Informing Patients About Sepsis

Professional Setting

The professional setting will be in a community-based teaching hospital. A digital projector, computer or laptop, and white screen are located in the room for the presentation. Participants are emergency and critical care nurses, hospital administration, and other clinicians. The nurse educator will inform participants of newly established Surviving Sepsis Campaign (SSC) guidelines and bundles because, in order for the campaign to be effective, all hospitals should participate in data collection and use bundles. 

Bundles are groups of treatments that improve medical outcomes. According to Kleinpell et al. (2013), surviving sepsis bundles include “(1) recommendations directly targeting the management of severe sepsis, (2) recommendations targeting high-priority general care considerations, and (3) pediatric considerations” (p. 214). Clinicians implement the bundles as a group because research has found that when clinicians provide them in groups, they offer optimal outcomes. Subsequently, severe sepsis and septic shock are often lethal because they progress at an alarming rate, and experts assert that the death toll will rise over the years. In addition, the SSC’s guidelines allow clinicians to recognize sepsis in its early stages and treat the symptoms aggressively before sepsis progresses. 

The nurse educator will provide an introduction to sepsis and its signs and to go over SSC’s guidelines and bundles. In addition, the participants will understand that they can access any material regarding the Surviving Sepsis Campaign via its website. The website offers a multitude of resources and information, as well as recorded web-conferences, so it is both convenient and necessary. Before the presentation ends, the nurse educator will provide participants with the “Surviving Sepsis Campaign Declaration Letter” and ask them to sign it in order to accentuate the necessary commitment to further data collection in their prospective areas and join the efforts to contribute to the campaign’s success.

Literature Review

Wheeler’s (2011) journal article “Pediatric Sepsis: Markers, Mechanisms, and Management” located in The Open Inflammation Journal is relevant because pediatric sepsis and adult sepsis have developmental differences; therefore, it seems therapeutic interventions would have their differences too. Part of the challenge exists due to a lack of studies regarding the epidemiology of pediatric sepsis. In addition, funding for pediatric sepsis is inadequate because it is not well known that sepsis is one of the major contributors to children’s premature deaths.

Dombrovskiy et al.’s (2005) article “Facing the challenge: Decreasing Case Fatality Rates in Severe Sepsis Despite Increasing Hospitalizations” located in Critical Care Medicine is relevant because their trend analysis found that severe sepsis cases account for 6% to 15% in the ICU, so they use 40% of ICU resources. In addition, the majority of severe sepsis cases were between 60 and 75 years old. Therefore, as the population ages, the number of severe sepsis cases will probably rise as well. The researchers concluded that a lack of health insurance has a negative impact on hospitals’ resources, and they predicted this would raise healthcare costs and require the government to reconsider how to allocate insurance for the future aging population. 

Nguyen et al.’s (2012) study “Implementation of Sepsis Management Guideline in a Community-based Teaching Hospital—can Education be Potentially Beneficial for Septic Patients?” is relevant because the researchers concluded that a Sepsis Education Program warranted accuracy in the initial diagnosis and provided evidence for clinicians regarding the SSC’s success rate. Because community-based hospitals have limited funding and resources, they are under pressure to minimize the number of patients they send to the ICU, so utilizing the SSC’s guidelines and bundles allow them to decrease the number of patients who need high-cost care. 

Tromp et al.’s (2010) study titled “The Role of Nurses in the Recognition and Treatment of Patients with Sepsis in the Emergency Department: A Prospective Before-and-after Intervention Study” located in the International Journal of Nursing Studies is relevant because the researchers concluded that the main challenge is a lack of implementation and formal guidelines designed for nurses. However, they found that a simple implementation program was inexpensive. Three emergency care nurses and the emergency care manager developed the protocol for the implementation program. They provided a formal introduction, but they also emailed nurses with specific instructions. For the most part, if nurses are able to determine a patient may be at risk, they can start the treatment immediately and decrease the number of patients who must be transferred to the ICU. 

The American Association of Critical Care Nurses’ (2010) guidelines titled “Severe Sepsis: Initial Recognition and Resuscitation” located on their website www.aacn.org is relevant because it is a concise guideline for early treatment and would provide nurses with more details on the most effective treatments. In addition, it is useful for understanding previous research and data collection because it defines the "AACN Evidence Leveling System" (Martin et al., 2010, p. 3). Studies that use "meta-analysis of quantitative studies or meta-synthesis of qualitative studies that consistently support a specific action, intervention, or treatment" (Martin et al., 2010, p. 3) is the highest level whereas Level E does not use clinical studies or Level M is based only on the manufacturer's recommendations. Most importantly, this source would aid the nurse in collecting his or her own data because it offers resources for practice. 

