Management of Sepsis

Sepsis is defined as the overwhelming response of the human body and life-threatening reaction to a probable or documented infection which results in tissue hypoperfusion and organ dysfunction. Major sepsis had become recently common worldwide. 1 in 4 patients who presents with sepsis is likely to die of septic shock (Dombrovskiy, Martin, Sunderram, & Paz, 2007). The current diagnostic criteria for sepsis are hyperthermia of >38.3°C or hypothermia <36 °C, heart rate of >90 beats per minute, tachypnoea, altered mental status, hyperglycaemia, hypotension Systolic Blood Pressure of <90 mmHg, MAP of <70 mmHg, or a significant change of >40 mmHg in adults (Levy et al., 2003). Severe sepsis on the other hand reflects a massive amount of organ dysfunction such as decreased urine output of < 0.5 ml/kg/hour, poor creatinine clearance >34.2 μmol/L, Lactate levels above normal limits and persistent hypotension.

The current management of sepsis have been divided into initial resuscitation, screening, diagnosis, antibiotic therapy, source control and infection prevention. In managing sepsis, initial resuscitation will deal with physiological needs of patients especially whist in the Emergency Department, the goal is to load fluids to prevent hypotension and continue to monitor oxygen saturations ensure effective tissue perfusion is achieved. The second step is to screen patients as early identification of sepsis means early commencement of treatment that will reduce mortality rate (Levy M, 2010). Following screening for sepsis, a diagnosis needs to be performed. The best method to diagnose sepsis up to date is to collect blood cultures. Blood cultures is the most definitive way to confirm sepsis by identifying responsible pathogens (Weinstein, Reller, Murphy, & Lichtenstein, 1983). Ideally, two or more blood culture is the recommendation as of the current ACI guideline to have a better chance at identifying the causative pathogen. The commencement of treatment begins with the administration of antimicrobial therapy. The clinical excellence commission recommends administration of a broad-spectrum antibiotic within 1 hour of recognition of septic shock. Measurable increase in mortality had been associated to each hour antibiotics therapy has been delayed (Kumar et al., 2006). In the process of treatment, source control shall be empirical as the need to identify the source of the infection will more than likely prevent it from spreading further. An example of this is an infected vascular access device. Removal of an infected device shall stop further development of microbial contamination. In the case of an infected tissue such as necrosis or fasciitis, it is important that a debridement should be done immediately following successful resuscitation. Finally, the need for prevention of infection is equally as important as treating an infection. Some examples are simple hand washing, establishing a precaution when handling bodily fluids and promoting oral hygiene. These are some steps in managing sepsis in the emergency department and identifying them is quite challenging without a full and proper assessment of a patient.

Simulation based strategies:

According to a journal published in Yale University, simulation in healthcare is the most powerful way to facilitate learning and improve patient safety and best outcomes (Zigmont, Kappus, & Sudikoff, 2011). In blooms taxonomy, knowledge is the simplest form of learning, however the learning being able to analyse and synthesise knowledge to be applied is the best way of assessing competence. For instance, multiple choice questions can assess the learner’s competence about a certain topic, however it is limited to test the most basic of knowledge, it cannot test comprehension and analysis of the situation. In the bloom’s taxonomy triangle, when simulation-based learning is used to improve practice, it will allow the learner to put together knowledge and comprehension, apply the understanding towards practice, analyse and reflect from the learner’s point of view on the topic at hand and synthesise learning to change current practice and retain knowledge even longer. The blooms taxonomy’s important point is evaluation which is very crucial to formulating critical thinking. Critical thinking validates clinical studies by judging it’s relevance in patient application and effectiveness of intervention (Adams, 2015).

How simulation-based learning is used:

“In broad, simple terms a simulation is a person, device, or set of conditions which attempts to present evaluation problems authentically” (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005). I strongly believe that high fidelity simulation learning is very important is important in the management of sepsis as it not only allows learners to treat and resuscitate patient presenting with sepsis, rather it would also help identify and recognise patients that are in early onset of sepsis before it is too late. Currently, there are sepsis simulation tools used in healthcare all over the United States of America and solely focused on medical professionals to resuscitate patients who present with severe sepsis. Most of the treatment outcomes recommended are aggressive and invasive including central venous pressure and arterial line blood pressure monitoring whilst in the intensive care unit. This may have already been caused by poor ward management or patients who have presented with sepsis but were not recognised earlier on the presentation. In the department I am currently working at, there is no proper training of how to detect sepsis apart from a simple screening tool provided by the agency for clinical innovation. This screening tool is hardly ever used and mostly fail to recognise and differentiate the patient’s presenting problems.

