replies
Sepsis
Aiza Butt, Hector Cortes, Theresa Weinschrott
Purdue University Northwest
Meghan McGonigal-Kenney, PHD, RN
NUR 45200 Quality and Safety for Professional Nursing Practice
September 4, 2022
Background of the problem
Definition: Sepsis is an inflammatory response to infection that can lead to organ failure. When the inflammatory response becomes generalized it can cause tissue hypoxia ultimately leading to dysfunction of organs and death (Gyawali et al.,2019).
According to Taeb et al. (2017), “Sepsis is associated with high morbidity and mortality, with estimates of more than $20 billion in annual U.S. healthcare expenditures.The incidence of severe sepsis in the United States is estimated to be about 300 cases per 100,000 population” (p. 296).
PICO Question: In emergency department patients, can using the sepsis bundle help identify sepsis earlier when compared to the current sepsis protocol on this unit in order to decrease mortality rate?
Problem: Sepsis rates have risen over 20% in the past year in our facility.
Goal: Improving the speed and accuracy of sepsis detection to decrease sepsis rates and lower mortality.
Search Strategy: The search strategy involves using PICO question and PICO template, using broad search terms initially, and then narrowed down to specific terms, scholarly article nursing databases, evidence based studies, national statistics, unit based data metrics.
Analysis of Current Condition
Sepsis rates at our facility have risen over 20% during the past year. We decided that the best way to reduce our sepsis rate was to place a sepsis alert system into our emergency department. Our current process is as follows. A patient comes into the ED (either by foot or by ambulance). We perform a basic assessment and triage the person. If the patient’s temperature is 101 or less, we place them in a regular ED room and screen them for COVID. They are seen by the physician in the order in which they arrived and based on their acuity. The doctor will then order labs to be drawn. Usually, we draw a chemistry profile (12 labs), a complete blood count, a sputum, and a urinalysis. The results take about 1-2 hours to come back. Unless we are looking for the lab results, we do not see them.
If the WBC comes back over 12, we start them on a broad-spectrum antibiotic until we know what specific antibiotic will work. This usually takes about 24-48 hours to determine. By that time the patient is usually in a hospital room.
We want to know if there is a better way to identify sepsis patients quickly and if there is a faster way to start treatment. We would love an evidence-based protocol we can follow.
Evidence
The evidence was found using key terms and Boolean Operators such as “sepsis” AND “bundle” AND “emergency room”. This was narrowed down to “sepsis patients” OR “emergency room” AND bundle OR protocol AND treatment OR diagnosis. We narrowed down the articles to the most recent research in the last 5 years. We used different databases such as CINAHL, Pubmed or Google search. We also paid attention to the type of evidence that was used in the articles to find the most reliable article.
The evidence suggests that using a sepsis bundle protocol has increased sepsis recognition, prompting earlier treatment resulting in decrease in mortality rates of emergency room patients with sepsis.
Sepsis Data
Our unit: blue Comparison unit 1: orange Comparison unit 2: grey
AAnaAAAAAA
Table and graph with narrative (use data from assigned problem)
Flowchart comparing current process versus what evidence says should be done with narrative identifying missed opportunities (indicators).
Analysis of Current Condition: What is Currently Being Done
Patient arrives in ED
Triage assessment with vitals: Temperature 101 or less?
Yes
Admit to ED room and COVID screen
Seen by physician in order of arrival and acuity
Labs drawn:
CBC/CMP
Sputum Sample
Urinalysis
Wait 1-2 hours
for results
WBC count >12?
Yes
Start on broad spectrum antibiotics:
Wait 24-48 hours to determine which specific antibiotic might work
Analysis of Current Condition: What Needs to be Done
Patient arrives in ED
Sepsis Red Flag Assessment: Systolic BP< or= 90?
HR>130?
RR>25?
O2 sats< or
=92?
Yes
Admit to ED room
Administer oxygen as needed to keep sats>94%
COVID screen
Pt to be seen by physician in order of acuity
Labs drawn: CBC/CMP/ LACTATE
Yes
Is Lactate > or = 2?
START SEPSIS SIX PATHWAY
Keep 02 sats>94%
Collect Blood Cultures
Administer IV antibiotics: Always verify Allergies First!!
Administer IV fluids: if Lactate > or= 2: 500 mL STAT
Check serial lactates
Measure urine output: urinary catheter if indicated
Cause Analysis
Possible causes that may be contributing to the problem of delayed sepsis recognition and treatment on our unit have been identified here. Our unit is currently not measuring serial lactates, which we have identified as a key component to diagnosing sepsis in a timely manner. It is one of the key components to the sepsis six bundle (Rhee et al., 2016).
