Creating a Culture of Safety: Blog Series for Nurses Week 2016

2016-NNW-blog-series.pngHappy National Nurses Week! As we approach the celebration this year, I’d like to take some time to share all that we have coming up for the week and into the rest of the month. There’s a lot of buzz online about what a Nurses Week gift should look like (Read: Not another water bottle. How about safe staffing?) As a leading web resource for nurses, we’d like to do our part to create a culture of safety this Nurses Week by providing you with up-to-date resources based on the latest evidence and reviewed by our peers. Be sure to check out all of our Nurses Week plans and take advantage of CE collections, free articles, eBook offers, and some opportunities for fun!
I’m excited to share that right here on our blog, we have a wonderful series of posts from nurse experts who’ve shared their insights and knowledge. I’ve enjoyed working with these colleagues – they’ve inspired me and taught me so much as we put together this series. I think you’ll enjoy it! 

Here’s what’s ahead: 
ashpe-award_2016-(1).jpgOn another note, I want to let you know that Lippincott received the Gold Award from the American Society of Healthcare Publication Editors (ASHPE) for Best Use of Social Media for our campaigns for National Nurses Week in 2015! Thank you to all of you for your likes, follows, comments, shares, retweets, etc. You were instrumental in helping us to achieve this goal! And congratulations to all the winners of these prestigious awards!

Be sure to follow us on all of our social media channels as we head into National Nurses Week 2016! We’ve got some special offers that you don’t want to miss!
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Have a great week, everyone!

Posted: 5/4/2016 10:29:46 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Nursing Informatics Day: Celebrate with NursingCenter and CIN: Computers, Informatics, Nursing

mollie-cummins.jpg“The most important thing for nurses to understand about informatics is that it’s not technology. Informatics is not about hard drives, and it’s not even necessarily about programming, and we certainly cannot fix someone’s problems with Outlook. Informatics is about how we’re managing data, information from both a process perspective and a technical perspective to advance health care.” Mollie R. Cummins, PhD, RN, FAAN has been a practicing nurse since 1994 and has made waves in the nursing informatics specialty throughout her career. She holds a doctorate in nursing science and information science from Indiana University, serves as an associate professor of nursing and adjunct professor of biomedical informatics at the University of Utah, and currently serves as the president of the Utah Nursing Informatics Network. Cummins also recently served as editor the ANI Connection and CIN Plus columns of the journal, CIN: Computers, Informatics, and Nursing.

CIN.pngNursing Informatics Day is May 12th and takes place during National Nurses Week. She says, “It’s important that nursing informatics celebrate its profession in conjunction with nurses week, especially this year because this year the focus is on safety. IT has been identified as one of the most promising approaches for improving safety in the clinical setting. IT-based strategies, such as barcode medication administration, can really reduce safety inefficiencies and vulnerability in the clinical setting, so it’s very important that nursing informatics be a part of this.” 

I had the chance to speak with Cummins over the phone about ways to celebrate Nursing Informatics Day and why nurses in all specialties should pay attention to technology in the workplace. 

Listen for the whole interview…
Be sure to stop by our National Nurses Week page for more ways to celebrate, including discounts and giveaways for nurses week! BONUS: Read the current issue of CIN on NursingCenter for free as our featured journal until May 15th. 
Posted: 5/2/2016 2:49:50 PM by Cara Deming | with 1 comments

