If you’re an emergency nurse or critical care nurse, you know a killer could show up on your shift.
It won’t be announced. It might be difficult to detect. It will escalate quickly, and it won’t discriminate among patients. It can affect anyone at any time — both the young and the old, and those who are chronically ill and those who are otherwise healthy.
Every two minutes in the U.S., it claims an individual’s life. Every day across the nation, it kills 12 children.
It’s sepsis, the leading cause of death in hospitalized patients. Sepsis kills 258,000 Americans each year — more than the total number of deaths associated with breast cancer, prostate cancer, and AIDS combined.
Reducing the scourge of sepsis has reached near fever pitch among hospitals, in part due to the financial incentives of bundle measures for severe sepsis and septic shock put in place by the Centers for Medicare and Medicaid in 2015 as part of its Hospital Inpatient Quality Reporting program. Even without the prompting of federal healthcare regulations, however, hospitals and professional associations are making the early diagnosis and treatment a top organizational priority.
From the creation of task forces and aggressive treatment algorithms to the development of real-time data sets and community education programs, hospitals are reducing sepsis mortality — some by as much as 50%. Nurse-led interventions, such as evidenced-based screening tools, have shown progress in lowering mortality, as well.
Here’s a look at some of the latest developments, including hot-off-the-press studies, in the clinical identification and management of sepsis:
New Treatment Guidelines
In January the Surviving Sepsis Campaign (SSC), a joint effort of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine, released new guidelines for the clinical management of sepsis.
The new guidelines update previous recommendations published by SSC in 2012. They include revised definitions for sepsis and septic shock, a new emphasis on frequent patient reevaluation, and the tailoring of hemodynamic therapy to individual patients.
The new definitions (the first since 2001) reflect advances in the pathophysiology, epidemiology, and treatment of sepsis and provide consistency in the diagnosis, reporting, and management of the life-threatening illness, according to SCCM.
The guidelines underscore the importance of identifying organ dysfunction in the early recognition of sepsis and encourage clinicians to investigate organ failure whenever they suspect infection. A new diagnostic tool called quickSOFA or qSOFA, an acronym for Sequential Organ Failure Assessment, provides three simple bedside tests that may warn of sepsis risk. Clinicians are urged to evaluate patients for —
- Altered mental status
- A drop in systolic blood pressure of less than 100 mm Hg
- A respiration rate in excess of 22 breaths per minute
Organ dysfunction should be investigated in patients exhibiting two or all three components of qSOFA, according to the guidelines.
SCCM says clinicians also should use updated criteria to diagnose septic shock, including defined levels of persistent hypotension and blood lactate.
The guidelines contain additional clinical recommendations on hemodynamics, infection, adjunctive therapies, metabolic considerations, and ventilation.
Learn more: View the guidelines and other resources from the SSC. Look for continuing education or other learning activities that review the new recommendations, such as this webinar series from the American Association of Critical-Care Nurses.
Regulated Protocols
Although the concept of regulating diagnosis and treatment is hotly debated, particularly among physicians, a new study demonstrates New York State has found success in the use of mandated safety measures for clinical management of sepsis.
“Rory’s Regulations,” named for a 12-year-old boy who succumbed to sepsis in 2012, requires clinicians at New York hospitals to perform a care checklist when sepsis is suspected and follow established evidence-based treatment protocols when it is identified, including early administration of antibiotics.
A National Institutes of Health-funded study published in the New England Journal of Medicine in June found the faster New York patients received a mandated three-hour bundle of sepsis-specific care, the lower their risk of related deaths. The study appears to affirm the state’s own findings that its regulations resulted in a 20% reduction in sepsis mortality among adults. However, it also found that one element of the state’s regulations, the rapid initial bolus of IV fluids, was not associated with lower sepsis mortality in adults.
Learn more: Read the Rory Staunton Foundation’s description of Rory’s Regulations and a synopsis of the recent study. The New York State 2015 Report on Sepsis Care Improvement Initiative: Hospital Quality Performance can be found here.
Long-term Seizure Risk
Although a link between sepsis and a raised risk of seizure in hospitalized patients has long been known, researchers at Weill Cornell Medical Center in New York City have found for the first time a connection between sepsis survival and long-term seizure risk.
The retrospective study, presented at the American Academy of Neurology annual meeting in April, found a higher incidence of emergency department visits or hospitalizations for seizures in patients who had survived sepsis than in the general population. The analysis also demonstrated a higher incidence rate ratio of seizures among sepsis survivors under age 65 than in older survivors.
Learn more: Read expert commentary on both the limitations of the study and its promising implications at Neurology Today.
Delayed Treatment in Overcrowded EDs
A new study has found overcrowded EDs might delay administration of life-sparing antibiotics in patients with sepsis.
Presented at the American Thoracic Society International Conference in May, the study determined that each one-hour delay in antibiotic treatment prompts a 7% to 10% increase in the chances a patient will die from sepsis.
The study’s authors suggest that rapid response team protocols employed for timely therapies for such conditions as stroke, heart attack, and trauma could improve time-sensitive treatment, as well.
Learn more: Sign in to read the complete study at the American Journal of Respiratory and Critical Care Medicine.
Fewer Missed Diagnosis in Pediatric Patients With Electronic Alert
A new tool helps practitioners identify sepsis in pediatric patients seen in EDs, reducing the incidence of missed diagnoses by 76%, according to a study published in June by the American College of Emergency Physicians.
Distinguishing between a child with non-septic fever and tachycardia from a child with sepsis or septic shock can be challenging, say the study’s authors. An electronic alert that combines vital signs and risk factors with physician judgment aids in quick clinical identification and treatment of sepsis in pediatric patients.
Built into a hospital’s electronic health record system, the alert works in two stages. A first-level alert is caused when the EHR documents an elevated heart rate (based on age) or hypotension during any point of a child’s ED visit. A series of questions about high-risk conditions, perfusion, and mental status will also be automatically activated if a pediatric patient presents with fever or risk of infection. Positive answers to the questions will prompt a second-stage alert, which in turn triggers a focused patient evaluation with the treatment team.
An editorial accompanying the study suggests the vital signs-based electronic alert is “both more sensitive and specific than prior alerts, as well as less prone to alert fatigue.”
Learn more: Explore the new protocol and access the full text of the study and accompanying editorial through the Annals of Emergency Medicine. See also another study, presented in May, which details the use of artificial intelligence and an EHR-based algorithm for early detection of sepsis in an academic multi-hospital system.
New Education Tool for Nurses
The Sepsis Alliance, the nation’s largest nonprofit sepsis advocacy organization, debuted a nursing education video at the National Teaching Institute & Critical Care Exposition in May.
The free 20-minute video offers an overview of the symptoms and consequences of sepsis, enabling viewers to recognize warning signs of the illness and understand the interventions necessary to successfully treat it.
The Sepsis Alliances encourages nurses in all settings, who may encounter sepsis in patients before they are referred to an emergency setting, to view the video and share it with their colleagues and patients.
Learn more: Watch and download the video, and keep up to date with other developments in identification and treatment through the Sepsis Alliance.
Eisenhower Medical Center is committed to keeping critical care, emergency, and other nurses on our team up-to-date on cutting-edge clinical developments. See open positions for RNs and apply with us to work with a healthcare leader dedicated to your professional development.
Originally posted on 21/6/2017