Action Plan
| Indicator | Evidence | Measurement | Goal | Implementation |
| Serial lactate measurement | Measuring lactate levels has been shown to prompt aggressive early treatment of sepsis (Bakker, 2017). | Charts will be audited to check for lactate results..Data will be collected on the number of patients diagnosed with sepsis who had a lactate drawn within the first hour of ER arrival (numerator) out of the total number of septic patients (denominator). | 100 percent of septic patients will have had their first lactate level drawn within one hour of admission | ER clinical staff will be educated on the importance of serial lactate measurements in order to identify/treat sepsis promptly. |
| Administer IV fluids within 2 hours | A MAP that is is less than 60 mmhg can result in lack of perfusion to organs causing organ failure (Taeb et al., 2017). | The data collected will be blood pressure measurements every 30 minutes to ensure that organs remain perfused. MAP should be greater than 60 mmhg. # of blood pressures taken Q 15 mins/ # of blood pressures taken | 100% of septic patients will maintain a MAP greater than 60 mmhg | ER staff will take routine vitals every 15 mins for suspected sepsis patients. |
Action Plan (Continued)
| Indicator | Evidence | Measurement | Goal | Implementation |
| Multidisciplinary support for septic patients | According to Taeb et al. (2017), “A multidisciplinary approach to assessment and management of septic patients is recommended. Nursing, nutrition support, respiratory therapy support, and pharmacy are critical to achieving good outcomes” (p. 304). | # of patients that receive multidisciplinary support/ # of total septic patients. Overall patient comfort level will be measured by a patient satisfaction survey. | 100% septic patients will verbalize improved quality care/life. 100% of septic patients will receive multidisciplinary support. | Nursing, respiratory, physician, CNA, staff will receive education on multidisciplinary support to improve compliance of comfort care for septic patients. |
| If sepsis is suspected, call sepsis code and start a time sensitive bundle. Evaluate the patient, initiate sepsis screen, early management bundle and sepsis order set. | It’s been noted that delays in sepsis recognition and treatment leads to higher mortality rates (Gunsolus, Sweeney, Liesenfeld & Ledeboer, 2019). | Number of sepsis code called (numerator)/Number of sepsis patients (denominator). | Sepsis code will be called 100% of the time when the patient is suspected of sepsis. | Use of a sepsis checklist to initiate septic bundle. |
| If non responsive to Fluids, begin vasopressors within 4 hours | A MAP that is is less than 60 mmhg can result in lack of perfusion to organs causing organ failure (Taeb et al., 2017). | The data collected will be blood pressure measurements every 30 minutes to ensure that organs remain perfused. MAP should be greater than 60 mmhg. # of pts non responsive to fluids/Total # of septic pts on fluids | 100% of septic patients will maintain a MAP greater than 60 mmhg | ER staff will take routine vitals every 15 mins for suspected sepsis patients and response to fluids |
Reference Page
Bakker, J. (2017). Lactate is the target for early resuscitation in sepsis. Revista Brasileira de Terapia Intensiva, 29(2), 124-127. https://doi.org/ 10.5935/0103-507X.20170021
Gunsolus, I. L., Sweeney, T. E., Liesenfeld, O., & Ledeboer, N. A. (2019). Diagnosing and Managing Sepsis by Probing the Host Response to Infection: Advances, Opportunities, and Challenges. Journal of clinical microbiology, 57(7), e00425-19. https://doi.org/10.1128/JCM.00425-19
Gyawali, B., Ramakrishna, K., & Dharnoon, A. (2019). Sepsis: The evolution in definition, pathophysiology, and management. Sage Open Medicine, 7, 2050312119835043. https://doi.org/10.1177/2050312119835043.
Igiebor, O., Nakeshbandi, M., Mehta, N., Ozaki, R., Lucchesi, M., Daley, M., Salifu, M. O., & McFarlane, S. I. (2020). Impact of Sepsis Intervention Protocol (SIP) on Adherence to Three-hour and Six-hour Bundles and Mortality Outcomes in the Emergency Department. International journal of clinical research & trials, 5(2), 149. https://doi.org/10.15344/2456-8007/2020/149
Rhee, C., Murphy, M., Li. L., Platt, R., & Klompas, M. (2016). Lactate testing in suspected sepsis: Trends and predictors of failure to measure levels. Critical Care Medicine, 43(8), 1669-1676. https://doi.org/ 10.1097/CCM.0000000000001087
Taeb, A. M., Hooper, M. H., & Marik, P. E. (2017). Sepsis: Current definition, pathophysiology, diagnosis, and management. Nutrition in Clinical Practice, 32(3), 296–308. https://doi.org/10.1177/0884533617695243.