Knowledge assessment of Sepsis Diagnosis and Management during COVID-19 pandemic among House O � cers & Medical O � cers in Ibrahim Malik Teaching Hospital in Khartoum State , Sudan , 2021

ElMuiz Abdelrahman Medical student, University of Khartoum, Faculty of Medicine, Khartoum, Sudan Khabab Abbasher Hussien Mohamed Ahmed Medical student, University of Khartoum, Faculty of Medicine, Khartoum, Sudan Ibrahim Mahgoub Medical Student, University of Khartoum, Faculty of Medicine, Khartoum, Sudan Mohammed Eltahier Abdalla Omer (  Mohammedeltahier100@gmail.com ) MBBS, Gadarif University Faculty of Medicine and Health Sciences Yassin Abdelrahim Abdalla MBBS, Omdurman Islamic University, Faculty of Medicine and Health Sciences Abdelgadir Ali Bashir Associate professor of Community Medicine, University of Khartoum, Faculty of Medicine, Khartoum, Sudan


Background
Sepsis is a life-threatening infection syndrome reaction, which is usually the common end of death for many infectious diseases around the world.. It involves organ dysfunction caused by a dysregulated host response to infection and may lead to death if left untreated. [1] Sepsis also represents a global health problem in terms of morbidity, mortality, social and economic costs. Although usually managed in Intensive Care Units, sepsis showed an increase prevalence among Internal Medicine wards in the last decade. This is substantially due to ageing of population and to multi-morbidity. [3] However, there is consensus that the incidence is increasing, driven by an ageing population with multiple comorbidities, increased use of immunosuppressive therapy and high-risk interventions. Mortality estimates for sepsis range from 27% to 36; however, the risk of death from sepsis has been falling over the recent decades despite the increasing incidence, perhaps due to improvement in care. [6]In the community, sepsis is usually a clinical exacerbation of a common and preventable infection. Sepsis also frequently results from infections acquired in health care settings, which are one of the most frequent adverse events during care delivery and affects hundreds of millions of patients worldwide every year. [1] Recent progress in sepsis research has been able to improve the knowledge about the basic pathophysiological process of sepsis. However, in daily ICU practice it remains di cult to identify and treat sepsis, its related conditions, adequately. There are still concerns about the lack of a consistent de nition and understanding of sepsis in the global medical community. [7] Sepsis is the presence of a documented or strongly suspected infection, with a systemic in ammatory response, as indicated by the presence of some of the following features-body temperature greater than 38 ºC or less than 36 ºC, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min or hyperventilation with PaCO2 less than 32 mmHg, White blood cell count > 12,000/mm 3 , <4,000/mm 3 , or with >10% immature neutrophils. Severe sepsis is sepsis complicated by acute circulatory failure characterized by persistent arterial hypotension, despite adequate volume resuscitation, and unexplained by other causes. [7] In the case of COVID-19, the effects on the respiratory tract are known, and most people are hospitalized and develop pneumonia to varying degrees; however, virtually all other organ systems are affected. When available, the Global Sepsis Alliance can more clearly emphasize that COVID-19 does cause sepsis. Approximately 2-5% of COVID-19 patients show typical signs of multiple lesions of sepsis after approximately 8-10 days. COVID-19 died of sepsis and its complications, so it is important to understand and recognize the early signs of sepsis and start treatment immediately after the diagnosis is made. [13] The Global Sepsis Alliance stated that COVID-19 can cause sepsis, which is the body's overwhelming lifethreatening response to infection, which can lead to organ damage or death. [14] Sepsis is a life-threatening syndromic response that my lead to death if left untreated. Sepsis often presents as the clinical deterioration of common and preventable infections. The increase in the incidence and severity of sepsis may be related to population aging, immunosuppression and multidrug resistant infections. On this connection, the majority of cases of sepsis (about 60-80%) have been observed in patients over 65 years old, with a 30-times increase in over 85 years old. At present, most of patients referring to Emergency Department (ED) share the above-mentioned features (Eg old age, chronic diseases) and quite a lot of sepsis patients are hospitalized from emergency room to non-intensive care unit. [3] Since diseases caused by infections are common in Sudan thus Sepsis cases will always be present. However, sepsis being a preventable case if diagnoses early and managed adequately. Thus House O cers and Medical O cers must have su cient knowledge regarding the diagnosis, management and other important medical information regarding sepsis otherwise the cases will be missed on its early stages or not managed su ciently or any form of low performance which will cause the septic patient to die a preventable death. Sepsis remains a major cause of morbidity and mortality worldwide, with increased burden in low-and middle-resource settings.
Sepsis and COVID-19 have many similarities, but the direct shift of sepsis management to COVID-19 management requires a little care.The pathophysiology of COVID-19 is currently not fully understood and seems to vary from person to person. Sepsis remains a major health burden worldwide and all protocols are poor. It is also important to note that further evaluation is needed in the context of COVID-19. In fact, with fast collaborative efforts towards COVID-19, perhaps sepsis management can ultimately see more bene ts from COVID-19. [15] Our research has assessed both the House o cers and Medical o cers' knowledge upon diagnosing and properly managing sepsis cases in Ibrahim Malik Teaching hospital. Thus my ndings are of substantial value because it re ects whether the House o cers and Medical o cers in Ibrahim Malik Teaching hospital are will prepared to deal with life threatening cases of Sepsis and potentially saving their patients' lives. Also my ndings are determining whether further trainings should be conducted regarding sepsis diagnosis and management thus not to let septic patients die a preventable death. It is shedding the light to Medical colleges and Hospital medical staff to give this topic more attention for the future and current House and Medical o cers. Tools and Date collections:

