Identify septic patients at triage to improve outcomes
Identify septic patients at triage to improve outcomes
Triage may miss severe sepsis cases
If you suspect a patient is having an acute myocardial infarction (MI), that patient will receive an electrocardiogram and be evaluated with cardiac markers. Yet, there are no definitive diagnostic tests to determine if your patient has sepsis, which has mortality near that of acute MI.
This is why as an ED nurse, you must be the "eyes and ears to identify patients at risk" for sepsis, with aggressive interventions done at triage, says Duane A. Young-Kershaw, RN, BSN, former ED clinical nurse specialist at Beth Israel Medical Center in Boston.
ED patients with severe sepsis, septic shock, or dysfunctional organs in the setting of infection are at greater risk of death according to a new study.1 Standard triage may miss a surprising number of patients with severe sepsis, notes Young-Kershaw.
"This study demonstrated a correlation with ED presentation and mortality," he says. Beth Israel's ED implemented a protocol to accurately identify septic patients called MUST (Multiple Urgent Sepsis Treatment). (To see patients eligible for the protocol, see box. To see the ED's entire sepsis protocol, go to www.mustprotocol.org.)
After a study was published showing increased mortality in ED patients with suspected infection and a blood lactate level higher than 4, the ED began using a point-of-care lactate device at triage, he says.2 "This screens at-risk patients and more quickly integrates them into our sepsis protocol," Young-Kershaw says. After a potentially septic patient is identified, nurses follow the treatment algorithm, which includes monitoring invasive pressures, central venous oxygen saturation (ScVo2), and titrating vasopressors.
More often, ED nurses are acting as the "extended arm of critical care," due to increased acuity and limited resources, notes Young-Kershaw. "ED nurses at Beth Israel are capable of accurately identifying the septic patient, competently treating them, and demonstrating skills equal to that seen in the critical care areas," he says.
At Cooper University Hospital in Camden, NJ, the ED and intensive care unit (ICU) jointly collaborated to implement an evidence based Early-Goal Directed Therapy protocol for sepsis in January 2005. Hypotensive patients presenting to the ED with suspected infection are evaluated for the protocol, says Mary Stauss, RN, MSN, APN, CEN, ED clinical nurse specialist.
Treatment includes aggressive fluid resuscitation, guided by central venous pressure (CVP), mean arterial pressure (MAP) and ScVO2 monitoring. Vasopressors and inotropic agents are given as determined by the patient's hemodynamic response. "Early antibiotic therapy and routine labs including a lactate level are also priorities," says Stauss. "The goal is to identify these patients early."
Obtaining a lactate level for patients with suspected infection has been helpful in identifying patients who in previous years may have not been recognized as having acute tissue hypoperfusion, Stauss explains. "Patients have presented with illnesses such as pneumonia and cellulitis that at first may not indicate a septic state," she says.
Here are some of the steps that ED nurses take when the protocol is used:
- The ED inserts a central line with oximetry capability. Continuous CVP and ScV02 monitoring also is initiated.
- Aggressive fluids resuscitation is begun, and CVP and MAP levels are monitored for response to this intervention. Vasopressors and inotropic drugs are given as needed to improve patient perfusion.
- ED nurses maintain continuous monitoring of hemodynamic changes in the patient's condition for negative and positive outcomes, and adjust therapies as needed.
The study reports that patients at highest risk for death are those with multiple organ dysfunction. "Our experience has also recognized similar results in our severe sepsis patient population, with a mean of two organ dysfunctions at the time of presentation, hypotension, and elevated lactate being the most common," says Stauss.
Having a lactate level drawn early can prompt early initiation of treatment, especially if the value is greater than 4, says Stauss. "Often these patients appear stable and can deteriorate without warning," she adds.
Early identification of organ dysfunction is essential in patients with a suspected infection, says Stauss. "Suspicion of infection will alert the nurse to draw the appropriate labs and administer antibiotics in a timely manner, within three hours of triage time in our institution," she says. "Early antibiotic administration has also been shown to improve outcome in septic shock patients."3
Identifying and controlling the source of infection rapidly also can improve outcome, says Stauss. "For example, getting the patient to surgery or removing source of infection will assist in a more rapid recovery for the patient with an infected port-a-cath," she says.
References
- Shapiro N, Howell MD, Bates DW, et al. The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection. Ann Emerg Med 2006; 48:583-590.
- Shapiro NI, Howell MD, Talmor D, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med 2005; 45:524-528.
- Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1,589-1,596.
Sources
For more information about care of sepsis in the ED, contact:
- Nathan I. Shapiro, MD, MPH, West Clinical Center 2 — Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Way, Boston, MA 02215. Fax: (617) 754-2350; e-mail: [email protected].
- Mary Stauss, RN, MSN, APN, CEN, Clinical Nurse Specialist, Emergency Department, The Cooper Health System, One Cooper Plaza, Suite 901A, Keleman Building, Camden, NJ 08103-1489. Telephone: (856) 968-8678. E-mail: [email protected].
- Duane A. Young-Kershaw, RN, BSN, Clinical Application Specialist, Cardiac & Patient Monitoring. Philips Medical Systems, 630 Allendale Road, Suite 100B, King of Prussia, PA 19406. Telephone: (800) 218-2045, ext. 5690. Fax: (508) 742-4178. E-mail: [email protected].
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