Aitken et al.'s (2011) article "Nursing Considerations to Complement the Surviving Sepsis Campaign Guidelines" published in Critical Care Medicine is relevant because the researchers specifically used nurses as their audience when they created their content. Most importantly, the resource supplements SSC guidelines and data collection, so nurses have further resources when collecting their data.

Kleinpell's et al. (2013) American Journal of Critical Care article "Implications of the New International Sepsis Guidelines for Nursing Care," is relevant because it emphasized critical care nurses’ roles in the SSC data collection. The authors asserted early treatment and recognition decreases advancement to severe sepsis and septic shock; therefore, when patients exhibit signs of sepsis, nurses can collect their data and add to the growing body of research regarding early signs and possible prevention. 

Levinson et al.’s (2011) article "Reducing Mortality in Severe Sepsis and Septic Shock" located in www.medscape.com is relevant because the researchers found that elements of SSC’s resuscitation and post-resuscitation/management bundles contributed to decreased mortality. Because clinicians want to decrease sepsis fatalities and mortalities, they would have the motivation to implement the SSC in their hospitals. The researchers concluded that standardizing the bundles would allow hospitals to decrease the number of patients who end up with severe sepsis and septic shock. 

The Society of Critical Care Medicine’s (2013) webpage “Implement and Improve” located on their website www.survivingsepsis.org is relevant because it is the ultimate guide to implementing a program in one’s hospital. Along with the bundle descriptions and guidelines, the website offers resources such as videos and web-seminars that cover topics such as how to present the information to implement the SSC and how to ask for administrative buy-in. In addition, the website provides a downloadable sheet regarding data collection, so that along with electronic records, hospitals are able to use the same means of record keeping. The SSC expects its online data collection will be ready late June 2013, so this will allow easier access and control. 

Tipler et al.’s (2013) retrospective study “Use of a Protocolized Approach to the Management of Sepsis can Improve Time to First Dose of Antibiotics” located in Journal of Critical Care is relevant because they developed a clear method in which a multidisciplinary team could work together and implement the campaign. Their protocol allowed them to effectively diagnose early signs, order antibiotics, and provide treatment in 61 minutes. The usual protocol takes about 160 minutes, so this would encourage other hospitals to design their own protocol regarding SSC’s bundles. 

(Bibliography omitted for preview. Available via download)

Discussion of relevant support of research problem

Within the literature section of challenges involving pediatric sepsis, Wheeler (2011) explained sepsis is not a disease but a syndrome, and children are equally susceptible. Moreover, pediatric sepsis involves “the loss of productivity related to years of life lost” (Wheeler, 2011, p. 3). In other words, children’s deaths do not allow them to have productive adult lives. In addition, Wheeler emphasized that many people, except for pediatricians, consider children miniature adults, so they mistakenly believe what will work for adults will work for children.

Within the literature section challenges involving under-resourced hospitals and sepsis, Dombrovskiy et al. (2005) noted “the rate of…uninsured among blacks is twice that among whites” (Discussion para. 4) in New Jersey. Therefore, a lack of insurance causes some patients to avoid going to the doctor when they feel ill. If their illnesses progress and become unmanageable, they end up going to the emergency room. Subsequently, Levinson et al. (2011) emphasized patients’ health backgrounds may contribute to their susceptibility to sepsis. 

Within the literature section of challenges involving under-resourced hospitals and sepsis, Nguyen et al. (2012) noted there was some resistance in initiating new guidelines when it was not preceded by an education program. Therefore, the education program eliminated former barriers such as a lack of agreement between caregivers. Instead of relying on a variety of resources, researchers concluded that having the same information to draw from alleviated the clinicians’ uncertainty and stress. 

Within the literature section challenges involving under-resourced hospitals and sepsis, Tromp et al. (2010) noted some emergency department nurses had a difficult time recognizing the initial signs, so they did not treat the patients according to the tested protocol. Overall, a lack of informal or formal training diminished the clinician’s ability to effectively diagnose and treat his or her patient. Similarly, within the literature section of collecting data and the Surviving Sepsis Campaign, Kleinpell et al. (2013) determined when hospitals provide nurses with training and education regarding their sepsis patients, nurses are able to quickly diagnose. In the past, nurses were unaware of their role in the SSC, so the lack of education hindered the campaign’s progress. In addition, Kleinpell et al. (2013) noted that nurses were able to adhere to protocol with additional education regarding the SSC. 

