Triage Tool for Sepsis Recognition

“Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.  Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year.  Early identification and appropriate management in the initial hours after sepsis develops improves outcomes,” (Rhodes, et al., 2017). According to the National Institute of Health Statistics, more than a million Americans develop severe sepsis every year.  Between 28 and 50 percent of these people die.  This high mortality rate creates a clinical problem and generates interest in improving the care of septic patients.

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The systemic inflammatory response syndrome (SIRS) criteria served as the original definition of sepsis.  SIRS definition contains two or more of the following: temperature greater than 38 degrees Celsius or less than 36 degrees Celsius, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minutes or PaCO2 less than 32mmHg, and white blood cell count greater than 12,000/mm³ or less than 4,000/mm³ or greater than 10% immature bands.  Another tool to identify organ dysfunction is the quick Sequential Organ Failure Assessment (qSOFA). Two points is a positive qSOFA, with increasing points patient outcomes are associated with higher mortality rates (Bhattacharjee, Edelson, & Churpek, 2017). Quick Sequential Organ Failure Assessment (qSOFA) criteria contains: respiratory rate greater than or equal to 22 breaths per minutes, altered mentation, and systolic blood pressure less than 100mmHg. These two, SIRS and qSOFA, are sepsis recognition tools.

Emergency departments play a vital role in identifying, treating, and managing septic patients.  The problem with SIRS criteria as a screening tool for sepsis is patients presenting to an emergency department do not have these laboratory tests, white blood cell and PaCO2, drawn hours prior to arrival.  This is one component that cannot be incorporated into a triage screening tool but updated throughout the stay in an emergency department.  Unless two other vital signs are abnormal there is potential to fail at recognizing a septic patient initially presenting to an emergency department.  Similarly, the qSOFA criteria has shown high specificity to sepsis and poorer outcomes (Bhattacharjee, Edelson, & Churpek, 2017).

Sepsis recognition is not enough to decrease risk of mortality in septic patients. Kumar, et al. (2006) discovered an association between effective antimicrobial administration within the first hour of documented hypotension increased survival in adults with septic shock. The 2016 International Sepsis Guidelines strongly recommends administration of IV antimicrobials initiation within one hour of sepsis recognition. The best way to improve patient outcomes for septic patients is to identify those with sepsis. The second way is to manage the septic patient, which includes initiation of antibiotics. To assess this clinical problem, the PICO question formulated is, in adult septic patients, how does a sepsis triage screening tool based on qSOFA, compared to the current 2+SIRS criteria, affect door to antibiotic time?

Methods

An electronic literature search was conducted using the CINAHL database. The search included 4 keywords: sepsis, antibiotic administration, SIRS, and qSOFA. All searches conducted were restricted to adults, 2010-2017-time frame, and articles in English. My first search resulted in 3,527 articles. A focus on articles that used SIRS or qSOFA for identification took priority. These terms, SIRS and qSOFA, were searched title specific.  This resulted in a final 289 articles. A secondary electronic literature search with the keyword of ‘nursing intervention and sepsis’ showed a few hundred articles. The research question was assessed using four journal articles that were peer reviewed. The independent variables were qSOFA and SIRS.

Summary of Evidence

Tromp, Hulscher, Bleeker-Rovers et al. (2010) researched the effects of a nurse driven implementation of a sepsis protocol care bundle. A prospective before and after intervention study at an emergency department of a university hospital in the Netherlands was conducted using three different five month increments. Period 1, July 1, 2006 – November 6, 2006, occurred before introducing the new care bundle based sepsis protocol. Period 2, November 6, 2006 – June 25, 2007, occurred after the sepsis protocol was put into place and before training. Period 3, June 25, 2007 – October 1, 2007, was after training and performance feedback. The sepsis care bundle consisted of seven elements. Six elements were required, the seventh was not required unless the patient was hypotensive or had an elevated serum lactate. The bundle included: measuring serum lactate concentration within six hours, obtaining two blood cultures before starting antibiotics, taking a chest radiograph, taking a urine sample for urinalysis and culture, starting antibiotics within three hours, hospitalize or discharge the patient within three hours, and volume resuscitation for serum lactate >4.0mmol/L or hypotension. The researchers used 2+ SIRS criteria to identify septic patients entering the emergency department. The sample size included 825 people, 16 years of age or older (Tromp, Hulscher, Bleeker-Rovers et al., 2010).

