Sepsis monitoring:

the role of the RN

NURS 217 Group Teaching Project

Presented by:
Mary Ganey
Rashelle Glover
Douglas Sheffield
Molly Trufant

WHY assess for sepsis?

EBP: routin
e sepsis
screening
= improve
d
pt. outcom
es!

Nurses are PIVOTAL in recognizing deterioration in pt. status

On admission
at least once per shift
PRN

Examples:
EWS documentation
with every set
of VS @ SUNY Upstate
@ACH: Sepsis Clinical
Pathway (per P&P)

What is sepsis?
Sepsis chemicals released into bloodstream to fight an initial
infection trigger inflammatory responses throughout the body
SIRS = systemic inflammatory response syndrome
Generalized inflammation in organs
Begins as local infection

Leading cause of death & harm

Higher mortality rate than stroke, acute MI, and trauma
CDC: affects as many as 750,000 hospitalized pts./year
Death rate for pt. c sepsis: 10% (1% without sepsis)

Hospitalizations due to sepsis cost MORE THAN $24 billion/year

How does sepsis progress?

Progresses rapidly!
May lead to DEATH.

ECK
H
C
E TO CYS
R
U
BE S R AGEN
YOU LICY & !
PO
RE S
U
D
CE
O
R
P

Pathophysiology of Sepsis
Initial Infection

tissue trauma
ischemic tissue
necrotic tissue
Viruses, bacteria,
fungi, parasites
Exotoxin release
Post-cardiac resuscitation
Perfusion deficits

Inflammatory
mediators, fluid &
protein into
interstitial space

FVD

Sepsis
Direct damage to
endothelium

SIRS
Massive release
of inflammatory
mediators

Hypermetabolism

Increased vascular
permeability
DECREASED ORGAN
PERFUSION

And

Pathophysiology of Sepsis
Activates
Coagulation
Cascade

WBCs digest
foreign debris

microemboli

Redistributed
(shunted)
bloodflow

Respiratory system usually shows first signs of compromise.

Signs & Symptoms

SIRS = first stage in the underlying progression of sepsis
Can lead to organ failure
Pt. must have at least two of the following:

systemic inflammation
96.8F (36C) < temperature < 100.4F (38C)
HR > 90 bpm
RR >20 breaths/min
PaCO2 <32 mmHg
12,000 cells/mm3 < WBC < 4,000 cells/mm3
OR bands >10%

A pt. who meets SIRS criteria in direct response to a known infection

source is diagnosed with sepsis.

Risk factors
Include:

Active infection
Chronic illness (i.e. DM, CV disease)
Immunosuppressive diseases (i.e. HIV/AIDS)
LT use of immunosuppressive therapy (i.e. chemotherapy)
Poor nutrition
Debilitation

SIRS may result from: surgery, trauma, MI, pancreatitis, or burn injury
Most common in the very old and very young
Post-op pts.: 10x more likely to die from sepsis than MI or stroke

Early Goal Directed Therapy (EGDT)

per
Clinical pathways (CP)
facility

An intervention incorporated by hospitals all over the country.

Goal = initiate sepsis treatments earlier:

Early communication of serum lactate levels
Antibiotics administered within 180 minutes from the diagnosis of sepsis and
within 60 minutes from the diagnosis of severe sepsis.
Initiating fluid replacement early to increase BP (MAP >65 mmHg) and U/O > 0.5
mL/kg/hr.
Rorys Regulations

New York Health Department believes that an approach to early

treatment will save at least 5,000 lives each year.

Sepsis Mortality Rates with and without EGDT

EBP: SIRS Criteria

Systemic inflammatory response syndrome
Screening tool
Determine need for further workup
In ER: triage tool to determine pt. acuity
REQUIRES CONFIRMATION WITH LABS (eg. WBC, Lactate)

>2 SIRS criteria c diagnosed infection dx of SEPSIS

Pts. who meet criteria and are persistently hypotensive (despite fluid
resuscitation efforts) are in SEPTIC SHOCK.

!
NEW

EBP: quickSOFA tool

qSOFA quick sepsis-related organ dysfunction assessment

Introduced by Sepsis-3 group in February 2016
Quick bedside screen for sepsis
Predictor of outcome (likelihood of poor outcome) in pts. with suspected infection
Can be easily and quickly be repeated serially
Can easily be used outside of the ICU setting

3 criteria:
Low blood pressure (SBP < 100mmHg) +1 point
High RR (>22 breaths per minute) +1 point
Altered mental status (GCS <15) +1 point

>2 qSOFA points near onset of infection = higher risk of POOR OUTCOME

http://www.mdcalc.com/qsofa-quick-sofascore-for-sepsis-identification/#next-steps

Case Study Mr. Green

Use the back of your qSOFA card to jot down your ideas.

