Better safe than sepsis - Tips for a hospital sepsis prevention program - American Nurse
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Better safe
than sepsis
Tips for a hospital sepsis prevention program
By Alexander Johnson, MSN, RN, ACNP-BC, CCNS, CCRN, and Hillary Crumlett, BSN, MS, RN, ANL
IMPROVEMENTS in sepsis care have made ing initiative support to reinforce organiza-
“good catches” more common than 20 years tional commitment.
ago, but sepsis remains a leading cause of in-
patient death. Carefully developed processes, Our experience
protocols, and program infrastructure increase Our sepsis improvement team used DMAIC
the likelihood of a successful outcome. The (Define, Measure, Analyze, Improve, and
Surviving Sepsis Campaign (SSC) international Control) Six Sigma methodology to design
consensus guidelines for sepsis summarize and launch the strategic plan for the initiative.
best practices based on the medical literature, We developed a team charter that included
but they don’t illustrate how to customize im- project scope, targeted outcomes, deliverable
plementation to specific organizations. Consid- goals, and required resources. The charter al-
er using the following guiding principles (and so helped affirm which members and leaders
examples from our experience) to develop an would serve on the team as well as their roles
individualized sepsis program infrastructure and responsibilities. This helped mitigate role
for your organization. confusion and clarified expectations to avoid
duplication of effort and oversight. Team
Executive sponsorship members also were expected to take informa-
Sepsis improvement teams must be inter- tion from team meetings and disseminate key
professional and formulated via a thorough information back to their own units.
stakeholder analysis to ensure the most ef-
fective representation and support from Nurse screening
team members. Although the team may be Since 2016, the SSC guidelines have recom-
tempted to bring improvement ideas straight mended that organizations consider a screen-
to the bedside and clinicians, begin by ing process for early sepsis detection. Gener-
mapping out a strategic plan. First, establish ally, the physiologic screening criteria should
an administrative or executive sponsor for enable early detection.
support when navigating barriers, such as But challenges such as alarm fatigue can
managing stakeholders, justifying equipment make screening difficult. Fortunately, elec-
needs, or obtaining resources. Executive tronic triggers and machine learning algo-
sponsors also can be helpful when promot- rithms are available in many electronic health
50 American Nurse Journal Volume 16, Number 4 MyAmericanNurse.comrecord (EHR) systems to help reduce alarm fa- and a provider order isn’t required. When the
tigue and mitigate the “white noise” some code line is called, the operator notifies the
alarm systems create. team via a paging distribution list. When acti-
Another challenge is that nurses may think vated, the team makes every effort to contact
they’re expected to diagnose the patient. the primary provider. However, our hospital
However, screening isn’t diagnosing. It’s sim- intensivist is prepared to intervene as a con-
ply evaluating whether certain criteria are met tingency plan or if clinical needs are more
that warrant reporting to the provider. A new time-sensitive.
positive screen also suggests that the patient’s
status is worsening, which would likely be re- Collaboration and performance metrics
ported to the provider, anyway. Collaboration must occur at the bedside and
with documentation. For example, the bed-
Our experience side nurse plays a critical role in the surveil-
Our EHR continuously monitors for sepsis cri- lance, monitoring, and early identification of
teria, firing an electronic alert when systemic patients who may meet sepsis criteria. How-
inflammatory response syndrome (SIRS) and ever, all of the interventions included in the
organ dysfunction criteria are met. A “remind sepsis bundle require a provider’s order, which
me later” button can be clicked if the nurse is requires strong nurse–provider collaboration
performing a more urgent clinical task. How- to increase the likelihood of early identifica-
ever, when sepsis criteria are met, the sepsis tion and timely treatment.
response system is activated with a bedside Accurate performance metrics depend on
in-person response by the sepsis nurse within precise documentation and coding. Collabo-
15 minutes. If the sepsis nurse validates that ration with coders and provider documenta-
criteria are met, the sepsis bundle is initiated tion specialists can help ensure that the cor-
as soon as possible and within 1 hour. Our rect severity of illness (SOI) and risk of
organization uses a predictive electronic trig- mortality (ROM) are reflected for the patient.
ger that checks more than 70 pre-existing For example, a patient with a history of
variables in the EHR. heart failure who develops pneumonia with
hypotension may have SOI and ROM more
Response system accurately captured if a diagnostic code of
Sepsis screening processes can aid early iden- “sepsis” or “severe sepsis” as opposed to
tification, but they must be coupled with re- “heart failure” is used, as appropriate. The
sponse systems to ensure interventions are sepsis team also may consider coaching the
implemented at the bedside in a timely man- top ten providers who demonstrate docu-
ner. Sepsis is a time-sensitive condition. Ac- mentation opportunities based on a hospital
cording to Seymour and colleagues, septic coder needs assessment.
