Poor knowledge can result in a missed or delayed diagnosis of septic shock or severe sepsis, as well as inappropriate or delayed patient management
Kirsty Lovick, BSc, is senior staff nurse at emergency assessment and discharge unit, James Paget University Hospital, Gorleston, Great Yarmouth.
Lovick K (2009) Improving nurses’ knowledge and awareness of sepsis to ensure better identification and patient management. Nursing Times; 105: 47, early online publication.
This one part unit explains why it is important to recognise the signs and symptoms of sepsis and the action to take if patients become septic.
Keywords: Sepsis, Nursing management, Resuscitation
- This article has been double blind peer-reviewed
1. Understand and differentiate between sepsis, severe sepsis and septic shock.
2. Identify the initial treatment required in managing septic patients.
In general the management of patients has become more complex as they are now older, sicker and more dependent and this places increased pressure on healthcare staff (Smith, 2003). Evidence suggests that nurses’ knowledge about the signs of acute illness and their response to these signs are poor (Robson et al, 2007). Gaps in knowledge can result in a missed or delayed diagnosis of septic shock or severe sepsis and lead to inappropriate or delayed management; prompt treatment is crucial to survival. There is evidence that up to 50% of patients admitted to intensive care units received suboptimal care before referral because of a failure to identify signs of deterioration and lack of skills in responding to acute deterioration (National Patient Safety Agency, 2007).
Doctors also appear to have poor knowledge. Poeze et al (2004) interviewed 1,058 doctors and found that only 17% agreed on a definition of sepsis, but 83% agreed it was frequently missed.
Lack of clarity about the definition of sepsis may contribute to the delay in diagnosis and early treatment and increase the risk of patient deterioration and mortality (Ziglam et al, 2006).
It is estimated that patients with sepsis take up 45% of intensive care bed days and 33% of hospital bed days in the UK (Padkin et al, 2003). Forty per cent of intensive care budgets are spent managing sepsis and the average cost of treating a patient admitted to hospital is £10,000 (Dellinger et al, 2004).
Nurses have a key role in identifying patients with sepsis or septic shock and providing appropriate treatment. They need knowledge about sepsis and nursing guidelines that provide a format for systematic assessment and management.
Surviving Sepsis Campaign
Worldwide, sepsis kills more people than lung cancer, and more people than bowel and breast cancer combined and the incidence is rising at a rate of 1.5% per year (Daniels, 2009). Concern about these figures led to the launch of an international campaign in 2004 to improve survival - The Surviving Sepsis Campaign. Although now officially concluded, the campaign demonstrated it is possible to change clinical practice and improve patient outcomes using evidence based guidelines.
The campaign’s main aims were to improve the management, diagnosis and treatment of sepsis. These aims were met by:
- Increasing awareness, understanding and knowledge;
- Changing perceptions and behaviour;
- Influencing public policy;
- Defining standards of care (Dellinger et al, 2004).
The campaign concluded that the greatest improvement to patient outcomes had been made through education and changing the process of care for patients with sepsis.
Sepsis typically starts with the systemic inflammatory response syndrome. This is the cascade of inflammatory events that are part of the body’s response to an insult in an attempt to maintain homeostasis (Lever and Mackenzie, 2007). Systemic inflammatory response syndrome (SIRS) is defined by the presence of two or more of the following symptoms:
- Temperature >38ºC or <36ºC;
- Heart rate >90 beats per minute;
- Respiratory rate >20 breaths per minute;
- White blood count >12,000 or <4,000 per ml (Levy et al, 2003).
Sepsis is defined as a known or suspected infection accompanied by evidence of two or more of the SIRS criteria (Robson and Daniels, 2008). It is a continuum, from a simple uncomplicated infection to severe sepsis. (Fig 1).
Changes in patients’ condition can be subtle and early indicators of sepsis can be missed. Careful and frequent assessment is the key to spotting deterioration. Respiratory rate is considered to be one of the most sensitive indicators of critical illness, yet it is a vital sign that is often neglected (Stevenson, 2004).
Severe sepsis is the presence of sepsis with organ dysfunction, hypotension or poor perfusion (Peel, 2008). All organs including the cardiovascular system, lungs, liver, kidneys and brain can be affected. Signs include:
- Hypotension: a systolic blood pressure of <90mmHg or a mean arterial pressure of <60mmHg. Changes in blood pressure may be a late indicator of deterioration as the body has compensatory mechanisms to maintain it. Fluid resuscitation must be given with the aim of improving blood pressure and cardiac output (Dellinger et al, 2004);
- Altered mental state: the AVPU system can be used to rapidly assess patients’ neurological status (A – alert; V – voice; P – pain; U - unresponsive) or the Glasgow Coma Score (GCS). Consciousness levels may be decreased due to hypoxaemia, hypoglycaemia or cerebral hypoperfusion due to shock or medications such as sedatives or analgesics;
- Hyperglycaemia in the absence of diabetes. This results from the metabolic and hormonal changes that are part of the stress response (Ruffel, 2004). It occurs in critically ill patients and insulin treatment may be required to maintain normoglycaemia;
- Hypoxaemia: oxygen saturations <93% or PaO2 <9kPa on an arterial blood gas analysis. Pulse oximetry must only be used as a guide, as the saturation recording may not be a true reflection of gaseous activity. British Thoracic Society (2008) guidelines recommended that arterial blood gases should be checked in all critically ill patients;
- Acute oliguria: urine output of <0.5ml/kg/hr. Poor urine output is an early sign that a patient’s condition may be deteriorating. Urine output is a sensitive measure of blood flow to the kidneys and other organs. It is essential that patients have an adequate circulating blood volume; the presence of hypotension, tachycardia and cool peripheries may indicate that extra fluid is required (Smith, 2003);
- Coagulopathy: INR >1.5 or platelets <100.
