Running head: SEPTIC SHOCK

Septic Shock
Angela DeVolder Blair RN
The Robert B. Miller College
BSRN 431 Nursing Research Project
Diane V. Tramel
October 25, 2015

Septic Shock
Introduction
Septic shock is the leading cause of mortality in patients admitted to the ICU (nbci,
2015). In the United States alone, there are over 750,000 cases of severe sepsis or septic shock
each year with many patients initially presenting to emergency departments (nbci, 2015). The
Mayo Clinic defines Sepsis as a potentially life-threatening complication of an infection (Mayo
Clinic, 2015). Sepsis occurs when chemicals released into the bloodstream to fight the infection
trigger inflammatory responses throughout the body and trigger a cascade of changes that can
damage multiple organ systems causing them to fail. If sepsis progresses to septic shock, blood
pressure drops dramatically, which may lead to death (Mayo Clinic, 2015).
Mortality associated with patients identified with severe sepsis or septic shock twelve
years ago was 30% (Cabrera, 2015). Studies indicate that patients treated with early goal-

Running head: SEPTIC SHOCK

directed therapy (EGDT) versus standard therapy had significantly lower mortality rate of 18%
than those receiving standard care therapy (Cabrera, 2015).
Problem Statement
On October 1, 2015 the core measure of septic shock was initiated at Oaklawn Hospital.
Not only is reimbursement based on recognizing and treating sepsis but most importantly, best
practice protocols have been placed to ensure that patients are receiving the necessary
interventions to improve organ perfusion and to limit multi-organ failure, controlling the source
of infection, and decrease incidences of mortality. When a patient presents to the emergency
department, it is imperative to recognize the signs and symptoms of septic shock. Signs and
symptoms include but are not limited to hypotension with a MAP of 65 or less, tachycardia,
tachypnea, hyperthermia or hypothermia, mental status change, and suspicion for infection (US
Library, 2015). If a patient meets this criteria for risk of sepsis, a sepsis protocol is placed and
initiated. The sepsis protocol at Oaklawn Hospital includes CBC, CMP, Blood Cultures, Urine
analysis with culture, Lactic Acid upon initial presentation and then a repeat Lactic Acid in three
hours, Blood Cultures, fluid bolus of 30ml/kg infused within 3 hours if the patient presents with
hypotension or Lactate of 4 or greater, administration of IV antibiotic therapy, and any additional
lab tests or imaging as determined by the physician (Oaklawn, 2015).
Upon the hospital officially initiating a protocol that has been standard practice in the
Oaklawn Emergency Department, I began to question what practices other hospitals had been
initiating or not initiating and contemplating how those practices affected their patient outcomes.
Research Question
In Sepsis, how does immediate aggressive fluid resuscitation and early antibiotic
administration compared to delayed sepsis recognition and treatment affect mortality within one
year of admission to the hospital?
Questions to consider when conducting the research include:
How long had the patient been ill before presenting for treatment in the ED? How long
could they have been septic prior to arrival?

Running head: SEPTIC SHOCK

Does the patient have other comorbidities?

What is the age of the patient?
How soon after identification of a septic patient are IV antibiotics started?
Hypothesis
Early goal-directed therapy including aggressive fluid resuscitation and early antibiotic
administration initiated upon the recognition of sepsis to patients presenting to the emergency
department decreases mortality rates in those identified patients.
How Study to be Conducted
Conducting a study on how interventions affect septic patients outcomes, mortality, and
successes can be challenging as there is an ethical responsibility of healthcare providers to
uphold. While case control studies would be helpful to determine the how patient cases had been
managed, evaluating specific risk factors such as comorbidities and evaluating the outcomes
based on these interventions, at some point, there must be true time research being conducted on
patients currently diagnosed with sepsis and documenting the outcomes of interventions
performed. In this specific study, researchers will be performing case control studies in which
researchers will be retrospectively reviewing patients charts diagnosed with sepsis and
documenting time of sepsis recognition, interventions performed such as fluid resuscitation and
antibiotic therapy and times, and comorbidities associated with these patients, and patient
outcomes. The patients would also be interviewed at a later date to determine the challenges they
face in seeking immediate treatment and their level of medical knowledge and their compliance
of their own comorbidities.
Location
The study is being conducted at a small rural hospital and although we evaluate and treat
many patients for the size of our facility, in order to have the numbers appropriate for a valid
study collaboration with another hospital with larger numbers of patients such as Borgess
Hospital in Kalamazoo would benefit the study so the location would be patients presenting to

Running head: SEPTIC SHOCK

Oaklawn Hospital and Borgess Medical Center containing the diagnosis of sepsis or septic shock
identified in the electronic medical record at any time during a patient stay at either hospital.
Sampling approach
The sampling approach investigated would be in collaboration with electronic medical
records pulling all charts of patients containing a diagnosis of sepsis at any time during their stay
at the hospital. This would be beneficial as patients dont always arrive septic but sepsis may
develop during their stay at the hospital and this could provide information of onset, early
recognition of signs and symptoms, and how quickly interventions were began and how those
interventions may or may not have affected the outcome of the patient. By observing patients
that turn septic during their stay, it also gives a better sampling of early indicators we should
be aware of as opposed to patients that have been at home for one week sick without consistent
monitoring.
Design Type and Why
A mixed methods type of research will be used for this study as qualitative and
quantitative data will be collected, analyzed, and interpreted into a cohesive whole. Two
approaches to data collection is more reliable and valid and a researcher can make a more
convincing case for a particular conclusion if both qualitative and quantitative data both lead to
the same conclusions. Explanatory designs encompasses two designs including collecting
quantitative data and forming percentages, averages, and numbers. The second phase is follow
up and asks participants to describe certain aspects of what they were feeling or thinking during
the experiment such as what was a determining factor that make you finally seek further
treatment for your illness?
Key Concepts
This study is intended to determine if early recognition and early interventions such as
fluid resuscitation and intravenous antibiotic therapy improve patients outcomes when it is
determined the patient is at risk for sepsis. Meta-analysis that have been reviewed have indicated

