Emergency Room Sepsis Bundle Practicum

Emergency Room Sepsis Bundle Practicum

The objectives of this practicum are three-fold as follows:

To assess a tertiary healthcare facility's emergency room nursing staff's current level of knowledge concerning the diagnosis of sepsis;

To assess a tertiary healthcare facility's emergency room nursing staff's current level of knowledge concerning the treatment of sepsis; and,

To provide guidelines for providing a sepsis resuscitation bundle that can be used for these applications to achieve a 25% reduction in mortality due to severe sepsis or septic shock.

Strategies for practicum

It is axiomatic that in order to improve anything, it must first be measured. Therefore, the practicum proceeds in a series of stages that are designed to first assess nursing staff's current level of knowledge concerning the diagnosis and treatment of sepsis and then to develop training opportunities that address identified weaknesses. This strategy is consistent with the results of a study of more than 400 patients presenting with severe sepsis or septic shock at a tertiary referral center in which absolute mortality declined from 48% to 27% during a 2-1/2-year period following implementation of a resuscitation bundle (Kilgore, 2008). According to the Society of Critical Care Medicine's Surviving Sepsis Campaign literature, "A 'bundle' is a group of therapies for a given disease that, when implemented together, may result in better outcomes than if implemented individually" (Severe sepsis bundles, 2011, para. 1). The sepsis bundle brings together individual evidence-based treatment elements and should be regarded as a best practice (Severe sepsis bundles, 2011). According to the clinicians at the Society of Critical Care Medicine, "The purpose of creating a bundle strategy is to clearly articulate a therapeutic framework that will function as a lever for change. We anticipate that making the Severe Sepsis Bundles standard practice will eliminate the piecemeal or chaotically applied of standards for sepsis care that characterize many clinical environments today" (Severe sepsis bundles, 2011, para. 2).

The sepsis bundle advocated by the Society of Critical Care Medicine (2011) is set forth in Table 1 below.

Table 1

Recommended Sepsis Resuscitation Bundle

Bundle Element

Step

Rationale/Implications

Corresponding Bundle Element

Bundle Element No. 1

Measure serum lactate

Given the high risk for septic shock, all patients with elevated lactate >4 mmol/L (36 mg/dL) enter the early goal-directed therapy portion of the Severe Sepsis Resuscitation Bundle, regardless of blood pressure.

Serum lactate measured.

Bundle Element No. 2

Obtain blood cultures prior to antibiotic administration

Collecting blood cultures prior to antibiotic administration offers the best hope of identifying the organism that caused severe sepsis in an individual patient. Failure to check blood cultures prior to antibiotic infusion will perhaps affect the growth of any blood-borne bacteria and prevent a culture from becoming positive later.

Blood culture obtained prior to antibiotic administration.

Bundle Element No. 3

Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission

Once severe sepsis is identified, antibiotics must be started rapidly to treat the underlying infection. Although early antibiotic administration seems to be an intuitive approach, administration of effective therapies is often delayed. Recent evidence supports that for patients with septic shock, the duration of hypotension prior the administration of antibiotics is a critical determinant in the survival of septic shock.

From the time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non-ED ICU admissions

Bundle Element No. 4

Treat hypotension and/or elevated lactate with fluids

Patients who are hypotensive or have a lactate greater than 4 mmol/L (36 g/dL) require intravenous fluids or colloid to expand their circulating volume and effectively restore perfusion pressure.

In the event of hypotension and/or lactate > 4 mmol/L (36 mg/dL) deliver an initial minimum of 20 mL/kg of crystalloid (or colloid equivalent).

Bundle Element No. 5

Maintain adequate central venous pressure

Goal-directed therapy represents an attempt to predefine resuscitation end points to help clinicians at the bedside to resuscitate patients in septic shock. The end points used vary according to the clinical study but attempt to adjust cardiac preload, contractility, and afterload to balance systemic oxygen delivery with demand.

In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dL) achieve central venous pressure (CVP) of > 8 mm Hg.

Bundle Element No. 6

Maintain adequate central venous oxygen saturation

The resuscitation of severely septic individuals with lactate >4 mmol/L (36 mg/dL) or in septic shock must start early. It seems that the longer the resuscitation is delayed, the less likely a beneficial effect will be accrued.

1. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dL) achieve central venous oxygen saturation (ScvO2) of > 70%.

2. Mixed venous oxygen saturation (SvO2) > 65% is an acceptable alternative.

Source: Severe Sepsis Bundles, 2011

In addition, the Severe Sepsis Quality Indicators set forth in Table 2 below are recommended for use in conjunction with the above-described bundles to help healthcare providers understand the measures that are used to evaluate their progress in improving the care of severely septic patients.

