As many of you know, I am a practicing acute care/critical care nurse practitioner in a hospital in the Philadelphia area. Recently I was called to a rapid response on a medical floor. The patient was an elderly gentleman who was admitted for a urinary tract infection the day prior and now had a temperature of 103° F, a systolic blood pressure of 80/50 mm Hg (normally 130/72), a respiratory rate of 26/min and has gone from being awake, alert and oriented to being lethargic. This scene plays out every day in our healthcare system; so how did the nurse know to call for the rapid response team to come evaluate the patient? She used the qSOFA (Quick Sequential Organ Failure Assessment) tool which identifies patients who are at risk for a poor outcome. Based on the nurse’s quick, critical thinking, the patient was evaluated and the diagnosis was changed to septic shock secondary to a urinary tract infection and he was transferred to the critical care unit for management and he survived. The nurse was the hero in this situation because she recognized this patient was in septic shock.
Sepsis, learning from the past
Sepsis is thought to occur in 750,000 people in the U.S. each year and it’s one of the leading causes of mortality and critical illness worldwide (Angus, 2013; Dieter-Lessnau, 2015). Sepsis is not a new diagnosis but, the guidelines on how to best recognize and manage it have been refined over the years as we learn more about this devastating diagnosis. In 2016, the definition of sepsis was changed to better reflect new knowledge on the pathophysiology of sepsis. For years, we have used the Systematic Inflammatory Response Syndrome (SIRS) criteria to identify patients with sepsis; however, new research has determined that the SIRS criteria was unhelpful because a SIRS response occurs with many other conditions and does not indicate dysregulation as once thought (Singer, et al., 2016; Rhodes, et al., 2017).
A new sepsis definition
As a result, a new definition of sepsis was established and was described in The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3)
in 2016 (Singer, et al., 2016). In 2017, The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock
were published (Rhodes, et al., 2017). Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer, et al., 2016; Rhodes, et al., 2017). Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality (Singer, et al., 2016; Rhodes, et al., 2017). The term ‘severe sepsis’ has been eliminated from the definitions.
Early recognition is key
We know that early recognition of a patient with sepsis and septic shock is the first step in sepsis management. What tools are available to nurses to identify a patient who is likely to have a poor outcome due to organ dysfunction potentially related to sepsis? New definitions and guidelines have identified two tools that can be used by healthcare professionals to help identify a patient at risk for poor outcomes.
The qSOFA tool is a resource to be used outside of a critical care unit, such as in the emergency department or a medical/surgical unit, or primary care/urgent care, to identify these types of patients.
The qSOFA tool looks at 3 variables:
- Respiratory rate greater than or equal to 22/min
- Altered mentation
- Systolic blood pressure less than or equal to 100 mm Hg (Singer, et al., 2016; Rhodes, et al., 2017).
The SOFA tool is used with critical care patients to identify a higher risk of patient mortality. Any change in 2 points or greater is equal to a higher risk of mortality. The variables evaluated in the SOFA tool are:
Post-Sepsis Syndrome Reality
- Liver function
- Cardiovascular system
- Central nervous system
- Renal system
Patients who live through an experience of sepsis often have post-sepsis syndrome and exhibit long-term physical, psychological, and cognitive disabilities which result in health and social implications (Iwashyna, 2010). It is imperative that nurses recognize this syndrome and educate their patients and their families and other members of the support network, about this condition.
Nurses, you are an integral part of the interdisciplinary team
Without a doubt, nurses are key in sepsis early recognition, management and education because you are with the patient 24 hours a day. Having access to the latest evidence-based clinical practice guidelines and using them for clinical decision support is crucial to improving patient outcomes. Sepsis Alliance
has an assortment of valuable resources for healthcare professionals and patients on sepsis. Wolters Kluwer is proud to partner with Sepsis Alliance to improve knowledge on this devastating, but preventable, condition.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Angus, D. C. (2013). Severe sepsis and septic shock. New England Journal of Medicine, 840-851.
Dieter-Lessnau, K. (2015, Oct. 8). Distributive shock. Retrieved July 20, 2016 from Medscape: http://emedicine.Medscape.com/article/168689-overview#a3
Iwashyna, T., et al. (2010). Long-term cognitive impairment and functional disability among survivors of sepsis. JAMA,304(16):1787-1794.
Rhodes, M.B., Evans, L.E., Alhazzani, W., et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M., Deutschman, C.S., Seymour C.W., et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).