Triage Tool for Sepsis Recognition

“Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.  Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year.  Early identification and appropriate management in the initial hours after sepsis develops improves outcomes,” (Rhodes, et al., 2017). According to the National Institute of Health Statistics, more than a million Americans develop

severe sepsis every year

.  Between 28 and 50 percent of these people die.  This high mortality rate creates a clinical problem and generates interest in

improving the care of septic patients

.

The systemic inflammatory response syndrome (SIRS) criteria served
as the original definition of sepsis. 
SIRS definition contains two or more of the following: temperature
greater than 38 degrees Celsius or less than 36 degrees Celsius, heart rate
greater than 90 beats per minute, respiratory rate greater than 20 breaths per
minutes or PaCO2 less than 32mmHg, and white blood cell count greater than
12,000/mm

³

or less than 4,000/mm

³

or greater than 10%
immature bands.  Another tool to identify
organ dysfunction is the quick Sequential Organ Failure Assessment (qSOFA). Two
points is a positive qSOFA, with increasing points patient outcomes are
associated with higher mortality rates (Bhattacharjee, Edelson, & Churpek,
2017). Quick Sequential Organ Failure Assessment (qSOFA) criteria contains:
respiratory rate greater than or equal to 22 breaths per minutes, altered
mentation, and systolic blood pressure less than 100mmHg. These two, SIRS and
qSOFA, are sepsis recognition tools.

Emergency departments play a vital role in identifying,
treating, and managing septic patients. 
The problem with SIRS criteria as a screening tool for sepsis is
patients presenting to an emergency department do not have these laboratory
tests, white blood cell and PaCO2, drawn hours prior to arrival.  This is one component that cannot be
incorporated into a triage screening tool but updated throughout the stay in an
emergency department.  Unless two other
vital signs are abnormal there is potential to fail at recognizing a septic
patient initially presenting to an emergency department.  Similarly, the qSOFA criteria has shown high
specificity to sepsis and poorer outcomes (Bhattacharjee, Edelson, &
Churpek, 2017).

Sepsis recognition is not enough to decrease risk of
mortality in septic patients. Kumar, et al. (2006) discovered an association
between effective antimicrobial administration within the first hour of
documented hypotension increased survival in adults with septic shock. The 2016
International Sepsis Guidelines strongly recommends administration of IV
antimicrobials initiation within one hour of sepsis recognition. The best way
to improve patient outcomes for septic patients is to identify those with
sepsis. The second way is to manage the septic patient, which includes
initiation of antibiotics. To assess this clinical problem, the PICO question
formulated is, in adult septic
patients, how does a sepsis triage screening tool based on qSOFA, compared to
the current 2+SIRS criteria, affect door to antibiotic time?

Methods

An electronic literature search was conducted using the
CINAHL database. The search included 4 keywords: sepsis, antibiotic
administration, SIRS, and qSOFA. All searches conducted were restricted to
adults, 2010-2017-time frame, and articles in English. My first search resulted
in 3,527 articles. A focus on articles that used SIRS or qSOFA for
identification took priority. These terms, SIRS and qSOFA, were searched title
specific.  This resulted in a final 289
articles. A secondary electronic literature search with the keyword of ‘nursing
intervention and sepsis’ showed a few hundred articles. The research question
was assessed using four journal articles that were peer reviewed. The
independent variables were qSOFA and SIRS.

Summary of Evidence

Tromp, Hulscher, Bleeker-Rovers et al. (2010) researched the effects of a nurse driven implementation of a sepsis protocol care bundle. A prospective before and after intervention study at an emergency department of a university hospital in the Netherlands was conducted using three different five month increments. Period 1, July 1, 2006 – November 6, 2006, occurred before introducing the new care bundle based sepsis protocol. Period 2, November 6, 2006 – June 25, 2007, occurred after the sepsis protocol was put into place and before training. Period 3, June 25, 2007 – October 1, 2007, was after training and performance feedback. The sepsis care bundle consisted of seven elements. Six elements were required, the seventh was not required unless the patient was hypotensive or had an elevated serum lactate. The bundle included: measuring serum lactate concentration within six hours, obtaining two blood cultures before starting antibiotics, taking a chest radiograph, taking a urine sample for urinalysis and culture, starting antibiotics within three hours, hospitalize or discharge the patient within three hours, and volume resuscitation for serum lactate >4.0mmol/L or hypotension. The researchers used 2+ SIRS criteria to identify septic patients entering the emergency department. The sample size included 825 people, 16 years of age or older (Tromp, Hulscher, Bleeker-Rovers et al., 2010).

