Sepsis in the Emergency Department: Improvements
Sepsis remains one of the most deadly diseases in the country. According to the literature, a majority of sepsis cases filter though the Emergency department. The diagnosis and treatment of sepsis are complex and the barriers to improving these things are even more intricate but the fact remains that improvement of sepsis care begins in the ED. Early recognition of sepsis using the SIRS criteria followed by multidisciplinary rapid response diagnostic testing and treatment are the keys to improvement of sepsis care in the ED.
Introduction Sepsis is defined by the Surviving Sepsis Campaign (SSC) as “the presence (probable r documented) of infection together with systemic manifestations of infection” (Dellinger et al. , 2013). Severe sepsis is defined by the SSC as “sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion” (Dellinger et al. , 2013). Despite advances in treatment modalities, the current literature reports mortality for severe sepsis and septic shock ranges from 20% to 60% (Burney et al.
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, 2012; Dickinson & Kellef, 2011; Turi & Von, 2011) making it the 10th leading cause of death in the United States.
The prevalence of sepsis is markedly higher among the elderly opulation and rises exponentially after the age of 65 (Gaieski et al. , 2010). With the baby boomer generation now approaching this age, systematic and effective treatment of sepsis has never been more important. Severe sepsis until the last decade was a grossly under recognized and undertreated illness. Although treatment protocols have improved impart due to the Surviving Sepsis Campaign, there exists an urgent need for improvement of prompt, methodical and aggressive care of severe sepsis and septic shock.
More than 500,000 cases of severe sepsis are initially anaged in US emergency departments annually with an average ED length of stay for these patients of 5 hours (Wang et al. , 2007). The SSC strongly recommends seven, time sensitive, initiatives. Within three hours of suspected, or diagnosed sepsis, the clinical team must measure lactate level, obtain blood cultures, administer broad spectrum antibiotics, and correct any hypotension or lactic acidosis with the administration of 30mL/kg crystalloid.
Within 6 hours, the SSC recommends applying vasopressors for sustained hypotension, measuring central venous pressure (CVP) nd central venous oxygen saturation (Scv02) and remeasuring lactate if initial lactate was elevated (Dellinger et al. , 2013). What is not obviously evident in these recommendations is the workload associated with completing these tasks, which for nurses, includes inserting multiple large bore IVs, multiple blood draws, assisting with invasive procedures and for physicians includes inserting invasive lines and managing a critically ill patient.
This puts a huge emphasis as well as a burden on the ED, for the improvement in recognition and initial management of sepsis. Definitions of Sepsis Sepsis is a physiologic response to an infection that begins with the systemic inflammatory response syndrome (SIRS). SIRS, originally defined in 1992, is characterized by a presence of two of the following five physiologic changes: 1 . Temperature < 98. 60 F or > 100. 40 F 2. Heart rate > 90/min 3. Respiratory Rate >20/min Body 4.
Hyperventilation, indicated by a PaC02 of 12,000/uL or the presence of >10% immature neutrophils (Simpson & Pitts, 2010) Severe sepsis is the presence of sepsis with the presence of organ failure separate from the site of infection. The hallmark signs of organ failure summarized by the American College of Chest Physicians includes: 1. Hypotension 2. Renal failure that manifests as a creatinine value increase > 0. 5 mg/dL, poor urine output (defined as < 0. 5 mL/kg for 1 h), or the need for renal replacement therapy 3. Altered mental status (from individual patient baseline) 4.
Thrombocytopenia (< 100,000 platelets/mL) 5. Respiratory failure that manifests by arterial hypoxemia (Pa02/F102 < 300) 6. Coagulation abnormalities (international normalized ratio > 1. 5 or activated partial thromboplastin time > 60 s) 7. Ileus 8. Hyperbilirubinemia (plasma total bilirubin level > 4 mg/dL) 9. Hyperlactatemia (> upper limit of normal) (Simpson & Pitts, 2010) Management of Severe Sepsis: More than 500,000 cases of severe sepsis are initially managed in the US emergency departments annually, with an average ED length of stay of 5 hours.
The cornerstones of management of severe sepsis includes prompt diagnosis, timely administration of appropriate antibiotics, and aggressive resuscitation. Recognition of Sepsis in the ED. It is well known within health care professionals as well as the general public that, in the first hours of a myocardial infarction or cerebral vascular ccident, time is tissue. This is also the case in severe sepsis and because of this, early recognition of sepsis is vital to improving outcomes. SIRS is the first line diagnostic for the recognition of sepsis. If the patient meets SIRS criteria, the next line of diagnostics is to test the serum lactate.
