Sepsis: A Challenge for all Nurses

By Patricia O’Malley PhD, RN, CNS and Tracy Morrison MSQA, BSN, RN

Sepsis is a global burden. About 27 million people develop sepsis each year. Of the 19 million who survive sepsis, many have lifelong burdens of disability from the deadly immune response against the infection and against their own bodies. Sepsis doesn’t discriminate; everyone is at risk of death from sepsis, which can result from the most minor infection. Each year, 8 million adults and 6 million children die from sepsis. Sepsis is the most common cause of maternal death in the world. In the United States, of every 100,000 people, 233 will experience stroke in their lifetime, 208 will have myocardial infarction, 333 will have breast or prostate or lung cancer, and 22.8 will have HIV. Of that same number, 377 people will experience sepsis. 

Sepsis arises when the body's response to an infection injures its own tissues and organs. It may lead to shock, multiple organ failure, and death, especially when not recognized early and treated promptly.   A local infection leads to systemic inflammation or Systemic Inflammatory Response Syndrome (SIRS).  

Organs begin to fail one by one beginning with the person’s weakest link – respiratory failure, gastrointestinal bleeding, or kidney failure.  Blood pressure declines as toxins vasodilate the circulatory beds. Cellular hypoxia and low tissue perfusion create the perfect environment for further organ failure. Vascular dehydration and rising lactate mark the beginning of a possible point of no return. The patient is apathetic and initially looks “good” despite the low blood pressure. But once the vasodilated vascular beds become increasingly empty, the warm shock becomes cold shock. The patient now is cold, pale and hypotensive. Lactate continues to rise, perfusion fails, and tissues begin to die. 

SEPSIS IS AN EMERGENCY! 

It is possible to make a difference in mortality and morbidity associated with sepsis through monitoring and early intervention. Graph 1 shows the incredible benefit of early recognition and beginning antibiotics quickly to save lives! 

Graph 1. Survival Benefit with EARLY Antibiotic Therapy 

Kumar A, Roberts D, Wood KE, et al.: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.  Crit Care Med, 34: 1589-1596, 2006.©

Because early recognition and treatment saves lives, EPIC has a built in warning system or Sepsis Best Practice Alert (BPA). The BPA fires when the patient has three or more warning signs of sepsis: Temperature over 100.4 F or below 96.8 F Respiratory rate >20 or PCO2 <32 Pulse >90/minute WBCs > 12,000 or <4,000.

This early warning system asks the nurse to pause and complete a sepsis screening since other pathology can have similar physiological findings. 

If the BPA tells you the patient is at risk, assess the patient! Complete the nursing assessment screen.  Perform one or more of the following actions suggested in EPIC: 

• Collaborate with your team leader 
• Notify the physician using SBAR and report that the patient may have early signs of sepsis 
• Initiate an ACT alert for concerns regarding patient clinical status or if response to sepsis symptoms is delayed. 
• Suggest the physician consider using the Sepsis Order Set 

Completion of the Sepsis Screen in EPIC will provide 12 hours of relief from further alarms.  If after 12 hours, the patient continues to have warning signs, the BPA will fire again, which will require a reassessment via the Nursing Assessment Sepsis Screen.

Why all this focus on sepsis? 

First, sepsis is a core measure for hospitals to report, according to CMS. It’s an all-or-nothing metric. To be compliant, hospitals need to meet all of the measures. 

Within 3 hours of presentation: Severe Sepsis:

• Measure serum lactate
• Obtain blood cultures prior to antibiotics
• Administer antibiotics

Within 6 hours of presentation: Severe Sepsis

• Repeat serum lactate if initial lactate is >2

Within 3 hours of presentation for Septic Shock:

• Measure serum lactate
• Obtain blood cultures prior to antibiotics
• Administer antibiotics
• Resuscitation with 30mL/kg crystalloid fluids

Within 6 hours of presentation for Septic Shock:

• Repeat volume status and tissue perfusion assessment
• Vasopressor administration (If hypotension persists after fluid)

Second, the New Knowledge, Innovations and Improvements Council of Premier Shared Governance (NKII Council) received a request from nursing staff to evaluate the Sepsis BPA and charged NKII to reduce the number of BPA alarms. 

The NKII Council in collaboration with nursing leadership, quality improvement, advanced practice and Jessica Slater RN from MICU MVH compared the Premier Sepsis BPA with current literature and other centers within Ohio as well as in other states. The Premier Sepsis BPA was found to be comparable and in many cases better than other center Sepsis BPAs.  

Next, alarm frequency was assessed. Open chart reviews revealed alarms were answered. However, the nursing assessment screen was bypassed and not completed. This resulted in continuing alarms.   

As a result, the NKII council, with the assistance of the EPIC team, modified the inpatient Sepsis BPA to be more identifiable to encourage completion. Second, NKII with assistance of the Premier Learning Institute has developed a short HealthStream module for all staff that will be launched in December.   

Make sure to watch the video from the Sepsis Alliance. You will never think about sepsis in the same way again. It is incredible and reminds all of us to watch, monitor and look for signs of sepsis. Use the evidence-based Sepsis BPA and nursing assessment screen to reduce alarms and keep patients safe! 

For the future, the NKII council, along with Quality Improvement, will continue to monitor the number of BPA alarms and completed nursing assessment screens in response to the BPA for all hospitals. The goal is fewer alarms and safer practices.

NKII Council thanks all that collaborated with us in this journey, including System CNO Syl Trepanier, hospital CNOs, the EPIC team, nursing informatics, quality improvement, sepsis alliance, and nurses across the system that provided ideas and evaluation. We will let you know the results of this project through Shared Governance Councils in 2017. The NKII Council is proud to have helped nursing, patients and the organization with this issue. We are here to serve!

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Source: Premier Health Nursing