Almost 750,000 Americans every year are victims of sepsis and the number of cases continues to grow. Sepsis the tenth leading cause of death in the United States and an estimated 28-50% of those patients die. Sepsis evolves over time and can be hard to detect. Sepsis is missed in many patients because the changes can come quickly.
Nurses are aware that sepsis can be fatal but may not be prepared to recognize it early and ensure appropriate emergency care.
(“Helping Patients,” 2013). The long term outcomes for sepsis can be improved with early assessment and proper treatment. When performing assessments on the floor the signs and symptoms of sepsis may go unnoticed until it is late in the stages of sepsis.
The first stage of sepsis is systemic inflammatory response syndrome (SIRS). If not treated correctly and aggressively this stage can lead to complete sepsis causing organ and system failure. SIRS can result from surgery, trauma, myocardial infarction, or burns.
If a patient is not identified early during this stage it can lead to mortality. To meet SIRS criteria a patient must have at least two of the following:
Temperature above 100.4 degrees Fahrenheit or below 96.8 degrees Fahrenheit
Heart rate faster than 90 beats per minute
Respiratory rate faster than 20 breaths per minute
White blood cell count above 12,000 cells/mm? or below 4000 cells/mm?, or greater than 10% immature (band) forms (OhioHealth System, 2016).
Nurses are taking vital signs on their patients every four hours and at shift change. Many
times nurses might miss the slight change in these vitals and not notice that a patient meets SIRS criteria or that the criteria are progressing.
The inpatient floors are using the Modified Early Warning Score (MEWS) in order to detect sepsis in their patients. Many patients are still not being diagnosed early enough in order to start SIRS and sepsis protocol measures. MEWS is a great tool but you have to use it in order to detect the sepsis. There should be a Best Practice Advisory (BPA) that populates when a patients vital signs are in the range to meet SIRS criteria.
The sepsis BPA would take information from the electronic medical record (EMR) that has already been established and help lead nurses to SIRS or sepsis criteria earlier. The BPA would appear on the EMR if a patient meets the following:
The patient is older than 18 years of age
Sepsis screen has not been documented ot previous screen was negative
Patient is positive for two or more signs of SIRS in the past six hours
Patient is positive for one or more signs of organ dysfunction in the past six hours
The BPA would not fire if the patient had already been given fluid therapy intravenously or if the sepsis bundle had been completed. Another criteria to keep the BPA from firing would be if the in the last six hours the patient had a lactate ordered or resulted, a blood culture ordered or resulted, antibiotics ordered or administered, and intravenous antibiotic administered or ordered. Once the BPA occurs it will be a hard stop that the nurse cannot get by without choosing one of the options listed on the BPA.
The first choice for the nurse would be to re-screen the patient. A hyperlink would be available to choose to re-screen the patient. If this option is chosen then the BPA will not fire
The next choice would be that the sepsis bindle is already in progress. This alerts the system that the patient is already getting treatment for sepsis. If this is chosen the BPA will remain off for six hours.
There would also be the option to choose that the will notify the primary nurse. This can be used if another clinical person has to get in the chart for patient care. If this tab is chosen it will not shut off the BPA. It will fire again the next time that the chart is opened until one of the above tabs are chosen.
Hawaii Pacific Health (HPH) initiated a sepsis BPA in 2014. Since this time they have decreased their severe sepsis and septic shock length of stay and mortality rates. According to the HPH case study (2016), Analysis of our sepsis patients in the pre-intervention period of 2012 and 2013 revealed positive margins of an average $9500 per patient. In the post intervention period (2014 – 2016), the average per patient margin was $13,300.
The University of California, San Francisco School of Pharmacy published a study regarding the results of using a BPA for sepsis patients. The time from diagnosis to antibiotic was decreased from 61.5 to 29 minutes. The patients receiving antibiotics within 60 minutes of diagnosis increased from 48.6 percent to 76.7 percent. The mean length for hospital stay was reduced by one third. (Jacobson, 2015, para. 15).
Mills Peninsula Medical Center started using a BPA to detect sepsis in 2012. From 2012 to 2016 they had a 72 percent reduction in sepsis mortality. They also attribute it to a 152 lives saved. The hospital showed a decreased length of stay showing a cost savings of 6.6 million dollars. (Ruble & Lim, 2016, p. 6)
In the current situation sepsis detection is being delayed or sometimes missed all together. A nurse cannot be looking at every bit of information on a patient all the time. For every hour of delayed sepsis diagnosis, it increases the chance of death between four and seven percent. (Healthcare Corporation of America website, 2018, para. 4). With a BPA in place this delay could be drastically cut down or avoided altogether.
The current mortality rate in my facility is 24.5 percent. This is up 2 percent from the previous year. The percentage of antibiotics administered in the first 60 minutes of detection is 65 percent. Patients and family members deserve better odds. Nurses deserve a better chance at detecting sepsis and caring for their patients.
Implementing a BPA will help with earlier detection of sepsis. It would take some of the pressure off of the nursing staff by picking up on sepsis signs. It has been proven at other hospitals that using the BPA decreases mortality, decreases length of stay and saves money. I feel that it would do the same at my facility.
Sepsis is a critical safety issue for patients. Many hospitals are putting forth initiatives for earlier sepsis detection my hospital included. These measures have not been enough to manage the occurrence of sepsis.
In order to implement this project there would need to be several stakeholders included in the process. First it would have to be given the okay from senior leadership. The implementation would have some costs to it so they would have to decide the budget for the project. The nurse informatiticist would also need to be involved. He or she would need to work with the Information Technology group and the EMR builders in order to build the BPA to fit what the hospital is already using.
The managers on the units would also have to be on board in order to promote the education and use of the BPA. They would also need to track the progress of the BPA. The staff educators would also need to be involved. There would need to be extensive education and support in using the BPA.
The biggest buy in would need to be from the physicians and nurses. The physicians would need to trust what the nurses are telling them form the BPA. The nurses will need to feel comfortable with the system. They will need solid protocols and standard of work in order to make the implementation work.
In order to test the process a pilot study should be implemented on one floor. Reports should be run for the first month to see when the BPA is firing and if it is picking up the information that is needed in order to identify sepsis in patients. It should also be tracked to make sure that it is not firing too much and causing alarm fatigue in the nursing staff.
The ease of workflow for the staff would need to be monitored when starting the pilot. This can be obtained through nurse and physician feedback. The data from post implementation should be compared to that of pre-implementation. This data can be obtained from reports in the EMR system. If the BPA is working there should be a shown decrease in sepsis mortality, cost of care, length of stay and organ failure.
The pilot data should be disseminated to the stakeholders. The nurses and physicians that are involved in the pilot should also be given the information collected in the pilot stage. Once the pilot is over and it has been implemented throughout the whole hospital then the patient population should also be a part those that are given