CLINICAL

EARLY RECOGNITION OF SEPSIS IN THE EMERGENCY DEPARTMENT: AN EVIDENCE-BASED PROJECT

Authors: Nanette Kent, BSN, RN, CEN, and Willa Fields, DNSc, RN, FHIMSS, La Mesa and San Diego, CA

epsis is a complex clinical syndrome that is challenging to diagnose and treat. Severe sepsis (acute organ dysfunction resulting from infection) is a major health problem that affects millions of persons globally. Severe sepsis has a reported inpatient mortality rate from 30% to 35%.1 The Surviving Sepsis Campaign was developed by the European Society of Critical Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine to help meet the challenges of sepsis and to improve its management, diagnosis, and treatment.2 This campaign developed guidelines that are of practical use for the bedside clinician in the diagnosis and treatment of severe sepsis. The purpose of this evidence-based early sepsis recognition project was to implement a sepsis screening measure for improving the identification, communication, and treatment of patients with sepsis.

Background

Sharp Grossmont Hospital is a 536-bed tertiary care, notfor-profit, Magnet designated community hospital in Southern California. The hospital is part of the Sharp HealthCare integrated regional health care delivery system, which was named a recipient of the 2007 Malcolm Baldrige National Quality Award. The Early Sepsis Recognition Project took place in the 60-bed emergency department, where approximately 80,000 patients are treated per year and an average of 225 patients are seen each day. The emergency department employs 150 registered nurses, 25 licensed vocational nurses, 30 health care

Nanette Kent is Educator, Sharp Grossmont Hospital, La Mesa, CA. Willa Fields is Professor, San Diego State University, and Program Manager, Sharp HealthCare, San Diego, CA. For correspondence, write: Nanette Kent, BSN, RN, 9275 Sinsonte Lane, Lakeside, CA 92040; E-mail: Nanette.kent@sharp.com. J Emerg Nurs . 0099-1767/$36.00 Copyright 2010 by the Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.07.022

partners, 44 clerical staff, 2 educators, 35 board-certified emergency physicians, and 15 nurse practitioners and physician assistants. Research has demonstrated that early recognition and treatment of severe sepsis promotes improved outcomes such as decreased mortality and morbidity.3,4 Algorithms for early detection and treatment of severe sepsis facilitate the consistent implementation of appropriate treatment.5 In 2006, the physicians and nursing staff at Sharp Grossmont Hospital adopted an established evidence-based sepsis algorithm for Early Goal Directed Therapy (EGDT). EGDT is a definitive resuscitation strategy that involves goal-oriented manipulation of cardiac preload, after-load, and contractility to achieve a balance between systemic oxygen delivery, oxygen demand, and tissue perfusion.5 The algorithm was based on the Surviving Sepsis Campaign recommendations and delineated a specific treatment course based on patient symptoms and clinical values (Figure). The algorithm directed that within the first 6 hours of a patients arrival at the hospital, depending on presentation and vital signs, particular treatment modalities should be instituted. According to the accompanying severe sepsis order set, adequate oxygen delivery and respiratory support, intravenous fluid resuscitation, medications to support cardiac output, and aggressive and early antibiotic administration should be implemented in an expeditious manner. An ED educational symposium, yearly competency sessions, and informal shift meetings were utilized to educate hospital staff in the use of the algorithm. Hospital intensivists provided a formal continuing educational series for physicians on EGDT for the diagnosis and treatment of sepsis. Despite adoption of the algorithm, there was no formal means for ED physicians and nurses to be held accountable for using the algorithm. Hospital intensivists reported that aggressive sepsis treatment was inconsistently implemented in the emergency department. Nurse educators in the emergency department also observed that the sepsis algorithm was not consistently implemented. Therefore a project ensued to improve implementation of the severe sepsis algorithm by introducing a measure to screen patients for severe sepsis (Table).

WWW.JENONLINE.ORG

CLINICAL/Kent and Fields

FIGURE Early goal-directed therapy for sepsis. BP, Blood pressure; C. diff, Clostridium difficile; CVP, central venous pressure; Hgb, hemoglobin; HR, heart rate; IV, intravenous; MAP, mean arterial pressure; NaCl, sodium chloride; PRBC, packed red blood cells; SBP, systolic blood pressure; ScvO 2 , central venous oxygen saturation; VS, vital signs. This figure is available in color and as a full-page document at www.jenonline.org.