The simulation should aim to teach all healthcare professionals including but not limited to: physicians, registered and enrolled nurses, lab technicians, assistant in nursing, and pharmacist. Learning should be as realistic as possible and should identify gaps in participant education. The learning space should replicate the relevant care environment and where possible, should be performed in the emergency department. If a setting such as a patient’s room is not achievable, the supplies should be coordinated by the facilitator such that it will depict the actual reality of the availability of the equipment and supplies. The training should be conducted in a classroom setting and will need to discuss the concepts and basics of the sepsis pathology and illness process. This will decrease the instances where the learner will be looking at printed materials and go over the documents hence avoiding frustration and stress. Following the classroom learning, a simulation event should be conducted and scenarios should be ready for the group to react.

Simulation is a very interactive method of teaching and will ensure the participant understands all the concepts and the patient care required in a specific scenario. It will also determine each learners’ actions and rationalise their actions towards each scenario. At the end of the simulation, A debrief and with the facilitator should be conducted and should discuss issues that may arise in each particular scenario. Some examples of issues that may arise will include poor knowledge of the equipment use, poor communication and untimely administration of antibiotics etc.

Types of simulation technology to be used:

The simulated learning may be conducted in a realistic patient care environment such as a simulation lab in the hospital or a spare unused bedspace in the hospital or department. It may use either a mannequin which will be computer controlled or patient-actors that may be given a certain scenario to perform but will only respond to questions when they are asked. Being in a realistic environment, the learners will be treated a true to life environment and use the available equipment and respond with realistic timelines. Ideally each scenario will have supplies and equipment for the use of the learners. The use of mannequins can provide a better learner experience. It is empirical for learners to familiarise themselves with the setting and the availability of the equipment to use. This removes significant worries and reduces the amount of time that the learners will be looking at resources or looking for equipment to use during the scenario and may affect significantly the efficacy of the scenario. The learner should perform each assessment against a mannequin or a real patient actor and “interact” in order to master the skill of assessment and communication. The intention of simulated learning is to ensure the learning does not happen in a passive manner. Simulated learning is only able to create realism to a certain degree, the debriefing at the end of the learning scenario will reinforce realisation and take the learner back to the situation and focus on the action and create a state of reflection. The role of the simulation facilitator is very important in reinforcing knowledge and reflection to be used in clinical practice (Arafeh, Hansen, & Nichols, 2010). Video playback can also help with reflection. Apart from being entertaining, video playback can create perspective to the whole simulation scenario and a good help in going back to the learner actions during the scenario (Arafeh et al., 2010).

Research in simulation studies & evaluate effectiveness in terms of outcomes:

Simulation is a great way of measuring outcomes and identifying dearth in basic knowledge about sepsis and its management. Learners will be highly motivated and very involved in the simulation (Hoberman & Mailick, 1992). According to an article I have read, simulations should be designed (1) to provide instruction on the scenarios, (2) to provide opportunities to assess performance and provide “diagnostic feedback”. (3) a facilitated learning experience (4) the fidelity of the simulated learning is kept towards the task’s goals and objectives. It is then effective and efficient in managing individual performance assessment, promotes safety of patients and reduces human errors (Salas & Burke, 2002). Simulation based learning is the answer to bridge the gap between knowledge and application of concepts. It will measure technical, problem solving and decision-making skills of each participants and will challenge each personalities to work as a team in order to provide an effective and efficient quality patient care with the goal to minimise human errors in the decision making process (Lateef, 2010). The effectiveness of the simulation can be further assessed using a good debriefing technique. There are two types of debriefing techniques. (1) Technical Debrief, (2) Cognitive Debrief. Technical debrief tends to go back into evaluating performance of each team member and usually talk amongst each other and self-correct as a team. With the help of a facilitator, a reflection can identify areas of improvement and further learning opportunities. A cognitive debrief on the other hand is to identify errors and difficulties encountered during the scenarios and is usually reported using a questionnaire or tool to directly measure the participants or learners’ perceptions (Farnik & Pierzchała, 2012). Although there are very little resource and peer-reviewed journals about debriefing there are a few strategies in debriefing being developed and new methods of assessment. In a final note, debriefing is considered the “heart and soul” of the whole simulated learning approach. It is crucial that a well-defined learning objective is made a basis of each scenario and used as a guide to debrief participants. A very good debrief is considered the “ideal reinforcement of current practice.” (Arafeh et al., 2010)

References:

• Adams, N. E. (2015). Bloom’s taxonomy of cognitive learning objectives.
  