Lactate is believed to be due to decreased end-organ perfusion, leading to anaerobic glycolysis and lactate production. Serum lactate is commonly used as a prognostic test for illness severity in ED patients with sepsis (Green et al. , 2011). Resuscitation in the ED. Rapid Quantitative resuscitation is recommended in all patients with tissue hypoperfusion. According to the SSC guidelines, the goals of fluid resuscitation include a CVP of 8-12 mm Hg, a MAP > 65 mm Hg, urine output > 0. 5 mukg/hour and an Scv02 of 70%. The strategy of resuscitation, completed in the first 6 hours was associated with a 15. % reduction in 28 day mortality (Dellinger et al. , 2013). Crystalloids should be the first initial fluid choice during resuscitation. If the patient remains hypotensive, vasopressor therapy should be initiated using norepinephrine as the tirst choice Dellinger et al. , 2013). Antimicrobial Therapy in the ED. The administration of broad- spectrum antimicrobials with the first hour of recognition of sepsis is vital to patient mortality. In multiple studies, each hour of delay in antibiotic administration is associated with a measurable increase in patient mortality (Dellinger et al. 2013). Another vital component of treatment is the choice of empirical antimicrobial therapy. Kumar et al. , found that survival rates after appropriate and inappropriate initial therapy were 52. 0% and 10. 3% respectively (Kumar et al. , 2009). This is a huge isparity for patients and therefore a large focus for EDS. Barriers to Care and Suggestions for Improvement Suboptimal treatment of sepsis is widespread. “Compliance with the 6 hour resuscitation pundle is poor, ranging from 19% to 52%” (Aitken et al. , 2011).
For example, even though the Surviving Sepsis Campaign (SSC) has distributed guidelines, reflecting the Early Goal Directed Therapy (EGDT) studied by Rivers and colleagues, suggesting the administration of antibiotics within 1 hour of suspected bacterial infection, the average time for the first infusion of antibiotics exceeds 3 hours. Other suboptimal findings include choosing the wrong type of antibiotic, lack of consistent hemodynamic monitoring, lack of treatment order sets and protocols and lack of support for processes needed to complete EGDT (Aitken et al. 2011). There is an urgent need in healthcare for improvement of prompt, methodical and aggressive care of sepsis. Sepsis Recognition and Alert. The early diagnosis of sepsis is extremely difficult. By the time patients with sepsis have apparent vital sign changes, they are critically ill and needing aggressive treatment. For this reason, early recognition of SIRS is vital. Identifying SIRS takes comprehensive knowledge of the criteria and meticulous assessment of patients. This has proven to be a major barrier to implementing the SSC guidelines (Turi & Von, 2011).
In one study conducted by Burney et al. , more than 85% of nurses reported that they were “somewhat” or “not at all” familiar with SIRS criteria and only 15. 8% of nurses reported that abnormal vital signs were reported in a timely fashion by support staff (Burney et al. , 2012). This is why one of the most important improvements that can be made in sepsis care is education on the criteria of SIRS and signs of severe sepsis ithin the ED. All staff whom interact with the patient, not Just RNs, need to be provided with this education.
Once a patient with SIRS is identified a rapid response needs to be initiated and treatment should begin immediately. This effort should not only be a multidisciplinary rapid response team (RRT), which has been indicated to improve outcomes (Tromp et al. , 2010), but also should involve members from each of the units and services needed for treatment (ED, ‘CU, Surgery if needed). This wide involvement will help to utilize all resources as well as assist to streamline the atient to a critical care environment with staffing levels to support the patient.
Treatment protocol. When surveyed, registered nurses considered delay in diagnosis by physicians to be the most significant cause of treatment interruption among patients with sepsis. Also, the majority of staff surveyed (89. 5% of nurses and 86. 0% of physicians) stated that a written protocol, similar to the ones already in place for the management of acute coronary syndrome and pneumonia, would help them to manage patients with sepsis (Burney et al. , 2012).
If a nurse suspects sepsis, based on the recognition ot SIRS, literature sugges s that this lead to the use ot a predominantly nurse driven, sepsis protocol where baseline diagnostic tests are ordered and the rapid response team is notified at the minimum, but also suggests that “protocol-directed care in the areas of fluid and vasopressor therapy is becoming more commonplace and has been shown to be safe” (Aitken et al. , 2011). This type of protocol can significantly improve the rapid diagnosis of sepsis and improve chances of SSC guideline completion (Tromp et al. , 2010).
If the patient meets diagnostic criteria for sepsis, then the physician should initiate the institutional sepsis bundle. This sepsis bundle should include recommendations from the SSC including qualitative resuscitation (based on CVP, MAP, Scv02, and urine output), broad- spectrum antibiotics, as well as source identification and control. The physician’s orders should also include central and arterial line placement and vasopressors if indicated. Antibiotic Availability and Selection. Widely agreed upon is the fact that the most important of the initiatives recommended by the SSC is the early administration of antibiotics.
A study in Critical Care Medicine by Gaieski et al. (2010), nalyzed for elapsed time from triage to the appropriate antibiotic administration to determine if there was a significant association. The researchers found a significant association at the one-hour time cutoff for both triage to antibiotics (mortality 19. 5 vs. 33. 2%) as well as qualification for EGDT to antibiotics (mortality 25. 0 vs. 38. 5%). This supports the argument that the prompt administration of appropriate antibiotics is a primary determinant of mortality in patients with severe sepsis (Gaieski et al. , 2010).
Unfortunately, studies have found that an incorrect antimicrobial agent is chosen in p to 35% of cases where the physician chooses the agent based on clinical judgment (Miano et al. , 2012) and when surveyed only half of the physicians (50. 0%) were “very confident” in choosing appropriate antibiotics for a patient with severe sepsis (Burney et al. , 2012). Antibiotic algorithms, based on common isolates and their susceptibility patterns, are highly effective at correcting these deficiencies. It should also be noted that resistance patterns should be monitored at a local and institutional level so that algorithms can be adjusted.