Categories: Technology

The Essentials of Negative Pressure Wound Therapy (NPWT): Part 2

I have learned quite a bit on my journey to gaining a better understanding of Negative Pressure Wound Therapy (NPWT). In Part 1 of this series, I provided an overview of NPWT, including what it is, how it works and the risks and benefits. In Part 2 of the series I will review the practical application of NPWT including prescribing orders, procedural steps, general patient care, and tips to troubleshoot the device. Let’s jump in!
What are the steps in applying NPWT? Each device has a specific design and manufacturer’s instructions for use that should be reviewed. The following procedural steps provide a general guide.
  1. Pre-medicate the patient for pain as needed and as prescribed.
  2. Prepare the wound by:
    • removing the prior dressing very carefully to avoid tissue damage and bleeding
    • debriding the wound, performed by a qualified practitioner
    • cleansing the wound as needed/prescribed
    • assessing wound size and depth
  3. Cut foam dressing to size and place into the wound. Document the number of foam pieces used; foam acts as a filter to catch blood clots and large tissue particles that might clog the vacuum system.
  4. Trim clear occlusive dressing to size, peel back one side of Layer 1 and place adhesive side down over wound. (see photo 1)
  5. Remove the remaining side of Layer 1 ensuring it creates a tight seal.
  6. Cut a hole into the clear dressing about the size of a quarter (2.5 cm). (see photo 2)
  7. Remove Layer 1 from adhesive pad connected to the pump tubing.
  8. Place pad and tubing directly over hole affixing it to the clear dressing. (see photo 3)
  9. Remove Layer 2 from the adhesive pad.
  10. Connect pad tubing to canister tubing and be sure the clamps are open.
  11. Turn on power to the vacuum device, set the prescribed pressure settings, and confirm that the dressing and foam shrink down. (see photo 4)




Wound Care Tips:
  • Use protective barriers, such as non-adherent or petroleum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT. 2
  • Avoid overpacking the wound too tightly with foam; this prevents negative pressure from reaching the wound bed, causing exudate to accumulate. 2
  • Avoid placing the tubing over bony prominences, skinfolds, creases, and weight-bearing surfaces to prevent tubing-related pressure ulcers. 2
  • Count and document all pieces of foam or gauze on the outer dressing and in the medical record, to help prevent retention of materials in the wound; 2 when possible, only use one piece of foam dressing.
  • With a heavy colonized or infected wound, consider changing the dressing every 12 to 24 hours as directed by the prescribing clinician.2

General Patient Care:
  • Assess the patient for wound healing issues, such as poor nutrition (low protein levels), diminished oxygenation, decreased circulation, diabetes, smoking, obesity, foreign bodies, infection and low blood levels.2
  • Assess and manage the patient’s pain; be sure to premedicate as needed before each dressing change.
  • Provide patient education on:
    • Alarms and device ‘noise’
    • Dressing changes
    • Signs of complications (bleeding, infection)
  • Patients should seek medical care if they notice:
    • Significant change in the color of the drainage (cloudy or bright red)
    • Excessive bleeding under the clear dressing, in the tubing or in the canister
    • Increased redness or odor from the wound
    • Increased pain
    • The device has been left off for more than 2 hours
    • Signs of infection, such as fever, redness or swelling of the wound, itching/rash, warmth, pus or foul smelling drainage
    • Allergic reaction to the drape/dressing: redness, swelling, rash, hives, severe itching. Patient should seek immediate medical assistance if they experience difficulty in breathing
Troubleshooting the Device
  • Confirm that the unit is on and set to the appropriate negative pressure, that the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure. 2
  • Be sure the negative pressure seal has not been broken and leaks are minimal.4
  • Ensure there are no kinks in the tubing and that all clamps are open.4
  • Address and resolve alarm issues; reasons for the unit to alarm include: canister is full, there is a leak in the system, battery is low/dead, therapy is not activated.
  • Do not leave the device off for more than two hours; while device is off, apply a moist dressing 2 and notify the prescribing clinician immediately.
  • Avoid getting the electrical device wet; educate the patient to disconnect the unit from the tubing and clamp the tubing before bathing.
  • Check the drainage chamber to make sure it is filling correctly and does not need changing.4
While I am not an expert in the field of wound care, I am now more confident and better prepared to manage patients receiving Negative Pressure Wound Therapy. I would love to hear your experiences. Let me know if you have any tips or other suggestions that can help nurses and patients safely operate and maintain these devices.
1. Centers for Medicare and Medicaid Services. (2014). Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. Retrieved from the Centers for Medicare and Medicaid Services:
2. Rock, R. (2014). Guidelines for Safe Negative-Pressure Wound Therapy: Rule of Thumb: Assess Twice, Dress Once. Wound Care Advisor, 3(2), 29 – 33
3. Federal Drug Administration. (2009). FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. Retrieved from the Federal Drug Administration:
4. Wound Care Centers. (2016). Negative Pressure Wound Therapy. Retrieved from Wound Care Centers:
 Myrna B. Schnur, RN, MSN

