The following is a guest blog post by Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse, Health Learning, Research & Practice, Wolters Kluwer.
September is Sepsis Awareness Month—an opportune time to reflect on the state of industry as it relates to reducing the impact of this potentially deadly condition. In terms of reach, the numbers are sobering: 1.5 million people in the U.S. contract sepsis each year, and a quarter of a million die annually from the condition.
In recent years, the healthcare industry has taken important steps to improve the sepsis outlook by keeping awareness and best-practice developments front and center. The Surviving Sepsis Campaign’s (SSC’s) 2018 release of the updated hour-1 bundle reflects this commitment by keeping care delivery in sync with the latest evidence—in this case the International Guidelines for Management of Sepsis and Septic Shock 2016.
The new bundle combines the SSC’s previously-released 3-hour and 6-hour bundles and prioritizes the need for early identification and more immediate response. Nurses play a critical role in this equation as the clinicians working on the frontlines of care. While sepsis is more likely to present in emergency departments and critical care environments, it is imperative that all nurses have the knowledge to quickly identify symptoms and begin appropriate treatment protocols.
The sepsis challenge is both mammoth and complicated, requiring a multi-pronged, multi-disciplinary approach that draws on the latest evidence and institutional accountability. There is much at stake for hospitals in terms of reputation as sepsis performance scores are now published on the Centers for Medicare and Medicaid Services’ Hospital Compare website, where patients can quickly and easily see how their facility of choice stacks up in terms of sepsis mortality.
Consequently, it is more important than ever for hospital clinical leaders to prioritize nursing education on the early signs of sepsis, especially when caring for at-risk patients. In addition, nurses need quick access to hour-1 bundle protocols at the point of care to ensure they are properly following the guidelines to optimize sepsis outcomes and save lives.
Sepsis Bundle Primer
The latest revision of the SSC bundles seeks immediate resuscitation and management of sepsis. In the update, SCC authors note: “We believe this reflects the clinical reality at the bedside of these seriously ill patients with sepsis and septic shock—that clinicians begin treatment immediately, especially in patients with hypotension, rather than waiting or extending resuscitation measures over a longer period.”
The guidelines detail five steps that should take place within one hour of identifying sepsis including:
- Measure lactate level. Remeasure if initial lactate level > 2 mmol/L.
- Obtain blood cultures before administering antibiotics.
- Administer broad-spectrum antibiotics.
- Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L.
- Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg.
The premise of the bundled elements is that the whole is better than the one. When implemented as a group, these protocols have the greatest impact on outcomes.
The Sepsis Knowledge Gap Challenge
Hospitals face nursing knowledge gaps related to sepsis on two fronts: 1) early identification; 2) adhering to best practice protocols. While nurses working in the ED or critical care are likely to have experience with sepsis and the hour-1 bundle, those working on the medical-surgical floor or in other specialty areas often lack a deep understanding of the complexities and urgency surrounding early identification and response.
To promote early identification, nurses need to first understand the symptoms that occur in patients who are septic. Key observations include:
- Extreme high or low temperatures
- Shortness of breath
- Extreme pain or discomfort
- Elevated heart rate and/or low blood pressure
- Cool and clammy skin
While the answers to these questions can provide a baseline, the reality is that sepsis is a complicated diagnosis that requires critical thinking. For instance, fever alone is not always the best indicator of the condition, as hypothermia and low temperatures are often more predictive of severity and death. In addition, nurses need awareness that certain patients are at higher risk of mortality, such as the very young and the elderly or those with certain co-morbidities like COPD, heart failure and diabetes.
The Quick Sepsis Related Organ Failure Assessment (qSOFA) provides an effective point-of-care prompt for identification of a suspected infection. The tool uses three criteria to determine sepsis mortality risk. These include one point for each of the following: low blood pressure (SBP≤100 mmHg); high respiratory rate (≥ 22 breaths per minute); or altered mentation. Nurses need to be educated to use this system and be made aware of alerts that point to these variables. For example, a positive score of 2 or higher would point to the need for intervention by a provider or initiation of rapid response protocols.
Standardizing Sepsis Identification and Response
To eliminate variations in sepsis care and ensure best-practice protocols are followed, hospitals must implement comprehensive and ongoing education programs for nurses that address three areas: 1) identification of early signs of sepsis; 2) hour-1 treatment bundle protocol and 3) use of qSOFA scoring. Technology is an important part of any strategy and should be a priority consideration for both education and point of care guidance.
The best clinical decision support tools at point of care provide automated updating of new evidence as it is established. In the case of the hour-1 sepsis bundle, these solutions foster confidence that nurses have that right information when they are with the patient, and if they forget, a quick look-up can provide the needed guidance.
Access to the most up-to-date digital professional development education resources help nurses garner a deeper understanding of sepsis, the latest standards and practice application. Hospitals can draw on the latest advancements to quickly create customized programs and exams that allow students to progress and master skills at their own unique level.
Sepsis mortality rates sit at greater than 40 percent. In the era of value-based care which focuses on patient outcomes, that’s significant and problematic for hospitals on many levels. Improving sepsis outcomes necessitates that clinical leaders invoke strategies that promote adoption of the latest evidence to move the needle on performance.
About Anne Dabrow Woods
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN is the Chief Nurse of the Health Learning, Research and Practice business unit at Wolters Kluwer. She is also a critical care nurse practitioner for Penn Medicine, Chester County Hospital, and she is adjunct faculty for Drexel University in the College of Nursing and Health Professions.