JOURNAL OF EMERGENCY NURSING

Kent and Fields/CLINICAL

TABLE

Severe sepsis screening tool I. Systemic inflammatory response syndrome (two or more of the following): Temperature 100.4F or 96.8F Heart rate 91 beats/minute Respiratory rate 20 breaths per minute White blood cell count 12,000/mm3 or 4000/mm3 or >0.5 K/L bands If two of these criteria are checked, move to Section II. II. Infection (one or more of the following): Suspected or documented infection Antibiotic therapy (not prophylaxis) If one of these criteria is checked, move to Section III. III. Organ dysfunction (change from baseline in one or more of the following within 3 days of new infection) Respiratory: arterial oxygen saturation <90% Cardiovascular: systolic blood pressure <90 Renal: urine output <0.5 mL/h; creatinine increase >0.5 mg/dL from baseline Central nervous system: altered consciousness (unrelated to primary neurologic pathology); Glasgow Coma Score 12 If one of these criteria is checked, move to Section IV. IV. SBAR Communication: Patient has screened positive for severe sepsis (please initial); contact physician Situation: Screened positive for severe sepsis Background: 1. Positive systemic inflammatory response syndrome (describe areas positive) 2. Known or suspected infection 3. Organ dysfunction: indicate which organ system(s) Assessment: Indicate complete vital signs and arterial oxygen saturation Recommendation: 1. I need you to come and evaluate the patient to confirm if he/she has severe sepsis 2. It is recommended that I order tests to obtain an arterial blood gas value, lactate level, and complete blood cell count. Can I proceed? 3. Are there any other laboratory tests you would like me to order? 4. If the patient is hypotensive, can I start an intravenous line and give a bolus of normal saline solution, 20 mL/kg/h? 5. Can I initiate a sepsis order set and request an ICU bed? Outcome of patient assessment by physician: Physician diagnosis of severe sepsis: Time: No severe sepsis diagnosis by physician
Reprinted with permission from Pat Posa, MSA, BSN, RN, System Performance Improvement Leader, Saint Joseph Mercy Health System, Ann Arbor, MI.

The project set out to answer the following question: In the emergency department, what effect will the implementation of a nursing-based screening measure for the early recognition of sepsis, with the utilization of Situation, Background Assessment, and Recommendation (SBAR) communication, have on the identification of patients with severe sepsis?

Severe Sepsis Screening Measure

The Severe Sepsis Screening Measure, developed by Saint Joseph Mercy Hospital, Ann Arbor, Michigan, has 4 sections: systemic inflammatory response syndrome (SIRS), infection, organ dysfunction, and physician communication (Table). If a patient meets the criteria in each of

WWW.JENONLINE.ORG

CLINICAL/Kent and Fields

the first 3 sections, the patient is considered at risk for severe sepsis and the physician is contacted for further direction. The screening measure is a supplement to the previously created severe sepsis algorithm and accompanying order set. The SIRS section includes vital sign and white blood cell count criteria. If the patient presents with one or none of the SIRS criteria, the severe sepsis screening is complete and the patient is considered not at risk for severe sepsis; no further action is required. If the patient presents with at least 2 of the SIRS criteria, then the patient is considered at risk for severe sepsis and the second section of the screening measure (infection) is completed. The infection section asks if the patient has a suspected or documented infection or is taking non-prophylactic antibiotic therapy. If the patient does not meet either of these criteria, the severe sepsis screening is complete and the patient is considered not to be at risk for severe sepsis; no further action is required. If the patient presents with one or both of these criteria, the patient is considered at risk for severe sepsis and the third section of the screening measure (organ dysfunction) is completed. The organ dysfunction section asks if the patient has had a change in oxygen saturation, blood pressure, renal function, and level of consciousness since the onset of the infection. If the patient has none of these changes, the severe sepsis screening is complete and the patient is considered not to be at risk for severe sepsis; no further action is required. If the patient presents with any one of the listed changes, the patient has screened positive for severe sepsis and the nurse is directed to communicate with the ED physician using the format in the fourth section (physician communication) of the screening measure. Physician communication utilizes the SBAR communication model: situation, background, assessment, and recommendation. SBAR, a handoff model originally developed for communication on submarines, has been adopted by many health care organizations for structured communication.6 The SBAR section of the screening measure provides a structured approach for nurse-to-physician communication. The nurse is instructed to inform the physician of the purpose of the call (Situationthe patient screened positive for severe sepsis), the patients condition (Background and Assessmentresults from the screening measure), and what the nurse wants from the physician (Recommendationfurther laboratory tests and treatments). Through the use of SBAR, the nurse actively collaborates with the physician in the assessment and treatment of severe sepsis.

Methodology

This evidenced-based project aimed to improve the timeliness of a severe sepsis diagnosis, physician communication, and subsequent sepsis treatment. Nursing staff were oriented to the screening measure at change of shift meetings, and the project leader followed up with individual nurses during the shift to determine whether the measure was being used appropriately and whether there were any questions. After human subjects approval was granted by the hospitals Institutional Review Board, patient data were collected before and after the intervention on Mondays, Wednesdays, and Fridays between 7 AM and 3 PM on all adult patients who presented to the emergency department, regardless of presentation or chief complaint. Patient data included discharge diagnoses and presence or absence of criteria on the first 3 sepsis screening measure sections (SIRS, infection, and organ dysfunction). Data were analyzed using descriptive statistics. The assumption underlying this evidence-based project was that a more diligent screening process for severe sepsis would result in early diagnosis and more prompt and aggressive treatment for severe sepsis.
Results

