Sepsis is an exaggerated and uncontrolled systematic inflammatory response to an infection or tissue injury. Sepsis is classified into three stages, with severe sepsis and septic shock being the most critical stages. According to the CDC report (2017), over 1.5 million people get sepsis in the U.S. and approximately 250,000 dies from sepsis every year. Statistics show that in every three patients who die in the hospital, one of them has sepsis (CDC, 2017). Sepsis is a life-threatening condition, and positive outcomes are only attained when early and aggressive interventions are adopted. Approximately half of the patients with sepsis require admission into the intensive care unit. The mortality rate for sepsis is unacceptably high, hence the need to come up with a comprehensive detection plan. Early detection of sepsis is a requirement for early goal-directed therapy to achieve positive outcomes.
The Problem
Why is Sepsis Mortality Rate still high?
According to Goerlich et al. (2014), sepsis is responsible for many deaths despite the significant clinical and research achievements. The high mortality rate endures because of the difficulties in the early identification of sepsis. The mortality rate of sepsis is at 65.5 per 100,000 persons in the US, which represents a dramatic increase. According to Maclay & Rephann (2017), sepsis rate per 100,000 patients doubled between 2000 and 2008 and in-hospital deaths are reported to be eight times higher in patients with sepsis. Sepsis mortality is costly to the patients and the healthcare system in general.
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A number of factors are responsible for the high mortality rates. First, noncompliance with evidence-based guidelines for sepsis management is attributed to delayed recognition of sepsis. The Surviving Sepsis Campaign was launched in 2002 after a number of international organizations met to discuss how to reduce sepsis mortality. The program led to the development of two management bundles for sepsis (a 6-hour resuscitation bundle and a 24-hour management bundle) (Alsalamy et al., 2014). The program has been revised twice, and now there is a 3-hour bundle and a 6-hour bundle. Evidence suggests that adherence to the management bundles can reduce mortality rate, but it is yet to be realized.
Another factor to consider is the availability of many detection methods. According to Alsalamy et al. (2014), there is no standardized method for early recognition of sepsis. SIRS tool is the conventional method used to detect sepsis, yet it has been criticized for being too general. Consequently, there are many screening tools; some have sensitivities ranging from 14% to 69% and specificities from 35 to 99% (Alsalamy et al., 2014).
Solution
Researchers agree that there is a need for a standardized screening tool with the highest level of sensitivity and specificity. Alsalamy et al. (2014) also add that the screening tool should cause little or no patient morbidity, it should be readily available, and it should identify the underlying conditions that will affect the treatment. Alsalamy et al. (2014) propose the use of an electronic alert system to detect severe sepsis and septic shock in the emergency department. The study was conducted in a 900-bed hospital for four months to test the effects of an electronic sepsis alert tool. The electronic sepsis screening tool was integrated into the electronic health record (EHR). The tool contained parameters used to differentiate sepsis from severe sepsis and septic shock. The tool automatically scans clinical and laboratory records, and if the patient meets the screening conditions, the system produces a “severe sepsis and septic shock” alert. The alert goes to the nurse who responds to the patients immediately. The tool has 95% sensitivity and specificity.
In another study, Goerlich et al. (2014) came up with another screening tool to replace systemic inflammatory response syndrome (SIRS). SIRS was developed in 1992, it checks the heart rate, respiratory rate, white blood cell count and temperature and assigns each factor a score. The SIRS score is used to measure the severity of sepsis. SIRS has been criticized as too sensitive yet to general. In the study, Goerlich et al. (2014) suggested the use of a Spot Check StO2 device to measure the heart rate, respiratory rate, and temperature. The total values of the different factors are then used to indicate whether the patient has sepsis or not. Goerlich et al. (2014) concluded that the Spot Check StO2 device has 85.7% sensitivity and 78.4% specificity. Spot Check StO2 device has better specificity than SIRS, and it can be used to identify sepsis in its early stages correctly.
Alternatively, Maclay & Rephann (2017) propose the use of quick sepsis organ failure assessment (qSOFA). The tool was created to address the problems in the SIRS. In their study, Maclay & Rephann (2017) used SOFA and qSOFA tools because they produce timely and specific detection of sepsis. The researchers conducted a primary research on developing a standardized approach for managing sepsis using QSOFA to improve patient outcomes. They created a framework for physicians and nurses to help them manage sepsis better. The plan involved a 3-hour bundle in the ED which involves measuring plasma lactate level, antibiotic treatment, and administration of intravenous crystalloid fluids at 30 mL/kg to treat hypotension. The plan also included the 6-hour bundle. By the end of the study, the team had responded to 30 sepsis alerts and treated patients using the suggested steps in the plan. By the end of the study, the facility reported a decrease in sepsis mortality by 17.7% (Maclay & Rephann, 2017).
Conclusion
Evidently, early detection of sepsis is a multifaceted process as shown by the different detection tools (MacQueen et al., 2015). Some researchers suggest the use of electronic alert system while others prefer QSOFA method. Some of the tools have proven to be more sensitive and specific, for example, qSOFA is seen as a more specific tool in comparison to SIRS. Health practitioners have to put into consideration the different patient factors. For examples, Annam et al. (2015) suggest the use of cord blood Haematological Scoring System to screen sepsis in neonatal patients. Hospitals should not restrict themselves to specific tools, for instance, qSOFA can be used with the electronic alert system to make it more efficient.
In conclusion, there is a need to develop a comprehensive and standardized sepsis improvement program. The program entails the right tools for early detection and treatment in general wards, ED, neonatal and other departments. The program will also include guidance routines for sepsis screening, monitoring, and treatment which will be incorporated into the treatment plan. The key to the success of the program lies in nurse education, communication, and monitoring. Sepsis is a burden to patients and the healthcare system, responsible for many deaths annually which can be avoided. A comprehensive and early detection tool will play an essential role in reducing deaths caused by sepsis.
References
Alsolamy, S., Al Salamah, M., Al Thagafi, M., Al-Dorzi, H. M., Marini, A. M., Aljerian, N., & Arabi, Y. M. (2014). Diagnostic accuracy of a screening electronic alert tool for severe sepsis and septic shock in the emergency department. BMC medical informatics and decision making , 14 (1), 105.
Annam, V., Medarametla, V., & Chakkirala, N. (2015). Evaluation of cord blood-haematological scoring system as an early predictive screening method for the detection of early onset neonatal sepsis. Journal of clinical and diagnostic research: JCDR , 9 (9), SC04.
Goerlich, C. E., Wade, C. E., McCarthy, J. J., Holcomb, J. B., & Moore, L. J. (2014). Validation of sepsis screening tool using StO2 in emergency department patients. journal of surgical research , 190 (1), 270-275.
Maclay, T., & Rephann, A. (2017). The Impact of Early Identification and a Critical Care–Based Sepsis Response Team on Sepsis Outcomes. Critical care nurse , 37 (6), 88-91.
MacQueen, I. T., Dawes, A. J., Hadnott, T., Strength, K., Moran, G. J., Holschneider, C., & Maggard-Gibbons, M. (2015). Use of a hospital-wide screening program for early detection of sepsis in general surgery patients. The American Surgeon , 81 (10), 1074- 1079.
