Implementation of a Tool to Identify Early Sepsis by Nurses

ABSTRACT

Sepsis is defined as the immune system’s overwhelming response to infection that results in life-threating organ dysfunction (Singer et al., 2016). In the United States sepsis affects 1.7 million hospitalized patients and causes approximately 270,000 deaths each year (Rhee et al., 2014). Because of their unique position of having frequent patient interaction, nurses can have significant impact in identifying patients with sepsis (Kleinpell, 2017). The purpose of this evidenced based project was to develop a policy that would assist nursing staff in the early identification of patients with signs and symptoms of sepsis. Within the timeframe of this project, a policy was developed using guidelines developed by the Surviving Sepsis Campaign (www.survivingsepsis.org, 2018) for a rural critical access hospital, train the nursing staff on one of the medical-surgical floors in the facility, and evaluate the compliance in use of the Evaluation of Severe Sepsis Screening Tool (www.survivingsepsis.org, 2018).

For this project, 15 nurses were trained to use a paper-based, 3-tired sepsis assessment tool to identify patients that presented with a history suggestive of infection, presented with at least two signs or symptoms of a systemic inflammatory response syndrome (SIRS), and identify the possibility of organ dysfunction not associated with a chronic condition. The staff was asked to perform the screening at the beginning of each shift as part of their daily assessment and notify the patient’s provider of any patient whose screen indicated either a new onset of sepsis or severe sepsis to request additional diagnostic and treatment orders.

The initial medical-surgical floor consisted of a staff of both registered nurses (RNs) and licensed practical nurses (LPNs) working 12-hour shifts. Training consisted of 1 on 1 meetings with the staff that was conducted as time allowed around their normal shift activities. After the first 2 training days a total of 83% of the full-time nursing staff received the training and agreed to participate in the study. Additional follow up found that of those staff members that initially agreed to participate 86.7% initiated the use of the paper screening tool and only 40% used the screening tool consistently.

The project was limited by the chosen 1:1 training method since the information provided to the nursing staff with a narrow scope of information and training with paper screening tool. While moving forward with the policy to the reminder of the facility it is recommended that a formal training program is developed and presented to the nursing staff during a designated time period that will allow the staff to concentrate and ask questions to clarify understanding of the implementation and use of the policy and screener.

LIST OF ABBREVIATIONS

CDC   Centers for Disease Control and Prevention

EHR   electronic health record

ICU   Intensive Care Unit

IRB   Institutional Review Board

LOS   length of stay

LPN   Licensed Practical Nurse

RN    Registered Nurse

SEP-1   CMS Sepsis Core Measurement

SIRS   Systemic Inflammatory Response Syndrome

SECTION 1

INTRODUCTION

Problem Description

 Sepsis is defined as the life-threatening organ dysfunction caused by a dysregulated host response to infection (Marik & Taeb, 2017). According to the Centers for Disease Control and Prevention (CDC), sepsis affects more than 1.5 million people in the United States each year and at least 250,000 Americans die from sepsis annually (CDC, 2017). Each year 1 in 3 hospital deaths are attributed to sepsis. According to the Mississippi State Department of Health, septicemia was the 10^th leading cause of death in the state with a 21% mortality rate as well as an 18.9% mortality rate in Sunflower County (Mississippi Department of Health, 2016). Similar to other life-threating conditions, such as myocardial infarction and ischemic stroke, sepsis is considered a medical emergency in which diagnosis and treatment is time sensitive. Patient outcome depends on early and aggressive intervention to restore adequate perfusion of organs (Dellinger, et al., 2013).

Available Knowledge

 In 2002, the Society of Critical Care Medicine in conjunction with the European Society of Intensive Care Medicine and the International Sepsis Forum created the Surviving Sepsis Campaign by introducing best practices of evidence-based treatment guidelines to reduce the mortality rates from sepsis (Society of Critical Care Medicine, 2014). The resulting guidelines created two sepsis bundles consisting of a six-hour resuscitation bundle and a twenty-four-hour management bundle guiding treatments to improve the quality of care of septic patients (Society of Critical Care Medicine, 2014). Studies that were conducted following the release of these initial treatment guidelines proved that when sepsis was diagnosed early and patients received a timelier adjunctive therapy, survival statistics were improved by one-third to one-half (Gao, Melody, Daniels, Giles, & Fox, 2005).

