Emergency Room Sepsis Bundle Practicum Research Proposal

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Numerator: number of patients for whom administration of low-dose glucocorticoids for septic shock was determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation

Denominator: total number of patients with septic shock

*Low-dose glucocorticoids refer to a daily dose of 200

300 mg of hydrocortisone or equivalent.

Quality Indicator No. 6:

Administration of drotrecogin alfa (activated) for severe sepsis and/or septic shock in accordance with a standardized ICU policy over the first 24 hours following the time of presentation.

The percent of patients for whom administration of drotrecogin alfa (activated)

for severe sepsis and/or septic shock was determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation.

Numerator: number of patients for whom administration of drotrecogin alfa (activated) for severe sepsis and/or septic shock was determined in accordance with a standardized ICU policy over the first 24 hours following the time of presentation

Denominator: total number of patients presenting with severe sepsis and/or septic shock.

Exclusion: non-severe sepsis.

Quality Indicator No. 7:

Glucose values maintained greater than the lower limit of normal and with a median value < 150 mg/dl (8.3 mmol/L) for severe sepsis and/or septic shock over the period 6 hours to 24 hours following the time of presentation.

The percent of patients for whom glucose values were maintained greater than the lower limit of normal and with a median value <

150 mg/dl (8.3 mmol/L) for severe sepsis and/or septic shock over the period 6

hours to 24 hours following the time of presentation

Numerator: number of patients for whom glucose values were maintained greater than the lower limit of normal and with a median value < 150 mg/dl (8.3 mmol/L) for severe sepsis and/or septic shock over the period 6 hours to 24 hours following the time of presentation.

Denominator: number of patients presenting with severe sepsis and/or septic shock

Notes:

1.

Monthly reporting of results is recommended for all indicators.

2.

The definition of severe sepsis, for purposes of the severe sepsis quality indicators, follows the algorithm used in the Evaluation for Severe Sepsis Screening Tool.

3.

The definition of septic shock, for purposes of the severe sepsis quality indicators, assumes failure to maintain MAP > 65 despite compliance with and completion of all elements in the Severe Sepsis Resuscitation Bundle.

Source: Severe Sepsis Quality Indicators

Assess learning needs of ER nurses understanding on sepsis: Pre- and Post-Tests

The questionnaire developed by Drs. Zaka U. Khan and Gary A. Salzman (2006) and published in Hospital Physician (pp. 27-28) shown in Table 2 below will be used to assess emergency room nursing staff's level of knowledge concerning sepsis and its treatment (answers and rationale for correct answers are provided at Appendix A).

Table 2

Proforma Copy of Nursing Sepsis Awareness Questionnaire

Choose the single best answer for each question.

Questions 1 and 2 refer to the following case.

A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate.

1. This patient's condition can best be defined as which of the following?

(A)

Multi-organ dysfunction syndrome (MODS)

(B)

Sepsis

(C)

Septic shock

(D)

Severe sepsis

(E)

Systemic inflammatory response syndrome (SIRS)

2. What is the first step in the initial management of this patient?

(A)

Antibiotic therapy

(B)

-Blocker therapy to control heart rate

(C)

Intravenous (IV) fluid resuscitation

(D)

Supplemental oxygen and airway management

(E)

Vasopressor therapy with dopamine

3. A 40-year-old man with a history of IV drug use presents with cellulitis with multiple abscesses of the right upper extremity. His current weight is 70 kg (lean body weight). He rapidly develops worsening respiratory distress and hypotension and ultimately requires intubation and mechanical ventilation. Blood gas analysis shows a pH of 7.23, Paco2 of 58 torr, Pao2 of 60 torr, and an oxygen saturation of 88%. His ventilator settings are assist-control mode with a tidal volume of 420 mL, respiratory rate of 16 breaths/min, positive end-expiratory pressure (PEEP) of 5 cm H2O, and Fio2 of 70%. His plateau pressure on the ventilator is 29 cm H2O.

