Early Sepsis Identification

Sepsis has been a common and a serious problem among most of the surgical patients and most of the patients in the emergency department. The early identification of severe sepsis and the early implementation of a sepsis screening tool improve the outcomes. Sepsis is a severe clinical syndrome which is defined by the presence of infection and systematic inflammatory response. Severe sepsis is the acute organ dysfunction which is secondary to infection. Septic shock is severe sepsis plus hypotension which is not reversed with fluid resuscitation. Infection is the pathologic process which is caused by the invasion of the sterile tissue or by potentially pathogenic microorganisms. The development of a sepsis screening tool will help reduce the mortality which is associated with severe sepsis and septic shock. Sepsis is a complex condition which in most cases is life threatening and is characterized by hematological derangements.

Section I. Practice Setting and Care Issue

A: Problem Identification

In the hospital setting, especially the emergency department sepsis is not always recognized early enough to implement life saving measures. Due to overcrowded waiting rooms the door to doctor time is lengthy and for the septic patient, that can be the difference between life and death. A sepsis screening tool can be implemented by nursing staff to initiate sepsis bundles in a timely manner. The area for implementation is the ED and the people who can implement this tool are all those who are involved in the patient care. The sepsis screening tool can be implemented through education, pilot, and easy document availability. Most of the medical personnel in most of Emergency have failed to prioritize sepsis diagnosis which may be due to the lack of proper training on how to diagnose severe sepsis.

B: Importance of the Problem

The main importance is the improving of the early diagnosis of severe sepsis and septic shock and the improving of the timeliness of the implementation of sepsis resuscitation bundle and also the improving of the patient outcomes including mortality rate and the cost of hospitalization. Infections that initiate the septic process can be a result of the introduction of either a bacterial, fungal, or viral pathogen. Bacterial pathogens have remained to be the leading cause of infection, with gram-positive microbes becoming more prevalent than gram-negative microbes. Additionally, the rate of fungal infection has also been on the rise, which has been attributed to changes in host immunity and changing dynamics of the healthcare system, with increased use of invasive procedures and immunosuppressive therapies. The goal of the sepsis screening tool is to reduce preventable harm to patients with sepsis through the early recognition of sepsis, improved time to the administration of antibiotics, and the appropriate fluid resuscitation.

C: Brief Description of Solution with Rationale – Recommendation for Change

Severe sepsis is a serious problem in many health institutions and has in most cases been left unattended to due to the lack of enough resources to implement proper tools for the early identification of the sepsis and sepsis shock and has been causing many deaths in the Emergency departments. Severe sepsis is one of the fulminant diseases which can cause dysfunction in most of the body systems and in most cases, it is reported to cause life-threatening homeostasis loss and at the same time, it can also lead to cardiovascular failure, renal system failure which in most cases may be fatal. The implementation of a sepsis screening tool in these Emergency departments could help in the early diagnosis of the disease and also help in the reduction of the mortality rate.

Section II: SUPPORT OF RECOMMENDATION AND INTEGRATION OF RESEARCH FINDINGS

A: Research Summary and Support

Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.

The main objective of the study according to Ague et al. was to determine the total outcome, the cost, and the incidence of all the cases of severe sepsis in the United States through the observational cohort study. The setting was all the non-federal hospitals in the seven largest states of the U.S. where n=847. In this article, there was the linking of all the discharge records of all the state hospitals in 1995 from all the 7 largest states in the United States with the entire population. The data was got from the total population and hospital data which was attained from the United States census, the American Hospital Association, The Health care Financing Administration, and the Centers for Disease control.

Sepsis according to Angus et al. is a common complex syndrome which occurs due to a systematic manifestation of several infections. This article defined sepsis, severe sepsis and also septic shock and the importance of sepsis awareness to the people living in the United States and that it is one of the 10^th leading causes of most of the death in the United States. Sepsis causes at least 10% of a 100 patients that were admitted in the intensive care unit and most of all the patients who are commonly reported to be septic are the elderly people of around 65 years and older, the others are those that are 1 year or even younger than one year, those people with chronic illnesses, immunosuppressed people, and those who have exposure to infections which are associated with invasive procedures or even surgical procedures.

