EARLY RECOGNITION OF SEPSIS EARLY RECOGNITION OF SEPSIS IN THE EMERGENCY IN THE EMERGENCY

DEPARTMENTDEPARTMENTNanette Kent RN, BSN Senior Specialist Emergency Department, EBPI Fellow Tonia McCoy, RN MSN, Senior Specialist Emergency Department, EBPI Mentor

Sharp Grossmont Hospital

• The largest and most comprehensive health-care facility in East San Diego County

• Covering 750 square miles.• Currently licensed for 446 bed

– Malcolm Baldrige National Quality Award

– Magnet designated

• Busiest ED in San Diego County– 80,000 patients per year– Average 225 patients per day

PICO Question:

In the Emergency Department, does the implementation of an assessment tool for identifying sepsis patients, with the utilization of SBAR communication, when compared to the current practice of following the Sepsis Early Recognition Algorithm for Goal Directed Therapy increase early recognition of sepsis?

Sepsis

• Severe sepsis– Acute organ dysfunction secondary to

infection

• Septic Shock– Severe sepsis plus hypotension not

reversed with fluid resuscitation– 25 % mortality

Surviving Sepsis Campaign

• Initiated in 2003 by the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine.

• Critical care and Infections Disease experts representing 11 international organizations.

• Developed guidelines that would be of practical use for the bedside clinician.

Surviving Sepsis Campaign

• Sepsis is a major cause of mortality, killing approximately 1,400 people worldwide every day, Surviving Sepsis Campaign (2008).

• In the Emergency Department at SGH, the algorithm for Early Goal Directed Therapy for Sepsis has not been consistently instituted.

Sharp Grossmont Hospital

Sepsis Tool

Sharp Grossmont Hospital

Sepsis Algorithm

EBP OBJECTIVES

To utilize a screening tool that will lead to increased recognition and early treatment of sepsis in the Emergency Department.

METHODS

• Staff were educated in the utilization of the sepsis screening tool.

• Staff were given additional education in the current sepsis algorithm.

• The tool screened for:– SIRS (Systemic Inflammatory Response Syndrome)

– Infection– Organ Dysfunction– Severe Sepsis

Sharp Grossmont Hospital

Revised Sepsis Screening Tool

METHODS

• First section screens for SIRS– SIRS includes objective vital signs data:

• Temperature ≥ 100.4 or ≤ 96.8 F• Heart Rate ≥ 90• Respiratory Rate ≥ 20• WBC count ≥ 12,000 or ≤ 4,000, or greater than

0.5K/uL bands

– If the patient has 2 or more of the above, they screen positive for SIRS

METHODS

• Second section screens for infection– The patient is screened for infection if they

have SIRS• Does the patient have suspected or

documented infection?• Has the patient received antibiotics (not

prophylaxis)?

– If one of the above is confirmed, the patient is screened for organ dysfunction

METHODS

• Third section screens for Organ Dysfunction

• Respiratory: SaO2 < 90 %• Cardiovascular: SBP < 90• Renal: urine output < 0.5ml/hr; creatinine

increase > 0.5mg/dl from baseline• CNS: altered LOC, Glascow coma scale ≤ 5

• Any one of the above, in addition to positive results from sections 1 and 2, indicates severe sepsis.

METHODS

The RN then approaches the ERMD, informing him using SBAR technique, that the patient has screened positive for severe sepsis.

SBAR Communication Technique

• Situation:– Screened positive for severe sepsis

• Background:– Positive for SIRS (describe)– Known or suspected infection– Organ dysfunction (describe)

• Assessment:– Share complete VS and SaO2

SBAR Communication Technique

• Recommendation:– I need you to come and evaluate the patient

to confirm if they have severe sepsis.– It is recommended that I get an ABG,

lactate, and CBC, Can I proceed and get these?

– Any other labs you would like me to obtain?– If the pt is hypotensive: Can I start an IV

and give a bolus of NS – 20 ml/kg?

Initial Data Collection

• Baseline data - Concurrent audits of 200 patients were completed utilizing the screening tool.

• Random audits on Emergency Department patients were performed.

Results

57

42

3 2

0

10

20

30

40

50

60

Sepsis Screening Tool (Baseline)

SIRS

Infection

Organ Dysfunction

Severe Sepsis

N = 200

Post Implementation Data Collection

• Staff utilized the screening tool on all patients, regardless of chief complaint or presentation.

• A total of 206 patients were screened.

Results

N = 206

32

13

52

0

5

10

15

20

25

30

35

Sepsis Screening Tool(Post Education)

SIRS

Infection

Organ Dysfunction

Severe Sepsis

N = 206

Results

N = 206

4 4

3

0

1

2

3

4

Sepsis Screening Tool(Post Education)

SBAR Commnication

Additonal Labs

IV Fluid Bolus

Conclusion

• Baseline data– Three patients qualified for complete utilization of

the screening tool.

• Post education– Five patients screened positive for utilization of the

screening tool.– Four received additional treatment

• There is a two-times greater chance of receiving appropriate treatment for sepsis with utilization of the sepsis screening tool.

Next Step

– Incorporation of the screening tool into EMSTAT electronic charting.

– Utilization of the tool during the triage assessment.

– Possibility of implementation of a " sepsis code " when patients present with SIRS symptoms at triage.

Questions…?

Thank you