Sepsis is caused by overwhelming

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1 Instructions for Continuing Nursing Education Contact Hours appear on page 239. Scripting Nurse Communication to Improve Sepsis Care Dawn Marie Drahnak Marilyn Hravnak Dianxu Ren Alice J. Haines Patricia Tuite Sepsis is caused by overwhelming immune response to infection. Risk factors include baseline immunocompetence of the patient, presence of comorbid conditions, and patient age (Kleinpell & Schorr, 2014). Severe sepsis can cause damage to and failure of multiple organ systems. In sepsis, chemicals released by the body to fight infection trigger widespread inflammation. Chemical mediators re - leased through the sepsis response damage the endothelial lining of blood vessels and lead to increased capillary leakage. Cytokine release prompts production of adhesion molecules on vascular endothelial cells and neutrophils, causing further endothelial injury through release of the neutrophil components. Activated neutrophils release nitric oxide, a potent vasodilator that contributes to septic shock (Opal & van der Poll, 2015). These events collectively can cause vasodilation, hypotension, misdistribution of blood flow, and hypoperfusion and dysfunction. Sepsis severity and the time to sepsis recognition and treatment impact the likelihood of mortality from organ dysfunction (Kleinpell & Schorr, 2014). Severe sepsis is a significant problem, with an incidence of 300 to more than 1,000 cases per 100,000 persons annually in the United States (Gaieski, Edwards, Kallan, & Carr, 2013). For , the rate of hospitalized patients with a principal diagnosis of septicemia or sepsis more than doubled from 11.6 to Providing nurses with current evidence to inform practice for treatment of patients with sepsis, coupled with appropriate tools (electronic screening and scripting) for report of positive screens, forms a strong foundation on which to build an interprofessional and organizational sepsis treatment program per 10,000 patients, with inhospital mortality of 15%-30%; mortality associated with severe sepsis ranged even higher at 30%- 60% (Hall, Williams, DeFrances, & Golosinskiy, 2011). A brief by Torio and Andrews (2013) reported sepsis resulted in an aggregate healthcare cost of $20.3 billion in Hall and colleagues (2011) identified the estimated annual inpatient cost of sepsis nationwide in 2008 as $14.6 billion. Nurses play a vital role in early sepsis recognition and initiation of targeted treatment. Nurses ability to assess a patient s vital signs and physical condition is key to early sepsis recognition (Kleinpell & Schorr, 2014). For knowledgeable screening, nurses must be familiar with a patient s sepsis risk factors and predisposition for infection (e.g., chronic disease, impaired immunocompetence), as well as factors likely to contribute to organ dysfunction (e.g., causative organism, genetic composition, preexisting organ dysfunction, timely therapeutic intervention, extremes of age [infants and elderly]) (Angus & van der Poll, 2013). Literature Review A literature review ( ) using keywords sepsis, evidencebased practice, nurse-driven, sepsis screening, scripting, guidelines, and sepsis bundles was conducted using Dawn Marie Drahnak, DNP, RN, CCNS, CCRN, is Assistant Professor, University of Pittsburgh at Johnstown, Johnstown, PA. Marilyn Hravnak, PhD, RN, CRNP, BC, FCCM, FAAN, is Professor, University of Pittsburgh School of Nursing, Pittsburgh, PA. Dianxu Ren, MD, PhD, is Associate Professor, University of Pittsburgh School of Nursing, Pittsburgh, PA. Alice J. Haines, DNP, RN, CMSRN, is Assistant Professor, University of Pittsburgh School of Nursing, Pittsburgh, PA. Patricia Tuite, PhD, RN, CCNS, is Assistant Professor, University of Pittsburgh School of Nursing, Pittsburgh, PA. July-August 2016 Vol. 25/No

2 CINAHL and Ovid MEDLINE. Early goal-directed therapy involving fluid resuscitation and appropriate anti biotic administration has been reported to improve patient outcomes, including significantly de - creased mortality (Angus et al., 2001; Gaieski et al., 2010). From the most recent studies (ProCESS, ARISE, ProMISe), some clinicians agree early identification impacts patient outcomes more than specific goal-directed algorithms that follow initial treatment/resuscitation (Mouncey et al., 2015; The ARISE Investigators and the ANZICS Clinical Trials Group, 2014; The ProCESS Investigators, 2014). One initiative to improve sepsis care is the Surviving Sepsis Cam - paign (Dellinger et al., 2013), which advocates systematic application of routine sepsis screening and early patient treatment. This campaign was initiated in 2004 and updated in 2008 by the Society of Critical Care Medicine; a third edition of evidence-based recommendations was published in 2013 (Surviving Sepsis Campaign [SSC], 2013) to improve patient care and outcomes. Moore and co-authors (2009) reported a decrease in sepsis-related mortality from 35% to 23% through use of the guidelines for early identification and treatment. Although guidelines provide essential information, they do not ensure a local practice change (Kuehn, 2013). Care bundles from the Institute for Healthcare Improvement (IHI) offer evidence-based interventions for defined patient populations and care settings to streamline