The findings showed that implementing a nurse-driven
sepsis care bundle provided an increase in early recognition of sepsis in
patients presenting to the emergency department. Additionally, when staff received
education and training on this intervention, compliance to the bundle improved
early recognition and treatment of patients with sepsis. Compliance to the
complete sepsis care bundle increased from 3.5% to 12.4%. This study measured antibiotics
started within three hours after staff training. Antibiotic administration
increased from which increased from 38% to 56%. These results are statistically
and clinically significant. Evidence exists that delay in care for septic
patients leads to worse outcomes (Bhattacharjee, Edelson, & Churpek, 2017).
This intervention study provides level IV (Melnyk & Fineout-Overhold, 2015)
evidence for an increased compliance to implementing a sepsis care bundle after
training. Some limitations to the study include that is was an uncontrolled study
at a single center and only one year in length. Having a broader understanding
of this disease across multiple countries and over extended periods of time
would improve the validity of the results. Strengths of this study include the
large sample size, nurse driven implementation, and SIRS criteria for sepsis
screening. Another strength is that this study, like other studies, reveal
education improves sepsis recognition and sepsis care. From this study, it can
be determined that the training and implementation of a sepsis care bundle
increases sepsis recognition and improves adherence to the bundle, improving
patient outcomes.

Yousefi, Nahidian, and Sabouhi (2012) conducted a study
to review the effects of an educational program about sepsis care of intensive
care unit (ICU) nurses.  This study was a
quasi-experimental interventional study with two groups over three time
periods: before, immediately after, and three weeks after.  Nurses with a bachelor’s degree or higher
level of education and one year ICU experience were included in the study.
Infection control committee or members that participated in a similar study
were excluded.  The sample size included thirty-two
nurses randomly enrolled into each of the test and control groups.  The data collection tool was a four-part
questionnaire to measure knowledge, attitude, and practice of ICU nurses.  The results obtained earn Level III evidence
(Melnyk & Fineout-Overholt, 2015).

The findings revealed there was no significant
difference between the control (c) and test (t) groups in terms of age, sex,
education, experience, and employment status. Mean scores of knowledge (t=62.5,
c=63.7), attitude (t=73, c=72.8), and practice (t=81.8, c=82.2) of ICU nurses
in the test and control groups had no significant difference before the
intervention. In the test group, attitude (t=79.7, c=73.3) and practice
(t=90.5, c=82.2) increased immediately after and attitude (t=83.3, c=73.2) continued
to trend up at the three weeks later mark. Education was found to be effective and
have a positive impact on attitude, knowledge, and practice on sepsis care of
ICU nurses, like other studies. The
study did have some limitations which included the ability of the nurses to
utilize books, media, and articles on the subject which could influence the
study.  This study is limited due
to the small sample size.  A larger
sample size in various departments and facilities would strengthen the evidence
and improve clinical significance. One important thing to consider with this
article is that the nurses observed were bachelor’s degree nurses.  Associate degree nurses are the majority of
the nursing workforce.  This could be a
weakness for the article in that they fail to capture the majority education of
nurses. The strength of this study
provides evidence supporting training statistically improved levels of attitude,
knowledge, and practice of ICU nurses in sepsis care.  Findings of this article are like
other studies.

Tarrant, O’Donnell, Martin, Bion, Hunter, & Rooney
(2016), conducted a qualitative design-grounded theory study using focused
ethnography to gain an understanding of the barriers to implementing the sepsis
six bundle components within an hour of recognition of sepsis.  Data collection occurred through various ways
including: over three hundred hours of observations, 43 staff members
interviewed, and shadowing multiple units and staff members across six pilot
hospitals in Scotland from March 2013 – May 2014. The results of this study
provide Level VI evidence (Melnyk, & Fineout-Overholt, 2015).

The main findings include that the Sepsis Six clinical bundle is not
six simple tasks but a series of complex processes. Gaining a better
understanding of the problems of interruptions and operational failures that
get in the way of task completion is ideal to improve compliance for Sepsis Six
within one hour. The researchers suggest focusing on individual behavior change
to improve compliance to Sepsis Six with a combination of reducing barriers and
challenges in the everyday workflow that are responsible for the delays in
Sepsis Six. The research hypothesizes that there would be greater compliance to
Sepsis Six within one hour window if the everyday barriers and challenges were
reduced. This study is limited to one country, Scotland.  Additionally, the length of study could have
missed problems and barriers associated with night shift.  Night shift tends to run with fewer resources
and less access to providers. Night shift is also associated with less
experience providers. These barriers need to be assessed to gain a better
understanding of delays in compliance to sepsis six bundle.  The strengths of this study lie in the
qualitative perspective to gain a better understanding of barriers to
implementing sepsis six bundle. The study highlights that a focus on education
and knowledge of sepsis is not enough, and emphasize the importance to reducing
barriers to promote ultimate compliance.

Gunn, Haigh, and
Thomson (2016) conducted a retrospective study, over a six-month period, on
patients presenting to the ED who had a sepsis six form completed.  The emergency department currently uses SIRS
criteria to identify septic patients. 
The purpose of the study was to determine if qSOFA would reliably
identify septic patients within the emergency department population.  The sample size was two hundred patients with
sepsis diagnosis.  One hundred and ninety-five
were positive for SIRS.  Twenty-nine were
positive for qSOFA. SIRS and qSOFA were compared to determine specificity and
sensitivity to identifying septic patients. This article is rated Level IV
evidence (Melnyk & Fineout-Overhold, 2015).

