Dear Editor,
Internationally, sepsis remains a complex condition with high mortality rates for
critically ill patients. With the associated high resource use in developed and developing
countries, early recognition and treatment have become a global priority area of focus
for critical care [1].
Since 2002, the European Society of Intensive and Critical Care Medicine (ESICM) and
the Society of Critical Care Medicine (SCCM) have collaborated to develop [2, 3] and
update international guidelines for the management of sepsis and septic shock. The
most recent guidelines were published in 2017 and outline 93 recommendations and best
practice statements for the medical treatment of sepsis in 21 categories including
diagnosis, initial resuscitation, antimicrobial therapy, fluid therapy, mechanical
ventilation, source control, and screening for sepsis and performance improvement,
among others [2, 3].
Nurses play a pivotal role in the early identification and management of sepsis. In
recognition of this, four leading international critical care organizations (the European
Federation of Critical Care Nursing Associations, EfCCNa, the European Society of
Intensive Care Medicine Nursing and Allied Healthcare Professionals Section; the SCCM,
and the World Federation of Critical CAre Nurses, WFCCN) collaborated to outline considerations
for nursing care based on the revised SSC guidelines. The President or Chair of the
organizations (authors) formed the core group and engaged with, and drew upon, nursing
members with expertise on sepsis care. Consensus on quality indicators was gained
through face to face communication with committees at organizational meetings and
via email among the leadership. Nurse-sensitive actions and quality indicators were
identified based on key areas of nursing care as outlined in the guidelines.
The role of the nurse in sepsis care
A number of nurse-led initiatives targeting sepsis care highlight the important role
that nurses play in sepsis care. For example, the use of nurse-led protocols for early
identification of sepsis, initiation of sepsis protocols to facilitate obtaining blood
cultures and starting early resuscitation measures, and nurse-led sepsis response
teams have demonstrated the impact of nurse-led multi-professional team-based care
in decreasing mortality, ICU length of stay, and ICU readmission rates [4, 5].
International critical care nursing interventions for patients with sepsis
Nursing interventions for sepsis care start with promoting early identification and
treatment of sepsis, as research continues to demonstrate increasing mortality rates
with the progression of organ system failure and septic shock [5]. Interventions include
the following:
Prompt identification of sepsis.
Monitor vital signs for elevated heart rate, reduced blood pressure, increased respiratory
rate, or elevated temperature. Detecting abnormal vital signs is the first step in
early sepsis recognition.
Consider implementing sepsis screening as part of routine nursing care for patient
assessments and patient care rounds.
Activate sepsis team/sepsis care protocols including transfer to higher level of care
as indicated.
2.
Provide sepsis treatment measures.
Obtain blood cultures prior to administering antibiotics whenever possible.
The SSC guidelines recommend obtaining two sets of blood cultures: aerobic and anaerobic,
if doing so results in no substantial delay in the start of antibiotic therapy.
Administer antibiotics as ordered. Nurses have a direct role in administering antibiotics
as part of sepsis treatment; therefore, awareness of the importance of prompt initiation
of antibiotics is a cornerstone of care.
Provide fluid resuscitation as outlined in the guidelines and directed by institutional
protocols.
The guidelines recommend aggressive fluid resuscitation of up to 30 mL/kg of intravenous
crystalloids within the first 3 hours, targeting a mean arterial pressure (MAP) of
65 mmHg in patients with septic shock requiring vasopressors. Resuscitation is recommended
to be guided by monitoring lactate levels as a marker of tissue hypoperfusion.
3.
Manage altered perfusion and shock.
Monitor and report alterations in perfusion including decreasing urine output, altered
skin perfusion, mental status changes, and changes in other perfusion metrics.
Monitor lactate levels as directed by institutional protocols and as ordered.
Assess and report response to sepsis care treatments.
Sepsis bundles have been advocated with each update of the SSC guidelines and focus
on early identification of sepsis by obtaining lactate levels, blood cultures before
antibiotics, fluid administration for resuscitation, and use of vasopressors for continued
hypotension despite fluid administration (Supplemental content).
4.
Promote awareness/implementation of the international sepsis guidelines.
Disseminate information on the international sepsis guidelines to members of the critical
care team, including the emergency department and ward staff, where sepsis care measures
are implemented before patients arrive in the intensive care unit.
Include a discussion of the guidelines during unit clinical care meetings and clinical
rounds.
Ensure clinician awareness of the surviving sepsis campaign guidelines website: http://www.survivingsepsis.org
which contains open access resources, toolkits, educational videos, bundles, and the
guidelines.