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A chest radiograph shows bilateral interstitial infiltrates, and a 2-dimensional echocardiogram demonstrates normal left ventricular function. What ventilator adjustments should be made?

(A)

Change the ventilator mode to synchronized intermittent mandatory ventilation

(B)

Increase PEEP

(C)

Increase respiratory rate to 24 breaths/min

(D)

Increase tidal volume to 600 mL

(E)

Leave the ventilator settings unchanged

4. Which of the following patients is an ideal candidate for noninvasive positive pressure ventilation (NIPPV)?

(A)

A 30-year-old comatose woman suspected of drug overdose

(B)

A 55-year-old man with acute anterior wall myocardial infarction with cardiogenic shock and recurrent ventricular arrhythmias

(C)

A 60-year-old man with peritonitis requiring 2 vasopressors

(D)

A 65-year-old patient with a massive stroke and inability to protect airway

(E)

A 70-year-old alert patient with respiratory failure due to chronic obstructive pulmonary disease exacerbation.

Following the administration of the questionnaire, respondents will be provided with the correct answers and areas of weakness identified for follow-up in-service training, on-the-spot guidance or other training interventions as deemed necessary. Following the administration of the training sessions designed to address shortcomings in nurses' knowledge, a post-test will be administered to determine if progress was made and if further refinements in the training protocols are necessary.

Define sepsis/list signs and symptoms

According to Jacoby and Youngson (2005), "The body's response to infection from invading bacteria, viruses or other infective agents is called 'sepsis.' In severe sepsis, this response goes out of control, causing inflammation and damage throughout the body's organs and blood system that can kill the patient" (p. 1914). Although severe sepsis can infect any part of the body, the most common sources of infection include:

1. The lungs;

2. The gut or bowels;

3. The skin through wounds or invasive devices such as an IV drip

4. The urinary tract from catheters with potential spread to the bladder and kidneys; and,

5. The brain or spinal cord (Jacoby & Youngson, 2005, p. 1914).

For clinicians, sepsis is any type of microbial infection that takes place in association with systemic inflammatory response syndrome (SIRS); consequently, the prevalence of SIRS is much greater than sepsis among hospitalized patients (Zhou, Olivier & McDonald, 2009). In addition, both sepsis and SIRS are occurring more often in hospitalized elderly patients, especially older African-American males (Zhou et al., 2009). In the United States, there are approximately 750,000 sepsis cases reported annually, accounting for about 600 deaths per day (Evans & Tippins, 2007), with a mortality rate ranging between 20% and 40% (Zhou et al., 2009).

Furthermore, in cases of severe sepsis, there is a concomitant dysfunction of the organs that is more prevalent among older populations with sepsis compared to their younger counterparts (Zhou et al., 2009). Although the mortality rate from sepsis differs from population to population, it is four times as high in elderly patients and researchers anticipate further increases in sepsis among the rapidly aging American population in the future (Zhou et al., 2009). In fact, despite significant progress in therapeutic interventions, sepsis remains the leading cause of death for non-cardiac intensive care unit patients in the United States today (Zhou et al., 2009). For the purposes of this practicum, the definitions provided by Kilgore (2008) will be used as follows:

1. Severe sepsis is defined as sepsis (an identified or suspected infectious source and two or more systemic inflammatory response syndrome criteria) with a serum lactate equal to or greater than 4 mmol/L;

2. Septic shock is defined as sepsis and persistent hypotension, or a systolic blood pressure less than 90 mm Hg after a fluid bolus of at least 20 mL/kg.

Plan for implementation of sepsis guidelines/bundle tool kit, audit records of septic patients' visits and summary of report

The implementation of the sepsis guidelines together with the development of the appropriate sepsis bundle tool kit will be followed by an audit of septic patients' visits and a summary of these reports. For this application, the Severe Sepsis Bundles developed pursuant to the 2008 practice guidelines of the Surviving Sepsis Campaign will be used together with the following steps:

1. Assess ER patients for sepsis and document report. All patients presenting in the emergency room will be screened for sepsis and the results of this evaluation.....

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