guidelines into a set of actionable items for use in a healthcare facility or practice. Their use has had a profound positive impact on patient outcomes (Resar, Griffin, Haraden, & Nolan, 2012). Current sepsis bundles provide screening protocols and interventions for early treatment of sepsis at two time points (3 and 6 hours). The 3-hour bundle includes blood cultures and measurement of lactate values, with administration of broad-spectrum antibiotics (within 1 hour) and fluids (30 ml/kg) for hypotension. Within 6 hours, vasopressor treatment is initiated to control hypo - tension unresponsive to fluid resuscitation. Monitoring of central venous pressure, central venous oxygen saturation, and lactate values (if initially elevated) also is recommended (Dellinger et al., 2013). A nurse manager survey developed by the American Association of Critical-Care Nurses (AACN) focused on current practice for the management of sepsis. More than half of hospital respondents appear - ed to have a systematic approach for the identification and screening of patients with severe sepsis. Direct patient care providers (e.g., pulmonologists, critical care physicians/ nurses) were involved most commonly in process development and implementation (Durthaler, Ernst, & Johnston, 2009). However, once procedures were developed, nurses reportedly had minimal responsibility to identify patients with severe sepsis. This trend remains true to date; having nurses at the point of care to implement sepsis bundles based on current evidence may result in less variability in screening and fewer missed opportunities for early diagnosis and treatment. The Third International Consen - sus Definitions for Sepsis and Septic Shock (Sepsis-3) (2016) provides updated definitions and clinical criteria. This revision, the first since 2001, will replace previous definitions, offer greater consistency for studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis (Singer et al., 2016). Improvement Needs/CQI Model The Six Sigma quality improvement model DMAIC (Define, Measure, Analyze, Improve, and Control) was used to guide this project (Pyzdek & Keller, 2010). As part of a gap analysis to determine the state of sepsis care (using the new SSC and 6-hour bundle criteria), the investigator conducted a pre-intervention, retrospective chart review. A random sam ple (n=71) of total patient medical records (N=492) for July March 2013 revealed sepsis as one of the hospital s top-10 diagnoses (Diagnosis-Related Groups 870, 871, & 872). The audit found nurses were not completing the sepsis screen consistently (once per day recommended); adherence to IHI s 3- and 6-hour bundles also was inconsistent. When the sepsis screen was implemented in 2010, process improvement follow up was not implemented to determine if the screening tool was reliable, userfriendly, or being used. Also, failure to develop supporting resources, such as nursing policy and physician order sets, may have contributed to nurses poor guideline adherence. Nurse administrators called for action to improve patient care and nurses involvement in SSC compliance. Overall goal of this project was to improve sepsis care by adopting the SSC guidelines and IHI bundles, applying a nurse education intervention, and using an electronic health record (EHR) sepsis screening and documentation tool. Data Collection Design A single-group pre-post survey design was used to assess the impact of education on nurses knowledge, perception, and attitudes regarding sepsis and screening adherence. A chart audit was conducted to determine adherence to sepsis screening, report, and treatment recommendations according to the SSC 2012 guidelines before and after the nurse education was completed and an EHR tool was initiated. Per mis - sion to conduct the project was obtained from the institution s Vice President of Patient Care Services. The project then was approved as a quality improvement project by the institution s Scientific Review Com - mittee of the Office of Research Administration. Setting and Sample The project took place in a 648- bed Level 1 trauma hospital, part of 234 July-August 2016 Vol. 25/No. 4

3 Scripting Nurse Communication to Improve Sepsis Care FIGURE 1. McKesson Horizon Expert Documentation Sepsis Screening Tool Copyright 2014 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Used with permission. Horizon Expert Documentation is a trademark of McKesson Corporation and/or one of its subsidiaries. TABLE 1. Sepsis Screening Criteria and Assessment General Variables Fever >38.3 C Hypothermia <36 C Heart rate >90 beats per minute Tachypnea Altered mental status Edema or positive fluid balance Hyperglycemia >120 mg/dl in the absence of diabetes Hemodynamic Variables Systolic pressure <90 mm Hg Mean arterial pressure <70 mm Hg Elevated mixed venous oxygen saturation >70% Elevated cardiac index Inflammatory Variables White-cell count >12,000/mm 3 or <4,000/mm 3 Normal white-cell count with >10% immature forms Elevated plasma C-reactive protein Elevated plasma procalcitonin Organ-Dysfunction/Tissue-Perfusion Variables Partial pressure of arterial oxygen to the fraction of inspired oxygen <300 Urine output <0.5 ml/kg/hr or 45 ml/hr for at least 2 hours Serum creatinine >0.5 mg/dl Coagulation abnormalities Absence of bowel sounds Platelets <100,000/mm 