Running head: SEPTIC SHOCK

there is no long term benefit of early recognition and fluid resuscitation as opposed to minimum
treatment being provided. This study is attempting to determine if quick recognition and early
administration of intravenous antibiotic therapy changes the patient outcomes and if the patients
comorbidities plays a factor into the patient outcome.
`Variables
The variables while studying sepsis and early interventions and patient outcomes are
identifiable by chart review and can be placed in quantitative categories such as vital sign
changes, quantities of fluids used for fluid resuscitation, times such as onset and recognition, and
numbers such as patient success or mortality rates. Qualitative variables include comorbidities
that patients may or may not be currently being treated for and are the patients compliant and to
what extent prior to sepsis identification and what factors caused the delay of seeking medical
treatment for the patients illness and why, and patients general medical knowledge level.
Operational Definitions
Sepsis - Sepsis occurs when chemicals released into the bloodstream to fight the infection
trigger inflammatory responses throughout the body and trigger a cascade of changes that can
damage multiple organ systems causing them to fail. If sepsis progresses to septic shock, blood
pressure drops dramatically, which may lead to death (Mayo Clinic, 2015).
Comorbidities The simultaneous presence of two or more chronic diseases in a patient.
Expected Statistical Approach
Numerical data collected from patient charts and would be entered into a spreadsheet
format and numbers would be compared of patients presenting with sepsis that were treated per
sepsis protocol versus patients treated with normal amount of intravenous fluid and later
antibiotic therapy. Lab values such as white blood cell count, lactic acid levels, and abnormal
vital signs would also be entered and calculated. With these numbers, it is also imperative to
include the patient outcome to determine if early recognition, interventions, and treatment
protocols increased the chance of a positive outcome for the patients. Early recognition and
interventions would likely improve patient outcome.

Running head: SEPTIC SHOCK

Data Collection Instrument

The data collection used for research will be using purposive sampling as the patients
charts that will be identified and audited will have the diagnosis of sepsis. The quantitative
portion of the collection process will include vital signs and abnormalities noted, time of
recognized onset of sepsis, lab values including lactic acid level at arrival and after fluid
resuscitation of three hours, time to fluid initiation and completion, time to intravenous antibiotic
therapy, and numbers determining patient outcomes like death at thirty days, sixty days, ninety
days, and one year following diagnosis of sepsis. This information will be put into a spreadsheet
format that will calculate percentages and numerical values.
The qualitative portion of the research will be performed in a non-biased way by asking
the patient questions regarding their comorbidities and using numbers such as Hemoglobin A1C
to determine how compliant the patients are with their current medical conditions indicating
what risk factors the comorbidities play in the sepsis outcome. For example, a healthy thirty five
year old man with no medical comorbidities with sepsis from pneumonia versus a 65 year old
man with a history of myocardial infarction, CHF, COPD, and diabetes suffering from sepsis
from pneumonia could have very different outcomes.
Possible Outcomes/Conclusions
The conclusions for the research performed indicated by the Meta-analysis that were
reviewed for Nursing Research indicated that there was no improved outcome for patients up to
one year after incidence of sepsis with aggressive fluid therapy but all studies that were reviewed
did not indicate how soon antibiotic therapy was started or make mention of comorbidities that
patients were suffering from. Anticipated outcomes would be early recognition and intravenous
fluid resuscitation along with early intravenous antibiotic therapy would improve the patients
outcomes and decreased mortality rates.
Limitations

Running head: SEPTIC SHOCK

Limitations are innumerable when performing medical research. There are ethical
dilemmas and obstacles in place to ensure that care is not withheld from a patient just to perform
research. Patients that do not have the diagnosis of sepsis in their chart will not identified and
have their case reviewed. Patients that do no present to Oaklawn Hospital or Borgess Medical
Center will be excluded from the research as the information will not be available in either data
or electronic medical record.
Future research
In the emergency department, providers, nurses, and staff are required to follow strict
sepsis protocol with the impression that initiating quick interventions will increase the patients
survivability and decrease mortality rates. After reviewing several meta-analysis research articles
when preparing for Nursing Research, it was disheartening to learn that in several studies, it was
found that there is no better chance for survival if patients receive all of the recommended
interventions as opposed to normal care defined as maintenance fluids and antibiotic therapy
when sepsis is suspected or identified.
Future research must be performed to determine what interventions will provide the
patient with the best outcome available. While current studies indicate no improved outcome
with fluid resuscitation alone, this study would include recognition of early antibiotic therapy
and also take into consideration the patients comorbidities.

Running head: SEPTIC SHOCK

References
Cabrera, Jorge. June 19.2015. Management of septic shock: a protocol-less approach.
Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4474443
Mayo Clinic Staff. 2015. Sepsis. Retrieved from: http://www.mayoclinic.org/diseasesconditions/sepsis/definition
Oaklawn Hospital Policy. 2015. Sepsis Protocol and Call-down.
US National Library of Medicine. 2015. Sepsis. Retrieved from:
http://www.nlm.nih.gov/medline/ency/article/000666.htm.