5.
Target sepsis with quality improvement initiatives.
Support and champion quality improvement initiatives aimed at improving sepsis care.
Use the SSC as a performance improvement initiative to identify gaps in care and specific
areas for improvement (Table 1).
Table 1
Sepsis nursing quality of care indicators
Sepsis care metric
Indicator
Time to perform blood culture sampling
Nursing quality indicator
1 (a) Blood culture (BC) sampling
Proportion of sepsis cases in which BCs were sampled
Measured: (n cases with BCs sampled/total number of sepsis cases) × 100
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\begin{document}$$ \frac{{n{\text{ cases with blood cultures sampled}}}}{{{\text{total
}}n{\text{ of sepsis cases}}}} \times 100 $$\end{document}
n
cases with blood cultures sampled
total
n
of sepsis cases
×
100
1 (b) Timing of blood culture sampling
Proportion of sepsis cases in which BCs were sampled before starting antimicrobial
Measured: (n cases with BCs sampled before start of antimicrobial therapy/total n
of sepsis cases in which blood cultures could be sampled without substantially delaying
the start of antimicrobial therapy) × 100
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\begin{document}$$ \frac{\begin{aligned} n{\text{ cases with blood cultures sampled
}} \hfill \\ {\text{before start antimicrobial therapy}} \hfill \\ \end{aligned} }{\begin{aligned}
{\text{total }}n{\text{ of sepsis cases in which blood cultures could be sampled }}
\hfill \\ {\text{without substantially delaying the start of antimicrobial therapy}}
\hfill \\ \end{aligned} } \times 100 $$\end{document}
n
cases with blood cultures sampled
before start antimicrobial therapy
total
n
of sepsis cases in which blood cultures could be sampled
without substantially delaying the start of antimicrobial therapy
×
100
Time to start antimicrobial therapy
2. Antimicrobial therapy (time to administration of antimicrobials once they have
been prescribed by the physician or advanced practice provider)
Proportion of cases in which antibiotic (AB) therapy was started within 30 min after
prescription
Measured: (n cases in which AB therapy was delivered with 30 min post prescription/total
n of sepsis cases with a prescription of a new antimicrobial therapy or a switch in
current therapy) × 100
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\begin{document}$$ \frac{\begin{aligned} n{\text{ cases in which antimicrobial
therapy was started }} \hfill \\ \text{ < } 3 0 {\text{min of prescription}} \hfill
\\ \end{aligned} }{\begin{aligned} {\text{total }}n{\text{ of sepsis cases with a
prescription of a new antimicrobial therapy}} \hfill \\ {\text{ or a switch in current
therapy}} \hfill \\ \end{aligned} } \times 100 $$\end{document}
n
cases in which antimicrobial therapy was started
<
30
min of prescription
total
n
of sepsis cases with a prescription of a new antimicrobial therapy
or a switch in current therapy
×
100
Time to reach fluid bolus goals
3 (a) Time to fluid bolus goals (time to administration of fluids once they have been
prescribed by the physician or advanced practice provider)
Proportion of cases in which fluid therapy was started within 30 min after prescription
Measured: (n cases in which fluid therapy was started within 30 min post prescription/total
n of sepsis cases in which fluid therapy was prescribed) × 100
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\begin{document}$$ \frac{\begin{aligned} n{\text{ cases in which resuscitation
fluids }} \hfill \\ {\text{were started }}\text{ < } 3 0 {\text{min of prescription}}
\hfill \\ \end{aligned} }{\begin{aligned} {\text{total }}n{\text{ of sepsis cases
in which }} \hfill \\ {\text{resuscitation fluids were prescribed}} \hfill \\ \end{aligned}
} \times 100 $$\end{document}
n
cases in which resuscitation fluids
were started
<
30
min of prescription
total
n
of sepsis cases in which
resuscitation fluids were prescribed
×
100
3 (b) 30 mL/kg of crystalloid fluid be given within the first 3 h (unless contraindicated)
Proportion of cases in which 30 mL/kg of crystalloid fluid was given within the first
3 h unless this was contraindicated
Measured: (n cases in which 30 mL/kg of crystalloid fluid was administered < 3 h of
prescription)/total n of sepsis cases in which resuscitation fluid was prescribed) × 100
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\begin{document}$$ \frac{\begin{aligned} n{\text{ cases in which 30mL/kg was administered
}} \hfill \\ {\text{ < 3h of prescription}} \hfill \\ \end{aligned} }{\begin{aligned}
{\text{total }}n{\text{ of sepsis cases in which }} \hfill \\ {\text{resuscitation
fluid were prescribed}} \hfill \\ \end{aligned} } \times 100 $$\end{document}
n
cases in which 30mL/kg was administered
< 3h of prescription
total
n
of sepsis cases in which
resuscitation fluid were prescribed
×
100
Time to perform blood lactate monitoring
4. Time to blood lactate monitoring (time to obtaining initial lactate level)
Proportion of cases in which lactate level was drawn within 30 min after prescription
Measured: (n cases in which lactate level was drawn < 1 h of sepsis onset/total n
of sepsis cases in which blood lactate level can be monitored*) × 100
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\begin{document}$$ \frac{\begin{aligned} n{\text{ cases in which blood lactate
was monitored }} \hfill \\ {\text{ < 1h of sepsis onset}} \hfill \\ \end{aligned}
}{\begin{aligned} {\text{total }}n{\text{ of sepsis cases in which }} \hfill \\ {\text{blood
lactate level can be monitored}} \hfill \\ \end{aligned} } \times 100 $$\end{document}
n
cases in which blood lactate was monitored
< 1h of sepsis onset
total
n
of sepsis cases in which
blood lactate level can be monitored
×
100
Maintaining glucose control
5. Glucose blood value levels < 180 mg/dL
Proportion of cases in which glycemia was < 180 mg/dL within 6 h of onset of hyperglycemia
Measured: (n cases in which glucose blood value levels were (< 180 mg/dL) < 6 h/total
n of sepsis cases presenting with hyperglycemia) × 100
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\begin{document}$$ \frac{\begin{aligned} n{\text{ cases in which glucose was normalized
}}\left( {{ < }\; 1 8 0 {\text{mg/dL}}} \right) \, \hfill \\ { < }\; 6 {\text{h of
onset hyperglycemia}} \hfill \\ \end{aligned} }{{{\text{total }}n{\text{ of sepsis
cases presenting with hyperglycemia}}}} \times 100 $$\end{document}
n
cases in which glucose was normalized
<
180
mg/dL
<
6
h of onset hyperglycemia
total
n
of sepsis cases presenting with hyperglycemia
×
100
Family care conference to address goals of care
6. Patients receiving family care conference to address goals of care within 72 h
of ICU admission
Proportion of cases in which patients received family care conference to address goals
of care within 72 h of ICU admission
Measured: (n cases in which a family care conference was held to address goals of
care within 72 h of ICU admission/total n of sepsis cases with an ICU admission of > 72 h) × 100
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\begin{document}$$ \frac{{n{\text{ cases in which a family care conference was
provided}}}}{{{\text{total }}n{\text{ of sepsis cases with an ICU stay > 72h}}}} \times
100 $$\end{document}
n
cases in which a family care conference was provided
total
n
of sepsis cases with an ICU stay > 72h
×
100
Total sepsis bundle performance
7. Compliance to all aforementioned quality indicators
Proportion of cases in which all elements of the sepsis bundle were implemented
Measured: (n cases in which all elements of the sepsis bundle were implemented/total
n of sepsis cases) × 100
*In settings where blood lactate monitoring is not readily available (low resource
countries), this indicator can be omitted from the quality control
Time to perform blood culture sampling.
Time to start antimicrobial therapy.
Time to reach fluid bolus goals.
Time to perform blood lactate monitoring.
Maintain compliance with all elements of the sepsis bundles.
Using these components as quality indicators, nurses can assess, evaluate, and report
on the implementation of SSC recommendations and help to improve care for patients
with sepsis (Supplemental content).
6.
Advocate for patient- and family-centered care to improve sepsis care outcomes.
Promote patient and family awareness of sepsis, including addressing the needs of
families of critically ill patients, setting goals of care, and holding family care
conferences to discuss goals of care.
7.
Ensure infection prevention measures are implemented for all critically ill patients.
Adhere to recommendations regarding healthcare-associated infection prevention.
The ultimate aim of updating clinical practice guidelines is to improve patient care.
As critical care nurses implement many of the sepsis care interventions as part of
nursing care, ensuring nurses’ awareness of the SSC guidelines is essential to maximize
benefit for critically ill patients. By instituting measures that are based on the
SSC guidelines, critical care nurses can improve care for patients with sepsis and
help to ensure that critically ill patients with sepsis receive expert nursing care
to promote optimal outcomes worldwide.
Electronic supplementary material
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