According to the Centre for Disease Control and Prevention, more than 1.5 million adults in the United States contract Sepsis with at least 250,000 lose their lives as a result. In the years 2010-2011, Sepsis was deemed as the 7th and 11th leading cause of death for infants and adults in the United States respectively. On the global front, the WHO notes that although “the global epidemiological burden of Sepsis is difficult to ascertain, some scientific publications reported that it affects more than 30 million people worldwide every year potentially leading to 6 million deaths” (WHO, 2017). This continues to be a major burden for the healthcare system with demand for infrastructural adaptations to counter it.
Sepsis continues to be a major recurring problem in hospitals due to inadequate public awareness as well as education targeting medical staff. In many hospitals, nurses are deemed as the first line of defense in the containment and control of different ailments including Sepsis. Their efforts are pivotal as they are in constant interaction with patients as well as the medical practitioners (Khardori, 2014). With their caregiving role and significant position in the patient management, the nurses can be fundamental in the early interventions against Sepsis. With many studies noting that Sepsis can be managed and controlled in early stages, there is a need for mechanisms to ensure that detection is achieved early enough within the healthcare settings.
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Despite the need to fight and detect the disease, many health organizations continue to face challenges which emanate from their lack of capacity. Many of the institutions are not fully prepared to actively mitigate Sepsis hence the appalling statistics. CDC notes that early detection is central in this endeavor and, therefore, has called for public awareness with the nurses being one of the key cohorts of the targeted group with the goal. It is important to note that early detection provides room for immediate treatment is usually the difference between life and death in the healthcare setting.
The mortality rate from untreated and unrecognized sepsis is greater than 50% in the patients that lack any form of intervention within the first three hours of being brought to the emergency department (Khardori, 2014). Expert assessment by nurses and immediate referrals can enhance efficiency in the management of sepsis where time and lives can equally be saved. In the light of this information, there is need to institute changes particularly targeting nurses to ensure that they well equipped to recognize and pursue all Sepsis management protocols to save lives in hospitals.
Problem Statement
The knowledge deficit due to lack of empowerment of nurses in the management of sepsis within the different hospital settings
Description of the Course
The training of nurse on the management of Sepsis will be pivotal in promoting early intervention. The nurses form a key link between the medical practitioners and patients. This is because they are the initial contact and through their assessments and observation can set up the channels that can be pursued by patients in pursuing integrated. It is prudent to note that many patients treated for Sepsis in the ICU are often from the other units such as operating rooms (ORs), general-medical surgical practice units (GPUs), EDs, long-term care facilities and other hospitals. This happens because diagnosis and treatment, in many instances, might have been suboptimal. The delays occasioned identification; transfer and management of critically ill patients in the first few hours after ICU admissions have been linked with enhanced mortality rates. It is this knowledge that highlights the need to boost awareness and training on Sepsis management among patients. Studies continue to point out the impact of integration of sepsis screen into the routine patient assessments and patient care rounds.
Rationale
This paper will, therefore, justifying the establishment of elaborate training of nurses on Sepsis detection and management in care provision. It takes into account the appalling statistics that continue to make Sepsis a major issue, particularly within the healthcare setting. Different approaches emerge as a by-product of the Sepsis training and management for nurses. This is fundamental in creating the appropriate interventions which might be singular or multifaceted with an appreciation of the diverse context of the major healthcare settings.
The empowerment of nurses is fundamental as it not only focuses on the training but establishment of protocols or bundles that are pertinent in improving the quality of outcomes in the provision of care to patients that continue to grapple with Sepsis. The institution of screen protocols and tools at the first interaction with patient generally shows a direct relationship between their use and enhanced recognition of sepsis which may lead to the early introduction of fluid resuscitation and initiation of antibiotics (Garay-Fernández, 2017). It is every healthcare system’s goal to lower complication and death rates associated with medical conditions. This is supported by major studies that indicate that patient with symptoms and signs of Sepsis who are assessed and treated in accordance to the established protocols within the first two hours of their presentation enjoy better outcomes and lower complications (Ward & Levy, 2017). The implementation of the sepsis screening tools will be pivotal in the reduction of morbidity and mortality.
Nurses are key players in the frontlines of identifying and initiating care provision for patients diagnosed with sepsis. It is this reason that many of the aforementioned protocols and tools are formed with nurses as their main focus. By creating awareness through training regarding the sepsis protocols and significance of initiating early recognition and treatment of sepsis, there will be a major reduction in the sequel and mortality rate of sepsis as envisaged by the World Health Organization.
