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1 Instructions for Continuing Nursing Education Contact Hours appear on page 251. Early Sepsis Identification Jennifer O Shaughnessy, Monica Grzelak, Aleksandra Dontsova, and Ingrid Braun-Alfano Continuous Quality Improvement Literature Summary Implementation of a sepsis screening tool led to earlier identification of sepsis and allowed quicker initiation of treatment, leading to reduced mortality (Lopez-Bushnell, Demaray, & Jaco, 2014; Moore & Moore, 2012). Sepsis screening through the electronic medical record (EMR) on medical-surgical and telemetry units decreased time from sepsis identification to intervention, improved evidence-based management, and decreased mortality (Mapp, Davis, & Krowchuk, 2013; McRee, Thanavaro, Moore, Goldsmith, & Pasvogel, 2014; Umscheid et al., 2014). Judd, Stephens, and Kennedy (2014) reported decreased hospital and critical care length of stay, hospital mortality, and total cost per case after implementation of an EMR sepsis screening tool. CQI Model This project used the seven-phase action cycle of the Knowledge to Action (KTA) framework (White & Dudley-Brown, 2012). Quality Indicator with Operational Definitions and Data Collection Methods Quality Indicators Nurses knowledge of sepsis measured by percentage of correct answers to questionnaires Time lapsed from sepsis manifestation to provider notification Operational Definitions Systemic Inflammatory Response Syndrome (SIRS): Temperature >38.3 C (100.9 F) or <36 C (96.8 F); heart rate >90 beats per minute, respiration rate >20 breaths per minute or PaCO 2 <32 mm Hg, WBC count <4,000 or >12,000, or >10% bands Sepsis: Two or more SIRS criteria in presence of diagnosed or suspected infection Severe sepsis: Sepsis plus evidence of organ dysfunction (SBP <90 mm Hg or mean arterial pressure <65 mm Hg, acute change of mental status, oxygen saturation <90% or increased O 2 requirements, urine output <0.5 ml/kg/hr; serum glucose >140 mg/dl in the absence of diabetes) Clinical Settings Hospital 1: A 52-bed medical-surgical unit at a 687-bed nonprofit Level II trauma center, teaching hospital Hospital 2: A 38-bed medical-surgical unit at a 554-bed nonprofit Catholic teaching hospital Patient Population Patients with acute and/or chronic conditions with or without telemetry Program Objectives Decrease the time from sepsis presentation to provider notification by increasing nurses awareness and knowledge of sepsis manifestations and guidelines. Compare paper-based sepsis screening to an EMR-based sepsis monitoring system. The purpose of this project was to facilitate early recognition of signs and symptoms of sepsis through utilization of a sepsis screening tool along with education of staff nurses on medical-surgical units in two acute care hospitals. The incidence of hospital admissions with primary or secondary diagnoses of septicemia doubled from 2000 to 2009; patients with sepsis tend to be sicker and have longer admissions, and are more likely to be discharged to long-term care facilities than to home (Elixhauser, Friedman, & Stranges, 2011). Sepsis mortality is estimated at one in four patients, with risk increasing as the disease advances (Dellinger et al., 2013). Of patients who experience sepsis or septic shock, almost one-quarter develop it while hospitalized on medical-surgical units (Tazbir, 2012), yet less than 40% of medicalsurgical nurses are able to recognize sepsis in their patients (Moore & Moore, 2012). The risk of mortality tends to be higher for patients diagnosed with sepsis while on general inpatient units compared to intensive care or emergency settings (Levy et al., 2010). Research demonstrated pa tients exhibit changes in physiologic parameters as early as 8 hours before adverse events; patients survival thus depends on nurses ability to recognize signs and symptoms of sepsis and communicate their observations to pro - viders (Mapp, Davis, & Krowchuk, 2013). The Surviving Sepsis Cam - paign (SSC) guidelines recommended routine screening of acutely ill 248