1. What places Mr. Green at risk for Sepsis?

2. Does he meet any qSOFA criteria?
3. What is your next step in providing care to
Mr. Green?
4. What do you anticipate Mr. Greens provider will order?

As the RN, expect to:

Transfer the pt. to the unit!
BUT, INITIATE TREATMENT BEFORE THEY ARE ADMITTED TO THE ICU.
Gather data and be prepared to share with the health care team (SBAR).

Measure lactate level

Obtain blood cultures before administering ABx
Administer broad-spectrum Abx
Give crystalloid IVF for hypotension

REMEMBER:
The ability to quickly recognize sepsis and begin therapies is what is going to drive
saving livesSo, if nurses are well-prepared, then patients with sepsis are recognized
early and the nurses can be the first to act.

In summary:
Sepsis is a leading COD in hospitalized patients worldwide.
Sepsis can be identified during routine observations by the RN.
All pts. with sepsis should have a management plan.
Recognize and respond to S/S sepsis QUICKLY!
Refer to your agencys P&P, as well as clinical pathways (CP).

Clear guidance on identification and EBP intervention is available

to support effective and safe care.

Sources:
Bernstein, M., RN, MSN, & Lynn, S. J., RN, MSN. (2013, January 11). Helping patients survive sepsis - American Nurse Today. Retrieved April 10, 2016, from http://americannursetoday.com/helpingpatients-survive-sepsis/
American Nurse Today: Official Journal of ANA (Vol. 8, No. 1)

Butcher, L. (2016). Stepping up against SEPSIS. H&HN: Hospitals & Health Networks, 90(1), 38. http://ezproxy.cayuga-cc.edu:2077/eds/pdfviewer/pdfviewer?sid=efa4903e-b0c5-4772-93273fe3542c60b1%40sessionmgr4002&vid=8&hid=4110
Dellacroce, H., RN, MSN, APN-C, CCRN. (2009, July 1). Surviving sepsis: The role of the nurse. Retrieved April 10, 2016, from http://www.modernmedicine.com/modernmedicine/news/modernmedicine/modern-medicine-feature-articles/surviving-sepsis-role-nurse?page=full
Harrison, P. (2013, May 22). Nurses Critical to Implementing New Sepsis Guidelines. Retrieved April 10, 2016, from http://www.medscape.com/viewarticle/804630

Lewis, S.M., Dirken, S.R., Heitkemper, M.M., Bucher, L., & Harding, M. (2014). Medical-surgical nursing:
Assessment and management of clinical problems. (pp. 1649-1650). St. Louis, MO: Elsevier.
McClelland, H., & Moxon, A. (2014, January 17). Early identification and treatment of sepsis. Retrieved April 10, 2016, from http://www.nursingtimes.net/clinical-archive/infection-control/earlyidentification-and-treatment-of-sepsis/5067163.fullarticle
O'Brien, J. (2015, September 8). The Cost of Sepsis. Retrieved April 10, 2016, from http://blogs.cdc.gov/safehealthcare/2015/09/08/the-cost-of-sepsis/
QSOFA (Quick SOFA Score) for Sepsis Identification. (2016). Retrieved April 10, 2016, from http://www.mdcalc.com/qsofa-quick-sofa-score-for-sepsis-identification/
Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA.2016;315(8):801-810. doi:10.1001/jama.2016.0287.
SIRS, Sepsis, and Septic Shock Criteria. (n.d.). Retrieved April 10, 2016, from http://www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/
Wawrzeniak, I. )., Loss, S. )., Moraes, M. )., De La Vega, F. )., & Victorino, J. ). (2015). Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and
septic shock in the Intensive Care Unit setting?. Indian Journal Of Critical Care Medicine, 19(3), 159-165. doi:10.4103/0972-5229.152759. http://ezproxy.cayugacc.edu:2077/eds/pdfviewer/pdfviewer?sid=efa4903e-b0c5-4772-9327-3fe3542c60b1%40sessionmgr4002&vid=10&hid=4110
What is qSOFA? (2016). Retrieved April 10, 2016, from http://www.qsofa.org/what.php
CRISMA Center: University of Pittsburgh Medical Center