  Journal of the Medical Library Association : JMLA, 103
  
  (3), 152-153. doi:10.3163/1536-5050.103.3.010
• Arafeh, J. M. R., Hansen, S. S., & Nichols, A. (2010). Debriefing in Simulated-Based Learning: Facilitating a Reflective Discussion.
  
  The Journal of Perinatal & Neonatal Nursing, 24
  
  (4), 302-309. doi:10.1097/JPN.0b013e3181f6b5ec
• Dombrovskiy, V. Y., Martin, A. A., Sunderram, J., & Paz, H. L. (2007). Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003.
  
  Crit Care Med, 35
  
  (5), 1244-1250. doi:10.1097/01.CCM.0000261890.41311.E9
• Farnik, M., & Pierzchała, W. A. (2012). Instrument development and evaluation for patient-related outcomes assessments.
  
  Patient related outcome measures, 3
  
  , 1-7. doi:10.2147/PROM.S14405
• Hoberman, S., & Mailick, S. (1992).
  
  Experiential management development: From learning to practice
  
  : Quorum Books.
• Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Lee Gordon, D., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.
  
  Med Teach, 27
  
  (1), 10-28. doi:10.1080/01421590500046924
• Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., . . . Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
  
  Crit Care Med, 34
  
  (6), 1589-1596. doi:10.1097/01.CCM.0000217961.75225.E9
• Lateef, F. (2010). Simulation-based learning: Just like the real thing.
  
  Journal of emergencies, trauma, and shock, 3
  
  (4), 348-352. doi:10.4103/0974-2700.70743
• Levy M, D. R., Townsend S,. (2010). The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis.
• Levy, M. M., Fink, M. P., Marshall, J. C., Abraham, E., Angus, D., Cook, D., . . . International Sepsis Definitions, C. (2003). 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.
  
  Intensive Care Med, 38
  
  , 367–374. doi:10.1007/s00134-003-1662-x
• Salas, E., & Burke, C. S. (2002). Simulation for training is effective when.
  
  Qual Saf Health Care, 11
  
  (2), 119-120. doi:10.1136/qhc.11.2.119
• Weinstein, M. P., Reller, L. B., Murphy, J. R., & Lichtenstein, K. A. (1983). The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations.
  
  Rev Infect Dis, 5
  
  (1), 35-53. doi:10.1093/clinids/5.1.35
• Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation.
  
  Semin Perinatol, 35
  
  (2), 47-51. doi:10.1053/j.semperi.2011.01.002

Sepsis is defined as the overwhelming response of the human body and life-threatening reaction to a probable or documented infection which results in tissue hypoperfusion and organ dysfunction. Major sepsis had become recently common worldwide. 1 in 4 patients who presents with sepsis is likely to die of septic shock (Dombrovskiy, Martin, Sunderram, & Paz, 2007). The current diagnostic criteria for sepsis are hyperthermia of >38.3°C or hypothermia <36 °C, heart rate of >90 beats per minute, tachypnoea, altered mental status, hyperglycaemia, hypotension Systolic Blood Pressure of <90 mmHg, MAP of <70 mmHg, or a significant change of >40 mmHg in adults (Levy et al., 2003). Severe sepsis on the other hand reflects a massive amount of organ dysfunction such as decreased urine output of < 0.5 ml/kg/hour, poor creatinine clearance >34.2 μmol/L, Lactate levels above normal limits and persistent hypotension.

The current management of sepsis have been divided into initial resuscitation, screening, diagnosis, antibiotic therapy, source control and infection prevention. In managing sepsis, initial resuscitation will deal with physiological needs of patients especially whist in the Emergency Department, the goal is to load fluids to prevent hypotension and continue to monitor oxygen saturations ensure effective tissue perfusion is achieved. The second step is to screen patients as early identification of sepsis means early commencement of treatment that will reduce mortality rate (Levy M, 2010). Following screening for sepsis, a diagnosis needs to be performed. The best method to diagnose sepsis up to date is to collect blood cultures. Blood cultures is the most definitive way to confirm sepsis by identifying responsible pathogens (Weinstein, Reller, Murphy, & Lichtenstein, 1983). Ideally, two or more blood culture is the recommendation as of the current ACI guideline to have a better chance at identifying the causative pathogen. The commencement of treatment begins with the administration of antimicrobial therapy. The clinical excellence commission recommends administration of a broad-spectrum antibiotic within 1 hour of recognition of septic shock. Measurable increase in mortality had been associated to each hour antibiotics therapy has been delayed (Kumar et al., 2006). In the process of treatment, source control shall be empirical as the need to identify the source of the infection will more than likely prevent it from spreading further. An example of this is an infected vascular access device. Removal of an infected device shall stop further development of microbial contamination. In the case of an infected tissue such as necrosis or fasciitis, it is important that a debridement should be done immediately following successful resuscitation. Finally, the need for prevention of infection is equally as important as treating an infection. Some examples are simple hand washing, establishing a precaution when handling bodily fluids and promoting oral hygiene. These are some steps in managing sepsis in the emergency department and identifying them is quite challenging without a full and proper assessment of a patient.

