Nurse compliance and recognition of sepsis following new guideline implementation

New Sepsis Guidelines and Nurses: Factors, Compliance and Consideration

Sepsis refers to the body’s dangerous reaction to an existing infection. Sepsis is extremely serious and if not treated swiftly with appropriate action it can lead to fast tissue and organ damage and death. The medical community has long been focused on getting better control of sepsis, as it is a damaging and debilitating condition that contributes to a host of preventable deaths. In fact, sepsis is one of the primary reasons for death in the number of hospitalized patients and is the cause of 20% of all admissions to intensive care units. (Ferrer et al., 2008). This data clearly indicates that sepsis is an aggravated problem that experts need to have better protocol for and preventative measures to counteract. In America, the rate of death from sepsis is one of the highest rates in the world with a mortality rate almost as high as 30% (Ferrer et al., 2008). This paper examines the new sepsis guidelines and all factors connected to these guidelines, such as the factors that provoked new guidelines, who the new guidelines impact the most, what this means for clinicians, and to what rate of success nurses and other healthcare professionals have been successful in implementing these new guidelines. Nurses are at the front lines of patient care and can often have a more powerful impact on patient wellness than physicians. This paper will review all relevant literature connected to sepsis guidelines, and seek to determine what needs to more aggressively change in the medical community in order to drastically minimize the rate of occurrence.

Most healthcare professionals are aware of the benefit of educational programs and interventions like the Surviving Sepsis Campaign (Rhodes et al., 2016). Campaigns like the Surviving Sepsis Guidelines offer just under 100 suggestions on the immediate management and resuscitation of patients with sepsis or septic shock; from this group the strongest recommendations were selected for the most excellent care of patients with this condition. Though it is important to note that not all clinicians support the implementation of new sepsis guidelines and methods; some believe that changes, which are too radical, could actually undermine efforts to stop or prevent sepsis (Simpson, 2016).

However, it’s important to engage in a thorough literature review on the subject since sepsis mortality and manifestation rates are still robust. Even though many clinicians have been subjected to the rigors of such educational movements such as Surviving Sepsis, there are still gaps in understanding why these interventions aren’t more effective. It’s definitely possible that many of the educational interventions, programs and campaigns have been too rigorous for the fast-paced and high stakes world of professional healthcare, medicine and the emergency department. It’s also possible that despite the educational attempts at sepsis care and prevention with clinicians, the knowledge might be there, however there still might be gaps in understanding. Hence, the more rigorous the literature review is, the more it will shed light on the practical improvements that need to be made in the case of this debilitating issue.

The article, “Improvement in Process of Care and Outcome After a Multicenter Severe Sepsis Educational Program in Spain” by Ferrer and colleagues seeks to determine how closely clinicians are following the new sepsis guidelines. This paper posits that better training and education can help bridge any gaps in understanding by ensuring that clinicians are all on the same page with the best practices. However, the authors of this study wanted to determine how effective such an educational program was on daily practices. This study examined 854 patients and engaged in a rigorous intervention with doctors and nursing staff from the ER department. Ultimately the study found that the educational intervention manifested in improved compliance, but not total compliance (Ferrer et al., 2008).

In a similar fashion, Kleinpell and associates sought to determine the overall role of the nurse and the entire nursing department in the treatment of sepsis care, in the study, “Implications of the New International Sepsis Guidelines for Nursing Care” (2013). In this article, the authors highlight how serious sepsis is and how even in recent times it has remained a pressing concern, despite efforts to manage this condition better with aggressive preventative efforts. Kleinpell and colleagues address the new guidelines for the management of this condition to better minimize it for both adult and child patients. Nurses are at the front lines of patient care, but critical care nurses are even more pivotal at prevention efforts as they have immediate involvement with evaluating patients who are particularly vulnerable for sepsis and with those who are already afflicted. Kleinpell and colleagues highlight how and why its so important for nurses to follow guidelines as they can impact the most change and improvement in patients. “Nurses’ knowledge of the recommendations in the new guidelines can help to ensure that patients with sepsis receive therapies that are based on the latest scientific evidence” (Kleinpell et al., 2013). The authors highlight some of the most important protocols to prevent and treat sepsis, continually connecting it back to the pivotal role of nurses.

Similarly, Kleinpell’s later work returns to these same themes, in the research study “Targeting Sepsis as a Performance Improvement Metric” (Kleinpell & Schoor, 2014). This study focuses as well on the critical role the nurse plays in controlling, preventing and treating sepsis. In particular, this study finds that specific performance improvement methods directed at early recognition and specific treatment can improve sepsis care through the professional excellence and responsibility of the nurse.
Focusing on the responsibility of the nurse is a wise decision when it comes to successfully treating and thwarting sepsis in patients of all ages. The study, “Nursing considerations to complement the Surviving Sepsis Campaign guidelines” by Aitken and colleagues (2011) sought to fine-tune the current sepsis guidelines based on current evidence in order to guide clinicians to offer the best patient care in treating aggravated or minor sepsis. At the end of this study, “Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions” (Aitken et al., 2011). This study shows that preventing and minimizing sepsis is a truly involved process, one that has numerous aspects and requires the utmost professional excellence.