Out of the 751,000 cease which were studied, 192,980 cases were identified which showed that in every 1,000 of the total population, there were 3.0 cases and in every 100 of the hospital discharges, there were 2.26 cases. 51.1% were able to receive intensive care treatment and 17.3% were cared for in a coronary care unit. The mortality rate was found to be 28.6% nationally which was equivalent to 215,000 death nationally which also increased according to the age of the patient. In children it was found to be 10% and the aged was found to be 38.4% which explained why the cases of sepsis were very high in the elderly than in the young patients. The costs for treatment were found to be very high which were estimated at about $22,100 per case and $16.7 billion per year. These costs were found to be very high in infants, the non survivors, the patients in the intensive care units, the surgical patients, and the patients who had cases of organ failure.

According to Angus in his article, many studies were conducted in order to be able to recognize early sepsis using different types of sepsis protocols like the bundles of treatment like the Six hour treatment bundle. Sepsis was found to be a very expensive to treat and also a fatal condition which has caused so many deaths in the United States annually.

Managing severe sepsis: a national survey of current practices

The main purpose of this study was to obtain the current practices which are used by the U.S. hospitals in the management of severe sepsis. The methods that were used were in the form of a questionnaire which was distributed to all the nurse managers who were also members of the ACCN ( Association of Critical Care Nurses) so as to get to assess all the practices which are currently associated with the management of severe sepsis and which also included the assessment of the priority in sepsis management, the identification of the patient, the sepsis screening process, the current treatment practices, the process measures and the total outcomes measurements, and also the demographics of the hospitals.

The main differences among the small hospitals which had a bed capacity of <200, the medium ones with 200-399 beds, and the large ones with > or = 400beds were identified with the use of a chi-square analysis and the t-test. The results were that the surveys that were completed, received and analyzed were 414 and it showed that as the bed size in the hospitals increased, so did the percentage of the hospitals severe sepsis cases where p=0.002. The screening for severe sepsis was found to commonly occur upon the laboratory test values which were found to be deteriorating.

A survey which was conducted on the critical care nurses showed that of the 17 SSC treatment guidelines, most of the hospitals frequently reported loyalty to those that concerned the immediate ordering of cultures, the immediate administration of broad-spectrum antibiotics, and the speedy initiation of the deep venous thrombosis prophylaxis. The laboratory test values deterioration was found to be the most common identifier of severe sepsis, despite the size of the hospital. Among all hospitals, the guideline which was the least followed was the immediate initiation of drotrecogin alfa (activated) therapy.

Validation of a Screening Tool for the Early Identification of Sepsis

Sepsis is one of the leading causes of mortality in most of the intensive care units and studies have shown that early implementation of the guidelines concerning sepsis management improves the survival rate. It was found that the early recognition of sepsis was one of the major obstacles to the implementation of the protocol and in order to be able to improve it, a three step sepsis screening tool which had escalating levels of decision making. An aggressive sepsis screen was found to help and improve on the early sepsis recognition and in so doing it would also help in the decreasing of the sepsis mortality. The main objective of this study was to come up with a sepsis screening tool which was supposed to decrease the mortality which is associated with sepsis.

All the patients who were admitted in the surgical intensive unit were screened at least twice a day by the nursing staff and the screen was to assess the SIR syndrome parameters which are the temperature, WBC (white blood cell) count, the respiratory rate, and the heart rate and then assign numerical scores of 0-4 for each parameter. All the patients who had a score of greater than or equal to 4 screened positive for sepsis and had to proceed to the next and second step of the screening tool where the source of the infection was identified. In case a patient tested positive for both the SIR syndrome and an infection, then the intensivist was to be notified immediately.

The results of this study were that a total of 4,991 screens were completed on a total of 920 patients over a period of about 5 months. A sensitivity of 96.5% was yielded by the screening tool with an 80.2% positive predicative value and a 99.5% negative predictive value. The use of this tool helped in the reduction of the mortality rate from 35.1% to 23.3%. This screening tool which is a three step process was proved to be a valid tool for the early diagnosis and identification of sepsis.

Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis

The main objective of this study was to show that the Early Goal-directed therapy reduced the mortality which is associated with septic shock and severe sepsis. A decision analysis was conducted in order to explore the costs that are associated with the implementation of the EGDT. The setting was the simulation of a U.S. ED (emergency Department) where a total of 1,000 simulation cohorts of septic patients who were adults (n=263 per cohort)

The overall results were that for every ED, there were about 91 cases per year and the cost was estimated to be $12,973in the ICU to the $26,952 in the ED and $100,113annual cost. The implementation of the EGDT was aimed at reducing mortality due to severe sepsis and the costs fell by 22.9% ($8,413-$8,978). There was the probability that EGDT implementation had a 99.4% up to 99.8% of saving lives and also saving costs. This study compared the costs that are incurred in the implementation of the EGDT for it to be used in the hospitals so that it can be able to assist and help in the early identification of severe sepsis and septic shock.