Simulation based strategies:

According to a journal published in Yale University, simulation in healthcare is the most powerful way to facilitate learning and improve patient safety and best outcomes (Zigmont, Kappus, & Sudikoff, 2011). In blooms taxonomy, knowledge is the simplest form of learning, however the learning being able to analyse and synthesise knowledge to be applied is the best way of assessing competence. For instance, multiple choice questions can assess the learner’s competence about a certain topic, however it is limited to test the most basic of knowledge, it cannot test comprehension and analysis of the situation. In the bloom’s taxonomy triangle, when simulation-based learning is used to improve practice, it will allow the learner to put together knowledge and comprehension, apply the understanding towards practice, analyse and reflect from the learner’s point of view on the topic at hand and synthesise learning to change current practice and retain knowledge even longer. The blooms taxonomy’s important point is evaluation which is very crucial to formulating critical thinking. Critical thinking validates clinical studies by judging it’s relevance in patient application and effectiveness of intervention (Adams, 2015).

How simulation-based learning is used:

“In broad, simple terms a simulation is a person, device, or set of conditions which attempts to present evaluation problems authentically” (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005). I strongly believe that high fidelity simulation learning is very important is important in the management of sepsis as it not only allows learners to treat and resuscitate patient presenting with sepsis, rather it would also help identify and recognise patients that are in early onset of sepsis before it is too late. Currently, there are sepsis simulation tools used in healthcare all over the United States of America and solely focused on medical professionals to resuscitate patients who present with severe sepsis. Most of the treatment outcomes recommended are aggressive and invasive including central venous pressure and arterial line blood pressure monitoring whilst in the intensive care unit. This may have already been caused by poor ward management or patients who have presented with sepsis but were not recognised earlier on the presentation. In the department I am currently working at, there is no proper training of how to detect sepsis apart from a simple screening tool provided by the agency for clinical innovation. This screening tool is hardly ever used and mostly fail to recognise and differentiate the patient’s presenting problems.

The simulation should aim to teach all healthcare professionals including but not limited to: physicians, registered and enrolled nurses, lab technicians, assistant in nursing, and pharmacist. Learning should be as realistic as possible and should identify gaps in participant education. The learning space should replicate the relevant care environment and where possible, should be performed in the emergency department. If a setting such as a patient’s room is not achievable, the supplies should be coordinated by the facilitator such that it will depict the actual reality of the availability of the equipment and supplies. The training should be conducted in a classroom setting and will need to discuss the concepts and basics of the sepsis pathology and illness process. This will decrease the instances where the learner will be looking at printed materials and go over the documents hence avoiding frustration and stress. Following the classroom learning, a simulation event should be conducted and scenarios should be ready for the group to react.

Simulation is a very interactive method of teaching and will ensure the participant understands all the concepts and the patient care required in a specific scenario. It will also determine each learners’ actions and rationalise their actions towards each scenario. At the end of the simulation, A debrief and with the facilitator should be conducted and should discuss issues that may arise in each particular scenario. Some examples of issues that may arise will include poor knowledge of the equipment use, poor communication and untimely administration of antibiotics etc.

Types of simulation technology to be used:

The simulated learning may be conducted in a realistic patient care environment such as a simulation lab in the hospital or a spare unused bedspace in the hospital or department. It may use either a mannequin which will be computer controlled or patient-actors that may be given a certain scenario to perform but will only respond to questions when they are asked. Being in a realistic environment, the learners will be treated a true to life environment and use the available equipment and respond with realistic timelines. Ideally each scenario will have supplies and equipment for the use of the learners. The use of mannequins can provide a better learner experience. It is empirical for learners to familiarise themselves with the setting and the availability of the equipment to use. This removes significant worries and reduces the amount of time that the learners will be looking at resources or looking for equipment to use during the scenario and may affect significantly the efficacy of the scenario. The learner should perform each assessment against a mannequin or a real patient actor and “interact” in order to master the skill of assessment and communication. The intention of simulated learning is to ensure the learning does not happen in a passive manner. Simulated learning is only able to create realism to a certain degree, the debriefing at the end of the learning scenario will reinforce realisation and take the learner back to the situation and focus on the action and create a state of reflection. The role of the simulation facilitator is very important in reinforcing knowledge and reflection to be used in clinical practice (Arafeh, Hansen, & Nichols, 2010). Video playback can also help with reflection. Apart from being entertaining, video playback can create perspective to the whole simulation scenario and a good help in going back to the learner actions during the scenario (Arafeh et al., 2010).