Literature Review
Lopez-Bushnell, Demaray, and Cathy (2014) the pathogenic, diagnostic and therapeutic landscape of sepsis is no longer associated with intensive care unit; many patients from other portals of entry to care, both outside and within the hospital, progress to severe diseases. The authors note that there are previous approaches that have been used in the improvement of outcomes with other ailments such as stroke, myocardial infarction, and trauma can be used in the management of sepsis. Lopez-Bushnell et al. (2014), note that this can be made possible through the comprehension of the pathogenesis that characterises both septic shock and severe sepsis. This has in the recent past led to the establishment of new interventions that emphasize early detection and rigorous management.
Rivers et al. (2013) focus on the efficiency of early goal-directed therapy (EGDT) in the management of sepsis. This therapy advocates for early identification of high-risk patients, source control, appropriate cultures, and appropriate antibiotic administration. This approach has proven to be effective in reducing mortality rates in comparison to the standard care by over 16%. However, with the EGDT the 6 hours management of sepsis has emerged and is commonly referred to as the resuscitation bundle or RB. RB is more specific in the management of sepsis, and it incorporates; “early diagnosis, risk stratification using lactate levels, hemodynamic response after a fluid challenge, antibiotics source control, and hemodynamic optimization” (Rivers et al., 2013). This article celebrates the major milestones attained in the implementation of RB by healthcare providers with nurses the key cogs in its execution.
“ Sepsis six” resuscitation bundle is highlighted by Ruth Kleinpell in her 2017 study. The author acknowledges that nurses play a critical role in the identification of patients with sepsis as they occupy a unique position by virtue of having constant interaction with patients. With the establishment of Sepsis six in New Zealand, the nurses are greatly empowered by the pertinent knowledge in the early identification of patients through elaborate protocols. The Sepsis six focuses on six key areas which are namely; “intravenous fluids, blood cultures, antibiotics, lactate, oxygen, and urine output” (Kleinpell, 2017).The nurse-led protocols are effective especially in the first stages of managing patients through detection and treatment of patients with Sepsis. Kleinpell argues that multifaceted performance improvement initiatives continue to highlight improved “compliance with sepsis performance measures with associated reductions in-hospital mortality in patients with severe sepsis and septic shock in ICU and ward settings” (Kleinpell, 2017).
The management of Sepsis within the health care system is deemed as multidisciplinary effort. As such, sepsis protocols are deemed much effective when they embrace such a multidisciplinary approach. According to Picard, O’Donoghue, Young-Kershaw, and Russell (2014), sepsis treatment largely focuses on “supporting failing organ systems.” The authors incorporate studies made at Deaconess Medical Centre (BIDMC) in Boston in regards to care extended to patients grappling with sepsis. The BIDMC protocol as identified in the study incorporated early goal-directed therapy that was advanced by Rivers et al. (2013). The multidisciplinary approach dubbed as Multiple Urgent Sepsis Therapies protocol incorporates various therapies as well as professionals. The professionals constitute the “Sepsis Team” which initiates the BIDMC protocol. The emergency department is the first initiation point with nurses taking an active role in assessing patients by utilizing a “previously described criteria and activate code sepsis.” It is the nurses who determine whether a particular patient is eligible for the said protocol, the other members of the team are informed. According to Picard et al. (2014) “the team includes, but is not limited to, the ICU attending physician and resident, emergency department attending physician and resident, the ICU clinical nurse specialist and the nursing admission facilitator.” The purpose of such a multidisciplinary approach in sepsis management is that the right clinicians are alerted early enough to effectively mobilize “early resuscitation effort and prepare the ICU to assume care of the patient” (Picard et al., 2014). Additionally, through empowerment of nurses with such a protocol ensures that they enjoy the synergy at the hospital setting to ensure that they meet the set goals. It also boosts liaison which ensures that quality outcomes are achieved in all stages that a sepsis patient is taken through from screening, treatment and eventual recovery.
Mitchell et al. (2013) appreciate the implications of a multi-faceted intervention in detecting clinical deterioration of patients within the hospital settings. The study acknowledges that hospital personnel such as nurses must be empowered to be able to manage patients through sepsis management. However, the study looks at the efforts that ought to be pursued or utilized in cases where clinical instability suffices as a major problem. This is usually evident in Emergency Rooms (ER) where many hospitals are overwhelmed by unplanned admissions to the ICU. It is in this particular point that protocols particularly those touching on sepsis may be overlooked especially if the nurses are not well trained or equipped with knowledge in regards to sepsis identification and treatment (Mitchell et al., 2013). The appropriate strategies elements necessary for the pursuit of stabilizing sepsis patient is usually challenging particularly in advanced cases.