shock mortality increases by 7% to 8% for
every hour of delay in antibiotic administra- Our experience
tion. The response system may consist of a We consider the coding team as members of
team that includes a nurse with critical care the sepsis team who can help improve out-
training, or it may be a modified version of comes by creating a more accurate denomina-
the rapid response team. However the team is tor of cases, providing new perspectives, and
constructed, it must be sent to the patient helping to give the team credit for the excel-
wherever they are in the organization. lent care that we know they give.
A response team can help add a sense of
urgency to the situation and may help man- Hour-1 bundle
age any nurse-provider disagreement about In 2018, the SSC issued a guideline update
the right course of action. You can cus- reinforcing the hour-1 bundle to expedite
tomize the members of your response team implementing the interventions previously
based on the resources and needs of your followed in the 3- and 6-hour bundles. Al-
organization. though the hour-1 bundle is controversial in
the medical community (from a regulatory
Our experience standpoint, it would be difficult to hold cli-
Our sepsis alert can be called by any clinician, nicians accountable for 1 hour), few argue
MyAmericanNurse.com April 2021 American Nurse Journal 51similar to the golden hour in trauma, acute
stroke, and acute myocardial infarction.
6 things in 60 minutes Our experience
In 2014, our organization believed that the 3-
The sepsis bundle used in our project—characterized by the slogan
and 6-hour bundles didn’t reinforce an ideal
“6 things in 60 minutes”—is based on the Surviving Sepsis Campaign
guidelines. Our goal was to at least initiate each of these interventions sense of urgency, so we implemented what
within 1 hour. we called “6 things in 60 minutes” to empha-
size the time-sensitive nature of resuscitation
Sepsis bundle (See 6 things in 60 minutes.) We promoted
1 Measure lactate level. Remeasure if initial lactate is >2 mmol/L. this internal goal with the slogan “Time is tis-
2 Obtain blood cultures before administering antibiotics. sue” to illustrate the clinical significance of the
sepsis-induced tissue hypoxia that may be
3 Administer broad-spectrum antibiotics. mitigated by promptly implementing the sep-
4 Begin rapid administration of 30 mL/kg crystalloid solution for lac- sis bundle.
tate ≥4 mmol/L and/or hypotension.
5 Start vasopressors if the patient is hypotensive during or after fluid Lactate measurement
resuscitation to maintain mean arterial pressure ≥65 mmHg. No biomarker exists to diagnose sepsis, but
6 Repeat the focused exam (after the initial fluid resuscitation) by a the serum lactate level can help determine
licensed independent practitioner or conduct a dynamic assessment severity and aid prognosis. The higher the lac-
of fluid responsiveness, such as stroke volume, with passive leg raise tate value, the worse the prognosis. The lac-
or fluid challenge. tate value also may help identify sepsis sooner
than traditional vital signs can, and observed
Sepsis bundle considerations for patients with COVID-19
decreases in lactate can help evaluate treat-
• Sepsis identification criteria can be applied to patients with COVID- ment response.
19 the same as for patients with sepsis from other sources.
The question of whether to sample arterial
• For patients with COVID-19 and acute hypoxemic respiratory fail- vs. venous lactate or point-of-care vs. labora-
ure on oxygen, maintain SpO2 no higher than 96%. For patients tory-processed lactate can be controversial,
refractory to conventional oxygen therapy, high-flow nasal can-
but whatever the method used, the lactate val-
nula is suggested.
ue indicates tissue hypoxia and is a more ac-
• The clinical significance and process for measuring and trending
curate measure of disease severity compared
serum lactate applies the same for sepsis from other sources.
to a physical exam or urine output. According
• Because of the risk of respiratory failure and acute respiratory dis- to SSC, the goal is lactate measurement and
tress syndrome (ARDS), the provider may select a conservative over
associated treatment initiation within 1 hour.
a liberal fluid management strategy.
• For adults with severe COVID-19 who don’t require mechanical Our experience
ventilation, I.V. remdesivir is suggested, ideally within 72 hours.