The findings showed that implementing a nurse-driven sepsis care bundle provided an increase in early recognition of sepsis in patients presenting to the emergency department. Additionally, when staff received education and training on this intervention, compliance to the bundle improved early recognition and treatment of patients with sepsis. Compliance to the complete sepsis care bundle increased from 3.5% to 12.4%. This study measured antibiotics started within three hours after staff training. Antibiotic administration increased from which increased from 38% to 56%. These results are statistically and clinically significant. Evidence exists that delay in care for septic patients leads to worse outcomes (Bhattacharjee, Edelson, & Churpek, 2017). This intervention study provides level IV (Melnyk & Fineout-Overhold, 2015) evidence for an increased compliance to implementing a sepsis care bundle after training. Some limitations to the study include that is was an uncontrolled study at a single center and only one year in length. Having a broader understanding of this disease across multiple countries and over extended periods of time would improve the validity of the results. Strengths of this study include the large sample size, nurse driven implementation, and SIRS criteria for sepsis screening. Another strength is that this study, like other studies, reveal education improves sepsis recognition and sepsis care. From this study, it can be determined that the training and implementation of a sepsis care bundle increases sepsis recognition and improves adherence to the bundle, improving patient outcomes.

Yousefi, Nahidian, and Sabouhi (2012) conducted a study to review the effects of an educational program about sepsis care of intensive care unit (ICU) nurses.  This study was a quasi-experimental interventional study with two groups over three time periods: before, immediately after, and three weeks after.  Nurses with a bachelor’s degree or higher level of education and one year ICU experience were included in the study. Infection control committee or members that participated in a similar study were excluded.  The sample size included thirty-two nurses randomly enrolled into each of the test and control groups.  The data collection tool was a four-part questionnaire to measure knowledge, attitude, and practice of ICU nurses.  The results obtained earn Level III evidence (Melnyk & Fineout-Overholt, 2015).

The findings revealed there was no significant difference between the control (c) and test (t) groups in terms of age, sex, education, experience, and employment status. Mean scores of knowledge (t=62.5, c=63.7), attitude (t=73, c=72.8), and practice (t=81.8, c=82.2) of ICU nurses in the test and control groups had no significant difference before the intervention. In the test group, attitude (t=79.7, c=73.3) and practice (t=90.5, c=82.2) increased immediately after and attitude (t=83.3, c=73.2) continued to trend up at the three weeks later mark. Education was found to be effective and have a positive impact on attitude, knowledge, and practice on sepsis care of ICU nurses, like other studies. The study did have some limitations which included the ability of the nurses to utilize books, media, and articles on the subject which could influence the study.  This study is limited due to the small sample size.  A larger sample size in various departments and facilities would strengthen the evidence and improve clinical significance. One important thing to consider with this article is that the nurses observed were bachelor’s degree nurses.  Associate degree nurses are the majority of the nursing workforce.  This could be a weakness for the article in that they fail to capture the majority education of nurses. The strength of this study provides evidence supporting training statistically improved levels of attitude, knowledge, and practice of ICU nurses in sepsis care.  Findings of this article are like other studies.

Tarrant, O’Donnell, Martin, Bion, Hunter, & Rooney (2016), conducted a qualitative design-grounded theory study using focused ethnography to gain an understanding of the barriers to implementing the sepsis six bundle components within an hour of recognition of sepsis.  Data collection occurred through various ways including: over three hundred hours of observations, 43 staff members interviewed, and shadowing multiple units and staff members across six pilot hospitals in Scotland from March 2013 – May 2014. The results of this study provide Level VI evidence (Melnyk, & Fineout-Overholt, 2015). 