On the other hand, within the literature section of collecting data and the Surviving Sepsis Campaign, Aitken et al. (2011) noted that nurses’ roles varied depending on their regions or countries. Often, some hospitals view the SSC guidelines as extensions of a nurse’s role, so a potential factor would have to do with the variety of nurses’ cultures, educations, and abilities around the world. 

Within the literature section of collecting data and the Surviving Sepsis Campaign, Tipler et al. (2010), researchers noted multidisciplinary teams have to decide on a specific protocol for success. In some cases, team members may not agree or may not equally participate. However, the researchers did not experience this in their study, so it seems if caregivers consider the benefit of their patients before anything else, they will be inclined to work together. 

According to Levinson et al. (2011), sepsis is lethal because it progresses at such a fast pace. Therefore, barriers to success would include the inability to identify symptoms. In addition to barriers regarding uncertainty, there is a lack of evidence concerning pediatric sepsis. Within the literature section of challenges involving pediatric sepsis, Wheeler (2011) noted pediatric cancer research received higher funding than pediatric sepsis, but every year, sepsis accounts for more deaths than lung cancer. The author concluded there is a lack of funding and education regarding pediatric sepsis, so the largest barriers are finances and the belief that we can treat pediatric sepsis and adult sepsis the same. 

Within the literature section challenges involving under-resourced hospitals and sepsis, Dombrovskiy et al (2005) noted that the elderly African American male population contributed to the largest amount of cases. Consequently, uninsured patients inevitably use the emergency room because they cannot afford regular healthcare, so the largest barrier may be the financial strain on the hospitals due to uninsured patients. In addition, their budgets may not allow for further funding of educational programs regarding preventative care and the danger of sepsis. 

Within the literature section challenges involving under-resourced hospitals and sepsis, Tromp et al. (2010) noted the early stages of sepsis were often easy to misdiagnose or miss, so some patients did not receive the bundles according to protocol. In addition, the guidelines continue to change as data collection grows. AACN (2010) is in the midst of updating their guidelines, so a potential barrier may be hospitals are unwilling to commit to newer guidelines as they come along. 

Correspondingly, within the literature section of collecting data and the Surviving Sepsis Campaign, Aitken et al. (2011) emphasized that the SSC’s guidelines effectively reduced sepsis mortality, but the majority of hospitals did not implement them. Research suggests that "a significant challenge to the guidelines process is the inherent limitations of the available literature" (Levinson et al., 2011, p. 2) and differing opinions in two of the most major randomized controlled trials (RCTs) cause hospitals to reconsider the SSC. In fact, Levinson et al. (2011) emphasized that “the failure to translate evidence into practice” (p. 1) is one of our greatest barriers to overcome. 

Within the literature section involving under-resourced hospitals and sepsis, Tipler et al. (2010) emphasized staffing may be a barrier to success. For example, Tipler et al. (2010) observed that an initial pharmacist shortage delayed processing and delivering of antibiotics. 

Within the literature section of challenges involving pediatric sepsis, Wheeler (2011) noted pediatric cancer receives more attention than pediatric sepsis. A best practice would involve using the SSC data collection tool regarding pediatric sepsis and contribute the results to the accumulating SSC database. Essentially, data collection that is specific to pediatrics will also promote awareness in what works and what does not work. In addition, informing others that pediatric sepsis has unique attributes may promote academic and private institutions to consider writing proposals for further research regarding “the epidemiology, pathophysiology, and treatment of pediatric sepsis” (Wheeler, 2011, p. 3). In addition, the SSC website offers a bundle for pediatrics. Researchers suggest that the differences in the adult and the pediatric bundles are slight, but the bundles themselves have shown evidence to decrease mortality and fatality in young and old.

Within the literature section of challenges involving under-resourced hospitals and sepsis, Dombrovskiy et al. (2005) noted that hospitals were able to manage severe sepsis cases outside of the ICU, so the majority of patients do not necessarily have to be transferred to the ICU as many believed. This suggests hospitals can use alternative, and less expensive, settings depending on the septic patient’s needs. 