Data were collected on 200 patients before implementation and 206 patients after implementation of the Severe Sepsis Screening Measure. When the screening measure was used to evaluate patient care prior to its implementation, 28% (n = 57) of patients presenting to the emergency department met the criteria for SIRS, 21% (n = 42) met the infection criteria, and 1% (n = 3) met the organ dysfunction criteria and would have progressed to an SBAR communication with the physician had the screening measure been implemented. Two of these patients were diagnosed with severe sepsis and died while in the hospital. The third patient was diagnosed with acute renal failure and was eventually discharged to a skilled nursing facility. None of the three patients received additional diagnostic tests or fluid boluses while in the emergency department. In contrast, after the Severe Sepsis Screening Measure was implemented, fewer patients met the criteria for SIRS (15%, n = 32) and infection (7%, n = 13), although 2% (n = 5) met the organ dysfunction criteria, and the nurses communicated with the physicians using SBAR for 4 of these patients. There was no documentation on the use of SBAR communication with the fifth patient. The SBAR communication resulted in additional diagnostic tests for the 4 patients and intravenous fluids for 3 of the patients. Two of the patients were diagnosed with severe sepsis and ultimately died. The other 2 patients

JOURNAL OF EMERGENCY NURSING

Kent and Fields/CLINICAL

were discharged with diagnoses of pancreatitis and pneumonia and discharged home and to a skilled nursing facility, respectively. The fifth patient, with no documentation of SBAR communication, was discharged from the hospital with a diagnosis of pneumonia.
Discussion

This situation resulted in limitations in measuring the efficacy of the tool.

Implications for Emergency Nurses

The Severe Sepsis Screening Measure has the potential to increase SBAR communication and facilitate aggressive treatment for patients with severe sepsis. No conclusions can be drawn regarding the effectiveness of the measure at this time because of the low frequency of positive screens for severe sepsis. Data will continue to be collected to determine whether this screening measure is effective in prompting nurses to implement the SBAR communication. The measure was simple to use and gave the emergency nurse clarity and direction for assessing specific signs or presentations. In addition, communication with ED physicians improved with the SBAR model. The measure gave the nurse the specific terminology and scripting to approach the physician when recommending additional treatment or interventions. In nursing staff feedback it was noted that the use of the measure heightened the nurses awareness of SIRS and sepsis symptoms and that the SBAR model helped them bridge critical communications with physicians. Of the 200 patients screened during the preimplementation period, 3 met the at-risk criteria for severe sepsis and SBAR communication with the physician. Had the Severe Sepsis Screening Measure been utilized, it is possible these patients would have received more aggressive treatment, including additional intravenous fluids and laboratory tests. After the screening measure was implemented, 5 patients screened positive for severe sepsis risk and 4 of these patients received additional treatment. The Severe Sepsis Screening Measure provided a structure to engage nurses in communicating succinct patient information to physicians, which resulted in additional diagnostic tests and treatments.
Limitations

In most cases, patients with severe sepsis present first to the emergency department for diagnosis and treatment. Not only should ED nurses be able to recognize the signs and symptoms of severe sepsis, they must be knowledgeable about the necessity of rapid and aggressive treatment of this syndrome. An easy-to-use measure can facilitate this awareness and lead to more consistency of treatment.
Conclusion

Results from this project suggest that utilization of a sepsis screening measure increased recognition of a small number of patients who presented to the emergency department with severe sepsis. Hospitals should benefit from utilizing a nurse-based screening measure to recognize severe sepsis, thus guiding nursing and medical care. Education of nursing staff in SIRS identification and a process for consistent communication of these findings to ED physicians would benefit both patient care and outcomes. Emergency nurse collaboration with physicians is always beneficial for staff and patients. Because of the deleterious effects of unchecked or under-treated severe sepsis, utilizing initial screening for severe sepsis that is performed by trained nurses should lead to earlier treatment of patients with this condition.
REFERENCES
1. Surviving Sepsis Campaign. About sepsis. http://www.survivingsepsis.org/ Introduction/Pages/default.aspx. Accessed September 29, 2009. 2. Dellinger R, Levy M, Carlet J, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36(1):296-327. 3. Jones A, Focht A, Horton J, Kline J. Prospective external validation of the clinical effectiveness of an emergency department-based early goal directed therapy protocol for severe sepsis and septic shock. Chest. 2007;132:425-32. 4. Nguyen H, Rivers E, Fredrick M, et al. Severe sepsis and septic shock: review of the literature and emergency department management guidelines. Ann Emerg Med. 2006;48:28-54. 5. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001; 345:1369-77. 6. Groah L. Tips for introducing SBAR in the OR. OR Manager. 2008; 22(4):1.

Limitations in this project included a low number of patients who screened positive for severe sepsis. Even though more than 400 patients were screened with the measure, only 8 patients screened positive for severe sepsis.

WWW.JENONLINE.ORG