Posted: 4/22/2016 6:43:57 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions Technology

The Essentials of Negative Pressure Wound Therapy (NPWT): Part 1

negative-pressure-wound-therapy.PNGSince I began working in a reconstructive surgery clinic several years ago, I have been exposed to a myriad of complex acute and chronic wounds that require advanced treatment modalities, such as Negative Pressure Wound Therapy (NPWT), in order to heal. These devices were new to me, and I quickly realized that they can be a source of great anxiety for both patient and clinician. I decided I needed more information and education on the topic. In Part 1 of this blog series, I will discuss the basics of NPWT, what it is, how it works, as well as risks and benefits. 

What is Negative Pressure Wound Therapy (NPWT)?
Also known as vacuum-assisted wound closure (VAC), NPWT is the distribution of negative pressure across a wound1. The therapy, which emerged in the early 1980’s, includes the placement of a dressing (foam or gauze) onto the wound and is connected to a vacuum pump via tubing1. A clear occlusive dressing is placed on top, forming an air tight closed system. Gentle, controlled suction is applied pulling wound debris into a collection chamber. The Food and Drug Administration (FDA) approved the first device for NPWT in 1997. Currently, there are over a dozen FDA approved devices available on the market1, many of which are small and lightweight, allowing patients full mobility3. Due to varying designs, it is important that you become familiar with the manufacturer instructions for the specific device in use.

Which types of wounds benefit most from NPWT?
  • Surgical wounds, especially those which need to heal by secondary intention1
  • Open abdominal incisions1
  • Dehisced surgical wounds1
  • Burns
  • Skin flaps and preparation for skin graft sites1
  • Traumatic wounds1
  • Chronic wounds, such as venous insufficiency ulcers, diabetic foot ulcers, and pressure ulcers1,4
  • Wounds at high risk for infection4
  • Wounds with copious drainage4
  • Meshed grafts, to either secure the graft in place or improve epithelialization4
  • Adjunct to skin graft/flap procedure4

How effective is NPWT? Compared to traditional forms of wound therapy, advantages of NPWT include:
  • Improved healing of transplanted skin and decreased length of hospital stay for patients receiving split thickness skin grafts.4
  • Decreased wound infections in patients following orthopedic trauma and open fractures.4
  • Improved wound healing, shorter length of stay, lower hospital mortality in patients with mediastinitis and unsuccessful wound healing following sternotomy.4
  • Improved wound healing in patients with diabetes mellitus and gangrene that might require amputation.4
What are the factors that increase a patient’s risk for adverse events with NPWT:
  • Increased risk for bleeding and hemorrhage2,3
  • Anticoagulant or platelet aggregation inhibitor therapy2,3
  • Friable or infected blood vessels2,3
  • Vascular anastomosis3
  • Infected wounds3
  • Osteomyelitis3
  • Spinal cord injury2
  • Enteric fistulas2
  • Exposed organs, vessels, nerves, tendons, and ligaments3

Are there any contraindications for NPWT?
  • Inadequately debrided wounds2
  • Necrotic tissue with eschar
  • Untreated osteomyelitis2,3
  • Cancer in the wound2,3
  • Untreated coagulopathy2
  • Unexplored fistulas
  • Exposed vasculature, nerves3, anastomotic site3, vital organs2
  • Osteomyelitis4