The main findings include that the Sepsis Six clinical bundle is not six simple tasks but a series of complex processes. Gaining a better understanding of the problems of interruptions and operational failures that get in the way of task completion is ideal to improve compliance for Sepsis Six within one hour. The researchers suggest focusing on individual behavior change to improve compliance to Sepsis Six with a combination of reducing barriers and challenges in the everyday workflow that are responsible for the delays in Sepsis Six. The research hypothesizes that there would be greater compliance to Sepsis Six within one hour window if the everyday barriers and challenges were reduced. This study is limited to one country, Scotland.  Additionally, the length of study could have missed problems and barriers associated with night shift.  Night shift tends to run with fewer resources and less access to providers. Night shift is also associated with less experience providers. These barriers need to be assessed to gain a better understanding of delays in compliance to sepsis six bundle.  The strengths of this study lie in the qualitative perspective to gain a better understanding of barriers to implementing sepsis six bundle. The study highlights that a focus on education and knowledge of sepsis is not enough, and emphasize the importance to reducing barriers to promote ultimate compliance. 

Gunn, Haigh, and Thomson (2016) conducted a retrospective study, over a six-month period, on patients presenting to the ED who had a sepsis six form completed.  The emergency department currently uses SIRS criteria to identify septic patients.  The purpose of the study was to determine if qSOFA would reliably identify septic patients within the emergency department population.  The sample size was two hundred patients with sepsis diagnosis.  One hundred and ninety-five were positive for SIRS.  Twenty-nine were positive for qSOFA. SIRS and qSOFA were compared to determine specificity and sensitivity to identifying septic patients. This article is rated Level IV evidence (Melnyk & Fineout-Overhold, 2015). 

SIRS had a higher sensitivity at 97%, and a 2.4% specificity. qSOFA showed a 90% specificity and a 48% sensitivity.  SIRS was reliable in identifying sepsis and qSOFA was reliable with detecting those required higher levels of care and mortality. These finding show clinical and statistical significance.  The researchers conclude that SIRS criteria serves as a useful triage tool in identifying septic patients.  The researchers further conclude that once positive SIRS criteria is established qSOFA should be conducted to assess severity and critical care need. Limitations of this study include the sample size, location, and length of time where the study took place.   Increasing the sample size over a longer period of time to gain a broader population would increase the strength of this article.  This study would be strengthened if an observation of a larger sample size took place, over a longer period, and over multiple facilities.  The strength of this study is the results that provide evidence for SIRS criteria as the better septic recognition tool.  The results indicate SIRS is best at identifying sepsis.  These results are statistically and clinically important.  If qSOFA was used instead of SIRS, many people would not have been included in a sepsis workup and could potentially have worse outcomes due to delay in recognition and sepsis care.  From this article, keeping SIRS criteria is vital for sepsis recognition.  However, including a qSOFA could benefit those critically ill in identifying those at higher risk for worse outcomes. 

Raith et. al (2017) published a retrospective cohort analysis study on the prognostic accuracy of the SOFA score, SIRS criteria, and a qSOFA within the first 24 hours of admission in discriminating in-hospital mortality among patients with suspected infection admitted to the ICUs. This study began in 2000 and continued to 2015. The sample size included 184,875 adults with infection-related primary admission diagnosis. The study took place in 182 ICUs in Australia and New Zealand. This study was rate a Level IV using Melnyk & Fineout-Overhold, (2015) evidence appraisal guidelines.

The results of this study showed SOFA had significantly greater discrimination for in-hospital mortality than SIRS criteria or qSOFA.  A SOFA of 2 or more points showed a 90.1% accuracy in mortality or ICU length of stay of three days or more.  The SIRS score of 2 or more points had a 86.7% accuracy, while a qSOFA score of 2 or more points revealed 54.4% accuracy.  The overall results favored a SOFA score over qSOFA and SIRS, showing greater accuracy for in-hospital mortality.  The strengths of this study include the duration, sample size, and location. Having this much diversity in the study decreases variables or outliers altering results. Additionally, the information gathered utilized a quality-surveillance data collection process reducing bias. One limitation the researchers address is the inability to apply this study to emergency department patients. This study used patients in the ICU. The statistical significance and clinical significance could be applied to an ICU setting, but for the clinical problem stated earlier this would not hold clinical significance in an emergency department setting.  Like the previous study, the use of SOFA in conjunction with SIRS criteria would be beneficial in determining those with greater critical care needs for proper placement and to identify those at higher mortality risk. 