2 Early Sepsis Identification patients for early identification of sepsis and early commencement of goal-directed therapy to increase chance of survival and improve patient outcomes (Dellinger et al., 2013). Project Site and Reason to Change Two hospitals in northern New Jersey were selected as project sites. One medical-surgical unit was identified at each facility based on similarity of patient population and acuity. No nurse-driven sepsis screening was performed on the units, but patients were known to exhibit signs of sepsis for over 24 hours before a provider was notified. Program Phase 1: Identify Problem. Identify, Review, and Select Knowledge. A 15-question nurse survey re - vealed gaps in knowledge of sepsis symptoms and progression. Ques - tions were derived from the 2015 World Sepsis Day (n.d.) educational assessment and relevant clinical scenarios. The pre-survey was completed by 34 of 44 nurses (77.3%) at Hospital 1 and 17 of 28 nurses (63.5%) at Hospital 2. The average percentage of correct answers on the pre-survey was 51% and 56%, respectively, for Hospital 1 and Hospital 2. Results supported the need to improve nurses knowledge of sepsis. A retrospective chart review was completed for the month before project implementation to identify time of clinical recognition of sepsis, as measured by time lapsed from when a patient met sepsis criteria to documentation of provider notification or rapid response team (RRT) initiation. At Hospital 1, 15 cases of sepsis were identified; only one case involved provider notification, which did not occur until 36 hours after the patient met the criteria. Hospital 2 had 18 sepsis cases; the provider was notified in four cases, with an average elapsed time of 182 minutes. Phase 2: Adopt Knowledge to Local Context. Evidence relevant to early sepsis identification included the SSC guidelines for sepsis screening (Dellinger et al., 2013) and the American Association of Critical- Care Nurses (2013) recommendations on effective communication. Hospital 1 used an electronic medical record (EMR)-based sepsis monitoring system, while Hospital 2 did not have sepsis clinical support tools at the time of the project. Jennifer O Shaughnessy, DNP, RN, CCRN, AG-ACNP-BC, is Advanced Practice Nurse, Beth Israel Medical Center, Newark, NJ. She was Staff Nurse, Beth Israel Medical Center, Newark, NJ, at the time of the study. Monica Grzelak, DNP, RN-BC, AG-ACNP-BC, is Advanced Practice Nurse, Atlantic NeuroSurgical Specialist, Morristown, NJ. She was Staff Nurse, Morristown Medical Center, Morristown, NJ, at the time of the study. Aleksandra Dontsova, DNP, RN, CCRN, AG-ACNP-BC, is Advanced Practice Nurse, Vital Medical Forces of Denville, Denville, NJ. She was Staff Nurse, Trinitas Regional Medical Center, Elizabeth, NJ, at the time of the study. Ingrid Braun-Alfano, DNP, RN, CCRN, AG-ACNP-BC, is Staff Nurse, Robert Wood Johnson University Hospital, Somerset, NJ. Acknowledgment: The authors would like to acknowledge Helen Miley, PhD, RN, CCRN, AG- ACNP, and Brian Hegarty, DNP APN, ACNP-BC, GNP-BC, for their continuous effort, support, and guidance during this study. Also, thanks to Deborah Durand, APN, RN, CCRN, CNS, and Rachael Santos, APN, RN, CNS, for their time and allowing use of the medical-surgical units for this study. Phase 3: Assess Barriers to Knowledge Use. At both facilities, champions were identified to assist with sustaining organizational support. Nurses who were balancing many competing priorities were resistant to adding yet another task to their schedules. This barrier was mitigated through education that early sepsis identification may prevent patients deterioration and/or expedite transfer of unstable patients to an intensive care setting. In addition, the ease of using a sepsis screening tool was demonstrated. Phase 4: Select, Tailor, and Implement Interventions. Education for nurses on the medical-surgical units was focused on sepsis pathophysiology and signs and symptoms, evidence-based management guidelines, and use of a sepsis screening tool and the Situation Background Assessment Recommendation (SBAR) communication tool. Education sessions, which incorporated presentation with discussion, were provided over a month with multiple sessions covering all shifts. A sepsis screening tool and structured SBAR communication tool were implemented. At Hospital 1, patients who received an EMR-generated sepsis alert were screened further by the nurse using the paper screening tool. At Hospital 2, nurses screened all patients using the paper tool at least once each shift. Nurses were instructed to notify the provider of any positive sepsis screens and encouraged to activate the RRT if there was evidence of acute organ dysfunction. Nurses were directed to use the SBAR template to highlight changes in the patient s condition and recommend evidence-based sepsis management (e.g., blood cultures, serum lactate, initiation of antibiotics and intravenous fluids) during provider notification. If a patient s baseline SIRS score was 2 or higher for documented reasons other than sepsis, clinical deterioration was judged by changes from the baseline. Evaluation and Action Plan Phase 5: Monitor Knowledge Use. After the educational sessions, nurses who completed the pre-survey were asked to complete a postsurvey. Post-surveys were collected from 34 (77.3%) nurses at Hospital 249