While great strides have been made to improve the safety of NPWT devices, serious adverse events may still occur. Clinicians should take time to review specific device instructions for use, indications, and contraindications and adequate staff training should be provided. Healthcare providers that understand the principles of NPWT can then collaborate to ensure that each patient is selected appropriately for therapy based on wound type, risk profile and care setting. In Part 2 of this series, I will review the procedure for applying a NPWT dressing, general patient care, and tips to trouble-shoot the device.
1. Centers for Medicare and Medicaid Services. (2014) Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. Retrieved from the Centers for Medicare and Medicaid Services:
2. Rock, R. (2014). Guidelines for Safe Negative-Pressure Wound Therapy: Rule of Thumb: Assess Twice, Dress Once. Wound Care Advisor, 3(2), 29 – 33.
3. Federal Drug Administration. (2009). FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. Retrieved from the Federal Drug Administration:
4. Wound Care Centers. (2016) Negative Pressure Wound Therapy. Retrieved from Wound Care Centers:
 Myrna B. Schnur, RN, MSN
Posted: 4/18/2016 9:32:50 AM by Lisa Bonsall, MSN, RN, CRNP | with 7 comments

Categories: Diseases & Conditions Technology

For whom do you care – patients or clients?

patients-or-clients.jpgThis topic came up a couple of times recently – once, in a conversation with nurse faculty preparing courses for undergraduate students; the second, during the Keynote Address at the Dermatology Nurses’ Association Convention. The faculty members were questioning which term – patient or client – is appropriate for use in the academic setting. In her Keynote, Everyday Ethics for Nurses in Everyday Practice, Leah Curtin, ScD(h), RN, FAAN touched on this topic and even dug deeper into the roots of each of the words, encouraging the audience to make their own decisions regarding the appropriateness of each term. 

Here’s a closer look at the terms ‘patients’ and ‘clients.’ 

  • Comes from the Latin word, patior, which means ‘to suffer’
  • Defined as ‘one who suffers’
  • Comes from the Latin word, clinare, which means ‘to lean’
  • Defined as ‘one who is the recipient of a professional service’
Based on the word roots and definitions, some may feel that the term ‘patient’ indicates a hierarchical relationship, where the term ‘client’ signifies a more collaborative relationship. It’s interesting then that many authors, clinician and non-clinician, use the terms interchangeably or even simultaneously. For example, “patient or client self-report measures” or “patient/client safety” is often found in the literature. However, we know that the written word is not how we speak and I’ve yet to hear a colleague ask “Is the patient/client NPO?” or say “The patient/client needs a new IV inserted.” 

I was surprised during a search on this topic, to find that this is not a new discussion. In a 1997 article from the Canadian Medical Association, Peter C. Wing, MB, ChB found that use of the term “client” was documented as early as 1970. He also shares results from his survey of 101 people attending an ambulatory back-pain clinic; almost ¾ of those surveyed stated a preference for ‘patient’ rather than ‘client.’

Personally, I can’t imagine referring to a person in my care as a client. It just sounds unnatural to me. Which do you prefer? 

For whom do you care – patients or clients?

  Create your own user feedback survey
Farlex, Inc. (2016, April 8). Retrieved from The Free Medical Dictionary:
Wing, P. (1997). Patient or client? If in doubt, ask. Canadian Medical Association, 287-289.

Posted: 4/13/2016 9:18:24 AM by Lisa Bonsall, MSN, RN, CRNP | with 9 comments

Categories: Inspiration

Advance your Nursing Career with Wolters Kluwer

wk-logo.bmpAre you looking to advance your nursing career by either writing for a nursing journal or reviewing the work of other nurses? Medical publishing is a vast and growing industry, and we need experienced nurses who are looking to advance their own career and the nursing profession as a whole by creating content and evaluating the content of others. 

Right now, Wolters Kluwer is seeking freelance clinical editors for Lippincott Procedures and Lippincott Advisor. Lippincott Procedures hosts over 1,600 evidence-based procedures used by nurses and other health care personnel caring for patients in acute, long-term, and ambulatory care settings worldwide. Lippincott Advisor houses a variety of entries in categories, such diseases, signs and symptoms, diagnostic tests, healthcare acquired conditions, sentinel events, and more. We need clinical editors to ensure that assigned product entries are current, accurate, and evidence based. Learn more about this opportunity and the application process. 

Wolters Kluwer also publishes over 50 Lippincott nursing journals seeking credible nurses to submit journal articles to be published. These journals, including American Journal of Nursing, Computers Informatics Nursing, and  Nursing2016 Critical Care, are interested in hearing from you and learning more about your ideas for upcoming journal issues. Read more about How to Write for Our Nursing Journals

Posted: 4/11/2016 2:24:53 PM by Cara Deming | with 3 comments

Categories: Education & Career

My time at the 2016 NSNA Annual Convention

nsna-annual-convention.jpgThis March, I traveled to the 2016 NSNA Annual Convention at the Disney Coronado Springs Resort in Orlando from March 30 – April 3. This was the first time NursingCenter attended this event, and I was really looking forward to all that the National Student Nurses Association (NSNA) had in store.
On the first day of the exhibit hall opening, I could see a line of eager and excited nursing students around the convention center hall. With over 3,000 students in attendance, I knew this was going to be an exhilarating day. 

As the doors to the hall opened, a flood of nurses entered the room and started making their way to the different booths. The NursingCenter team was ready with tons of free nursing tip cards, black notebooks, pens, and flyers. Wolters Kluwer also hosted interactive events, including video interviews and their very own WKNurseEd Instagram fun cutout. 

I loved getting to know the nursing students and discover how they use our site and our other Wolters Kluwer products, like Lippincott CoursePoint, PrepU, and our LWW nursing textbooks

nsna-booth-(4).jpg             5_Y927_NC_nursing_tips_ONLINE_pdf_126396_Page_01.jpg             snan-intagram.jpg

disney.jpgAfter the exhibit hall closed, I was able to enjoy the Coronado resort, which hosts a 22-acre lake (and even small alligators!), a giant pool with a 50-foot replica of a Mayan temple, and a number of hammocks to kick back in after a long day. I can’t wait to be back at this resort when I attend the National Conference for Nurse Practitioners in May!

Are you attending any nursing conferences this year? Check out our Nursing Events Calendar for an entire conference listing. Don't forget about NursingCenter's Tips & Timesavers for Conference Attendees!

Posted: 4/8/2016 8:25:40 AM by Cara Deming | with 1 comments

Categories: Continuing Education

5,000+ Calories/Day: A sports nutrition challenge

As National Nutrition Month comes to an end, I am reminded how nutrition isn’t just about cutting calories and eating healthy. There is so much more that we don’t think about on a regular basis, unless it affects the patients in our care or our personal lives.

sports-nutrition.pngI regularly visit an adolescent sports medicine facility with one of my children. The clinicians there deal with a variety of conditions and issues, ranging from orthopedic injuries and concussions to eating disorders and, in our case, impaired growth related to caloric expenditure through sport.

Some people may see a kid who is fit and active and think “Wow, he is so lucky!” I see a kid who is competitive to the point that his growth charts have taken some sharp declines during a critical adolescent growth period. While I’m proud of his commitment and determination, I also am concerned for his growth and development.

We are fortunate to have a great resource in our area that has helped us turn things around for my son. He is a swimmer and a runner who trains for hours each day, and to meet his nutritional needs for sport and catch-up growth, he must take in over 5,000 calories each day! Sounds easy, right? Actually, it is a challenge and requires quite a bit of hard work. I ask that you let this post serve as a reminder to be open to the struggles of others; sometimes the problems they face aren’t as simple as you may think.

For some related reading on this topic and more on nutrition, explore Nutrition Today, a journal with articles written by “leading nutritionists and scientists who endorse scientifically sound food, diet, and nutritional practices,” including the following related to sports nutrition:  
Posted: 3/28/2016 10:16:51 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Diseases & Conditions

Nurse Who Moved: Margretta "Gretta" Madden Styles

NursingCenter is celebrating Certified Nurses Day, which happens every year on March 19th. Why March 19th? It happens to be the birthday of the pioneer and inspiration behind nurse certification, Margretta "Gretta" Madden Styles, RN, EdD, FAAN.

While we would have been beyond thrilled and honored to interview this innovator in the nursing profession, sadly, Styles passed in 2005 after a long, successful life and career. We thought we would adjust our ‘Nurse on the Move’ blog to feature one of the top ‘Nurses Who Moved’ and truly shaped the profession.
Life and Education 

Styles was born in Pennsylvania in 1930. She was married to her husband for 47 years, Reverend Douglas Styles, and the couple had three children.

Styles attended Juanita College and earned undergraduate degrees in biology and chemistry. She went on to Yale University to earn her master’s degree in nursing and then on to the University of Florida, where she earned her doctorate in education.

Nurse educator, author, and innovator

Styles started teaching as an associate professor in 1967 at Duke University and then moved on to become the dean of nursing at various universities, including University of Texas Health Science Center at San Antonio, Wayne State University in Detroit, and the University of California, San Francisco. 

Styles campaigned and advocated for stricter certification requirements and credentialing standards for nurses. She wrote at great length on this topic and later helped to create the American Nurses Credentialing Center (ANCC). Her influence on refining the nursing profession in the U.S., extended internationally, and, for a time, Styles also served as president of the Internal Council of Nurses.

While her legacy will always be tied to her role in the creation of the ANCC, her impact on the nursing profession is still widely prevalent. She is often quoted and referenced in medical publications and has had many awards and grants named in her honor. Styles was also inducted into the American Nurses Association hall of fame.  

And, of course, the profession will continue to honor Styles’ work and accomplishments on her birthday every March 19th for Certified Nurses Day.
Happy Birthday, Gretta and Happy Certified Nurses Day! Be sure to check our Certified Nurses Day page on March 19th for lots of great resources and deals to honor this special day.

By Kim Fryling-Resare

Posted: 3/14/2016 8:07:11 AM by Cara Deming | with 2 comments

Categories: Leadership

Making Sense of the Updated Sepsis Definitions

sepsis-definitions.pngLast month, new definitions for sepsis and septic shock (Sepsis-3) were released and published in the Journal of the American Medical Association (JAMA). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) is the work of a consensus panel of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. There have been multiple revisions and evolutions to the definitions of sepsis and treatment strategies over the years as we continue to increase our understanding of the complex biology of sepsis and the physiologic effects of sepsis on the body. We are constantly adapting this knowledge to clinical practice. Despite advances in our understanding of sepsis biology, it remains a condition associated with high morbidity and mortality worldwide. Despite constant advances in pharmacologic treatments and organ support devices (i.e. mechanical ventilation, renal replacement therapies, etc.) early identification and treatment of patients with sepsis remains the cornerstone of improving survival. The new definitions simplify the classification of sepsis and provide tools to identify those with suspected infection that are at risk of developing complications of sepsis by utilizing the Sequential (sepsis-related) Organ Failure Assessment (SOFA) and qSOFA scores. 

The new definitions and risk assessment scores take the focus off inflammation and place it on the organ dysfunction related to the dysregulated host response that is sepsis. In fact, Sepsis-3 defines sepsis as “Life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al. 2016).” A lay term definition is also provided in the article describing sepsis as “a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs” (Singer et al. 2016). This provides helpful terminology in speaking with families about the complex and complicated condition. 

Why the change? 
Prior to the release of Sepsis-3, healthcare providers generally referred to four different levels of sepsis: systemic inflammatory response syndrome (SIRS), sepsis (SIRS in response to a confirmed infectious process), severe sepsis (sepsis plus organ dysfunction as evidenced by hypotension or hypoperfusion to one or more organs), and septic shock (sepsis with persisting arterial hypotension or hypoperfusion despite adequate fluid resuscitation).

Over the years, there has been much controversy over the SIRS criteria, as they are considered to have poor specificity and sensitivity for predicting the development of sepsis. The SIRS criteria – fever, tachycardia, tachypnea, leukopenia/leukocytosis – are present in many conditions, both in chronic medical illness and in acute reactions to infection. A patient with acute bacterial pharyngitis with dehydration from poor intake and tachycardia from dehydration and fever can be treated outpatient and is at very low risk of progressing to septic shock despite meeting SIRS criteria. Furthermore, the “levels” of sepsis infers there is a continuum or spectrum that a patient with sepsis follows in the course of illness and this is not the case. 
What’s New: 
In a nutshell, the focus of the new definitions as described above is defining sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sequential (sepsis-related) Organ Failure Assessment (SOFA) is presented as a tool to identify organ dysfunction and the risk of a patient with infection in developing sepsis. SIRS has been eliminated from sepsis vocabulary, as has severe sepsis, which was considered redundant. So now we have: 
  1. Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is measured by changes in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score of two points or more. In a patient with unknown baseline, the beginning score is zero. 
  2. Septic shock: a subset of sepsis with vasopressor requirement to maintain MAP >65 and serum lactate > 2 mmol/L in the absence of hypovolemia (i.e. after a patient has received adequate fluid resuscitation). 
The SOFA Score (Vincent et. al 1996) provides clinical measures to identify organ dysfunction; these criteria identify infected patients most likely to develop sepsis. Organ dysfunction is identified as an acute change in SOFA score of greater than or equal to two. These clinical variables include PaO2/FiO2 ratio, platelet count, bilirubin, MAP with and without the presence of vasoactive agents, Glascow Coma Scale, creatinine and urine output.  

The qSOFA (Quick SOFA) Criteria is an additional tool highlighted in Sepsis-3. The clinical variables of the qSOFA are: 
  • Respiratory rate > 22
  • Altered mentation (GCS < 15)
  • Systolic blood pressure ≤ 100
The presence of any two of these criteria (qSOFA) in a patient with a known infection should prompt further evaluation for organ dysfunction. This tool can be utilized by the bedside nurse. 

Nursing implications of Sepsis-3
While these definitions will not change how we treat patients with sepsis or presumed sepsis, they do provide more straightforward terminology, as well as a bedside tool to evaluate a patient with infection, potentially allowing us to both identify at-risk patients sooner and treat earlier.  The presence of the qSOFA criteria in a patient with infection should prompt further evaluation of the patient and possible measurement of the more detailed SOFA criteria to evaluate for organ dysfunction. As a nurse, awareness and understanding of the most up-to-date terminology surrounding sepsis improves care of our patients and allows for better communication of patient information to colleagues in a consistent manner. Nurses are in a key position at the bedside to monitor and identify patient in the early stages of clinical decline and have the potential to positively impact patient outcomes by facilitating early interventions and treatment of the septic patient.

With this information, we can improve our communication. In the past, we might have said, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. I just have a feeling this patient is declining; he looks like he might be septic.” Now, with our new definitions, we can say, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. Since admission, he has deteriorated clinically; his qSOFA score is two, he has a respiratory rate of 30 and his systolic blood pressure is 80. When he arrived in the ED, his SOFA score was one due to a creatinine of 1.5. Now his urine output is down to 15 mL/hr, and his MAP is 60. I think we need to order more labs and have someone come re-evaluate the patient for possible transfer to the ICU.” As nurses, we often know when something is changing and our patient’s clinical condition is headed in the wrong direction. Familiarization with these tools provides us with more objective data to present and support our concerns.      

It has now been several weeks since the release of Sepsis-3. In reviewing medical commentary, there are varying supports and criticisms of both the new definitions and on the utility of the SOFA and qSOFA scores. True, qSOFA and SOFA are not diagnostic of sepsis or septic shock, the SOFA is a predictor of mortality; but they provide objective data points that can be easily measured in the hospital setting. What remains unchanged is our goal of early identification and early treatment to reduce overall morbidity and mortality related to sepsis. Sepsis is a complex condition; in addition to overt symptomatology, there is complex biochemical, genetic and endogenous factors involved in the pathobiology of sepsis. Some pathways are well understood while others are only on the brink of being understood. 

I am personally happy with the new definitions and the simplicity of the diagnostic terms of sepsis vs. septic shock. I am looking forward to the improved dialogue and communication using the SOFA criteria. As with any changes in medicine, there is typically a lag time from publication to implementation. At my hospital, in particular in the ICU, there has certainly been a lot of buzz and support for the new terminology. I would love to hear how other hospitals and facilities have reacted to Sepsis-3! 

Megan Doble, MSN, RN, CRNP
Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
Vincent  JL, Moreno  R, Takala  J,  et al; Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.

Posted: 3/13/2016 7:10:31 AM by Lisa Bonsall, MSN, RN, CRNP | with 9 comments

Categories: Diseases & Conditions

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