For pediatric cases of sepsis, there needs to be an aggressive strategy in place, to minimize mortality. This was the focus of the research study, “Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department” by Cruz and colleagues (2011). This study particularly targeted the proper strategy for use in ERs when identifying septic shock, adding that symptoms such as slower recognition and incomplete fluid resuscitation were common. These researchers highlighted the importance of a computerized triage system, which set off an alarm whenever the vital signs of the child became abnormal. Such a technological tool can pinpoint sepsis faster and help facilitate time-sensitive interventions (Cruz et al., 2011).
However, so many of the sepsis guidelines are in place to prevent sepsis and to minimize the infection if it does in fact manifest. The research study “Adherence to PALS Sepsis Guidelines and Hospital Length of Stay” by Paul and colleagues (2012) sought to assess the adherence to sepsis guidelines within a pediatric emergency department setting. This study evaluated such guidelines by looking specifically at how closely clinicians adhered to the Pediatric Advanced Life Support (PALS) of 2006 with the help of a multivariate negative binomial regression. This study found that when clinicians followed the guidelines closely, acting immediately when needed, the hospital stays for patients were shorter. It’s also worth noting that in a subsequent study, Paul and colleagues were able to demonstrate meaningful and dramatic improvement to the PALS guidelines for aggravated sepsis and septic shock (2014). This research study showed the exact methods used to improve the adherence to such national guidelines using a five component sepsis bundle:  (1) recognition of septic shock, (2) vascular access, (3) administration of intravenous (IV) fluid, (4) antibiotics, and (5) vasoactive agents” (Paul et al., 2014). This is another piece of evidence that demonstrates the power of streamlining educational interventions into accessible steps for clinicians.

In a comparable manner, the study, “Early Detection and Treatment of Severe Sepsis in the Emergency Department: Identifying Barriers to Implementation of a Protocol-based Approach” by Burney and associates (2012) sought to identify the obstacles that were preventing clinicians from more closely following sepsis prevention and treatment guidelines. Burney and colleagues used a survey given to nurses and doctors within the emergency department to attempt to evaluate the knowledge and confidence they had about using the guidelines, and to determine their current methods along with their perceived obstacles to total excellence in this regard. This research study was so effective as it was able to pinpoint the exact issues that prevent clinicians from subscribing to these guidelines at all times: “These barriers included the inability to perform central venous pressure/central venous oxygen saturation monitoring, limited physical space in the emergency department, and lack of sufficient nursing staff. Among nurses, the greatest perceived contributor to delays in treatment was a delay in diagnosis by physicians” (Burney et al., 2012).

The research study, “Early Recognition and Management of Sepsis in Adults: The First Six Hours” by Gauer (2013) found that aggressive, strategic action taken within the first six hours of recognition was instrumental in drastically minimizing the number of sepsis related deaths. “Early antibiotic therapy can improve clinical outcomes, and should be given within one hour of suspected sepsis. Blood product therapy may be required in some cases to correct coagulopathy and anemia, and to improve the central venous oxygen saturation” (Gauer et al., 2013). This study is important as it highlights the necessity in acting rapidly to implement these evidence-based protocols to reduce mortality rates.

Like so many of the research articles that this paper has examined, the study, “The role of nurses in the recognition and treatment of patients with sepsis in the emergency department” by Tromp and colleagues (2010), had meaningful commentary on the very important role that nurses play in this issue. These researchers sought to determine if a multidimensional implementation program to reduce sepsis that focused on nurse training and performance feedback, could have an impact in reducing the manifestation of the condition or how long it ravages the patient. The study found that, “Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.” (Tromp et al., 2010).

In a similar fashion, the research study, “Impact of Sepsis Bundle Strategy on Outcomes of Patients Suffering from Severe Sepsis and Septic Shock in China” by Wang and associates (2012) started from the thesis that sepsis manifests such poor outcomes for patients as a result of delays in diagnosis and subsequent action. Hence the researchers compared the methods between treating sepsis with a group that had received Surviving Sepsis Campaign (SSC) improvement bundles in emergency group and one that did not. The group that had SCC bundles had drastically improved outcomes. This study also provocatively demonstrated that some of the obstacles to full implementation of such guidelines are knowledge, attitude and behavior (Wang et al., 2012). This is important; as such a study demonstrates not only what works, but also what challenges are in the way of moving forward with this kind of progress.

Robson and Daniels discuss the necessity of concrete and clear knowledge of sepsis guidelines in the study, “The Sepsis Six: helping patients to survive sepsis.” This study highlights how sepsis is not just a deadly condition, it’s an expensive one: in Europe the cost of sepsis figures around 7.6 billion euros per year, and in America, it’s around $16 billion dollars per year. This article discusses how evidence has shown that the education of nurses is key and critical to minimizing mortalities from this condition. The authors have streamlined the most important things for nurses to do as the “Sepsis Six.” These are six things that nurses can do in the first hour of recognizing that sepsis has occurred to reduce mortality and improve patient outcomes. Likewise the research study “The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study” completed by Daniels and colleagues, expands on these findings with a bigger participant group. Their findings drew support for the SSC resuscitation bundle but shows that programs that simplify the educational pillars to address the sepsis six can improve how swiftly and effectively these powerful interventions are given.