Magazine article American Nurse Today

The SEOSIS Challenge: Developing Processes and Educating Staff Lead to Reduced Mortality

Magazine article American Nurse Today

The SEOSIS Challenge: Developing Processes and Educating Staff Lead to Reduced Mortality

Article excerpt

WHEN 35-year-old Tom Jenkins (*) arrives by ambulance at the emergency department (ED), he's lethargic. His medical history indicates idiopathic thrombocytopenia purpura (ITP) that hasn't required treatment since age 18. He takes no medications or supplements. Yesterday, Mr. Jenkins had episodes of vomiting and diarrhea that increased over night. His wife reports that 2 weeks before he was sluggish but had no other symptoms.

Initial vital signs are blood pressure 70/40 mmHg, no fever, sinus tachycardia of 160 beats/minute (bpm), and respiratory rate of 32 breaths/minute. The ED physician identifies that Mr. Jenkins is hypovolemic and orders an I.V. fluid bolus of 1,000 mL of 0.9% normal saline followed by a maintenance rate of 100 mL per hour. After the bolus is infused and the maintenance rate is started, Mr. Jenkins' blood pressure drops to 68/38 mmHg. The physician orders a second bolus of 1,000 mL of normal saline. The ECG monitor alarms, showing ventricular fibrillation. Mr. Jenkins has no pulse, and a cardiac arrest is called. ED staff members begin advanced cardiac life support measures, but their efforts aren't successful. The death certificate documents septic shock from asymptomatic infection as the cause of death.

Sepsis requires the same rapid intervention that's been successful for patients having a heart attack or a stroke. Because the clinical signs and symptoms of sepsis can vary depending on the type of infection and because symptoms may mimic other health conditions, diagnosis can be difficult, especially in the early stages. However, the key to recovery is early intervention. (See Sepsis facts.)

The Surviving Sepsis Campaign and Centers for Medicare & Medicaid (CMS) have developed bundles to encourage early treatment, but these need to be fully operational at the clinician level. (See Campaigning for change.) Our work to do so resulted in a significant reduction in sepsis mortality.

The situation

Our hospital used sepsis awareness campaigns to encourage rapid treatment based on established protocols, but we experienced resistance to the CMS sepsis quality bundle, which is outlined in its core measures. Clinicians voiced concerns about the aggressive time frames and the amount of fluids demanded by guidelines. Physicians said the approach didn't give them time to consider the potential for triggering pulmonary fluid overload. However, the sepsis time clock doesn't allow time for this kind of consideration.

Although education, data collection, and outcomes were being shared with clinicians, we needed to take additional action to change practice and improve mortality.

Steps for improvement

In September 2015, the hospital established an interprofessional sepsis team led by the nursing director of emergency and critical care and supported by the department of performance improvement. The team included frontline nurses, respiratory therapists, pharmacists, physicians, and informatics and quality management staff.

Using the "plan, do, study, act" performance improvement method, the team identified its aim statement--to increase compliance with the CMS sepsis core measure to 80% by June 1, 2018--and gathered baseline statistics. We determined that our severe sepsis mortality was 25% with poor bundle compliance. The team identified several barriers to compliance, including varied physician practice, inconsistent use of the guidelines, and lack of knowledge about the sepsis bundle.

Tools for success

The team developed a sepsis algorithm, a sepsis tracking tool that helps document the bundle elements, and a nurse-driven sepsis policy. (See Sepsis algorithm and Sepsis tracking tool.) The sepsis policy gives nurses the autonomy to initiate treatment based on the bundle elements. In addition, a new Code Sepsis Team was launched, composed of an intensive care unit (ICU) nurse and phlebotomy and respiratory therapists. …

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