Research in simulation studies & evaluate effectiveness in terms of outcomes:

Simulation is a great way of measuring outcomes and identifying dearth in basic knowledge about sepsis and its management. Learners will be highly motivated and very involved in the simulation (Hoberman & Mailick, 1992). According to an article I have read, simulations should be designed (1) to provide instruction on the scenarios, (2) to provide opportunities to assess performance and provide “diagnostic feedback”. (3) a facilitated learning experience (4) the fidelity of the simulated learning is kept towards the task’s goals and objectives. It is then effective and efficient in managing individual performance assessment, promotes safety of patients and reduces human errors (Salas & Burke, 2002). Simulation based learning is the answer to bridge the gap between knowledge and application of concepts. It will measure technical, problem solving and decision-making skills of each participants and will challenge each personalities to work as a team in order to provide an effective and efficient quality patient care with the goal to minimise human errors in the decision making process (Lateef, 2010). The effectiveness of the simulation can be further assessed using a good debriefing technique. There are two types of debriefing techniques. (1) Technical Debrief, (2) Cognitive Debrief. Technical debrief tends to go back into evaluating performance of each team member and usually talk amongst each other and self-correct as a team. With the help of a facilitator, a reflection can identify areas of improvement and further learning opportunities. A cognitive debrief on the other hand is to identify errors and difficulties encountered during the scenarios and is usually reported using a questionnaire or tool to directly measure the participants or learners’ perceptions (Farnik & Pierzchała, 2012). Although there are very little resource and peer-reviewed journals about debriefing there are a few strategies in debriefing being developed and new methods of assessment. In a final note, debriefing is considered the “heart and soul” of the whole simulated learning approach. It is crucial that a well-defined learning objective is made a basis of each scenario and used as a guide to debrief participants. A very good debrief is considered the “ideal reinforcement of current practice.” (Arafeh et al., 2010)

References:

• Adams, N. E. (2015). Bloom’s taxonomy of cognitive learning objectives.
  
  Journal of the Medical Library Association : JMLA, 103
  
  (3), 152-153. doi:10.3163/1536-5050.103.3.010
• Arafeh, J. M. R., Hansen, S. S., & Nichols, A. (2010). Debriefing in Simulated-Based Learning: Facilitating a Reflective Discussion.
  
  The Journal of Perinatal & Neonatal Nursing, 24
  
  (4), 302-309. doi:10.1097/JPN.0b013e3181f6b5ec
• Dombrovskiy, V. Y., Martin, A. A., Sunderram, J., & Paz, H. L. (2007). Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003.
  
  Crit Care Med, 35
  
  (5), 1244-1250. doi:10.1097/01.CCM.0000261890.41311.E9
• Farnik, M., & Pierzchała, W. A. (2012). Instrument development and evaluation for patient-related outcomes assessments.
  
  Patient related outcome measures, 3
  
  , 1-7. doi:10.2147/PROM.S14405
• Hoberman, S., & Mailick, S. (1992).
  
  Experiential management development: From learning to practice
  
  : Quorum Books.
• Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Lee Gordon, D., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.
  
  Med Teach, 27
  
  (1), 10-28. doi:10.1080/01421590500046924
• Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., . . . Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
  
  Crit Care Med, 34
  
  (6), 1589-1596. doi:10.1097/01.CCM.0000217961.75225.E9
• Lateef, F. (2010). Simulation-based learning: Just like the real thing.
  
  Journal of emergencies, trauma, and shock, 3
  
  (4), 348-352. doi:10.4103/0974-2700.70743
• Levy M, D. R., Townsend S,. (2010). The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis.
• Levy, M. M., Fink, M. P., Marshall, J. C., Abraham, E., Angus, D., Cook, D., . . . International Sepsis Definitions, C. (2003). 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.
  
  Intensive Care Med, 38
  
  , 367–374. doi:10.1007/s00134-003-1662-x
• Salas, E., & Burke, C. S. (2002). Simulation for training is effective when.
  
  Qual Saf Health Care, 11
  
  (2), 119-120. doi:10.1136/qhc.11.2.119
• Weinstein, M. P., Reller, L. B., Murphy, J. R., & Lichtenstein, K. A. (1983). The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations.
  
  Rev Infect Dis, 5
  
  (1), 35-53. doi:10.1093/clinids/5.1.35
• Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation.
  
  Semin Perinatol, 35
  
  (2), 47-51. doi:10.1053/j.semperi.2011.01.002