Table 2

Severe Sepsis Quality Indicators

Quality Indicator No.

Definition of Indicator

Specifications

Quality Indicator No. 1: Blood cultures collected before broad-spectrum antibiotic administration for severe sepsis and/or septic shock over the first 6 hours following the time of presentation.

The percent of patients who had blood cultures collected prior to broad-spectrum antibiotic administration for severe sepsis and/or septic shock over the first 6 hours following the time of presentation.

Numerator: the number of patients who had blood cultures collected before broad-spectrum antibiotic administration for severe sepsis and/or septic shock over the first 6 hours following the time of presentation

Denominator: the number of patients presenting with severe sepsis and/or septic shock

Quality Indicator No. 2:

Median time in minutes to broad-spectrum antibiotic(s) administration for severe sepsis and/or septic shock following the time of presentation.

Median time in minutes to broad-spectrum antibiotic(s) administration for severe sepsis and/or septic shock following the time of presentation.

The median time in minutes to broad-spectrum antibiotic(s) administration for severe sepsis and/or septic shock following the time of presentation

Note: For this indicator, time of presentation is determined as follows:

(i) If the patient presented to the ED with severe sepsis and/or septic shock, the time of presentation is the ED triage time.

(ii) If the management of severe sepsis and/or septic shock is annotated in the chart as beginning on a unit transferring the patient to the ICU, the annotated time and date of the initiation of the resuscitation on the transferring unit is the time of presentation.

(iii) If the management of severe sepsis and/or septic shock is NOT annotated as beginning on a unit transferring the patient to the ICU, the ICU admission time is the default value for the time of presentation.

(iv) If the patient is newly treated for severe sepsis and/or septic shock while in the ICU longer than 24 hours after admission to the ICU for another diagnosis, the annotated time and date of the initiation of resuscitation for the management of severe sepsis and/or septic shock is the time of presentation.

Quality Indicator No. 3:

Central venous pressure (CVP) of > 8 mmHg achieved for septic shock or severe sepsis with lactate > 4 mmol/L

(36 mg/dl) over the first 6 hours following the time of presentation.

The percent of patients for whom a goal CVP of > 8 mmHg was achieved for septic shock or lactate > 4 mmol/L (36 mg/dl) over the first 6 hours following the time of presentation

Numerator: the number of patients for whom a goal

CVP of > 8 mmHg was achieved for septic shock or lactate > 4 mmol/L (36 mg/dl) over the first 6 hours following the time of presentation

Denominator: the number of patients with septic shock or severe sepsis with lactate > 4 mmol/L (36 mg/dl).

Exclusion: patients with non-severe sepsis or severe sepsis with lactate < 4 mmol/L (36 mg/dl)

Quality Indicator No. 4:

Central venous oxygen saturation (ScvO2)* > 70% achieved for septic shock or severe sepsis with lactate > 4 mmol/L (36 mg/dl) over the first 6 hours following the time of presentation

*mixed venous oxygen saturation (SvO2) > 65% may be substituted

The percent of patients for whom a goal ScvO2 > 70% (or SvO2 > 65%) was achieved for septic shock or lactate > 4 mmol/L (36

mg/dl) over the first 6 hours following the time of presentation.

Numerator: the number of patients for whom a goal

ScvO2 > 70% (or SvO2 > 65%) was achieved for septic shock or lactate > 4 mmol/L (36 mg/dl) over the first 6 hours following the time of presentation

Denominator: the number of patients with septic shock or severe sepsis with lactate > 4 mmol/L (36 mg/dl)

Exclusion: patients with non-severe sepsis or severe sepsis with lactate < 4 mmol/L (36 mg/dl).

Quality Indicator No. 5:

Administration of low-dose* glucocorticoids for septic shock determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation

The percent of patients for whom administration of low-dose glucocorticoids for septic shock was determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation.

Numerator: number of patients for whom administration of low-dose glucocorticoids for septic shock was determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation

Denominator: total number of patients with septic shock

*Low-dose glucocorticoids refer to a daily dose of 200

300 mg of hydrocortisone or equivalent.

Quality Indicator No. 6:

Administration of drotrecogin alfa (activated) for severe sepsis and/or septic shock in accordance with a standardized ICU policy over the first 24 hours following the time of presentation.

The percent of patients for whom administration of drotrecogin alfa (activated)

for severe sepsis and/or septic shock was determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation.

Numerator: number of patients for whom administration of drotrecogin alfa (activated) for severe sepsis and/or septic shock was determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation

Denominator: total number of patients presenting with severe sepsis and/or septic shock.

Exclusion: non-severe sepsis.

