Mandy Odell, MA, RN, PGDip.
Nurse Consultant in Critical Care, Royal Berkshire and Battle Hospitals NHS Trust, Reading, Berkshire
Sepsis is a complex disease that includes in its continuum systemic inflammatory response syndrome (SIRS), sepsis and severe sepsis. It is the leading cause of severe illness and death in medical and surgical patients in intensive care (Bone, 1997).
While it is often a condition associated with patients in critical care areas, sepsis is seen in patients in all hospital settings and requires a hospital-wide, multidisciplinary approach (Nightingale, 2001). In addition, sepsis and SIRS are conditions that are difficult to recognise.
A national campaign has now been established to improve early detection of sepsis by health professionals.
Sepsis facts and figures
Analyses from the Case
Mix Programme Database provided by the Intensive Care National Audit and Research Centre (ICNARC) reported that ultimate hospital mortality for admissions who met the criteria for severe sepsis within the first 24 hours of admission to ICUs in England, Wales and Northern Ireland was 45% (Padkin et al, 2001). In Scotland, the mortality associated with severe sepsis in the ICU (identified at any point during the ICU stay) was 35% based on Scottish Intensive Care Society Audit Group data (Scottish Intensive Care Society Audit Group, 2002).
The identification and subsequent management of sepsis can be challenging for all health-care professionals. In 1992, in order to more easily define and recognise sepsis, the American College of Chest Physicians/Society of Critical Care Medicine developed a set of descriptive terms that described the disease continuum (Box 1).
Basic observations of respiratory rate, heart rate, blood pressure, consciousness level and urine output can alert the nurse to a deterioration in the patient’s condition. Symptoms such as rising respiratory rate and heart rate, lowering systolic blood pressure, deteriorating consciousness level and diminishing urine output should prompt further review and action. Simple measures such as oxygen and fluid therapy, and review and intervention by more senior and experienced personnel could prevent further deterioration of the patient.
However, even when patient observations are performed and recorded, these warnings can be missed. Lack of supervision of staff, and lack of knowledge can result in a failure to appreciate clinical urgency and failure to seek advice (McQuillan et al, 1998). The response of health professionals to deterioration in a patient’s condition can be delayed (Schein et al, 1990). As a result, care in general wards can be suboptimal, resulting in increased mortality and morbidity among patients (McQuillan et al, 1998).
Although evidence suggests respiratory rate is the most sensitive predictor of impending deterioration (Goldhill, 1999), nurses do not record respiratory rate as frequently as they record pulse and blood pressure. This indicates that front-line staff may be failing to recognise the relevance of specific observations.
Nurses and doctors need to pay attention to basic patient observation, and understand their relevance and inter-relationship. There may be an over-use of electronic aids to detect blood pressure and pulse, and we are sacrificing respiratory rate recording with over-reliance on pulse oximetry. A patient may appear well saturated with oxygen, but the fact that the saturation is being maintained by a rapid respiratory rate, a clear sign that the patient is in trouble, may be overlooked. Additionally, the level of oxygen saturation has no relationship to carbon dioxide levels, and while oxygenation may be acceptable, it may be accompanied by dangerously high CO2.
A new generation of nurses may have lost the skills of patient assessment through touch, and therefore miss the subtle signs of the radial pulse and may be unable to count the respiratory rate effectively.
Promoting early identification
Early-warning systems give staff a framework by which they can establish when patient parameters are outside the accepted range (Morgan et al, 1997). A numerical guide is also useful to detect whether the patient is improving or deteriorating over time. If general ward nurses and doctors recognise and understand the course of sepsis, early detection is possible, support and treatment can be optimised and outcome improved.
The Sepsis Care Initiative (SCI) was instigated early in 2001 with the formation of an editorial advisory board comprising nurse consultants, intensive care staff, anaesthesiologists and haematologists. The aim of the initiative, endorsed by the Intensive Care Society and sponsored by Eli Lilly and Company, was to help develop educational resources that raise awareness of the problems associated with sepsis and ensure that all health-care workers whatever their skills, experience or clinical setting, are able to identify sepsis at an early stage.
Designed as the first in a series, the SCI Resource Kit provides a number of different resource materials to suit a wide range of clinical and educational needs. The kit includes a Powerpoint presentation provided on disc, giving a comprehensive insight into sepsis that can be accessed at a number of different levels of experience and knowledge. Posters and pocket guides are also available. Further additions to the resource are being developed to cover areas such as paediatrics, patient assessment and the surgical patient.
Good supportive care will improve a patient’s chances of survival (Bone, 1997). The main aims are to:
- Control infection
- Restore fluid status
- Ensure adequate oxygen delivery
- Maintain renal function
- Provide nutrition.
