Evaluating the impact of end-tidal carbon dioxide monitoring in emergency department sepsis patients

Severe sepsis and septic shock remain significant international health burdens with high mortalities and financial implications. Rapid identification of the septic patient is imperative as compliance with guideline-recommended, time-specific bundles has been shown to decrease sepsis-related mortality. Despite this, compliance with the bundles remains low. Evidence has suggested that end-tidal carbon dioxide (EtCO2) monitoring may be a viable intervention to aid in overcoming some barriers to sepsis identification and initiation of treatment. The purpose of this project was to evaluate whether the use of end-tidal carbon dioxide (EtCO2) monitoring in patients being evaluated for sepsis in the adult emergency department will result in decreased time to recognition and time to antibiotics, and increased bundle compliance, including overall, antibiotic, and intravenous fluid compliance, as compared to those who do not receive EtCO2 monitoring. Using the Ottawa Model of Research Use as a conceptual model, this project consisted of a pilot evaluation of EtCO2 monitoring as part of an existing Code Sepsis response, followed by aggregate data review. Time to antibiotics and recognition, percent of patients receiving antibiotics in three hours, and total bundle compliance increased, while the percent of patients receiving appropriate intravenous fluids decreased. None of these results showed statistical significance. The results of the pilot evaluation do not support the addition or removal of EtCO2 monitoring. There are several indications for future research, including a longer evaluation time and evaluating potential confounders. END-TIDAL CARBON DIOXIDE MONITORING IN EMERGENCY 5 End-Tidal Carbon Dioxide Monitoring in Emergency Department Sepsis Patients Background and Significance Severe sepsis and septic shock remain significant international health burdens with high mortalities and financial implications (Hall, Williams, DeFrances, & Golosinskinskiy, 2011; Rhodes et al., 2015). In 2002, the Surviving Sepsis Campaign was founded with the goals, amongst others, of generating a guideline for the identification and treatment of severe sepsis and septic shock and reducing overall mortality from these conditions (Surviving Sepsis Campaign [SSC], 2016). Since inception, the Surviving Sepsis Campaign has released multiple guidelines for the identification and treatment of severe sepsis and septic shock (Dellinger et al., 2013; Rhodes et al., 2017). Rapid identification of the septic patient is imperative as compliance with the guideline recommended, time-specific bundles has been shown to decrease sepsis-related mortality, particularly the rapid administration of appropriate antimicrobial therapy in septic shock patients (Kumar et al., 2006; Rhodes et al., 2015; Thompson et al., 2016; Tromp et al., 2010; Wang, Xiong, Schorr, & Dellinger, 2013). Despite strong evidence that following bundle recommendations improves patient outcomes, compliance percentages for the initial resuscitation remain at only approximately 20% of cases (Levy et al., 2012; Rhodes et al., 2015; Wang et al., 2013). Failure to recognize, lack of knowledge, and resource barriers, such as laboratory testing, are cited as major reasons for poor bundle compliance (Carlbom & Rubenfeld, 2007; Daniels, 2011; Kissoon, 2014; Siontis et al., 2015). Evidence has suggested that end-tidal carbon dioxide (EtCO2) monitoring may be a viable intervention to aid in the identification of sepsis and the acuity of septic patients by providing an indication of mortality risk and initial lactate level (Hunter, Silvestri, Dean, Falk, & Papa, 2013).