New York and New Jersey EDs are fighting sepsis with programs aimed at swift detection and treatment. But many nurses say the war cant be won with small, isolated changes. Rather, results come from implementing well-planned, evidence-based, standarized interdisciplinary protocols.
Preventing and taking early control of this life-threatening bloodstream infection isnt easy. Sepsis is the 10th-leading cause of death in the U.S., according to a study published online Feb. 27, 2009, in the journal Critical Care. And it seems to be increasing in incidence. Data from the National Hospital Discharge Survey, 2008, indicate the rate of hospitalizations for septicemia or sepsis per 10,000 people more than doubled from 2000 through 2008.
Those considered at high risk for sepsis include the young and old, patients with compromised immune systems or drug or alcohol addictions, and patients with intravenous, wound drainage or urinary catheters. Others at high risk are the malnourished, those who have had recent surgery, diabetics and patients without spleens, said Jocelyn C. Sese, RN, MSN, CEN, ED clinical nurse specialist at Maimonides Medical Center in Brooklyn, N.Y.
ED nurses have to be on high alert for sepsis, said Lisa Rasimowicz, RN, BSN, CIC, an infection preventionist at Hunterdon Medical Center in Flemington, N.J.Vassar Brothers Medical Center healthcare professionals involved in the Code Sepsis program include, from left, Denise Quirk-Hall, RN, ED staff educator; Judy Flaherty, RN, CPHQ; Andrea Croniser, RN; Edel Normanly, RN; and Maggie Miller, RN, ED associate nurse manager.
“As soon as patients come into the emergency department, their vital signs are taken [looking for] things like elevated temperatures or low blood pressure, which may be an indication that the patient has already developed sepsis,” Rasimowicz said. “The nurses … do full history assessment in the triage area to get an idea of if there have been any recent infections, if [patients have been] on antibiotics recently and for what.”
Blueprints of care
Vassar Brothers Medical Center in Poughkeepsie, N.Y., has seen sepsis mortality drop by about 32% since launching its Code Sepsis program in September 2010.
“Before we started [Code Sepsis], our survival rate of … patients [with sepsis] was about 62% and has increased to about 82%,” said Judy Flaherty, RN, CPHQ, manager of clinical outcomes at Vassar Brothers.
Average time to identify sepsis in Vassar Brothers ED has plummeted from 1 hour and 51 minutes to 23 minutes. Time from sepsis recognition to antibiotic administration has gone from 1 hour and 7 minutes to 23 minutes, Flaherty said. The Code Sepsis protocol starts with early identification. If a patient presenting in the ED has three symptoms suggestive of sepsis, nurses activate a Code Sepsis with a blast communication to the ED sepsis team. The team, which immediately gathers around the identified patient, includes nurses, an ED physician, a physician assistant, a phlebotomist and others.
“The physician will evaluate the patient, and then we begin the sepsis protocol, if it is warranted,” said Margaret Cusumano, RN, MSN, CNO at Vassar Brothers. “Our goal here is less than 60 minutes from door to antibiotics.”
While the team includes more than nurses, Denise Quirk-Hall, RN, MSN, ED staff educator at Vassar Brothers, said nurses play vital roles in the success of these programs.
“The RNs really own this initiative, and their commitment can be measured in their positive patient outcomes,” Quirk-Hall said.
Sepsis protocols differ among hospital EDs. While Maimonides follows the algorithm proposed by the Greater New York Hospital Association Strengthening Treatment and Outcomes for Patients (STOP) Sepsis Collaborative, for example, Sese and colleagues at the facility have modified the protocol. “One thing thats unique to Maimonides is that were using this point-of-care fingertip lactate testing that can give us a lactate result within 60 seconds, versus the 30-minute to one-hour turnaround time for serum results,” Sese said. “The fingertip point-of-care lactate testing allows the triage nurses to catch those occult or cryptogenic sepsis patients who present with completely normal blood pressures … who turn out to have elevated lactates. Early recognition facilitates rapid resuscitation of IV fluids and early antibiotics.”
ED nurses are alerted to perform lactate testing by a sepsis screening tool at triage, which generates a sepsis icon on their electronic dashboard when patients present with two or more systemic inflammatory response syndrome symptoms.
The Maimonides ED started using lactate fingertip testing in August 2011. While final data is not yet out, Sese said implementing a triage sepsis screening tool, including lactate measurement, and the sepsis alert have reduced time-to-treatment significantly.
Knowledge equals power
The U.S. Department of Health and Human Services awarded North Shore-LIJ Health System a $700,000, three-year grant to develop a comprehensive sepsis education program for ED and critical-care nurses. North Shore-LIJ started working on the training program in January 2012, appointing a taskforce of nurse leaders in the ED and critical care and physician experts. Known as the Taming Sepsis Education Program for RNs, the initiative includes an online evidence-based curriculum, with pre-and post-tests, followed by hands-on training in the North Shore-LIJ simulation center, said Kathleen Gallo, RN, PhD, MBA, FAAN, senior vice president and chief learning officer at North Shore-LIJ Health System in Great Neck, N.Y.
“The emergency nursing curriculum focuses very much on triage, and what to be alert for — including not only signs and symptoms but also understanding pathophysiology,” Gallo said.
Other parts of the curriculum address the importance of bundling protocols to standardize care and multidisciplinary teamwork, as well as how best to care for sepsis patients in a culturally diverse environment. North Shore-LIJ long has focused on sepsis quality initiatives. In 2008, sepsis was the health systems greatest cause of in-hospital mortality. By 2011, the health systems efforts at improving sepsis outcomes resulted in a 35% reduction in mortality rates for severe sepsis and septic shock.
Sepsis care wisdom
While improvements in sepsis mortality are encouraging, protocols of care are a work in progress, requiring vigilant monitoring and reflection, Cusumano said.
“Every month, there is a core group of us from the emergency room … and we look at every single patient and address every fallout,” she said. “We want to look at anything that is later than an hour.”
Lisette Hilton is a freelance writer.