Validation of a Screening Tool for the Early Identification of Sepsis

In the recent years, the Goal-directed Therapy has been commonly used in the identification of severe sepsis and septic shock. This approach involved the adjustments of the cardiac preload, afterload and the contractility to being able to balance oxygen. The main objective of this study was to evaluate the early goal-directed therapy efficacy before the patient is admitted into the ICU.

All the patients who came into the Emergency department were randomly assigned and assessed for sepsis and septic shock and if they tested positive for sepsis they were to receive the 6 hours of the early goal-directed therapy or even the standard therapy before they were admitted into the ICU. The clinicians who were supposed to care for the patients were to be blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) Scores were to be obtained for about 72 hours and then they were compared to all the other groups.

The overall results were that out of the 263 patients that were enrolled, it was found out that 130 of them were randomly assigned to the EGDT and 133 were assigned to the standard therapy. The results were then compared where we had mortality of 30.5% of the patients that were assigned to the EGDT as compared to the 46.5% mortality rate of the patients who were assigned to the standard therapy. Between 7 to 72 hours it was found that the patients who were assigned to the EGDT had a higher mean (+/-SD) central venous oxygen saturation (70.4+/-10.7 percent vs. 65.3+/-11.4 percent), a lower lactate concentration (3.0+/-4.4 vs. 3.9+/-4.4 mmol per liter), a lower base deficit (2.0+/-6.6 vs. 5.1+/-6.7 mmol per liter), and a higher pH (7.40+/-0.12 vs. 7.36+/-0.12) than the patients who were assigned to the standard therapy (P < or = 0.02 for all the comparisons). In the same period, mean APACHE II scores were significantly lower, which showed that there was less severe organ dysfunction and in the patients who were assigned to the EGDT than in those that were assigned to the standard therapy (13.0+/-6.3 vs. 15.9+/-6.4, P < 0.001). This showed that the EGDT was beneficial with respect to the outcomes of the patients with severe septic shock and sepsis.

B. Rationale and Support of the Solution

The rationale for the implementation of the sepsis screening tool is to aid in the reduction of the increasing mortality rates by initiating the early recognition of septic patients. This makes it easy for the medics and the nurses to be able to treat these septic patients and administer proper antibiotics early enough to be able to save the life of the patient. With the help of the 5 articles, the implementation of a sepsis screening tool would be much easier since they support the project with helping in the reduction of the mortality rates which are due to severe sepsis and septic shock.

Once the hospital staff is able to detect the disease through the use of the sepsis screening tool, there is the recommendation of several interventions. Early identification and treatment microbiological causative organisms through obtaining appropriate cultures and administration of broad-spectrum antibiotics is an important step, with bundle suggesting administration of antibiotics within one hour of severe sepsis diagnosis Rivers, et al., 2001). Early and aggressive treatment of hypotension initially through fluid resuscitation and monitoring of MAP and central venous pressure (CVP) is an integral part of early goal-directed therapy, and if required, the use of vasopressors with additional guidance from central venous oxygenation saturation (ScVO2) values.

In the implementation of the project, there are challenges that are expected to slow down the success of the project which can still be solved with time since some patients may lack two signs of SIRS with an infection even though they are septic like the patients who are elderly may in most cases not have a fever, immunosuppressed patients who may not have an elevated WBC counts or even patients who are on beta blockers.. This makes it hard for the sepsis screening tool to give correct results. A large number of barriers to implementation were found to exist. Some common themes were a lack of knowledge, lack of desire to change current practice and a lack of agreement or mistrust in the efficacy of the guidelines. With time,

C. Recommendation – Synthesis and Integration

Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients and ED patients.

