunity status of the patient, moreover, nurses related barriers such as Shortage of the staff, the burden of caring for several patients (Increase nurses' workload),delay recognition of sepsis and septic shock, lack of training program, lack of motivations, lack of awareness and familiarity with EGDT protocol, delay in obtaining samples from the patient for sepsis workup Finally organization related barriers such as lack of collaboration and communication between different departments, prolonged laboratory turnaround times, presence of logistics barriers (as places, administration affairs& papers), time consumed in admission procedures, lack of expertise of the multidisciplinary team.

Recommendations
In line with the findings of the study, the following recommendations are made: • Educate emergency care nurses about sepsis and sepsis management using early goal directed therapy.
• Regular staff meetings, training sessions, and conferences should be held to go over implementation impediments, their classification, and their management.
It included age, gender, level of education, years of experiences, implementation of early goal directed therapy.Part II: Patient related barriers:

Table ( 1): The distribution of the studied emergency care nurse's sociodemographic data. (n = 60)
SD: Standard deviation