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Discussion and Conclusions

Sepsis is a terrible disease with poor outcomes.  Understanding the best recognition tool and management are key to surviving sepsis.  The overall articles bring collective information on improving sepsis recognition and decreasing door-to-antibiotic time.  The studies described range from Level III to Level VI according to Melnyk and Fineout-Overholt’s (2015) level of evidence guide.  Having meta-analysis, randomized control trials, or even well-designed controlled trials without randomization would increase the validity of the results.  As previously stated, education is found effective in increasing knowledge and recognition on sepsis care.  Implementing an educational program on sepsis recognition and care is clinically significant to improve sepsis outcomes. Education should be incorporated into a sepsis care bundle to improve compliance and sepsis recognition. Additionally, if qSOFA or SOFA were used after SIRS criteria to determine critical care status this would increase results and provide knowledge on patient outcomes.

The overall evidence in the studies is not enough to make changes in clinical practice.  There is not enough collective strength of evidence to make a change in clinical practice. However, the articles did support SIRS criteria for greatest sensitivity to sepsis recognition with qSOFA showing higher sensitivity to mortality. The sources of evidence support the continuing use of SIRS criteria for a sepsis triage screening tool. Recognizing sepsis and reducing barriers are key to improving antibiotic administration. The results of the study showed the importance of education and reducing barriers to improving sepsis recognition and management. According to the evidence, SIRS criteria is providing better recognition for sepsis. The evidence leads to septic patients benefiting from an additional screening tool, the qSOFA, if they have 2+ SIRS criteria to rule out higher mortality and critical care needs. Further evidence is needed on qSOFA replacing SIRS for sepsis identification prior to implementing in the clinical setting. It appears most evidence conducted is from retrospective studies. Randomized control trials or meta-analysis would strengthen this claim for SIRS over qSOFA in emergency department triage screening tool for sepsis recognition. 

References

Bhattacharjee, P., Edelson, D. P., & Churpek, M. M. (2017). Identifying Patients With Sepsis on the Hospital Wards. Chest, 151(4), 898-907. doi:10.1016/j.chest.2016.06.020

Gunn N, Haigh C, Thomson J. (2016) Triage of Sepsis Patients: SIRS or qSOFA – Which is best? Emergency Medicine Journal ;33:909-910.

Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., . . . Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine, 34(6), 1589-1596. doi:10.1097/01.ccm.0000217961.75225.e9

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., . . . Dellinger, R. P. (2017). Surviving Sepsis Campaign. Critical Care Medicine, 45(3), 486-552. doi:10.1097/ccm.0000000000002255

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: a guide to best practice. Philadelphia, PA: Wolters Kluwer. (n.d.). Sepsis Fact Sheet. Retrieved March 22, 2017, from https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx

Raith, E., Udy, A., Bailey, M., Mcgloughlin, S., Macisaac, C., Bellomo, R., & Pilcher, D. V. (2017). Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit. Jama, 317(3), 290. doi:10.1001/jama.2016.20328

Tarrant, C., O’Donnell, B., Martin, G., Bion, J., Hunter, A., & Rooney, K. D. (2016). A complex endeavour: an ethnographic study of the implementation of the Sepsis Six clinical care bundle. Implementation Science, 11(1). doi:10.1186/s13012-016-0518-z

Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., Berg, D. T., Borm, G. F., Pickkers, P. (2010). The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study. International Journal of Nursing Studies, 47(12), 1464-1473. doi:10.1016/j.ijnurstu.2010.04.007

Yousefi H, Nahidian M, Sabouhi F. Reviewing the effects of an educational program about sepsis care on knowledge, attitude, and practice of nurses in intensive care units. Iranian Journal of Nursing and Midwifery Research 2012; 17(2): S91-S95.