The anticipated results after the implementation of the sepsis screening tool is that the ED is able to recognize all the patients suffering from severe sepsis early enough to initiate early treatment of the disease. This will lead to the decrease in the mortality rate since most of the patients will be able to get treated early enough. When the ED uses this sepsis screening tool, it will be able to detect severe septic patients early enough to be able to implement lifesaving interventions like the timely antibiotics, intravenous fluids, and the appropriate placement of the patients in the intensive care units. Many nurses in most of the health facilities have o poor knowledge of the signs and symptoms as well as the immediate management of sepsis. This lack of knowledge contributed very much to the high mortality rates of sepsis since it resulted to late diagnosis and the suboptimal treatment of vulnerable patients suffering from severe sepsis. This showed that there is the need to conduct studies and awareness programs to the nursing staff in order to boost their knowledge and awareness of sepsis.

The future recommendations as concerning this project include the collection and the analyzing of the septic patients data which also includes the mortality rates, the adoption and the implementation of the SSC (surviving sepsis campaign) guidelines to reevaluate the mortality rates in order to determine the success of the project.

Rationale for including the study and how it supports or does not support your solution or recommendation.

Section III: Safety, Costs, and Feasibility Issues

A. Safety Issues

This project is deemed safe and worthy of time and resource investment since safety in any project is critical to its overall project success. This project is the safest since its implementation affects none of the normal operations of the Emergency department in that all the other activities still goes on as scheduled(Moore, et al., 2009). The main aim of the tool is to reduce the mortality that is associated with the severe sepsis and septic shock. This tool helps in the early diagnosis and recognition of the severe sepsis and septic shock which makes it very safe since it aides in the saving of the patient's life. Most of the patients who die in many hospitals especially in the Emergency departments usually die because of neglect by most of the hospital staff which in most cases may not be intentional but due to the lack of the knowledge into the early diagnosis of the disease thus making the disease to advance into fatal levels where the patient cannot be saved. This tool has no risks that are exposed to the staff which makes it very safe and easy to use (Maley, et al., 2006).

B. Costs

The cost to implement a sepsis screening tool is minimal and limited to printing the tool and staff education. The early diagnosis and intervention is essential to patient safety in regard to sepsis. The costs for the implementation of the project are briefly summarized in Appendix 2. These include the costs that are incurred into the implementation of this sepsis screening tool in a health facility and they include the costs for phone calls, printing and copying, salaries for supporting staff, stationaries, and also the costs that are incurred in the training of the medical personnel like the nurses who are to conduct the whole screening process.

C. Feasibility

The proposal of a sepsis screening tool is a feasible project in light of resources and other alternatives for the health institution. Through the proper training of the nursing staff in the health institution, the implementation of the sepsis screening tool will be very easy since the tool has to be completed by the nurses. If the nurses have the required knowledge of sepsis, it will be a very easy procedure and this will help in the reduction of the increasing mortality rates. This project is practical since there are the people that are involved, equipment, time, and financial support for success. The hospital staff, administrators, and the community are in support of the project since it helps in saving of peoples lives. The project needs to be given some time after being implemented for it to be fully appreciated by the whole of the nursing staff and for them to get used to the procedures of conducting the tool.

Section IV: Plan of Action to Effectively Implement and Communicate Change

A: Project Objectives

The objectives of this project is to help to reduce the inpatient sepsis mortality by around 25% and also to increase the sepsis bundle compliance also by around 25% in the few years to come. These bundles are designed in order to allow the teams to be able to follow the timing, the sequence, and the goals of the individual elements of care. The main objective of this research is the utilization of a sepsis screening tool which will lead to an increased early treatment and recognition of sepsis in the emergency department. The tool is designed to screen for Systematic Inflammatory Response Syndrome (SIRS), infection, organ dysfunction and severe sepsis.

In the Emergency Department, the implementation of a sepsis screening tool for the identification of severe sepsis patients with the utilization of the SBAR communication increases the early recognition of sepsis as compared to the current practice of the Sepsis Early Recognition Algorithm for Goal Oriented Therapy which still has not been consistently used. The Patients exhibiting signs of sepsis will be evaluated using the sepsis screening tool upon triage in the emergency department. Patients with severe sepsis will be identified and the appropriate sepsis bundle will be implemented. After the project is implemented, the mortality rate due to severe sepsis will be greatly reduced within 3months after the implementation of the sepsis screening tool.

