Nursing Considerations to Complement the Surviving Sepsis Campaign Guidelines

Leanne M. Aitken, RN, PhD, FRCNA; Ged Williams, RN, MHA; Maurene Harvey, RN, MPH; Stijn Blot, RN, Cc, RN, MNSc, PhD; Ruth Kleinpell, RN, PhD; Sonia Labeau, RN, MNSc; Andrea Marshall, RN, PhD; Gillian Ray-Barruel, RN, Grad Cert ICU Nursing, BA (Hons); Patricia A. Moloney-Harmon, RN, MS, CCNS, FAAN; Wayne Robson, RN, MSc; Alexander P. Johnson, RN, MSN, ACNP-BC, CCNS, CCRN; Pang Nguk Lan, RN, MSc; Tom Ahrens, RN, DNS, FAAN

Disclosures

Crit Care Med. 2011;39(7):1800-1818. 

In This Article

Abstract and Introduction

Abstract

Objectives: To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis.
Design: Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus.
Methods: We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding.
Results: Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points.
Conclusion: Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.

Introduction

Sepsis, including severe sepsis and septic shock, continues to be a major healthcare problem internationally. Although mortality related to severe sepsis and septic shock have reduced slightly in the past decade, it remains >20%.[1,2] As part of the response to optimize care for this group of patients, evidence-based clinical practice guidelines have been published by the Surviving Sepsis Campaign (SSC) to facilitate clinicians to improve the outcomes of patients with sepsis and septic shock.[3,4]

Although the SSC guidelines[4] provide a comprehensive review of the medical management of patients with sepsis and septic shock, they are frequently silent on the nursing care that is essential for optimal outcome of these patients. Expert nursing knowledge and skill are required for both the identification of the deteriorating patient as a result of newly developed sepsis and the ongoing implementation of competent care for the known severe sepsis patient. The World Federation of Critical Care Nurses, as the premier organization for critical care nurses worldwide, consequently formed an international group of interested experts in the area to provide guidance for nursing care of severe sepsis patients.

This care is provided by every registered nurse, as well as many of the advanced practice nurses (e.g., Nurse Practitioner, Clinical Nurse Specialist, or Consultant) who practice in the acute hospital setting. Internationally, advanced practice nursing roles vary in scope, education, and authorization. Although the scope and requirements for some of these roles are designated by legislation, for example, the scope of practice of the nurse practitioner, many of the roles are professional extensions of the registered nurse role. Given this variation in nursing roles from one region or country to another, we have not attempted to limit the recommendations contained within this document to care provided only by registered nurses, but have extended it to cover the practice of all nurses, regardless of their specific role.

Most of these recommendations relate to the adult septic patient, with the majority of interventions not tested in the pediatric patient. Despite this, many of the recommendations are likely to be applicable to the pediatric setting. Throughout the document, we have identified where specific information confirming or denying application to patients in specific age groups exists. Recommendations specific to the pediatric septic patient are contained within a section later in the article.

Although this article is designed to provide guidance for every nurse who cares for patients with severe sepsis, we also have provided recommendations regarding practice in areas of joint responsibility with other members of the healthcare team. For example, nurses frequently influence which central venous catheters or endotracheal tubes are purchased and used, as well as provide care related to the device after insertion. In addition, although most nurses do not order drugs, they do participate in protocol development and often advocate for the timely ordering and administration of medications important to patient outcomes in severe sepsis. Consequently, it is essential that nurses are familiar with the best available evidence.

Of note, this document is not designed to provide information regarding strategies for implementation to ensure practice is based on these recommendations. Rigorous and comprehensive implementation and evaluation strategies are essential but constitute a separate body of knowledge and as such are not reviewed in this document. Clinicians are encouraged to become familiar with appropriate strategies before implementing the recommendations outlined throughout this document. Therefore, the aim of this review is to provide a series of recommendations, based on the best available evidence, to guide clinicians providing nursing care to patients with severe sepsis.

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