 The mortality and related healthcare costs associated with sepsis is of such magnitude that in 2015 the Centers for Medicare and Medicaid Services along with The Joint Commission launched a sepsis core measure reporting requirement (SEPS-1) for all Joint Commission accredited hospitals (Weingart, 2015). Sutter health systems in California instituted a program designed to improve early identification and intervention of sepsis that involved educating the nursing staff about the sepsis continuum; created a sepsis screening tool to evaluate every patient during daily assessments as well as any changes in condition; and a workflow that included treatment guidelines after confirmation of a positive sepsis screen. This nurse-driven program resulted in a 50% reduction in mortality rates from severe sepsis after one year (Nurses are first line of defense for screening sepsis, 2017).

 A study of 32 intensive care unit (ICU) nurses measured compliance of following the implementation of a sepsis protocol. The study found that with little to no education of the protocol that 81% of the nurses were compliant with the screening tool and following an eight hour training program, compliance increased to over 90% (Yousefi, Nahidian, & Sabouhi, 2012). A Michigan based hospital system found nurse compliance of a sepsis screening tool to be less than acceptable at only 23%. They initiated the use of nurse champions on the unit with compliance increasing to 74% (Campbell, 2009).

Rationale

 Because of their constant patient interactions, nurses can have a significant role in identifying changes in a patient’s condition. As a result, sepsis screening can be integrated as part of routine daily assessment and rounds (Kleinpell, 2017). A rural critical access hospital with no current sepsis screening protocol was selected to implement a nurse led sepsis screening tool. The medical center has 25 acute care beds and is staffed by both registered nurses as well as licensed practical nurses. The evaluation for severe sepsis screening tool, as developed by the Surviving Sepsis Campaign and Institute for Healthcare, was selected and will allow staff to analyze specific assessment data and lab values to determine when patients exhibit signs of new onset of sepsis and report those findings to healthcare providers allowing for more timely interventions.

Framework

 The Roy Adaptation Model, developed by Sister Callista Roy, focuses on the patient and nurse interaction as a holistic adaptive system in constant interaction with the internal and external environment and a goal of the human system to maintain integrity in the face of environmental stimuli (Phillips, 2010). Roy defined the nurse as a healthcare professional focusing on the human life processes and patterns of people with a commitment to promote health and full life potential (Roy, 2009). Because of the direct focus on nurse and patient interaction, the Roy Adaptation Model was used as the framework for this evidence-based project. Nursing assessment relies on observations skills, intuition, accurate measures, and interviewing skills to systematically collect data in order to identify both the internal and external stimuli that affects health. Nurses are in position that allows for an accurate identification and implementation of interventions on the stimulus affecting the patient’s overall well-being (Roy, 2009).

Aims

The purpose of this evidenced based project was to develop a policy that would assist nursing staff in the early identification of patients with signs and symptoms of sepsis.                

Goals/Outcomes

It is anticipated that this evidence based project will reveal that following initial training of the nursing staff regarding the protocol, including use of the screening tool, that 100% of the full time will receive the training and that 95% of the staff will use the screening tool consistently.

SECTION 2

METHODS

Context

Within the timeframe of this evidence-based project, a policy was developed using guidelines by the Surviving Sepsis Campaign (www.survivingsepsis.org, 2018) for a rural critical access hospital, trained the nursing staff on one of the medical-surgical unit in the facility, and evaluated the compliance in use of the Evaluation of Severe Sepsis Screening Tool (www.survivingsepsis.org, 2018).

Interventions

The nursing staff was provided education on completing the sepsis screening tool along with a sepsis fact sheet during their shift (see Appendix A). Inclusion and exclusion criteria were presented, and the nurses were asked to complete the screening tool following their patient assessments. The paper screening tools became part of the patient chart and reviewed for completeness on a weekly basis.

Measures

 The target population of the study was limited to the professional nursing staff assigned to the medical-surgical units at the facility. Demographics of the nursing staff was collected including license level, years of experience, years of service to the facility, and highest education degree earned (see Appendix B) These staff members identified patients that meet the screening criteria to include patients that do not have a current diagnosis of sepsis, are not currently receiving routine antibiotic therapy, and do not have a resuscitate status. The nurses provided a paper-based screening tool to complete following their daily assessment for the identified patients. The evaluation of severe sepsis screening tool was chosen for this project because it has a 96.5% sensitivity and 96.7% specificity (Moore, et al., 2003) (see Appendix C).