B: Implementation Plan

A generic pathway has been developed and is aimed at supporting the recognition of severe infection and sepsis in the ED and also to be able to give flawless guidelines for notification and the initial sepsis management. The sepsis pathway helps in promoting the early flagging of sepsis and severe infection, the involvement of most senior clinicians in the diagnosis of severe sepsis and also its management, the appropriate administration of antibiotics, the monitoring of serum lactate in order to be able to assist in the early diagnosis and monitoring of sepsis, and lastly the referral of care to other experienced clinical teams. In the implementation of the sepsis screening tool (Appendix 1), the current pathways for sepsis will stay the same (Appendix 3). The nurse will follow the screening tool guidelines; alert the MD upon a positive assessment.

The only thing that will change in the Emergency Department is the use of the sepsis screening tool for the early diagnosis of sepsis and septic shock. Once the RN records all the signs of the patient and the patient is diagnosed with severe sepsis or septic shock, the only thing that is due to change is the early commencement of treatment of the patient. This tool will be able to screen a patient and determine if he has the diseases so that immediate treatment can start immediately to prevent losing the patient.

The project is scheduled to begin within the next two months on the 30^th of October, 2011. Before the implementation of the project, measures have to be put in place to ensure that all the medical staff and the other supporting staff are well informed about the introduction of the sepsis screening tool. This is to make sure that they are well prepared both physically and mentally in order to be able to adjust to the changes. All the nurses in the Emergency department are going to implement the new tool since patients come in during the day and also during the night time. So all the patients who come into the Emergency department should be screened. The MD of the Emergency department should be in charge of the whole project and since he is the project director, he should be able to answer all the questions that are asked by the other staffs that are helping in the implementation of the project.

The setting will take place in the Emergency department of a hospital. Most of the septic patients who end up in the emergency department end up losing their lives because of late diagnosis of the disease. The only people who will be required to be educated on the usage of this tool are the medical staff including the nurses and the physicians. The patients, in this case, are not affected at all. The only thing that is needed of them is the symptoms and signs which are recorded by the RN in the screening tool in order to assess if the patient has severe sepsis or septic shock.

C: Communication Plan

The first step in the communication plan is to establish the Executive support which includes the identification of an Executive sponsor who is to support the team with all the required resources and assist in the management of all the barriers to the sepsis screening tool implementation. The next step is to identify all the right people for your team. This will greatly increase your effectiveness and also increase the chances of success. The team could include the following personnel: the Emergency Director, the senior and junior medical and nursing clinicians, the Nurse Educator or the Clinical Nurse Consultant, the Pharmacist, and the Infectious Diseases physician if available.

Effective teams must have Team members who have a fundamental knowledge of the process and who work with or have a particular interest in the process, Team members that represent all parts of the process, and also an ideally one member should be trained in quality improvement methodology. The Staff meeting will be held in order to educate and inform nurses, pharmacist and MDs of the implementation of the screening tool.

Project Summary

The key to reducing the high mortality rate that is caused by sepsis is the early recognition of severe sepsis. The first six hours are critical since with each passing hour, the mortality rate increases rapidly. Many of the sepsis patients may not look sick but they are seriously sick and dying and need urgent treatment of which they cannot be treated for sepsis before it is recognized in their bodies. Nurses play a very important role in the early diagnosis and identification of patients suffering from sepsis with the help of a sepsis screening tool. A nurse triggered pathway has a great potential to save a significant number of lives in worldwide hospitals. Clinicians and nurses need to be educated on the use of a sepsis screening tool to aid in the early identification of severe sepsis.

The early identification of sepsis originates with the identification of all the risk factors for severe sepsis in the Emergency department that cause the disease and are highly associated with it. The risk factors for the development of sepsis include: the extremes of age either being very young or being very old, suppressed immune systems due to excessive chemotherapy and the use of steroids, due to HIV infection, addictive habits like the drug and substance abuse; the receiving of invasive procedures like surgery and intravenous catheters, and chronic diseases like diabetes and chronic obstructive pulmonary disease.

It is very important for nurses and the entire medical staff together with the support staff to monitor all the 5 parameters that are meant for the early detection of sepsis using the sepsis screening tool. These parameters include the body temperature, the increase in the respiratory rate, the decreased MAP (Mean arterial pressure), the increased heart rate, and the elevated body temperature.

A simple screening tool performed by nursing staff can accurately identify early sepsis in both medical and surgical patients in an Emergency department setting. We identified a trend towards a higher sensitivity and specificity for our Sepsis screening tool in the medical population compared to the surgical population, although these findings need to be validated in a larger study. Our data suggest that a simple screening tool for sepsis may provide a means to successfully identify early sepsis in an Emergency Department setting.