Sepsis in children may have adverse effects if it goes undetected early enough. Kleinpell, Aitken, and Schorr (2013) note that much of the suboptimal care extended to sepsis patients is directly linked to delayed recognition and intervention. This is a major problem across different healthcare centers due to inadequate tools to ensure caregivers comprehend the necessary tools that are fundamental to the management child patients suffering from sepsis. In the study, an emergency department protocol is evaluated on its effectiveness in distinguishing septic shock from other conditions and promoting adherence to national treatment (Kleinpell, Aitken, & Schorr, 2013) . A goal-directed therapy, in this case, suffices as effective in addressing challenges stemming from septic shock in children. A computerized triage system is discussed in this paper highlights the shortcomings that may arise from the nurses to fully being equipped with the IT knowledge required in handling the said machines as appreciated in the ED protocol.
In establishing the best protocol for the management of sepsis in hospitals a 2015 study by Steinmo and others advocates for a combination of the sepsis six and severe sepsis resuscitation bundle. Using a 500-bed acute general hospital as an observational cohort for their study, the researchers established the implementation of the protocols saw the reduction of mortality from 44.1% to 22.0% (Steinmo et al., 2015) . The findings of the study signal the effectiveness of “simplified pathways such as sepsis six and education programs such as survive sepsis in order to enhance of the rate of the delivery of life-saving interventions to patients suffering from sepsis (Steinmo et al., 2015) . However, the implementation of these programs cannot be fully effective without the contribution of the medical personnel more so nurses. They are a constant feature in virtually all steps of interventions and evaluation of outcomes. Non-compliance with bundle can be problematic in that health care centers may be unable to fully process the non-reducing mortality rates as a result of sepsis. Therefore, as much as the care bundles are formulated the key personnel –the nurses must be sensitized on why the protocols are essential. The internalization of the implications of the sepsis bundles will be fundamental in creating a cultural shift within the health care system that will help in the realization of reduction of the mortality and morbidity rates linked with the disease.
Roney et al. (2015) review various recommendations that ought to guide nurses in the provision of care to patients identified with severe sepsis. Using the GRADE system, the researcher evaluated the various recommendations. The recommendations were classified in prevention, initial resuscitation, supportive nursing care and pediatrics categories (Roney et al., 2015) . All these categories have a nurse as the key personnel involved. Therefore, any aspects of care extended to sepsis patient are founded on the need for consensus among different practitioners including nurses who are better placed to actualize the recommendations. Empowerment does not only occur through the provision of guidelines but also having inclusion which will see the nurses participating in the formulation of the appropriate strategies that will lead to the mitigation of sepsis.
The essence of timely detection and intervention is also advocated for by Lacroix in his 2014 article. The author notes that severe sepsis is behind high mortality in hospitals. Accordingly, there is a need for a comprehensive management protocol that enhances effectiveness and ease in the detection and provision of primary treatment of sepsis from the emergency room and ultimately to the intensive care unit. The paper denotes that comprehensive management does not only focus on the guidelines but also specific roles assumed by different personnel in the sepsis management. As such, nurses have their specific but yet extensive role in the management of severe sepsis which is fundamental to ensuring that the process of care experience sustained improvements (Lacroix, 2014). It is also prudent to empower nurses with the tools to carry out self-audit which will enable them to understand the mechanics of the protocols in line with the existing technological advancements and scientific breakthroughs.
Nurse champions are critical elements in the implementation of protocols and other measures meant to empower nurses in establishing the best ways to manage sepsis. Delaney, Friedman, Dolansky, and Fitzpatrick in their 2015 article dubbed Impact of a Sepsis Educational Program on Nurse Competence argues that its time hospitals focussed on empowering nurses through the incorporation of nurse champions. Within the ICU environment, nursing champions as highlighted in the study are key in ensuring that nurses fully comply with sepsis bundles or protocols. This can be ascertained through one-on-one interviews with nurses as well as observation. This helps greatly in creating the needed rapport to highlight how effective the protocols are and how well they are acclimatized to the challenges faced by an organization in its effort to counter surging rates of sepsis. In many hospital settings, protocols are adjusted with the intent of making them effective and sensitive to the unique circumstances that prevail in the particular context (Friedman et al., 2015). Nurse champions are critical in the empowerment agenda as they also offer oversight to the implementation of protocols which enhances patient safety outcomes. In light of the study by Friedman et al. (2015) nurse champions were incorporated in the Michigan Health and Hospital Association Keystone ICU sepsis screening protocols. The inclusion saw “improved compliance with ICU sepsis screening, from 23% pre-introduction to 74%, but had virtually no effect on patient outcomes related to the percentage of patients treated for sepsis” (Friedman et al., 2015).