At our organization, a key process improve-
• For adults with severe or critical COVID-19, a short course of sys- ment was implementing “repeat lactate” as a
temic corticosteroids is recommended. standing order. This feature allows nurses to
• For mechanically ventilated adults with COVID-19 and moderate- order and acquire a repeat lactate as long as
to-severe ARDS, prone ventilation for 12 to 16 hours is suggested. sepsis is diagnosed and treatment is initiat-
• For adults hospitalized with COVID-19, pharmacologic venous ed. The process provides nurses with more
thromboembolism prophylaxis is recommended. autonomy and increases the likelihood of
Sources: Alhazzani et al 2020, Alhazzani et al 2021, Dellinger et al 2017, Levy et al 2018.
achieving bundle compliance by acquiring
Learn more about maintaining a successful sepsis prevention program during a pandemic
the repeat lactate within the first 4 to 6 hours
at myamericannurse.com/?p=74273. of resuscitation.
Education and training
that, in theory, it’s a worthy goal. Complet- Education and training are primary compo-
ing every element of the sepsis bundle with- nents to any strong sepsis program. Simula-
in 1 hour may not be possible, but focus tion is a best practice, when possible or ap-
should be placed on attempting to initiate propriate, to promote retention and knowledge
each component in 1 hour if possible. The transfer. However, facilities, space, staff, equip-
guiding principle of the hour-1 bundle is ment, supplies, cost, and other limitations
52 American Nurse Journal Volume 16, Number 4 MyAmericanNurse.comVirtual simulation
In the virtual simulation training used in our organization, a staff
member receives a shift handoff and enters and navigates a virtual
may create barriers to launching simulation patient room. The scenarios provide no prompting, so the learner
training for any clinician on the team who’s needs to decide what to do. Trainees can navigate the electronic
likely to care for patients with sepsis. Lead- health record or click on anything in the room to obtain more infor-
ers frequently are challenged to be creative mation (such as laboratory data, intake and output, patient history,
when spearheading education that’s effi- physical, and assessment data). They also can talk with the patient
and check the bedside monitor for sepsis criteria. After evaluating the
cient, cost-effective, and focused on creating
patient information, participants choose treatments and interven-
the behavioral changes likely to improve pa- tions, for example, by clicking on the lactate machine to check a
tient outcomes. Our hospital was faced with serum lactate or on the medication cart to administer fluids, vaso-
similar limitations and focused on innovative pressors, or antibiotics.
solutions to navigate these common con- The program doesn’t prompt case completion in response to inter-
straints, while also generating a return on ventions or treatments, which allows the participant to undertreat or
our investment. overtreat the patient before exiting the virtual patient room. This
adds a level of realism that quizzes or slideshow-style e-learning
Our experience modules can’t.
With a financial grant from the hospital’s foun- Learners receive instant feedback about their performance based
dation, our team launched a web-based, vir- on customizable thresholds for a passing score created by the nurs-
ing leadership team. Administrator access allows leaders to see which
tual simulation program (NovEx™—Novice to
staff are logged in, their completion rates, the amount of content
Expert Learning) based on SSC guidelines. The clicked, and who might require remediation.
program includes case scenarios (based on re-
al-life cases) in either a virtual emergency de-
partment, intensive care unit, or unit environ-
ment. (See Virtual simulation). tracking tool in our EHR. A flowsheet tool
The simulations provide experiential learn- such as this can be customized for any orga-
ing that reinforces the guiding principles for nization’s needs and serve several purposes
identifying and treating sepsis. The unique- during workflow, such as a resuscitation and
ness of the simulation experience helped gen- responder checklist, responder-to-responder
erate a high level of sepsis awareness leading communication tool, bedside reference, hand-
up to the kick-off of the screening and re- off tool, project leader tracking tool, sepsis
sponse system. Sepsis simulations are now care plan or care pathway, scripting or care
mandatory for all nurses and patient care goal resource, and real-time data collection
technicians as part of the new-employee ori- tool.
entation process. The reverse-side of the paper flowsheet in-
cludes a list of commonly administered, Cen-
Data collection ters for Medicare and Medicaid Services
Many conventional sepsis quality improve- (CMS)–approved, I.V. sepsis antibiotics from
ment programs rely solely on retrospective our formulary. The paper tool was particularly
data collection from the quality department, helpful during the initial program launch or
frequently for patients with the sepsis diagno- when sepsis program changes or barriers oc-
sis code, to measure team performance and curred. It provided a care summary so the
drive process improvement. Although retro- sepsis project leader could follow-up with
spective data can allow for more robust data frontline clinicians for feedback or coaching
collection, it’s limited because patient coding opportunities. The tool encourages sepsis re-
can take anywhere from 4 to 6 weeks post- sponder awareness, adherence to expecta-
discharge to generate the sample for abstrac- tions, and decreased care variation and
tion. Concurrent, prospective data collection helped serve as a method for staff to actively
can provide a real-time indicator of sepsis participate in data collection and quality. It al-
protocol adherence. so included scripting to help guide responders
through challenging situations, such as nego-
Our experience tiations with providers about implementing
In our organization, we drafted a paper flow- the sepsis bundle.