3 Plasma total bilirubin >4 mg/dl Lactate >1 mmol/liter Decreased capillary refill or mottling Source: Adapted from Dellinger et al. (2013) a regional health system in central Pennsylvania. The sample included 681 nurses (60% of the facility s acute care clinical nurses) who attended an annual clinical education session. EHR Tool to Capture Sepsis Screening, Recognition, and Reporting Education introduced nurses to the institution s newly developed Nursing Practice Policy for Sepsis Screening and Reporting, with a requirement for screening all patients older than age 18 as part of the 8-hour nursing assessment (8:00 a.m., 4:00 p.m., midnight) with the McKesson Horizon Expert Docu - mentation Sepsis Screening Tool (McKesson Techonology Solutions, Alpharetta, GA; see Figure 1). The screening criteria and nursing assessment for signs of infection facilitate early recognition of sepsis (see Table 1). Nurses were instructed to report positive screens to the healthcare provider and obtain orders to implement the SSC s 3- and 6-hour bundles. The policy also provided a script for nurses to report screening findings with use of the ISBAR tool (Introduction, Situation, Back ground, Assessment, and Recommend ation) to eliminate communication barriers (AACN, July-August 2016 Vol. 25/No

4 2013); use of the tool was practiced and reinforced in the education intervention. Educational Intervention for Nurses to Increase Knowledge of Sepsis The primary author developed a voice-over slide presentation that included review of sepsis pathophysiology, patient assessment (see Table 1), risk factors, SSC guideline bundles, documentation, and report of findings. An expert panel of the institution s Nurse Planning Com - mittee and the manuscript authors reviewed the presentation and made recommendations for revision. After three rounds of review and revision, consensus was achieved. Nurse participants completed a 5-minute survey before and after the 30-minute education, which concluded with a role-playing case study to increase nurses comfort with using the EHR sepsis tool and reporting positive findings to the provider. The module served as the sepsis competency for all nurses attending the annual educational session and now is viewed by new staff during hospital orientation. Nurses Perception and Attitude Concerning Sepsis Awareness Construction of the nurse assessment tool followed the same pro - cess of iterative expert panel review and revisions; four rounds were conducted before consensus was achieved. Pre-test included nurse demographics (sex, age, education, years since graduation, years on project unit). Pre- and post-tests included Likert-style items about nurse perceptions and attitudes related to sepsis care (1=don t know, 5=strongly agree), and 10 items about nurses sepsis knowledge (1=very uncomfortable, 4=very comfortable). The last section assessed nurses knowledge of sepsis pathophysiology and appropriate measures for identification, reporting, and treatment of sepsis. Pre- and post-tools were numbered to ensure linkage of each nurse s survey responses, but no identifiable information was collected. Institutional Adherence to Recommended Sepsis Guidelines Sepsis screening adherence was concurrently audited (using the established policy at the time: sepsis screening once each day of the patient s hospitalization at 8:00 a.m.). A point prevalence audit for nurses adherence with sepsis screening was completed 1 month after education via a report run from McKesson Horizon Expert Docu mentation. Total patient census (N=360) was analyzed and only inpatients for 24 hours (n=178) were included. A comparison of the percentage of adherence to sepsis screening before and after education based on the established policy at the time was conducted. Results Demographic information collected for nurses (N=680) who participated in the education revealed participants were primarily young (ages 19-29), Caucasian, and female. Most nurses held diploma degrees and were in the profession 0-5 years. Results of the survey of nursing perception and attitudes before and after participating in the educational process were favorable. The Wilcoxon Signed-Rank Test was used to evaluate the Likert scale items. Nurses rated themselves as significantly more knowledgeable about sepsis after the education, significantly more certain the hospital has a consistent definition and treatment for sepsis, an increased belief peers were aware of the differences in sepsis states, and increased comfort about their ability to recognize sepsis and report it to a provider (all p<0.0001). The pre- and post-nursing know - ledge scores are listed in Table 2. Responses to multiple-choice know - ledge questions were dichotomized as correct or incorrect, and the Statistical Analysis System (SAS) Version 9.3 (Cary, NC) PROC FREQ program was conducted to compute tests and measures of association in a 2 X 2 contingency table (Pre and Post by Correct and Incorrect) using McNemar s test for paired data. All 10 knowledge questions demonstrated a statistically significant difference between the pre- and posttest (all p<0.001). For 9 of 10 questions, statistically significant im - provement was found in the percentage of nurses who answered the item correctly in the post-test (improvement ranges for scores increased by 