Nurses need to be educated in identifying the symptoms and treatment of sepsis to react effectively. The Surviving Sepsis Campaign has created evidence-based guidelines to assist hospital and staff in creating a facility customized screening protocol. The screening tool consists of a 3-tiered paper-based assessment to be completed by the nurse following patient assessments. The first-tier screens for the presence of systemic inflammatory response syndrome (SIRS) that includes a heart rate >90, temperature >38°C or <36°C, white blood cell count >12,000 or <4000 or >10% bands, and/or respiratory rate >20 or partial pressure of carbon dioxide (PaCO₂) <32 mm Hg. To decrease the number of false-positive screens in patients whose abnormal vitals could already be attributed to a condition other than sepsis, these symptoms were only scored if they had emerged within the previous 8 hours. For any patients that had 2 or more SIRS criteria, the second-tier would seek if a possible infection was indicated as a source of the patient’s condition. When infection was indicated, the patient met the criteria for a positive sepsis screen, the nurse would then complete the screening for organ dysfunction in the third-tier of the tool.

Nurses are in a position that includes regular patient contact so that sepsis screening can be integrated as part of their daily routine. By conducting a review of the patient’s current vital signs, available laboratory reports, and conducting a daily physical assessment nurses can quickly and accurately determine if a patient has two or more symptoms of SIRS. SIRS can be due to multiple causes but when combined with an infection, it is a presumptive indication of sepsis. Any patient presenting with two or more symptoms of SIRS with a possible source of infection, the next step of the protocol would assess to determine if signs of hypoperfusion or organ dysfunction is present. Following these indications, the nurse would immediately contact that patient’s primary care provider with the documented findings and expect orders that are consistent with the sepsis protocol to include blood cultures, serum lactic acid, as well as the initiation of a broad spectrum antibiotic (Dellinger, et al., 2013).

Analysis

Following the data collection period, data were analyzed with descriptive statistics to evaluate the percentage of nurses that implemented the protocol as well as the percentage that used the tool properly and consistently.

Ethical Considerations

To ensure the protection of the rights and welfare of human subjects involved in the project, Institutional Review Board (IRB) approval was obtained prior to the implementation of any research activities within the facility (see Appendix D). Following IRB approval, a letter of permission to conduct the research at the facility, including necessary access to patient records and electronic healthcare record was obtained (see Appendix E). To ensure confidentiality of participants, no patient identification information was collected, recorded, or used darting this project. Additionally, informed consent from the participating nursing staff was obtained (see Appendix F).

SECTION 3

RESULTS

 A nurse demographic data tool was completed by each of the participants prior to implementation of the protocol. The staffing schedule for the pilot unit consisted of 10 RNs and 8 LPNs. A total of 15 participants were trained including 8 RNs and 7 LPNs (Figure 1). The education levels of the nursing staff included 3 Bachelor prepared RNs and 5 Associate degree RNs. Staffing was comprised of 13 females and 2 males with 93% being under the age of 45 years and 1 nurse being between 45-54 (Figure 2).

Figure 1 Nursing Staff Training

Figure 2 Staff Age Range

Of those receiving the training, implementation of the protocol was calculated by any nurse that completed screening tools on identified patients during at least one shift. After the first 2 training days a total of 83% of the full-time nursing staff received the training and agreed to participate in the study. Additional follow up found that of those staff members that initially agreed to participate 86.7% initiated the use of the paper screening tool and only 40% used the screening tool consistently (Figure 3). During the study period a total of 80 screening tools were received on a total of 34 unique patients that had an average 2 ½ day length of stay (LOS) in the facility.

Figure 3 Protocol Implementation

SECTION 4

DISCUSSION

Summary

  While completing the literature search it was noted that two studies reported the results of nurse compliance with recommended screening tools (Nurses are first line of defense for screening sepsis, 2017; Yousefi, Nahidian, & Sabouhi, 2012). For hospitalized patients on medical-surgical wards the onset of sepsis is often insidious with symptoms appearing one at a time and often hours apart. Because nursing shifts are commonly twelve hour shifts and often nurses will care for the same patients on consecutive days, the bed-side nurse is most likely the member of the health-care team to recognize these subtle changes in a patient’s condition. There is often a gap in the nurse’s knowledge and practice that can be attributed to high patient caseloads that delay patient assessments, lack of management involvement in nurse-driven protocols, and little ongoing training about the importance of sepsis screening.

