Performance protocols in the approach to the patient with sepsis in the emergency department

a systematic review with meta-analysis


  • Carolina Ferreira Centro Hospitalar e Universitário de Coimbra, Serviço de Urgência, Coimbra, Portugal | Health School of the Polytechnic Institute of Viseu, Viseu, Portugal
  • António Madureira Dias Health School of the Polytechnic Institute of Viseu, Viseu, Portugal | Health Sciences Research Unit: Nursing (UICISA:E), Nursing School of Coimbra, Coimbra, Portugal
  • Eduardo Santos Health School of the Polytechnic Institute of Viseu, Viseu, Portugal | Health Sciences Research Unit: Nursing (UICISA:E), Nursing School of Coimbra, Coimbra, Portugal



sepsis, shock, septic, antibiotic prophylaxis, mortality, clinical protocols


Introduction: Sepsis has become a major health problem affecting millions of people annually, and its early identification and appropriate treatment in the first hours is emergent. The implementation of protocols can improve outcomes, however this is still a subject under debate.

Objetive: To describe the impact of the use of protocols in emergency departments on the approach to patients with sepsis in order to reduce time to the first antibiotic and mortality.

Methods: A systematic review with meta-analysis was conducted following the methodology proposed by the Joanna Briggs Institute. Two independent reviewers performed the critical appraisal, extraction and synthesis of data.

Results: Seven studies were included. The results of the meta-analysis showed no differences in the mortality rate (all hospital time) (RR=0.84, 95%CI=0.63-1.14, p=0.27). However, for 30-day mortality there are significant differences favouring the group that used protocols in the approach to the sepsis patient (RR=0.80, 95%CI=0.68-0.95, p=0.01) and a reduction of time to antibiotics (MD=-41.83, 95%CI=-77.89- -5.77, p=0.02).

Conclusion: Emergency department protocols reduce mortality and the time until the first antibiotic is taken. Therefore, their implementation is essential to improve health outcomes.


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ARISE & ANZICS (2014). Goal-Directed Resuscitation for Patients with Early Septic Shock. The new england journal of medicine, 1-11. DOI: 10.1056/NEJMoa1404380

Bone, R.C., Balk, R.A., Cerra, F.B., Dellinger, R.F., Fein, A.M., Knaus, W.A., & Sibbald, W.J. (1992). Definitions for Sepsis and Organ Failure and Guidelines for the use of innovative therapies in Sepsis. Chest. 101. 1644-1655. DOI 10.1378/chest.101.6.1644

Carneiro, A. H., Andrade-Gomes, J., & Póvoa, P. (2016). Cara sépsis-3, lamentamos dizer-lho, mas não gostamos de si. Medicina Interna, 23(4), 56-60.

Delawder, J.M., & Hulton, L., (2019). An interdisciplinary code sepsis team to improve sepsis-bundle compliance: a quality improvement project. Journal of Emergency Nursing, 2019, 1-8.

El Khuri, C., Dagher, G.A., Chami, A., Chebl, R.B., Amoun, T., Bachir, R., Jaafar, B., & Rizk, N. (2019). The Impact of EGDT on Sepsis Mortality in a Single Tertiary Care Center in Lebanon. Emergency Medicine International, 2019. 1-8. Disponível em:

Ferrer, R., Martin-Loeches, I., Phillips, G., Osborn, T.M., Townsend, S., Dellinger, R.P., Artigas, A., Schorr, C. & Levy, M.M. (2014). Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic Shock From the First Hour: Results From a Guideline-Based Performance Improvement Program. Critical Care Medicine. 42 (8). 1749-1755. DOI: 10.1097/CCM.0000000000000330

Francis, M., Rich, T., Williamson, T., & Peterson, D. (2009). Effect of an emergency department sepsis protocol on time to antibiotics in severe sepsis. Canadian Journal of Emergency Medicine, 12(4), 303-10.

Husabø, G., Nilsen, R.M., Flaatten, H., Solligård, E., Frich, J.C., Bondevik, G.T., Braut, G.S., Walshe, K., & Hovlid, E. (2019). Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study. Plos One, 15(1).

McColl, T., Gatien, M., Calder, L., Yadav, K., Tam, R., Ong, M., Taljaard, M., & Stiell, I. (2016). Implementation of an Emergency Department Sepsis Bundle and System Redesign: A Process Improvement Initiative. Canadian Journal of Emergency Medicine, 0 (0), 1-10. DOI 10.1017/cem.2016.351

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., McGuinness, L. A., Stewart, L. A., Thomas, J., Tricco, A. C., Welch, V. A., Whiting, P., & Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj, 372, n71.

Peltan, I.D., Brown, S.M., Bledsoe, J.R., Sorensen, J., Samore, M.H., Allen, T.L., & Hough C.L. (2019). ED Door-to-Antibiotic Time and Long-term Mortality in Sepsis. Chest, 155(5), 938-946.

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Kumar, A., Sevransky, J. E., Sprung, C. L., Nunnally, M. E., Rochwerg, B., Rubenfeld, G. D., Angus, D. C., Annane, D., Beale, R. J., Bellinghan, G. J., Bernard, G. R., Chiche, J. D., Coopersmith, C., … Dellinger, R. P. (2017). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine, 43(3), 304-377. DOI: 10.1007/s00134-017-4683-6

Santos, E. J. F., & Cunha, M. (2013). Interpretação Crítica dos Resultados Estatísticos de uma Meta‐Análise: Estratégias Metodológicas. Millenium, 44, 85‐98.

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J. D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., Van der Poll, T., Vincent, J. L., & Angus, D. C. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 315(8), 801-810. DOI: 10.1001/jama.2016.0287.

Song, J., Cho, H., Park, D.W., Sejoong, A., Kim, J.Y., Seok, H., Park, J., & Moon, S. (2019). The Effect of the Intelligent Sepsis Management System on Outcomes among Patients with Sepsis and Septic Shock Diagnosed According to the Sepsis-3 Definition in the Emergency Department. Journal of Clinical Medicine, 8,1-12. DOI: 10.3390/jcm8111800

Tufanaru, C., Munn, Z., Aromataris, E., Campbell, J., & Hopp, L. (2017). Chapter 3: Systematic reviews of effectiveness. In E. Aromataris & Z. Munn (Eds.), Joanna Briggs Institute Reviewer's Manual: The Joanna Briggs Institute.

Tse, C.L., Lui, C.T., Wong, C.Y., Ong, K.L., Fung, H.T., & Tang., S.Y.H. (2017). Impact of a sepsis guideline in emergency department on outcome of patients with severe sepsis. Hong Kong Journal or Emergency Medicine, 24(3), 123-131.



How to Cite

Ferreira, C., Dias, A. M., & Santos, E. (2021). Performance protocols in the approach to the patient with sepsis in the emergency department: a systematic review with meta-analysis . Millenium - Journal of Education, Technologies, and Health, 2(9e), 91–99.



Life and Healthcare Sciences