Best Practices
In boosting quality management of sepsis within health organizations and in cognizance of the role that nurses may play some practices can be identified. The most appropriate and effective as per the literature review is the sepsis six. The sepsis six is best implemented through a training program dubbed Surviving Sepsis Campaign. The program familiarizes nurses with the guidelines surrounding the sepsis six therapies which are:
1. Administer 100% oxygen
2. Evaluation of blood gases to establish which antibiotics ought to be used
3. Administration of antibiotics
4. Administration of IV fluids
5. Observation of the lactate levels
6. Insertion of catheter and monitoring of the fluids as they go in and out of the body
The Surviving Sepsis Campaign must be made a key feature in regular health organization training. Nurse champions may also be integrated to offer oversight of how well the protocols have been embraced and implemented by the caregivers. Such a concerted approach will see to it that patient outcomes improve and decreased mortality and morbidity rates as envisioned by World Health Organization.
Recommendations
Sepsis continues to be a major killer medical condition. The mortality rate from untreated and unrecognized sepsis is greater than 50% in the patients that lack any form of intervention within the first three hours of being brought to the emergency department. However, with proper interventions and early detection sepsis in both adults and children can be brought down.
Nurses being the first point of contact for patients can aid in the containment of sepsis and its initial management. As such, there is need to empower the nurses with the right knowledge and awareness on the protocols that are critical in countering the surging rates of sepsis.
Multidisciplinary and hybrid approaches are most appropriate such as EGBDT and sepsis six which promote cohesiveness and synergy that is pertinent to any synchronized healthcare system.
The inclusion of nurse champions is fundamental in cultivating awareness and evaluative based training on how well to handle sepsis case.
References
Delaney, M. M., Friedman, M. I., Dolansky, M. A., & Fitzpatrick, J. J. (2015). Impact of a Sepsis Educational Program on Nurse Competence. The Journal of Continuing Education in Nursing , 46 (4), 179-186. doi:10.3928/00220124-20150320-03
Garay-Fernández, M. (2017). Sepsis Management: Non-antibiotic Treatment of Sepsis and Septic Shock. Sepsis , 117-133. doi:10.1007/978-1-4939-7334-7_9
Khardori, N. (2014). Sepsis: Diagnosis, Management and Health Outcomes (Allergies and Infectious Diseases) . UK: Palgrave.
Kleinpell, R. (2017). Promoting early identification of sepsis in hospitalized patients with nurse-led protocols. Critical Care , 21 (1). doi:10.1186/s13054-016-1590-0
Kleinpell, R., Aitken, L., & Schorr, C. A. (2013). Implications of the New International Sepsis Guidelines for Nursing Care. American Journal of Critical Care , 22 (3), 212-222. doi:10.4037/ajcc2013158
Lacroix, J. (2014). Faculty of 1000 evaluation for Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. F1000 - Post-publication peer review of the biomedical literature . doi:10.3410/f.717997908.793497361
Lopez-Bushnell, K., Demaray, W. S., & Cathy, J. (2014). Reducing Sepsis Mortality. Medsurg Nursing , 23 (1), 9-14.
Mitchell, I., McKay, H., Van Leuvan, C., Berry, R., McCutcheon, C., Avard, B., … Lamberth, P. (2013). A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation , 81 (6), 658-666. doi:10.1016/j.resuscitation.2010.03.001
Picard, K. M., O'Donoghue, S. C., Russel, K. J., & Young-Kershaw, D. A. (2014). Development and Implementation of a Multidisciplinary Sepsis Protocol. Critical Care Nurse , 26 (3), 45-54.
Rivers, E. P., Katranji, M., Jaehne, K. A., Brown, I. S., Abou Dagher, G., Cannon, C., & Coba, V. (2013). Early interventions in severe sepsis and septic shock: a review of the evidence one decade later. MINERVA MEDICA , 78 , 712-724.
Roney, J. K., Whitley, B. E., Maples, J. C., Futrell, L. S., Stunkard, K. A., & Long, J. D. (2015). Modified early warning scoring (MEWS): evaluating the evidence for tool inclusion of sepsis screening criteria and impact on mortality and failure to rescue. Journal of Clinical Nursing , 24 (23-24), 3343-3354. doi:10.1111/jocn.12952
Steinmo, S. H., Michie, S., Fuller, C., Stanley, S., Stapleton, C., & Stone, S. P. (2015). Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement “Sepsis Six”. Implementation Science , 11 (1). doi:10.1186/s13012-016-0376-8
Ward, N. S., & Levy, M. M. (2017). Sepsis: Definitions, Pathophysiology and the Challenge of Bedside Management . Cham: Humana Press.
WHO. (2017). Sepsis: Improving the prevention, diagnosis and clinical management of sepsis. Retrieved from http://www.who.int/sepsis/en/