OBJECTIVES
The data was collected using interview-based questionnaires. This questionnaire is an author-structured questionnaire with the objective of assessing the knowledge upon Sepsis diagnosis and management. The criteria used in this questionnaire was inspired from a paper done by Keeley A et al. [12] The questionnaire contains four sections. Section One contains written consent & Socio-demographic informations. Section Two involves General knowledge and Insight about sepsis, including assessing the impact on performance on previously trained O cers upon sepsis. As well as assessing their insight on their knowledge upon sepsis diagnosis and management. Section Three deals with Sepsis diagnosis criteria, the criteria included SIRS criteria, Severe sepsis criteria, Septic shock criteria and nally qSOFA score criteria. Section Four composed of Sepsis treatment and management.
Sepsis six management bundle was used as the assessment base.

Results
Baseline characteristics: We enrolled 155 participants 66% of them was female, mean age was 25 (SD=1.7) 66% was house o cer and 55% receive training upon how to diagnose, manage and prevent sepsis. (Table 1)  Majority of participants stated that they are not too knowledgeable about sepsis, its treatment and complications associated with it (62%). 57% view sepsis as a condition and 21% view it as a syndrome 61% stated that they know difference between sepsis and septic shock. (Figure 1, 2

and 3)
Knowledge about sepsis diagnosis: On asking 10 questions related to knowledge about sepsis diagnosis the most answered wrongly question was the platelet count on sepsis (92% answered wrongly) followed by creatinine and bilirubin level (88% answered wrongly). the most answered correctly question was leukocytes status (55% answered correctly). ( gure 4) 30% of participants know that the only difference between systemic in ammatory response syndrome (SIRS) and sepsis is presence of infection. ( Figure 5) On asking about qSOFA criteria 19% know that respiratory rate must be more than 22 breaths per second, 16% know that systolic blood pressure must be more than 100 mmHg and 29% knows that Glasgow coma scale is included speci cally in qSOFA criteria. (Figure 6, 7 and 8) Knowledge about sepsis treatment and management: On asking eight question regarding sepsis management majority of participants did not know what meant by sepsis six bundle, the most answered wrongly question was glucose level target (88% answered wrongly) the most answered correctly question was type of antibiotic used (65% answer correctly). (Figure 9) Knowledge Score: The mean knowledge score about sepsis diagnosis was 2.6 out of 10 (SD= 1.8), and about sepsis management was 2.8 out of 8 (SD=1.8) the mean overall score was 5.5 out of 18. (Table 2) No signi cant difference found between participants who were trained upon diagnosis and management of sepsis and those who were not. (Table 3)   Participants were asked the uid volume challenge that they would prescribe for each patient. Responses were compared with the Surviving Sepsis Campaign's recommended volume during the study (20 ml/kg). [9]. This similarity in poor management results only shows that its due to poor training and focus upon sepsis as a topic regarding its management. Even though 55% of the participants received training upon Sepsis, the results showed no signi cant difference between the trained and the non-trained nor the clinical experience between House o cers and Medical o cers whereas the overall median score knowledge to the trained participants is 6 in similar to the score of 5 to the non-trained participants in similar to a study done by Michael Courtney, Bussa Gopinath, Matthew Toward, Rajesh Jain, Milind Rao done in in two UK hospitals, with 77 questionnaires were completed. In 2014 that showed there was no signi cant difference between doctor grades (FY1 and SHO) in any scenario [9]. This is most likely that Sepsis as topic overall is complicated when it comes to de nition and perception of its diagnostic criteria, and poor training might have a signi cant role in it as well. In my study assessments of participants' insight about their knowledge it showed that the majority of participants stated that they are not too knowledgeable about sepsis, its treatment and complications associated with it (62%) in contrast to a study was done by Elizabeth Roebuck in Sept. 2015 in North England with over 144 clinicians completed the survey, gaining a 21.8% response rate. 54% of clinicians felt like they had good knowledge, leaving 46% of clinicians feeling a lack of knowledge [10]. This difference in knowledge and con dence is most likely attributed to the quality of training in college level and the hospital setting. In my study asking about qSOFA criteria 19% know that respiratory rate must be more than 22 breaths per second, 16% know that systolic blood pressure must be more than 100 mmHg and 29% knows that Glasgow coma scale is included speci cally in qSOFA criteria. Thus overall poor performance in similar to a study done by Merijn C F Mulders, Feike J Loots, Joey van Nieuwenhoven, Jan C ter Maaten, Hjalmar R Bouma in March 2021 Two thousand ve hundred and sixty GPs were invited and 229 agreed to participate in a survey, reached out to through e-mail and WhatsApp groups. And mainly the results showed that few of the responding GPs had heard of the qSOFA (27.7%) [11]. This clear lack of knowledge of qSOFA criteria and its importance in early septic patients' assessment is most likely manifested in poor training in both college and hospital settings.In my study regarding the participants' knowledge upon the main difference between SIRS and Sepsis is that 30% of participants know that the only difference between systemic in ammatory response syndrome (SIRS) and sepsis is presence of infection.

Conclusion
The Study ndings illustrated that the capacity to perceive and manage sepsis among Teaching hospital database doesn't re ect the actual number practicing in the hospital and actually they're way less than the available number. All of this contributed to not reaching the goal sample size and had to settle to 78% response rate. Figure 1 How knowledgeable are you about sepsis, its treatment and complications associated with it Knowledge about difference between sepsis and septic shock participant's response about sepsis management questions