3 2 and 19 (67.9%) nurses at Hospital 2. Mean post-scores were 77% for nurses from Hospital 2 and 86% for nurses from Hospital 2. Adherence to the once-a-shift sepsis screening was monitored during the intervention month through site visits and chart audits. At the end of the intervention period, the time from a positive sepsis screen to provider notification was reassessed via a chart review. This process identified 19 cases of sepsis at Hospital 1 and 31 cases at Hospital 2. Results and Limitations Phase 6: Evaluate Outcomes. The objective of improving nursing knowledge related to sepsis identification was accomplished, as evidenced by a 50% increase in nurses average post-scores at Hospital 1 and a 53% increase at Hospital 2 compared to pre-survey results (see Figure 1). The overall improvement suggested the effectiveness of sepsis education sessions in enhancing nurses understanding of sepsis manifestations and management. This project achieved its main purpose as evidenced by an increased percentage of sepsis cases reported to healthcare providers and decreased average time from sepsis manifestation to provider notification. The percentage of instances in which the nurse notified the provider improved from 6.7% to 84.2% at Hospital 1 and from 22.2% to 45.2% at Hospital 2 (see Figure 2). Most identified yet unreported sepsis cases in the post-intervention group were instances where pro viders were already aware of the patients condition and treatment was already in progress. If these instances were excluded from analysis, adjusted percentage of provider notification would be 95% for Hospital 1 and 54% for Hospital 2. The time to notification after intervention at Hospital 1 decreased to an average of 42 minutes, while the average was 138 minutes at Hospital 2. The EMRbased screening achieved greater reduction in time to provider notification in terms of relative reduction and absolute reduction to the shortest mean time to notification (see Figure 3). Overall adherence to use of the screening tool was estimated to be 20%-50%, although the project design did not allow individualized monitoring of screening. The short duration of this project was a major limitation. A greater improvement might be seen on the medical-surgical units as sepsis screening becomes routine. The time frame of this project limited the ability to evaluate the long-term impact of the intervention. Phase 7: Sustain Knowledge Use. After determining early identification of sepsis was improved following the interventions, project leaders recommended all medical-surgical units at these hospitals adopt this process, with ongoing sepsis education for all medical-surgical nurses. EMR-based sepsis screening was proposed to replace paper screening to allow automatic and continuous screening of all patients. If use of paper screening tools continued at a facility, proj- Test Score % FIGURE 1. Comparison of Pre- and Post-Education Survey Scores Location Hospital 1 Hospital 2 56 Pre-Survey 77 Post-Survey FIGURE 2. Comparison of Adherence to Provider Notification Adherence to Provider Notification Paper 22.2% Pre-Intervention 86 Screening Method Electronic Medical Record 6.7% 45.2% 84.2% Post-Intervention 250

4 Early Sepsis Identification Instructions For Continuing Nursing Education Contact Hours Early Sepsis Identification Deadline for Submission: August 31, 2019 MSN J1711 To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation through the AMSN Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to 2. Evaluations must be completed online by August 31, Upon completion of the evaluation, a certificate for 1.0 contact hour(s) may be printed. Learning Outcome After completing this learning activity, the learner will be able to discuss early identification of sepsis through routine screening and nursing education. Learning Engagement Activity Ask yourself the following questions: Are you required to complete an annual competency on identification of sepsis? Does your organization conduct a debriefing after cases of sepsis/septic shock have been identified on medicalsurgical units? Fees Member: FREE Regular: $20 The author(s), editor, editorial board, con - tent reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article. This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN). Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Com - mission on Accreditation. Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP Licensees in the state of California must retain this certificate for four years after the CNE activity is completed. This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director. FIGURE 3. Comparison of Mean Time to Provider Notification by Screening Method Mean Time in Minutes 2,500 2,000 1,500 1, Paper 182 Screening Method Electronic Medical Record 2,160 Pre-Intervention Post-Intervention ect leaders recommended the presence of infection should be assessed before signs of a systemic response. Lessons Learned/Nursing Implications Improvements can be made in sepsis identification and provider notification when clinical nurses have adequate tools and support. While implementation of standardized screening tools can help nurses identify sepsis, that step alone is not sufficient. Education of nursing and allied health staff is paramount to successful screening. Basic comprehension of sepsis pathophysiology aids in understanding the importance of screening parameters. Nurses must recognize sepsis has the same level of urgency as stroke or an acute coronary event. Educa tion should consist of initial orientation before implementing screening and subsequent reinforcements (e.g., annual competencies, sepsis symptoms quick reference cards). Additionally, nurses appear to respond more favorably to real case studies than to detached clinical information (e.g., textbooks, journals). Continued education efforts should include debriefing after cases of severe sepsis/septic shock have been identified on medical-surgical units to determine missed opportunities for intervention that could have helped prevent progression. The accurate, consistent documentation of vital signs is essential to sepsis screening. When vital signs are recorded incorrectly or omitted for periods of up to 12 hours, critical changes can be missed. All staff tasked 251

5 with obtaining and recording vital signs should be included in continuing education with reinforcement of sepsis screening parameters. Finally, administrative support and presence of a local sepsis champion are invaluable for the successful establishment of efficient sepsis screening. Conclusion Routine sepsis screening and nursing education related to sepsis led to an improvement in early identification of sepsis as evidenced by increased frequency of provider notification and decreased time to notification. The improvement was considered the result of an in - creased focus on sepsis identification, increased knowledge of sepsis, and use of sepsis screening. When routine sepsis screening becomes part of nurses practice, improvement in early sepsis identification can be achieved; this has the potential to limit sepsis progression, reduce morbidity and mortality, and decrease related healthcare costs (Judd et al., 2014). Because nurses in all practice areas care for patients with sepsis, they need routine education on the escalating symptomatology and management of sepsis. REFERENCES American Association of Critical-Care Nurses. (2013). Breaking through barriers: Effectively communicating sepsis conditions. Aliso Viejo, CA: Author. Dellinger, P.R., Levy, M.M., Rhodes, A., Annane, D., Gerlach, H., Opal, S.M., Sevransky, J.E. & the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. (2013). Surviving Sepsis Campaign: Inter - national guidelines for management of severe sepsis and septic shock: Critical Care Medicine, 41(2), doi: /dcc.0b013e d Elixhauser, A., Friedman, B., & Stranges, E. (2011). Septicemia in U.S. hospitals, 2009 (Statistical Brief #122). Retrieved from statbriefs/sb122.pdf Judd, W.R., Stephens, D.M., & Kennedy, C.A. (2014). Clinical and economic impact of a quality improvement initiative to enhance early recognition and treatment of sepsis. The Annals of Pharmaco - therapy, 48(10), doi: / Levy, M., Dellinger, R., Schorr, C., Townsend, S., Linde-Zwirble, W., Marshall, J., & Angus, D. (2010). The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine, 38(2), doi: /ccm.0b013e3181cb0cdc Lopez-Bushnell, K., Demaray, W.S., & Jaco, C. (2014). Reducing sepsis mortality. MEDSURG Nursing, 23(1), Mapp, I., Davis, L., & Krowchuk, H. (2013). Prevention of unplanned intensive care unit admissions and hospital mortality by early warning systems. Dimensions of Critical Care Nursing, 32(6), McRee, L., Thanavaro, J., Moore, K., Gold - smith, M., & Pasvogel, A. (2014). The impact of an electronic medical record surveillance program on outcomes for patients with sepsis. Heart & Lung, 43(1), Moore, L., & Moore, F. (2012). Epidemiology of sepsis in surgical patients. Surgical Clinics of North America, 92(6), doi: /j.suc Tazbir, J. (2012). Early recognition and treatment of sepsis in the medical-surgical setting. MEDSURG Nursing, 21(4), Umscheid, C., Betesh, J., VanZandbergen, C., Hanish, A., Tait, G., Mikkelsen, M., & Fuchs, B. (2014). Development, implementation, and impact of an automated early warning and response system for sepsis. Journal of Hospital Medicine, 10(1), White, K., & Dudley-Brown, S. (2012). Translation of evidence into nursing and health care practice. New York, NY: Springer Publishing Company World Sepsis Day. (n.d.). Educational assessment. Retrieved from world-sepsis-day.org/ 252