Early recognition of sepsis in hospitalized patients and timely, protocol-driven interventions are spelled out for critical care nurses in new international guidelines.

"Critical care nurses play an important role in identifying patients with sepsis and these guidelines reinforce certain management areas that nurses directly oversee," Ruth Kleinpell, PhD, RN, from Rush University, in Chicago, Illinois, told Medscape Medical News.

"We are focusing on earlier management of patients because we know how that affects patient outcomes," she said.

The guidelines, part of the Surviving Sepsis Campaign, were first published earlier this in year in Critical Care Medicine and Intensive Care Medicine .

A document detailing the nursing implications of these new guidelines was presented at the American Association of Critical-Care Nurses (AACN) 2013 National Teaching Institute and Critical Care Exposition, held in Boston, Massachusetts.

Recently published in the American Journal of Critical Care, the guide outlines key management steps nurses must take within 3 hours of severe sepsis and within 6 hours of initial signs and symptoms of septic shock (2013;22:212-222).

We are focusing on earlier management of patients because we know how that affects patient outcomes.

Previous guidelines published in 2008 suggested that nurses have a 6-hour and a 24-hour window to carry out protocol-defined steps.

This change reflects a new focus on early identification and initiation of treatment, said Dr. Kleinpell and her copresenter Christa Schorr, RN, assistant professor of medicine, Cooper Medical School of Rowan University, in Camden, New Jersey.

Within 3 hours of severe sepsis, nurses must:

  • Measure lactate level

  • Obtain blood cultures before dispensing antibiotics

  • Administer broad-spectrum antibiotics

  • Give 30 mL/kg crystalloids for hypotension or lactate ≥4 mmol/L

Within 6 hours of initial signs and symptoms of septic shock, nurses must:

  • Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg)

  • In the event of persistent arterial hypotension despite volume resuscitation or initial lactate ≥ 4 mmol/L (36 mg/dL), nurses must measure central venous pressure and measure central venous oxygen saturation

  • Remeasure lactate level if initial lactate level was elevated

"There are a total of 13 things that need to be done within the first 6 hours," Schorr said. "And if those things are done, you are maximizing the opportunity for patients to have a good outcome."

Another key change from previous guidelines is establishing goals of care and the need to hold family care conferences within 72 hours of intensive care unit (ICU) admission to discuss the patient's prognosis.

"These changes should help ensure that patients are receiving goal-oriented treatment," Dr. Kleinpell said. "And they reinforce the use of palliative care as well as end-of-life care for patients in whom these treatment options would be best."

Performance Improvement

 The focus on the new Surviving Sepsis Campaign is not only on the early identification and treatment of patients, but on the recognition that nurses are critical to performance improvement and data collection.

"This process doesn't just come from the ICU, it comes from the [operating room] or from the floors or from the [emergency room] so this is a multi-disciplinary, cross-departmental disease process and critical care nurses are getting patients at whatever point they become critical," Schorr explains.

So if a patient is identified as septic in the ER, for example, initiation of treatment starts there before they are admitted to the ICU.

Because nurses are responsible for each of the steps, they are in the right position to gather data as the process unfolds from the ER to the ICU and provide feedback to physicians and other members of the critical care team along the way.

"It's a continuous loop," Schorr notes, "and that's what really makes a significant difference."

Asked to comment on the importance of nurses implementing the new sepsis guidelines, Thomas Ahrens, PhD, RN, research scientist, Barnes-Jewish Hospital, St. Louis, Missouri, pointed out that nurses are at the bedside so often they are the first to recognize that a patient is developing sepsis.

"The ability to quickly recognize sepsis and begin therapies is what is going to drive saving lives," he said. "If sepsis gets a toehold and starts to take effect, there are very few effective treatments and mortality will rise. So if nurses are well prepared, then patients with sepsis are recognized early and the nurses can be the first to react."

Dr. Kleinpell and Dr. Schorr have disclosed no relevant financial relationships. Dr. Ahrens is the chief learning officer for an online learning company, Novice to Expert.

American Association of Critical-Care Nurses (AACN) 2013 National Teaching Institute and Critical Care Exposition: Abstract C75M479. Presented May 21, 2013.


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