By Ilene B. Gottesfeld, Ed.D, RN; Clinical Development Specialist, Medical Simulation Corporation
How many of us have known someone with sepsis?
How many have experienced sepsis personally either among family members, friends, colleagues—even ourselves?
As professionals we are acutely aware of the increased profile of sepsis of late. But do we know why it has risen to such a level of importance in discussion or why it has become a critical quality initiative? Do we fully understand the implications of sepsis, even in its early stages? Do we know the stages of the sepsis and its progression? Have we been trained to recognize early signs and symptoms? Are we current on the latest revision of the Surviving Sepsis Campaign Guidelines? Do we know and adhere to specific protocols to treat patients with sepsis criteria? Is our facility committed to providing resources to effectively treat sepsis patients and decrease morbidity and mortality?
If you have answered no to any of the questions posed, or if your curiosity is piqued, please read on. If your experience and practice provide you with valuable insights, please share them with us. Help us to be more proficient and successful in our care of sepsis patients.
Some Context for the Urgency about Sepsis
A healthy 12 year-old boy falls and cuts his arm in gym class. The cut is bandaged, and he returns to his daily routine. By midnight the following evening, he feels ill and experiences sharp leg pains and vomiting. He awakens the next morning with a fever of 104° F and increased leg pain. His pediatrician suggests antipyretics (alternating acetaminophen and ibuprofen) and fluids. Symptoms progress throughout the day, with chills and bruising on his body. He is no longer able to tolerate food or fluids. Unable to stand by 6 pm, he is taken to the pediatrician’s office, vomited, examined (“cut ‘looked ok’ and leg unremarkable”), rapid strep test performed (negative), and he is sent to the hospital for rehydration with the diagnosis of ‘Flu.’ An hour later he is in the ER, assessed (“vital signs, physical examination, and blood work”) and rehydrated intravenously. Based on review of symptoms, he is again diagnosed with the flu and sent home 2 hours later with an antiemetic. CBC results (following discharge) exhibit elevated WBC and increased bands. The family is not contacted. The next morning his status is appreciably worse: diarrhea, fever, and increased bruising. By evening the bruising has become even more widely distributed across his body, and petechiae are visible: The slightest touch is painful, his toes are cold, and his nose is cyanosed, as are the lateral aspects of his body. A call to the pediatrician sends him back to the ER. He is subsequently admitted to the ICU, placed on oxygen, and diagnosed with Streptococcus pyogenes (Strep A). His status continues to deteriorate, and by the following day he is in septic shock, sedated, intubated, and mechanically ventilated. Over the next 48 hours, his organ systems shut down (“MODS – multiple organ system dysfunction”): Hypoperfusion, oliguria, inability to clot, and more. He is successfully resuscitated twice. The third event is unsuccessful.
The Greater Significance of This Tragedy: Would We Know What We Would Do Differently?
What does all of this mean to us as responsible professionals? It impacts our performance and speaks to our need to be more aware of symptoms that may indicate or at the very least, suggest sepsis. Should we have heightened awareness of early signs and symptoms of the sepsis continuum? It is necessary for us to be knowledgeable regarding current sepsis management practices and what we should do if we were in that same situation. Would we have recognized that this could be sepsis or dismissed it as a ‘normal’ childhood injury with coincidental flu-like symptoms?
We would like to think that if in this situation, our actions would be different, and the outcome would be changed. But we can’t change the events of the past we can only impact the present and future. The questions then are: What can we do, how can we do it, and when? And why is this so critical?
Nationwide, the incidence of sepsis is greater than 750, 000 cases annually. Of those cases, mortality is estimated between 25 and 50%. Each hour of delay in antibiotic therapy increases the mortality risk by 7%. In New York State (where this young boy lived and died), the number of severe sepsis cases increased 68% over a 6 year period (from 26,001 in 2005 to 43,608 in 2011), and the number of sepsis cases in that same time frame increased 41% (71,049-100, 073). Mortality ranged from 15-37% during that time. While percentages vary state-to-state, some with higher incidence, some lower, the problem persists.
What Can We Do to Fight Sepsis?
There are many ways we can impact those numbers institutionally and individually. The New York State Department of Health states, in a recent publication: ‘A patient may have a greater chance of dying from sepsis if care is provided by an institution ill-prepared to deal with this illness or from providers not thoroughly trained in identifying and treating sepsis.’ They have since required all hospitals in the state to adopt protocols to identify and treat sepsis. Many facilities in other states have actively implemented strategies or have had them in place for years.
Clinical-based research has demonstrated the success of adherence to practice guidelines in decreasing the morbidity and mortality of sepsis. Evidence has shown that early recognition and treatment significantly reduces the progression of the sepsis continuum. Recent publication of the 2012 Surviving Sepsis Campaign Guidelines underscores the critical nature of heightened awareness, identification, and early intervention.
As healthcare professionals it is in our DNA to strive to make a difference. As individuals we can impact outcomes by actively expanding our knowledge of sepsis; helping to develop protocols where there are none; increasing compliance with protocols, procedures, and processes; apply our critical reasoning skills and consider possibilities other than what might be ‘standard’ presentation (sepsis is often subtle in its initial presentation); listen to what the patient has to say.
There is no single solution. But provider compliance with evidence-based practice guidelines does significantly decrease the morbidity, mortality and financial burden of sepsis. We can play a role in the process. We just need to be motivated to do so.
About the Author
Ilene Gottesfeld EdD, RN, serves as a clinical development specialist and educator for Medical Simulation Corporation. She has over 40 years of clinical nursing experience focusing primarily on pediatric and cardiovascular nursing as well as 20 years of higher education and instructional design experience focusing on curriculum development for all venues. She joined MSC in 2012. Ilene has worked closely with physician and nurse leaders on the development of web-based and Simulation-based Education Programs. Ilene has served as a clinical nurse specialist and Pediatric Nurse Practitioner in the care if children and adults with congenital and acquired heart disease. She also has coordinated nursing simulation laboratories and served as program chair of an associate degree nursing program. Ilene received a bachelor’s degree in nursing from Boston University, a master’s degree in nursing from University of Florida, a post-master’s certificate nurse practitioner from Molloy College, and doctorate in instructional design and distance education from Nova Southeastern University.
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