sheet that included the key interventions re-
quiring completion or consideration during Daily rounding and rapid feedback
the resuscitation period. This flowsheet has A successful sepsis program can’t be
been converted to an electronic storyboard launched with tools alone. To improve pa-
MyAmericanNurse.com April 2021 American Nurse Journal 53tient outcomes and meet team and organiza- to navigate barriers and process problems.
tional goals, tools must be incorporated into
a strong process. For example, the prospec- Our experience
tive rounding tool should be used to provide Based on input from frontline staff, we added
rapid, real-time feedback to frontline care- piperacillin/tazobactam to our automated
givers. Caregiver behaviors or habits are less medication delivery system so nurses had it
likely to change without transparency and on the unit instead of having to wait for a
feedback, which should be detailed and giv- pharmacist to prepare and send it. This
en soon enough after the patient case so the change allows us to deliver the antibiotic
clinician remembers the patient (face-to-face more quickly. In addition, we use role grids to
feedback is preferred, although email feed- help define roles and expectations for every
back can be helpful). member of the sepsis resuscitation team.
Ideally, feedback should be provided by a
trusted subject matter expert (SME) so that it’s Outcomes improvement
viewed as credible, creates accountability, and With persistence and patience, you can use
incentivizes staff. The SME can use tools to these guiding principles to lead your sepsis
guide their patient and staff rounds. When program to improved patient outcomes, in-
SMEs participate in daily rounding, they can cluding sepsis bundle compliance, observed
evaluate the current sepsis screening and re- mortality, and sepsis identification. Since we
sponse system workflow, as well as monitor launched our sepsis program in 2014, ob-
for ongoing strengths, barriers, or opportuni- served mortality has decreased from 43% to
ties. Positive reinforcement for expectation less than 15%. Sepsis bundle compliance has
adherence or above-and-beyond performance improved to consistently exceed 60% (sur-
also can be given during these rounds. passing state and national averages), and out-
SME presence on rounds can help em- comes have been sustained or improved since
power staff to ask questions or voice con- we launched the CMS Core Measure. In 2021,
cerns, creating opportunities for relation- bundle compliance is exceeding 80%.
ship-building. Perhaps most importantly, We’ve also seen fiscal improvements. Not
SMEs serve as a living, breathing portrayal of often does a program improve clinical prac-
the sepsis program. This helps create daily tice and regulatory adherence, save lives, de-
awareness, accountability, and momentum crease costs, and generate revenue, but that’s
for the program. been our experience. The program’s ability to
drive improved outcomes in all of these areas
Our experience is the result of contributions from a committed
A clinical nurse specialist was important not team at all levels of the organization.
only for daily rounding, but also for spear-
heading the improvement of patient outcomes A road worth taking
through project management, advanced edu- The guiding principles described in this article
cation and training, unit presence as a clini- can be customized to meet the needs of your
cian, and implementation of evidence-based organization to help you build a successful
practices. sepsis program. However, the voices and efforts
of nurses and clinical staff will provide the
Continuous quality improvement tools roadmap for implementation and success. As
Sustaining performance and outcomes is the most clinicians know, this road is one worth tak-
true challenge of a sepsis program. Tools— ing because “Saving one life makes you a hero,
process maps, workflow algorithms, role but saving 100 likely makes you a nurse.” AN
grids, operations manual, electronic feedback
tools, and report cards—developed in collab- Access references and additional outcomes data at
myamericannurse.com/?p=74273.
oration with the entire clinical team can help.
These tools aid consistency, create built-in re- Alexander Johnson is a clinical nurse specialist for critical care at
dundancy, decrease practice variation, sup- Northwestern Medicine Central DuPage Hospital in Winfield, Illi-
port teaching and coaching, and hold team nois. Hillary Crumlett is director of operations for inpatient nursing
members accountable. They also can be cus- and the emergency department at Northwestern Medicine Huntley
tomized based on feedback from the team Hospital in Huntley, Illinois.
54 American Nurse Journal Volume 16, Number 4 MyAmericanNurse.comYou can also read