SIRS
had a higher sensitivity at 97%, and a 2.4% specificity. qSOFA showed a 90%
specificity and a 48% sensitivity.  SIRS
was reliable in identifying sepsis and qSOFA was reliable with detecting those
required higher levels of care and mortality. These finding show clinical and
statistical significance.  The
researchers conclude that SIRS criteria serves as a useful triage tool in
identifying septic patients.  The
researchers further conclude that once positive SIRS criteria is established
qSOFA should be conducted to assess severity and critical care need. Limitations
of this study include the sample size, location, and length of time where the
study took place.   Increasing the sample size over a longer period of time to gain a
broader population would increase the strength of this article.  This study would be strengthened if an
observation of a larger sample size took place, over a longer period, and over
multiple facilities.  The strength of
this study is the results that provide evidence for SIRS criteria as the better
septic recognition tool.  The results
indicate SIRS is best at identifying sepsis. 
These results are statistically and clinically important.  If qSOFA was used
instead of SIRS, many people would not have been included in a sepsis workup
and could potentially have worse outcomes due to delay in recognition and
sepsis care.  From this article, keeping
SIRS criteria is vital for sepsis recognition. 
However, including a qSOFA could benefit those critically ill in
identifying those at higher risk for worse outcomes.

Raith
et. al (2017) published a retrospective cohort analysis study on the prognostic
accuracy of the SOFA score, SIRS criteria, and a qSOFA within the first 24
hours of admission in discriminating in-hospital mortality among patients with
suspected infection admitted to the ICUs. This study began in 2000 and
continued to 2015. The sample size included 184,875 adults with
infection-related primary admission diagnosis. The study took place in 182 ICUs
in Australia and New Zealand. This study was rate a Level IV using Melnyk & Fineout-Overhold, (2015) evidence appraisal guidelines.

The
results of this study showed SOFA had significantly greater discrimination for
in-hospital mortality than SIRS criteria or qSOFA.  A SOFA of 2 or more points showed a 90.1%
accuracy in mortality or ICU length of stay of three days or more.  The SIRS score of 2 or more points had a
86.7% accuracy, while a qSOFA score of 2 or more points revealed 54.4%
accuracy.  The overall results favored a
SOFA score over qSOFA and SIRS, showing greater accuracy for in-hospital
mortality.  The
strengths of this study include the duration, sample size, and location. Having
this much diversity in the study decreases variables or outliers altering
results. Additionally, the information gathered utilized a quality-surveillance
data collection process reducing bias. One limitation the researchers address
is the inability to apply this study to emergency department patients. This
study used patients in the ICU. The statistical significance and clinical
significance could be applied to an ICU setting, but for the clinical problem
stated earlier this would not hold clinical significance in an emergency
department setting.  Like the previous
study, the use of SOFA in conjunction with SIRS criteria would be beneficial in
determining those with greater critical care needs for proper placement and to
identify those at higher mortality risk.

Discussion and Conclusions

Sepsis is a terrible disease with poor outcomes.  Understanding the best recognition tool and management are key to surviving sepsis.  The overall articles bring collective information on improving sepsis recognition and decreasing door-to-antibiotic time.  The studies described range from Level III to Level VI according to Melnyk and Fineout-Overholt’s (2015) level of evidence guide.  Having meta-analysis, randomized control trials, or even well-designed controlled trials without randomization would increase the validity of the results.  As previously stated, education is found effective in increasing knowledge and recognition on sepsis care.  Implementing an educational program on sepsis recognition and care is clinically significant to improve sepsis outcomes. Education should be incorporated into a sepsis care bundle to improve compliance and sepsis recognition. Additionally, if qSOFA or SOFA were used after SIRS criteria to determine critical care status this would increase results and provide knowledge on patient outcomes.

The overall evidence in the studies is not enough to
make changes in clinical practice.  There
is not enough collective strength of evidence to make a change in clinical
practice. However, the articles did support SIRS criteria for greatest
sensitivity to sepsis recognition with qSOFA showing higher sensitivity to
mortality. The sources of evidence support the continuing use of SIRS criteria
for a sepsis triage screening tool. Recognizing sepsis and reducing barriers
are key to improving antibiotic administration. The results of the study showed
the importance of education and reducing barriers to improving sepsis
recognition and management. According to the evidence, SIRS criteria is
providing better recognition for sepsis. The evidence leads to septic patients benefiting
from an additional screening tool, the qSOFA, if they have 2+ SIRS criteria to
rule out higher mortality and critical care needs. Further evidence is needed
on qSOFA replacing SIRS for sepsis identification prior to implementing in the
clinical setting. It appears most evidence conducted is from retrospective
studies. Randomized control trials or meta-analysis would strengthen this claim
for SIRS over qSOFA in emergency department triage screening tool for sepsis
recognition.

References

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