7.28%-63.5%). One question ( What is the first step in the initial management of the patient with sepsis? ) was answered correctly less frequently in the posttest (-18.25% of nurses). An audit to measure adherence to documentation of nursing sepsis screening post-education was conducted. A comparison of adherence to sepsis screening from the gap analysis before education (once per day) and 1-month after intervention (three times per day) was completed. The majority of all units experienced a decrease in the percentage of patients for whom sepsis screening never occurred. Although full adherence to the protocol was not achieved post-education, the full adherence requirement increased from screening once per 24 hours in the pre-phase to three times in 24 hours in the post-phase. Neverthe - less, dichoto mization of the results as never screened or screened at least once in 24 hours (combining the categories screened > never but < compliant, and compliant combined) dem - onstrated the number of patients who never received the recommended screening de creased from 40.6% to only 8.9% (see Figure 2), while the number who received at least some screening increased from 59% to 91%. Further analysis of the data using chi-square test demonstrated statistical significance in improved incidence of sepsis screening post-educational intervention (p<0.0001). Limitations The voice-over slide presentation ensured consistent delivery of educational material to the intended audience, served as a future resource for new staff, and maximized nurs- 236 July-August 2016 Vol. 25/No. 4

5 Scripting Nurse Communication to Improve Sepsis Care TABLE 2. Outcome Frequency Distribution* Pre and Post-Test Sepsis and Systemic Inflammatory Response Syndrome (SIRS) Knowledge Variable Pre-Test Answered Correct Frequency (%) Post-Test Answered Correct Frequency (%) Difference in % Pre- & Post-Test McNemar s Test (p-value) A lactate greater than meq/l would warrant a critical value report. N= (31.06) N= (93.45) p< Blood cultures should be obtained and the first antibiotics administered within how many hours of diagnosis of sepsis? 345 (50.96) 407 (60.12) p= How often should a patient be screened for sepsis? N= (44.68) 592 (87.44) p< Identification of the SIRS or a sepsis state case study (depicting patient with severe sepsis) Identification of the SIRS or a sepsis state case study (depicting patient with sepsis) N= (19.14) N= (82.69) p< N= (60.24) 635 (93.80) p< Identification of the SIRS or a sepsis state case study (depicting patient with SIRS) N= (47.89) N= (97.37) p< What is the first step in the initial management of the patient with sepsis? N= (54.11) N= (35.86) p< Severe sepsis may be manifested as (circle all that apply): N= (38.72) 495 (73.12) p< The initial sepsis resuscitation bundle in the adult patient with sepsis and hypotension calls for a bolus of which amount and kind of intravenous fluid? N= (39.80) N= (94.96) p< Which of the vital signs are out of the normal range according to the SIRS criteria? N= (81.46) N= (88.74) p< ing resources. However, not having an expert consistently available for questions and clarification may have contributed to nurses answering the initial management know - ledge item incorrectly more often after intervention. Addi tionally, difficulties in implementing the intervention in different settings (emergency department, acute care, intensive care) have been recognized. The study was limited to one facility with acute care nurses and a post-intervention adherence measurement immediately after the intervention. Finally, patient management with a focus on escalation or transition of care was not discussed adequately and should be addressed in future education. The same number of nurses did not complete both surveys, and some individuals did not complete every item (see Table 2). Although surveys were distributed and collected systematically, nurses were not monitored for completion of surveys prior to collection. How ever, differences between groups and items were small and unlikely to bias results. In addition, authors did not determine if improvements in sepsis care as illustrated by improved nurse knowledge and adherence to sepsis screening resulted in decreased rates of sepsis and sepsis mortality. A longer project time, collection, data specific to rates of sepsis and sepsis outcome, and more advanced analysis and control for patient acuity would be needed for this determination. Nursing Implications Application of sepsis care bundles has reduced mortality in hospitals participating in the SSC, but the number of hospitals involved and their adherence remain low (SSC, 2013). Adoption of IHI bundles for sepsis care can be improved locally through use of a nursing education intervention and bundle components, coupled with a systematic method to screen for sepsis, recognize screening findings, and communicate them in a systematic manner. National Patient Safety Goals (NPSGs) focus on solving problems in healthcare safety. The Joint Commission (2016) initially identified effective communication as July-August 2016 Vol. 25/No