A variety of new approaches discussed at the fourth International Conference on Sepsis in the ICU, held in London in June this year, included early goal-directed therapy in the detection and treatment of occult global tissue hypoxia, normalising glycaemia, low-dose steroids, and the use of recombinant human activated protein C (rhAPC).
First, early goal-directed therapy aims to optimise central venous pressure, mean arterial pressure and haematocrit with fluid and red cell transfusion, and inotropes. This therapy, provided at the earliest opportunity, before admission to ICU, can have significant short- and long-term benefits (Rivers et al, 2001).
Second, hyperglycaemia is more common in ICU patients and conventional treatment is to keep glucose below 12mmol/L. Maintaining blood glucose below 6.1mmol/L was found to have a dramatic effect on surgical ICU patients by effectively halving mortality (Van Den Berghe, 2002).
Third, low-dose steroids have been found to reduce mortality in patients with septic shock who have adrenal insufficiency (Annane et al, 2002).
Lastly, recombinant human activated protein C (rhAPC) or drotrecogin alfa (activated) received its license in August 2002, for the treatment of adults with severe sepsis and multiple organ failure and has been shown to reduce mortality by 6.1% in patients with severe sepsis (Bernard et al, 2001).
Critical care initiatives
Changes to the delivery of critical care services, as outlined in the Department of Health Review, Comprehensive Critical Care (DoH, 2000), have sought to improve the management of critically ill patients. New initiatives such as critical care outreach teams have been put in place to support ward staff in this important role (Odell et al, 2002), and education and training courses have been developed with this goal in mind (Smith, 2000).
Sepsis and SIRS are a common and devastating occurrence in patients in all hospital areas. The disease process and host response is complicated, multifactorial and difficult to recognise and manage. Both doctors and nurses would benefit from a multidisciplinary, aggressive approach to the early recognition and treatment of sepsis in order to reduce mortality and morbidity, and to make some impact on the considerable cost to our health-care systems.
Educational aids such as the SCI resource kit and training programmes, coupled with the new initiatives of critical care outreach and early warning systems may contribute to a significant impact on patient outcomes.
- The SCI Resource Kit can be obtained free of charge from Eli Lilly and Company on 01256-315999 (Republic of Ireland: 00-353-1661-4377)
- Nurses can access information for relatives and patients through www. criticalcareinfo.org
- The Intensive Care Society can be contacted on 020-7291 0690 or www.ics.ac.uk
American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Critical Care Medicine 20: 864-874.
Annane, D., Sebille, V., Charpentier, C. et al. (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. Journal of the American Medical Association. 288: 7, 862-871.
Bernard, G.R., Vincent, J.L., Laterre, P.F. et al. (2001) Efficacy and safety of recombinant human activated protein C for sever sepsis. New England Journal of Medicine 344: 10, 759-762.
Bone, R.C. (1997) Managing sepsis: what treatments can we use today? Journal of Critical Illness 12: 1, 15-24.
Department of Health. (2000) Comprehensive Critical Care. London: The Stationery Office.
Goldhill, D.R., White, S.A., Sumner, A., (1999) Physiological values and procedures in the 24 hours before ICU admission from the ward. Anaesthesia 54: 529-534.
McQuillan, P., Pilkington, S., Allan, A. et al. (1998) Confidential enquiry into quality of care before admission to intensive care. British Medical Journal 316: 1853-1858.
Morgan, R.J.M., Williams, F., Wright, M.M. (1997) An early warning scoring system for detecting developing critical illness. Clinical Intensive Care 8: 2, 100.
Nightingale, P. (2001) Sepsis Care Initiative Resource Kit. Maidenhead, Berks: Gardiner-Caldwell Communications.
Odell, M., Forster, A., Rudman, K., Bass, F. (2002) The critical care outreach service and the early warning system on surgical wards. Nursing in Critical Care 7: 3, 132-135.
Padkin, A.J., Goldfrad, C., Young, J.D., Rowan, K. (2001) The prevalence of severe sepsis in the first 24 hours in the ICU, in England, Wales and Northern Ireland. Intensive Care Medicine 27: S458.
Rivers, E., Nguyen, B., Havstad, S. et al. (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine 345: 19, 1368-1377.
Schein, R.M.H., Hazday, N., Pean, M. et al. (1990) Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 98: 1388-1393.
Scottish Internsive Care Society Audit Group (2002) Annual Report. Glasgow: Scottish Intensive Care Society. Also available at www.scottishintensivecare.org.uk
Sepsis Care Initiative. (2001) Sepsis Care Initiative Resource Kit. Maidenhead, Berks: Gardiner-Caldwell Communications.
Smith, G. (2000) ALERT: Acute Life Threatening Events - Recognition and Treatment. Portsmouth: Open Learning Centre. University of Portsmouth.
Van Den Berghe, G. (2002) Beyond diabetes: saving lives with insulin in the ICU. International Journal of Obesity and Related Metabolic Disorders 26: (suppl 3). S3-S8.