ED sepsis interventions dramatically cut deaths

Patients avoid ICU admission

Immediately after a 70-year-old man presented with fever, tachycardia, low blood pressure and abdominal pain, ED nurses gave acetaminophen, started two large-bore intravenous (IV) lines of normal saline infusing wide open, obtained all blood work including cultures and lactate, obtained a portable chest X-ray and electrocardiogram, and administered antibiotics with lab results pending.

By the time the labs came back showing an elevated white count and lactate, the patient's heart rate and temperature were down and the man reported feeling better. "Due to early intervention and early administration of antibiotics, this patient avoided an ICU admission and continued to improve on a step-down unit," says Kelly Powers, RN, an ED nurse at Christiana Care Health System in Wilmington, DE. "This is a reflection of what early recognition, early intervention and teamwork can do for patient outcomes."

There is growing evidence that early interventions for sepsis and septic shock can save lives in the ED. After a severe sepsis protocol was implemented in Loma Linda (CA) University Medical Center's ED, 100% of patients received central venous pressure/central venous oxygen saturation (CVP/Scvo2) monitoring compared with 64.8% before, and 100% received antibiotics compared with 89.7% previously. More patients received corticosteroids (29.9% compared with 16.2%), which is given if patients are on vasopressor therapy or if adrenal insufficiency is suspected. Mortality rates decreased from 39.5% to 20.8%.1,2

At Christiana Care, a "Sepsis Alert" program decreased mortality rates for patients with severe sepsis to 30.2% from 61.7 % during a two-year period. An ED order set was created, and nurses were given one-on-one education about sepsis, use of antibiotics, and setting up CVP lines.

Patricia Burchell, RN, BSN, an ED nurse at Christiana Care, says, "We stress the importance of early recognition of sepsis patients and early administration of antibiotics within the first hour." The ED interventions increased the percentage of patients receiving antibiotics within an hour from 86% to 97%, and they decreased the average time from triage to first antibiotic administration from 2.9 hours to under two hours.

An in-house "sepsis alert" is called to bring extra help to the patient's bedside, as is already done with trauma and cardiac patients, says Burchell. The alert is called when the patient has an elevated white blood cell count, when fluid boluses fail to return vital signs to normal range, or for elevated lactate levels over 4 mmol/L. Educating more than 100 emergency nurses about the new interventions was a challenge, says Powers. Inservices were given during different shifts, with check-off sheets used to verify attendance, and during orientation, new nurses attended a lecture with a slide show and were given handouts with the ED's new order set and information about sepsis care, she adds.

Charts of sepsis patients are reviewed each month to determine how long it took to start antibiotics, to place a central line, and complete a fluid bolus, says Powers. "We then take what we learn and give feedback to staff nurses, both good points and what needs to be improved," she says. For example, ED nurses are praised for short times to fluid resuscitation, but they are reminded that Scvo2 monitoring needs to be done for every patient.

When implementing Loma Linda's sepsis protocol, technology and education were the biggest challenges, says Teri D. Reynolds, RN, BSN, clinical educator in the department of emergency services.

"With extended stays in the ED and patient acuity on the rise, ED nurses are being asked to increase their technological skills to those of ICU nurses," she says. "What used to be an ED motto of 'stabilize and move' is now 'stabilize and provide extended care.'"

ED nurses must be comfortable using CVPs, arterial lines, Scvo2 monitors, and the many drips and medications now ordered for sepsis patients, says Reynolds. "Complicating things further is the problem of the nursing shortage. Educating new graduates and nurses with little experience can be very challenging," she says.

The ED hired a full-time sepsis educator to provide group and individual training to day and night shift nurses, review sepsis charts, and provide feedback to the staff, says Reynolds. (See the order set used by emergency nurses.)

Positive outcomes are shared with ED nurses. For example, an 88-year-old man presented with altered level of consciousness, decreased blood pressure, decreased oxygen saturation, and extreme hypothermia. "The triage nurse was able to spot signs of sepsis," says Reynolds. ""The bedside nurse took immediate action and initiated our sepsis goal-directed therapy."

Labs and cultures were sent, fluids were started, and a central line was placed with Scvo2 monitoring, all within one hour. During the next hour the patient was placed on vasopressors to support his blood pressure, given intravenous antibiotics, and continued fluid resuscitation. "Due to the timely recognition of sepsis by the ED nurses and their prompt actions, this patient was able to walk out of the hospital doors all on his own and return to his family and normal daily activities," says Reynolds.

References

  1. Nguyen HB, Corbett SW, Steele R, et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 2007; 35:1,105-1,112.
  2. Nguyen HB, Lynch EL, Mou JA. The utility of a quality improvement bundle in bridging the gap between research and standard care in the management of severe sepsis and septic shock in the emergency department. Acad Emerg Med 2007; 14:1,079-1,086.

Sources

For more information about early interventions for sepsis patients, contact:

  • Patricia Burchell, RN, BSN, Emergency Department, Christiana Care Health System, Wilmington, DE. E-mail: PBurchell@christianacare.org.
  • Kelly Powers, RN, Emergency Department, Christiana Care Health System, Wilmington, DE. E-mail: KPowers@christianacare.org,
  • Teri D. Reynolds, RN, BSN, Clinical Educator, Department of Emergency Services, Loma Linda (CA) University Medical Center. E-mail: TReynold@llu.edu.