Within the literature section challenges involving under-resourced hospitals and sepsis, Tromp et al. (2010) asserted nurses must receive effective training in order to recognize early sepsis. Having a formal introduction to the bundles and the implementation process was inexpensive and deemed to be effective. Also, they provided the nurses with feedback so they knew what areas they needed to improve. Using email and the Electronic Health Record seems to be a good practice because clinicians can use it and the Internet, in general, to reach wider audiences and promote the SSC. In addition, clinicians can distribute information regarding the SSC, so their community will know that the campaign’s guidelines and bundles provide optimal outcomes for patients suffering from sepsis. 

Within the literature section of methods to encourage statewide support of the Surviving Sepsis Campaign, Levinson et al. (2011) noted nurses administer medications and influence the central venous catheter or endotracheal tubes’ purchase and use, so hospitals should provide nurses with the most current evidence regarding the SSC guidelines. Correspondingly, nurses’ familiarity with the program will grow and they will become more effective in identifying early symptoms. 

Within the literature section involving under-resourced hospitals and sepsis, Tipler et al. (2010) emphasized that solid training regarding sepsis diagnosis allowed the multidisciplinary team to effectively reduce time because they adhered to the protocol as soon as they recognized signs of sepsis. When they used a strict protocol they decreased the amount of time it took to diagnose and to order, process, and administer antibiotics. For example, the researchers concluded that in the initial period, there are “3 key factors that influence the time to antibiotic delivery” (Tipler et al., 2013, p. 149), therefore the best practice is to have the means to override the ID consultant’s permission in the case everyone agreed that the patient was septic. Given the rapid progression from severe sepsis to septic shock, the researchers were able to “decrease the time to first dose antibiotics for patients with severe sepsis” (Tipler et al., 2013, p. 149). Because the team consisted of clinicians, ID consultants, admissions, and pharmacists, their prearranged agreement allowed them to skip former time-consuming protocol. However, a good practice for further studies should include the patient’s outcome in order to determine how effective length of time is when treating sepsis. 

In sum, based on the research, the best practices regarding the SSC are education and a willingness to collect data. As caregivers and leaders, nurses have the ability to collect significant data. The data that the SCC gathers ultimately will lead to centralized research regarding the cause of sepsis and the best way to prevent or treat it. Regardless, the initial diagnosis is the most crucial step when decreasing sepsis cases, so early prevention will alleviate the financial burden of uninsured patients.

References

AACN Practice Alert. (2010, April). Severe sepsis: Initial recognition and resuscitation [PDF]. American Association of Critical Care Nurses.

Aitken, L. M., Williams, G., Harvey, M., Blot, S., Kleinpell, R., Labeau, S., ... Ahrens, T. (2011). Nursing considerations to complement the Surviving Sepsis Campaign guidelines. Critical Care Medicine, 39(7), 1800-1818. doi: 10.1097/CCM.0b013e31821867cc

Dombrovskiy, V. Y., Martin, A. A., Sunderram, J., & Paz, H. L. (2005). Facing the challenge: Decreasing case fatality rates in severe sepsis despite increasing hospitalizations*. Critical Care Medicine, 33(11), 2555-2562.

Kleinpell, R., Aitken, L., & Achorr, C. A. (2013). Implications of the new international sepsis guidelines for nursing care. American Journal Of Critical Care, 22(3), 212-222. doi: 10.4037/ajcc2013158

Levinson, A. T., Casserly, B. P., & Levy, M. M. (2011). Reducing mortality in severe sepsis and septic shock. Seminars in Respiratory and Critical Care Medicine, 32(2).

Nguyen, H. M., Schiavoni, A., Scott, K. D., & Tanios, M. A. (2012). Implementation of sepsis management guideline in a community-based teaching hospital -- can education be potentially beneficially for septic patients? The International Journal of Clinical Practice, 66(7), 705-710. doi: 10.1111/j.1742-1241.2012.02939.x

Society of Critical Care Medicine. (2013). Implement and Improve. Surviving Sepsis Campaign. Retrieved from http://www.survivingsepsis.org/Improvement/Pages/default.aspx

Tipler, P. S., Pamplin, J., Mysliwiec, V., Anderson, D., & Mount, C. A. (2013). Use of a protocolized approach to the management of sepsis can improve time to first dose of antibiotics. Journal of Critical Care, 28(2), 148-151. doi: 10.1016/j.jcrc.2012.08.021

Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., Van den 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.

Wheeler, D. S. (2011). Pediatric sepsis: Markers, mechanisms, and management. The Open Inflammation Journal, 4(Suppl 1-M1), 1-3. Retrieved June 5, 2013, from http://www.benthamscience.com/open/toinfj/articles/V004/SI0001TOINFJ/1TOINFJ.pdf