Quality Indicator No. 7:

Glucose values maintained greater than the lower limit of normal and with a median value < 150 mg/dl (8.3 mmol/L) for severe sepsis and/or septic shock over the period 6 hours to 24 hours following the time of presentation.

The percent of patients for whom glucose values were maintained greater than the lower limit of normal and with a median value

150 mg/dl (8.3 mmol/L) for severe sepsis and/or septic shock over the period 6

hours to 24 hours following the time of presentation

Numerator: number of patients for whom glucose values were maintained greater than the lower limit of normal and with a median value < 150 mg/dl (8.3 mmol/L) for severe sepsis and/or septic shock over the period 6 hours to 24 hours following the time of presentation.

Denominator: number of patients presenting with severe sepsis and/or septic shock

Notes:

1.

Monthly reporting of results is recommended for all indicators.

2.

The definition of severe sepsis, for purposes of the severe sepsis quality indicators, follows the algorithm used in the Evaluation for Severe Sepsis Screening Tool.

3.

The definition of septic shock, for purposes of the severe sepsis quality indicators, assumes failure to maintain MAP > 65 despite compliance with and completion of all elements in the Severe Sepsis Resuscitation Bundle.

Source: Severe Sepsis Quality Indicators

Assess learning needs of ER nurses understanding on sepsis: Pre- and Post-Tests

The questionnaire developed by Drs. Zaka U. Khan and Gary A. Salzman (2006) and published in Hospital Physician (pp. 27-28) shown in Table 2 below will be used to assess emergency room nursing staff's level of knowledge concerning sepsis and its treatment (answers and rationale for correct answers are provided at Appendix A).

Table 2

Proforma Copy of Nursing Sepsis Awareness Questionnaire

Choose the single best answer for each question.

Questions 1 and 2 refer to the following case.

A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate.

1. This patient's condition can best be defined as which of the following?

(A)

Multi-organ dysfunction syndrome (MODS)

(B)

Sepsis

(C)

Septic shock

(D)

Severe sepsis

(E)

Systemic inflammatory response syndrome (SIRS)

2. What is the first step in the initial management of this patient?

(A)

Antibiotic therapy

(B)

-Blocker therapy to control heart rate

(C)

Intravenous (IV) fluid resuscitation

(D)

Supplemental oxygen and airway management

(E)

Vasopressor therapy with dopamine

3. A 40-year-old man with a history of IV drug use presents with cellulitis with multiple abscesses of the right upper extremity. His current weight is 70 kg (lean body weight). He rapidly develops worsening respiratory distress and hypotension and ultimately requires intubation and mechanical ventilation. Blood gas analysis shows a pH of 7.23, Paco2 of 58 torr, Pao2 of 60 torr, and an oxygen saturation of 88%. His ventilator settings are assist-control mode with a tidal volume of 420 mL, respiratory rate of 16 breaths/min, positive end-expiratory pressure (PEEP) of 5 cm H2O, and Fio2 of 70%. His plateau pressure on the ventilator is 29 cm H2O. A chest radiograph shows bilateral interstitial infiltrates, and a 2-dimensional echocardiogram demonstrates normal left ventricular function. What ventilator adjustments should be made?

(A)

Change the ventilator mode to synchronized intermittent mandatory ventilation

(B)

Increase PEEP

(C)

Increase respiratory rate to 24 breaths/min

(D)

Increase tidal volume to 600 mL

(E)

Leave the ventilator settings unchanged

4. Which of the following patients is an ideal candidate for noninvasive positive pressure ventilation (NIPPV)?

(A)

A 30-year-old comatose woman suspected of drug overdose

(B)

A 55-year-old man with acute anterior wall myocardial infarction with cardiogenic shock and recurrent ventricular arrhythmias

(C)

A 60-year-old man with peritonitis requiring 2 vasopressors

(D)

A 65-year-old patient with a massive stroke and inability to protect airway

(E)

A 70-year-old alert patient with respiratory failure due to chronic obstructive pulmonary disease exacerbation.

Following the administration of the questionnaire, respondents will be provided with the correct answers and areas of weakness identified for follow-up in-service training, on-the-spot guidance or other training interventions as deemed necessary. Following the administration of the training sessions designed to address shortcomings in nurses' knowledge, a post-test will be administered to determine if progress was made and if further refinements in the training protocols are necessary.

Define sepsis/list signs and symptoms

According to Jacoby and Youngson (2005), "The body's response to infection from invading bacteria, viruses or other infective agents is called 'sepsis.' In severe sepsis, this response goes out of control, causing inflammation and damage throughout the body's organs and blood system that can kill the patient" (p. 1914). Although severe sepsis can infect any part of the body, the most common sources of infection include: