1. Kilburn, Freda L. DSN, RN
  2. Bailey, Phelan RN, CEN
  3. Price, David RN, CEN

Article Content

PATIENTS WITH SEPSIS admitted to the ED for evaluation are often challenging to assess and treat. At our hospital, we developed a seven-page order set for adult patients to help clinicians recognize sepsis earlier and initiate evidence-based treatment promptly. However, we weren't sure how well the ED nurses were implementing it during the triage process.


Because the first hour of treatment is critical to a patient's survival, ED nurses must recognize a potentially septic patient and implement evidence-based treatments immediately. To ensure proper implementation, we developed a protocol to integrate a comprehensive order set for diagnosing sepsis into our hospital's electronic medical record (EMR) database. This article describes our experience and results.


Some sepsis insight

Sepsis is widely recognized as a clinical syndrome that results from the human body's response to infection, but considerable confusion exists about the sequence of events that occur during sepsis.1 Understanding the events related to sepsis is paramount because if the nurse can't clinically correlate a defined process, signs and symptoms of sepsis may be overlooked or misinterpreted.1


The volume of literature on sepsis is massive and spans years of attempts to establish definitions and clinical treatment parameters.2 In 1992, a consensus conference of 35 sepsis experts formulated a framework to define systemic inflammatory response syndrome (SIRS).3 At present, as in 1992, SIRS is defined as a clinical inflammatory response to an insult (such as an infection, trauma, and ischemia), including two or more of the following:


* body temperature less than 96.8[degrees] F (36[degrees] C) or greater than 100.4[degrees] F (38[degrees] C)


* heart rate greater than 90 beats/minute


* respiratory rate greater than 20 breaths/minute and PaCO2 less than 32 mm Hg


* white blood cell (WBC) count less than 4,000/mm3 or greater than 12,000/mm3 and greater than 10% immature bands.2



Sepsis is the presence of SIRS together with presumed or confirmed infection. Severe sepsis is associated with organ dysfunction (such as altered mental status and acute oliguria), or hypoperfusion (such as hyperlactatemia). Septic shock is defined as severe sepsis with perfusion abnormalities and hypotension despite adequate fluid resuscitation.3,4


What's the best treatment?

Assessment and therapy for sepsis is directed toward identification of the infection source, antibiotic administration, fluid replacement, and support for organ dysfunction. Because time is critical, any delay in identification and initiation of therapy negatively affects patient outcomes. The literature has stated that for every hour delay in administrating appropriate antibiotics, mortality increases by 7%.5


Recommendations from the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 include early goal-directed therapy (EGDT) as part of the initial resuscitation.4 EGDT relies on invasive monitoring with arterial and central venous catheters that allows clinicians to normalize central venous pressure with I.V. fluids and mean arterial pressure with vasopressors.5 EGDT should take place within the first hour (the pivotal period) and treatment should continue within a 6-hour timeframe. Specimens for blood cultures should be obtained before antibiotic administration, and broad-spectrum antibiotic therapy should begin immediately, before culture results are back. The goal of these clinical guidelines is to improve patients' survival rates and decrease the use of hospital resources and readmission rates.4


Improving protocols

Our 23-bed ED is located in a rural, northeastern Kentucky hospital. Presently, the ED utilizes an order set of interventions for treatment of severe sepsis and septic shock. Multiple interventions are coalesced into a protocol that focuses on therapies directed toward specific physiological goals (such as stabilized BP) as well as alternate therapies (when the desired outcomes aren't attained). Our order set has been criticized because of its length (seven pages), and because it doesn't lay a foundation for SIRS, early sepsis detection, or EGDT. Therefore, utilization of the document by nursing staff is low to nonexistent.


A decision was made to review 3 months of medical records for patients who'd been admitted with sepsis and to conduct a literature review for sepsis protocols so that we could revise our sepsis adult order set.


We conducted a comprehensive search in the EMR database. In January, February, and March 2012, 42 out of 6,500 ED patients were admitted with a sepsis diagnosis. From the 42 medical records, the variables reviewed were age, gender, vital signs, SpO2, WBC count, lactate level, suspected clinical source of sepsis, and whether the order set had been implemented in the ED or after admission to the hospital unit. The purpose was to identify the number of patients admitted to the ED that met SIRS criteria and to determine if the adult sepsis order set had been initiated for these patients.


Eliminating the effect

Of the 42 patient records reviewed, 21 met two or more of the criteria for SIRS. Reviewing temperature, heart rate, and respirations, we found that 13 of the 21 patients had vital signs indicating clinical criteria for SIRS. However, of these 21 patients, only three admitted to the hospital had received treatments in the ED based on the adult sepsis order sets.


Following our data collection period, we acknowledged that we needed to improve and sustain excellent care of patients with sepsis. Using the EGDT, we developed a recognition and treatment order set to be incorporated into our EMR at triage.


The protocol helps ED nurses identify patients with SIRS and alerts the ED physician to utilize the adult sepsis order set for admission to other hospital units. We also recommended educational sessions directed toward the ED staff, ICU staff, healthcare providers, and other hospital staff to update and inform them of the process. The adult order set was referred to the Quality Management department for review and revision to make it more user friendly. The 2012 update from the international sepsis guidelines were integrated into the adult order set.


One change that was made in the ED was adding a SIRS/sepsis assessment section to the triage nurse admission data sheet. As of July 2013, the director of nursing education began developing the educational programs for the implementation of the sepsis protocol. Data from the admission criteria are being monitored to determine how the rate of recognizing sepsis has improved.


Lessons learned and recommendations

The purpose of this project was to improve patient care and clinical outcomes in our ED. It was determined that clinical nurses needed a prioritized, evidence-based tool that could identify quality indicators to produce the desired clinical outcomes. The lack of utilization of a sepsis adult order set led to the need for a protocol with established criteria for early recognition and treatment by nurses.


Presently, we're in the process of strategically implementing the sepsis protocol. The triage assessment section includes a screening tool that has been implemented, and data are being recorded. During the last 4 months, 70 patient medical records have been reviewed. Twenty-six patients with sepsis were identified by the triage nurse and admitted with that diagnosis. This is a 37% increase in patients meeting the criteria for SIRS compared with 14.5% before implementation. Our plans include:


* forming a five-member committee to explore and identify resources such as in-house experts to educate the ED, ICU, and clinical nurses about the standards of care for sepsis.


* formulating a template, for use by clinical nurses, to be a part of the triage and daily assessment for documentation in the EMR. (This has been in place since mid-2013).


* providing clear and concise communication to our senior organizational leaders, especially the CEO, chief medical officer, and vice president for nursing services. We've been invited to talk about the sepsis program in the ED at the Nurse Executive Council meeting of the Shared Governance Model of Nursing Practice. A poster of this program has been presented at the state nursing association conference.


* evaluating performance improvement postimplementation of the protocol.



Our recommendations for future projects such as this one include building relationships across all disciplines, identifying early quality indicator goals, developing a tracking/monitoring system to record patient data, and reaching out to other healthcare facilities that provide care to patients at risk for sepsis to learn about their treatment protocols.


Preventing future emergencies

We realize that guidelines and protocols alone, without support and facilitation of all involved, won't guarantee that the sepsis triage protocol will bring about change in practice. In the clinical environment of a busy ED, the time saved by using a nurse SIRS triage assessment could positively impact the patient flow and expedite timely treatment. Our goal is to ensure that our ED continues to use the protocol to improve outcomes of patients presenting with sepsis.


At risk for sepsis?3,4

Patients with sepsis aren't always easy to identify. Familiarity with the following risk factors can help identify patients who are at high risk:


* age extremes (older adults and the very young)


* recent trauma or surgeries


* indwelling invasive devices (central venous catheters, arterial catheters, urinary catheters, and feeding tubes)


* immunosuppression


* local infection sites (such as abscesses, urinary tract infections, or foreign bodies).





1. Jones AE, Brown MD, Trzeciak S, et al. The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis. Crit Care Med. 2008;36(10):2734-2739. [Context Link]


2. Vincent JL, Martinez EO, Silva E. Evolving concepts in sepsis definitions. Crit Care Nurs North Am. 2011;23(1):29-39. [Context Link]


3. Tazbir J. Early recognition and treatment of sepsis in the medical-surgical setting. Medsurg Nurs. 2012;21(4):205-209. [Context Link]


4. McCormick M. Recognizing the signposts for sepsis. Nursing made Incredibly Easy! 2009;7(3):40-51. [Context Link]


5. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637. [Context Link]