Early recognition: The key to improving sepsis outcomes

Every day patients are admitted into hospitals with the diagnosis of sepsis.

Sepsis affects over 1.5 million people annually in the U.S. and is the leading cause of hospital mortality and critical illness worldwide(1).  Sepsis is not a new diagnosis. It’s one we have been battling for years. Although guidelines for managing sepsis have changed over time as new research has become available, one thing that has not changed is the knowledge that early recognition of sepsis is critical and improves patient outcomes. 

The changing definition of sepsis and septic shock

In 2016, the previous definition of sepsis changed for diagnoses of sepsis and septic shock, more commonly called Sepsis 3 by the Third International Consensus Definition. In 2017, the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock were published(2), showing that sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (2,3). Septic shock is now recognized to be a subset of sepsis in which the underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality (3).  Another significant change in the latest sepsis definition and guidelines was that the designation of severe sepsis was eliminated. 

Early recognition of a patient who is at risk or has sepsis is paramount to ensuring that interventions are quickly pursued. The latest sepsis guidelines recommend that clinicians screen all patients to assess for organ dysfunction and risk of mortality. 

Tools for recognizing the patient at risk for mortality 

The quick sequential organ failure assessment (aSOFA) tool is a resource that is used outside of a critical care unit, such as in an emergency room, medical/surgical unit, urgent care center or even in primary care. 

The qSOFA tool evaluates 3 variables:

  • Respiratory rate greater than or equal to 22/min
  • Altered mentation
  • Systolic blood pressure less than or equal to 100 mm Hg (2,3). 

Patients who have a qSOFA score of 0 to 1 are not at high risk for in-hospital mortality. Patients with a qSOFA score of 2-3 are at high risk for in-hospital mortality at a 3 to 14-fold increase (2,3). 

If a patient has a qSOFA score elevation, they will need to have further evaluation. The qSOFA score has come under scrutiny; recent research on qSOFA reliability has revealed that the more comorbidities a patient has, the less reliable the qSOFA score is in determining the risk of organ dysfunction and the risk of mortality and that more research is needed to find a more reliable to identify risk of mortality (5).  

The SOFA tool is used most often in critical care units to identify a higher risk of mortality. This scoring system evaluates 7 different organ system variables and is calculated using the worst values in the 24-hour period.  

The organ systems that are evaluated with SOFA include: 

  • Pulmonary/Respiratory – looks at PaO2/FiO2 ratio
  • Coagulation – platelet level
  • Liver – bilirubin level
  • Cardiovascular – evaluates mean arterial pressure and use of vasopressors
  • Brain – Glasgow coma score
  • Kidney/Renal – evaluates creatinine level and urine output (2,3). 

Early recognition and intervention: The responsibility of the interdisciplinary team

Physicians, nurses, advanced practice nurses, and physician assistants are integral to recognizing the patient with an infection who is at risk for sepsis and septic shock and must intervene as quickly as appropriate. In addition, clinicians are also responsible for educating patients and their families on early recognition of signs, as well as when to bring the patient to a healthcare provider for evaluation and treatment. Healthcare professionals are key leaders in facilitating patient and family education about sepsis treatment and post-care. 

References:

(1) Rhee, C., Dantes, R., Epstein, L., et. al. (2017). CDC Prevention epicenter program: Incidence and trends of sepsis in U.S. hospitals using clinical vs claims data, 2009-2014. JAMA; 318: 1241-1249.

(2) Rhodes, A., et., al. (2017). Surviving sepsis campaign: International guidelines for the management of sepsis and septic shock. Critical Care Medicine; 45(3). 

(3) Singer, M., et. al. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis 3). JAMA; 315(8): 801-810.

(4) Mantra, S., Som, A., & Bhattacharjee, S. (2018). Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systematic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalizing patients with suspected infection: a meta-analysis of observational studies. Clinical Microbiology Infection; 24(11): 1123-1129. 

Author:

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN

Chief Nurse of Health, Learning, Research and Practice, Wolters Kluwer

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