 While only one research article was identified that specifically reported nurse compliance with a sepsis screening protocol, it can effectively serve as benchmark for compliance using both standard protocol implementation as well as compliance following a formal education session regarding the process and importance of early sepsis recognition. Yousefi, Nahidian, & Sabouhi (2012) studied 32 intensive care unit (ICU) nurses to report on nurse knowledge, attitude, and practice of sepsis screening following usual facility protocol implementation and then again following an 8-hour training session specific to sepsis. They found that while 81% of the nurses consistently implemented the screening tool immediately after implementation the compliance increased to greater than 90% following the training session.

 While the initial 40% compliance rate among nurses during this project appears to be significantly below an 81% benchmark, it can be argued that compliance among ICU nurses should be expected to be higher given their lower caseload, higher acuity patients, and often rapid changes in patient condition. However, given the results of one study involving Sutter Health Systems reporting a decrease in mortality rates of 50% among sepsis patients when nurse screening compliance is at 80% it should be realistic to set a minimum benchmark at this point (Schorr & Barnes-Daly, 2017). It would be expected that inclusion of a formal training session that included a pre- and post-knowledge evaluation would significantly increase the compliance among nurses using the protocol consistently.

Limitations

 The major limitation of this study was the staff training time during implementation of the protocol. The original design included a formal training session to be conducted with the nursing staff during a regularly scheduled staff meeting. Approval to begin the project was not received until after all November staff meetings had occurred and there were no December staff meetings scheduled. This resulted in staff training becoming limited to individual meetings as time allow during shift changes. This process resulted in a lack of understanding of the protocol among all staff and there was some misinformation disseminated among the nursing group. The month of December proved to be problematic as well. There was an unusual number of both vacation and personal leave requests that resulted in vacancies being filled by either part time staff or nurses from units that did not receive the training.

 The protocol was not mandated by the facility and no daily oversight of completion of the screening tool was provided. As nurses knew that participation was completely voluntary, some nurses stopped completing the screening tool prior to the end of the study period voicing complaints that they were too busy during their shift to complete an additional form. They did indicate that if the screening was part of electronic health record (EHR) and could be completed in real time during the bed-side assessment then they would be more likely to continue patient screenings.

 During the literature review, many facilities did incorporate sepsis screening tools as part of their EHRs that could provide automatic alerts to both nursing and medical staff when patients met sepsis criteria. This proposal was discussed with the facility but the current EHR system is a web-based leased product and any changes must be requested and completed by the vendor. Due to budgetary constraints, no additional changes to the EHR system was going to be made during the remainder of 2018.

Conclusions

Improving recognition and time to treatment of sepsis is an important step toward decreasing sepsis-related mortality. Studies have found that mortality rates for patients diagnosed with septic shock on a general medical-surgical ward were higher than for patients diagnosed in the ICU, even though the ward patients were typically younger and healthier at baseline (Lundberg & Perl, 2010). The sepsis screening tool was designed in 3 tiers to improve its specificity. EHR-based screening tools that rely purely on physiologic data have been considered for the early detection and management of sepsis, although they lack the specificity gained with the incorporation of a nurse’s clinical judgement (Gyang, Shieh, Forsey, & Maggio, 2014).

 In their 2011 study, Sawyer, Deal, and Labell, report using a real time EHR method for sepsis detection that is based solely on objective measures; however, their positive predictive values (PPV) was 19.5%. That nurse-led screening protocol is able to incorporate real time physiologic data available from an EHR and pair that with the clinical judgment of a bedside nurse provides a screen that is both sensitive and specific. (Gyang, Shieh, Forsey, & Maggio, 2014).

 It is recommended that the facility continue to develop the protocol and implement it for every unit. The revisions necessary to the current protocol should include a formal training course that includes a pre- and post-evaluation tool that captures the staff’s understanding and comprehension of the training. This training piece could be offered to all current nursing staff as well as provided to new hires as part of the orientation process as either an instructor led program or utilizing their current on line training modules. Following the training, a facility champion for the protocol should be identified that could help to evaluate staff understanding and compliance with the protocol by daily interactions with the various units in the facility.

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APPENDIX A

SEPSIS TRAINING FACT SHEET

APPENDIX B

NURSE DEMOGRAPHIC DATA TOOL

APPENDIX C

EVALUATION OF SEVERE SEPSIS SCREENING TOOL