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Sepsis mortalities cut 50% with ED changes
When researchers surveyed 2,461 physicians in various countries about their initial care of severe sepsis, they were surprised to find that only two complied with all of the recommendations of the Surviving Sepsis Campaign.1 In the United States, only 30% of ED physicians said they reported initial lactate measurement, and only 44% would insert a central venous catheter in a patient with septic shock.
"Forty percent of ED physicians said that they could not implement published guidelines because of time pressure," says Michael Reade, MPH, the study's lead author and an intensive care physician at Austin & Northern Hospitals at the University of Melbourne, Australia. "Additionally, around 20% of U.S. ED physicians reported they had no knowledge of the Early Goal Directed Therapy study on which the current Surviving Sepsis Guidelines for the first six hours of management are largely based."
The ED at McKay-Dee Hospital Center in Ogden, UT, has "had wonderful results" with sepsis treatment, says Kayleen L. Paul, RN, CEN, director of critical care, emergency, and trauma services. Paul credits this success to diligently following the Institute for Healthcare Improvement (IHI)'s Sepsis Resuscitation Bundle. (For more information, go to www.ihi.org. Click on "Topics," then "Critical Care," and "Sepsis.") "We've reduced the severe sepsis and septic shock mortality at our hospital from 32.3% in 2008 to 16.7% in 2009," Paul says.
Here are changes the ED made:
The IHI Sepsis Bundle was divided into ED and intensive care unit (ICU) components.
ED nurses are responsible for obtaining the serum lactate, obtaining blood cultures, administering the appropriate antibiotic within three hours of registration, appropriate fluid resuscitation, and vasopressors as needed. "The ICU takes over with the other five components of the bundle," says Paul.
Compliance and outcomes are tracked carefully.
JoAnn Spencer, RN, MSN, the hospital's program manager for intensive medicine clinical programs, says, "We ensure that physicians and staff get early feedback on these patients, identify ways to improve, and celebrate successes." Spencer reviews admissions daily on all sepsis patients admitted to ICU or Intermediate Care.
"The ED care is completed by that time, but immediate feedback is given to staff on specific patients," says Spencer. "If we missed a bundle component, we review the chart right away to figure out what happened. Then we take immediate steps to improve a process, if necessary, or educate staff."
A checklist tool was developed to facilitate quick identification and intervention with early sepsis in the ED. [The Sepsis Criteria Worksheet used by ED nurses is included.]
"Of course, the trick is in identifying the patient early. The checklist really helps with that," says Paul. "In fact, we have committed to the hospital Board of Trustees that our critical care service line will meet all 11 components of the sepsis bundle at 90%. It's a stretch goal, but I really think we can do it. We are fully committed, because it's clear that this protocol saves lives."
Your goal: ID sepsis in the early stages
ED nurses at Northwest Community Hospital in Arlington Heights, IL, have been given education on identifying patients "who may be in the early stages of sepsis when it is still potentially reversible," says Sharon Esterquest, RN, clinical educator of the ED.
"It is important that ED nurses are keenly aware of the signs and symptoms of sepsis that may not be blatantly evident in the early stages," says Esterquest. "Equally important is the need to recognize the populations most at risk for developing sepsis."
Mental status changes or hyperventilation are two early signs. "Fever may or may not be a present, especially in the elderly or immunocompromised patient," adds Esterquest.
Other early symptoms include low-grade fever, chills, skin rash, joint pain, low urine output, dizziness, and diarrhea, says Esterquest. Once symptoms are identified, determine those patients most at risk by evaluating for the following co-morbid factors: elderly, neonates, a history of diabetes mellitus, a history of immunodeficiency, recent trauma, recent significant burns, history of alcohol and substance abuse, history of chronic disease, recent surgery, invasive procedures or invasive lines, and indwelling catheters, she says.
The preprinted order set used by Northwest Community's ED nurses includes a triage portion. This asks the nurse to indicate presenting symptoms suspicious for sepsis, as well as any risk factors. "If there is a possibility of immunosuppression, the form prompts staff to immediately move the patient to the appropriate area," says Esterquest. [The order set and advanced triage guidelines used by ED nurses are included.]
The remainder of the pre-printed order set "reads like a recipe, to ensure proper laboratory tests, fluid boluses, use of vasopressors, antibiotic selection and consultation with the critical care physician," says Esterquest.
Nurses initiate the order sets if there is any possibility of sepsis. Using advanced triage protocols for sepsis, ED nurses can start an intravenous line and order a complete blood count with differential, a complete metabolic panel, prothrombin time/partial thromboplastin time, type and screen, lactate, two sets of blood cultures, and a urine culture.
ED nurses are taught to draw two sets of blood cultures. "Whomever collects the first set is responsible to collect the second, so not to cause any confusion or delay in the administration of antibiotics," says Esterquest. "When drawing blood cultures, we suggest that staff automatically draw an additional tube for lactic acid, should it be ordered. This will prevent delays and additional sticks for the patient."
Zero in on these 3 sepsis interventions
ED nurses at University of Maryland Medical Systems in Cambridge, MD, have been educated about specific patient scenarios "that should raise their antennae of suspicion regarding sepsis," says Gail Shorter, RN, MS, CEN, an ED nurse at Shore Health System in Easton MD. "The ED is now much more proactive when a patient arrives who may fit into the sepsis framework."
Here are three areas of focus:
Central line placement.
"Using a Foley catheter leg strap to attach the pressure transducer to the patient's arm at the phlebostatic axis keeps the tubing protected in a busy ED setting," says Shorter.
Intraosseous vascular access.
"We are starting to see these used more, both from the field and in the ED, for immediate access for fluid resuscitation," says Shorter.
"We are currently expanding our access to rapid infusers in the ED to support sepsis care, as well as patients experiencing hypovolemia for other reasons," says Shorter.
Rush patient out of ED in this case
ED nurses at Northwest Community Hospital in Arlington Heights, IL use "critical care alerts" to expedite the transfer of patients from the ED to critical care in life-threatening or organ-threatening emergencies. These emergencies includes cases of severe sepsis with persistent hypotension and/or a serum lactate over 4 mmol/L.
"The activation of this alert requires a response in not more than 30 minutes," says Sharon Esterquest, RN, clinical educator of the ED. "In treating sepsis, this facilitates a more timely initiation of hemodynamic monitoring via the placement of a central venous catheter with continuous monitoring of central venous oxygen saturation."