6 FIGURE 2. Comparison of Non-Adherent, Partially Adherent, and Adherent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0 Pre 40.6% 40.6% 8.9% Non-Adherent one of its NPSGs and the 2016 update ( Get important test results to the right staff person on time ) continues to address effective communication. The Situation-Back - ground-assessment-recommend - ation (SBAR) process has been effective as a communication tool in acute care settings to structure highurgency conversation (Velji et al., 2008). Increasing nurses knowledge of sepsis and sepsis screening, as well as providing them with the SBAR approach, supports nurses in communicating positive sepsis screens to providers. Education and supportive nursing practice policy lead to more consistent use of the EHR sepsis screening documentation tool and im proved screening. Electronic tem plates and decision-support tools can assist nurses with consistent documentation and adherence to protocols and care standards. Electronic prompts and worklists can also enhance adherence (Tur isco & Rhoads, 2008). A meth od for sepsis screening using the Systemic Inflammatory Re - sponse Syndrome Criteria was pro - Post 69.1% Partially Adherent 18.5% 21.9% Adherent Comparison of percentage of all hospitalized patients for whom staff were never adherent to recommended sepsis screening, recognizing, and reporting or adherent at least once in a 24-hour period before and after Surviving Sepsis Campaign guideline adoption, nurse education, and use of the EHR sepsis screening and documentation tool. Chi-square test demonstrated a statistical significance in improvement in incidence of sepsis screening post-intervention (p<0.0001). ven to be a valid tool for the early identification of sepsis. Implemen - tation of the tool and a logic-based sepsis protocol de creased sepsis-related mortality in one surgical intensive care by one-third (Moore et al., 2009). Con tinued auditing for screen ing adherence (every 8 hours) with communication to nursing staff on the degree of adherence must continue. Real-time feedback will allow nurses to improve aherence. The project s focus was screening and reporting positive findings. Next steps will include further education to support recognition of tissue hypoperfusion and its treatment (6- hour bundle components) and use of newly developed computerized physician order entry sepsis care orders. Auditing for adherence to screening should go further to determine if screening results in appropriate reporting and initiation of the care bundles, which would in turn be expected to improve sepsis patient outcomes. Auditing also should focus on retrospective rapid re - sponses, analyzing if patients were screened, the screen was positive and reported in a timely manner, and treatment was implemented according to SSC 2012 guidelines. Many units have unique patient needs and therefore perform nursing assessments and vital sign measurements differently. A standardized approach to sepsis screening may not be the answer. It may be appropriate to examine similar units, and collaborate with nurses and other clinicians to determine appropriate frequency and timing for sepsis screening according to the unit s specific patient population. Further study will be needed to determine if patient outcomes are better with 8-hour vs. 12-hour screening. Conclusion Providing nurses with current evidence to inform practice for treatment of patients with sepsis, coupled with appropriate tools (electronic screening and scripting) for report of positive screens, forms a strong foundation on which to build an interprofessional organizational sepsis treatment program. Education, communication scripting, nursing policy, and EHR prompts can improve adoption of the IHI bundles and SCC 2012 guidelines for sepsis care. Contin - uous quality improvement efforts and auditing will position the organization to improve processes and provide optimal patient outcomes. Nevertheless, continued vigilance and administrative support for this initiative will be needed to enhance adherence and ensure success. REFERENCES American Association of Critical-Care Nurses (AACN). (2013). Breaking through barriers: Effectively communicating sepsis conditions. Retrieved from aacn.org/wd/elearning/docs/elearning pdf/ breaking-through-barriers.pdf Angus, D., Linde-Zwirble, W., Lidicker, J. Clermont, G., Carcillow, J., & Pinsky, M. (2001). Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Critical Care Medicine, 29(7), July-August 2016 Vol. 25/No. 4

7 Scripting Nurse Communication to Improve Sepsis Care Instructions For Continuing Nursing Education Contact Hours Scripting Nurse Communication to Improve Sepsis Care Deadline for Submission: August 31, 2018 MSN J1612 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 Augsut 31, Upon completion of the evaluation, a certificate for 1.2 contact hour(s) may be printed. Learning Outcome After completing this learning activity, the learner will be able to describe communication strategies for improving sepsis care. Fees Member: FREE Regular: $20 The author(s), editor, editorial board, content 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 Commission 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. Angus, D., & van der Poll, T. (2013). Severe sepsis and septic shock. The New England Journal of Medicine, 369(21), Dellinger, R., Levy M., Rhodes, A., Annane, D., Gerlach, H., Opal S., The Surviving Sepsis Guidelines Committee including the Pediatric Subgroup. (2013). 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