The combination of hypotension, slow blood flow, hypoxaemia and metabolic acidosis will interfere with normal clotting mechanisms. Microthrombi form in small vessels interfering with blood flow to the tissues and the organs, which combined with hypotension and hypovolaemia can cause organ failure (Robson and Newell, 2005);
- Raised serum lactate: >2mmol/L. A raised lactate is a sign of severe sepsis and indicates that tissues are not receiving enough oxygen and have to rely on anaerobic metabolism, producing lactic acid.
Septic shock is defined as severe sepsis with hypotension that does not respond to intravenous fluid resuscitation of 500ml-2,000ml given rapidly (Dellinger et al, 2004). Hypotension is not always a reliable indicator of shock, as some patients may maintain a systolic blood pressure above 90mmHg, so further signs and symptoms need to be considered before a diagnosis of septic shock can be made. These include:
- A positive fluid balance;
- An unexplained metabolic acidosis;
· Decreased capillary refill time >2 seconds (Lever and Mackenzie, 2007). This indicates poor perfusion.
Early identification of signs and symptoms
Research shows that early identification and treatment within the “golden hour” is the key to reducing mortality (Dellinger et al, 2004). The first six hours after diagnosis present a small window of opportunity in which to reverse tissue hypoxia and prevent established organ failure. The Surviving Sepsis Campaign produced a six hour resuscitation bundle (Dellinger et al, 2004) and aspects of patient care that can be achieved at ward level are known as the “sepsis six” (Box 1).
Box 1. Sepsis six
- Give high flow oxygen
- Take blood cultures
- Give IV antibiotics
- Give IV fluid
- Measure lactate and haemoglobin
- Insert urinary catheter and monitor urine output hourly
By increasing knowledge and awareness of sepsis, nurses are in an ideal position to ensure patients are reviewed, thereby preventing deterioration into severe sepsis or septic shock. For every hour’s delay in beginning treatment, a patient’s risk of death increases by 7.6% (Kumar et al, 2006).
The process of increasing awareness of sepsis needs to be carried out with a proactive, multidisciplinary approach. Educational programmes have the potential to increase awareness as well as identifying advocates, such as link nurses, to champion sepsis awareness.
The critical care outreach team have a pivotal role in supporting nurses to identify and manage sepsis, and in facilitating escalation of care (Carter, 2007).
By developing and using a sepsis screening tool (Fig 2), nurses can use patient observations to identify whether patients have sepsis, severe sepsis or septic shock. Using the “sepsis six” (Box 2) will empower nurses to take action and ensure patients are promptly reviewed and management is initiated.
Introducing the concepts of sepsis pathophysiology and treatment using an evidence based approach increases awareness of sepsis, leading to reductions in mortality, length of stay and cost. It also creates a sense of responsibility so that the problem is addressed through early identification and treatment.
Increasing nurses’ knowledge and awareness of sepsis will help to improve recognition and prompt aggressive management, ensuring that patients are given the best possible chance of survival.
For the Portfolio Pages corresponding to this unit see the document above.
Portfolio Pages contain activities that correspond to the learning objectives in the unit. They are presented in a convenient format for you to print out or work through on screen and can be filed in your professional portfolio as evidence of your learning and professional development.
Click here for more Guided learning units.
British Thoracic Society (2008) Emergency Oxygen Use in Adult Patients. London: BTS.
Carter C (2007) Implementing the severe sepsis care bundles outside the ICU by outreach. Nursing in Critical Care; 12: 5, 225-230.
Daniels R (2009) Defining sepsis, severe sepsis and septic shock.
Dellinger RP et al (2004) Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Critical Care Medicine; 32: 3, 858-873.
Kumar A et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine; 34, 1589-1596.
Lever A, Mackenzie I (2007) Sepsis: definition, epidemiology and diagnosis. British Medical Journal; 335: 879-883.
Levy M et al (2003) International sepsis definitions conference. Critical Care Medicine; 31, 1250-1256.
National Patient Safety Agency (2007) Recognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients. London: NPSA.
Padkin A et al (2003) Epidemiology of severe sepsis occurring in the first 24 hours in intensive care units in England, Wales and Northern Ireland. Critical Care Medicine; 31: 2332-2338.
Peel M (2008) Care bundles: resuscitation of patients with severe sepsis. Nursing Standard; 23: 11, 41-46.
Poeze M et al (2004) An international sepsis survey: a study of doctors’ knowledge and perception about sepsis. Critical Care; 8: 6, 409-413.
Robson W, Daniels R (2008) The sepsis six: helping patients to survive sepsis. British Journal of Nursing; 17: 1, 16-21.
Robson W et al (2007) An audit of ward nurses’ knowledge of sepsis. Nursing in Critical Care; 12: 2, 86-92.
Robson W, Newell J (2005) Assessing, treating and managing patients with sepsis. Nursing Standard; 19: 50, 56-64.
Ruffel AJ (2004) Sepsis strategies: an ICU package? Nursing in Critical Care; 9: 6, 257-263.
Smith G (2003) ALERT Acute Life-Threatening Events Recognition and Treatment (2nd ed). Portsmouth: University of Portsmouth.
Stevenson T (2004) Achieving best practice in routine observation of hospital patients. Nursing Times; 100: 30, 34-35.
Ziglam H et al (2006) Knowledge about sepsis among training-grade doctors. Journal of Antimicrobial Chemotherapy; 57: 5, 963-965.