Lauren Waltman and Frances Zondlo

SEPSIS EDUCATION TO IMPROVE RECOGNITION1

In Emergency Department nurses, does nursing education improve recognition of signs and symptoms of sepsis and knowledge of a hospital sepsis protocol?

Lauren Waltman and Frances Zondlo

The Pennsylvania State University-Capitol Campus

Abstract

The purpose of this capstone research project was to determine if increasing awareness, education, and knowledge of a sepsis protocol bundle improved identification of signs and symptoms of sepsis. Multiple evidence-based research articles were utilized to address this purpose. It was found in result comparison of pre and post quizzes provided to emergency department nurses, that identification of sepsis improved when staff was provided with educational materials. The research revealed that with increased knowledge, nurses were more confident in their abilities to better care for patients and enabled to more quickly identify the signs and symptoms associated with sepsis. It was also identified that nurses need to increase communication, both nurse to nurse and nurse to doctor, to decrease the lag time in care.

Keywords: sepsis, protocol bundles, nurse education, patient outcomes, signs and symptoms

Problem Statement

Sepsis is a quick and sometimes silent killer among hospitalized patients. There has been a growing incidence of sepsis, severe sepsis, and septic shock. Turi and Von Ah (2013) state that sepsis affects approximately 750,000 Americans annually. Even more shocking is that fact that between 28 to 50% of those cases end in death, which has made sepsis now the 10th leading cause of death (Turi and Von Ah, 2013).

These authors were intrigued by these statistics and researched into why this is occurring. After reviewing information about sepsis knowledge within the medical field, it was determined that the severity and time-sensitivity of sepsis is not at the highest priority. Furthermore, these writers concluded that this lack of knowledge could be aiding in the number of sepsis cases each year. Without the appropriate knowledge base, nurses, who are on the frontlines, are not fully equipped to catch the subtle signs that indicate sepsis. Even more on the frontline of patient care are emergency department nurses, whom are tasked with quick and efficient assessment of patient complaints to give the doctor the best shot at a correct diagnosis.

Therefore, the PICO question proposed for this capstone project is in Emergency Department nurses, does nursing education improve recognition of signs and symptoms of sepsis and the utilization of a hospital sepsis protocol? As these writers completed capstones in the Harrisburg Hospital emergency department, it was determined that this topic is pertinent and sustaining with the continued growth in sepsis cases annually.

Kliger, Signer, and Hoffman (2015) found that when a Nurse Leadership program was implemented into study hospital in order to reduce sepsis, there was a decrease in mortality rates. However, there was a marked increase in the number of reported cases of severe sepsis/septic shock. These researchers believe that when there was increased knowledge of the signs and symptoms of sepsis, the so-called silent killer was more readily diagnosed. In a similar study by Delaney, Friedman, and Fitzpatrick (2015), it was stated that there was an increased risk of mortality by 7.6% for each hour that sepsis goes undiagnosed.

Based on the above information and review of Harrisburg Hospital’s current sepsis protocol, these writers determined that more light needs to be shed on this disease to increase nurse knowledge and, ultimately, patient outcomes. By testing baseline knowledge and increasing education of sepsis, this disease can be better managed and save lives.

Literature Review

Search of the Literature

In order to gain knowledge on sepsis, nurse knowledge, and protocol bundles, these authors completed an electronic search of the current literature using PubMed, Nursing Reference Center, and CINAHL. To narrow the search, the following search terms were used: “sepsis protocol bundles”, “nurse utilization of sepsis bundles”, “emergency department sepsis protocols”, “nursing”, “knowledge”, “sepsis”, “baseline”, “nursing education”, “early detection of sepsis”, “detection of sepsis”, “nurse impact”, and “patient outcomes using sepsis protocol.” The articles were reviewed based on support for nurse education and increasing knowledge of sepsis, determination of increasing education to increase septic patients outcomes, and nurse utilization of a sepsis protocol bundle and patient outcomes in adult patients presenting to the ED with suspected sepsis.

Critical Appraisal of the Evidence

Nurse’s Knowledge of Sepsis

In reviewing the literature, it is daunting to see the results and confidence of nurses with regard to, first, identification of sepsis. Robson, Beavis, and Spittle (2007) surveyed 73 nurses to gather baseline information about their ability to detect and identify sepsis, including the signs and symptoms. The authors’ survey included identification of the SIRS criteria; five case studies, in which the nurses had to identify if the patient had sepsis and then what would be the appropriate intervention(s); and ten true or false questions that outlined the standard definitions of sepsis. Based on the results of the audits, it appeared that nurses in the study did not have a solid understanding of sepsis and all of the criteria that aid in classification. It is common knowledge that a high temperature is a key sign of infection and either a high (>38 oC) or low (<36 oC) temperature is one of the criteria for a SIRS diagnosis. 97% knew that a high temperature was a sign, whereas only 22% of surveyed nurses knew that a low temperature could also indicate sepsis (Robson et al., 2007). Elevated lactate levels are another diagnostic indication of sepsis, but this survey found that there was “general lack of awareness among ward nurses” to this regard as nurses responded that they were unsure when questioned about lactate levels (Robson et al., 2007).

Nurses’ Confidence with Sepsis Diagnosis

As novice nurses are emerging from school and entering the workplace, confidence is an area that needs improvement as knowledge and experience increase. One study, performed on the use of educational programs to increase nurse knowledge, shed light on confidence of nurses in identifying sepsis (Delaney, Friedman, Dolansky, & Fitzpatrick, 2015). In this study, nurses participated in a pre-and posttest that included an educational component series between the tests to increase knowledge. The tests examined the nurses in the following areas: “Institute for Healthcare Improvement (IHI) bundles, health literacy and cultural competency, TeamSTEPPS communication and teamwork, and staging sepsis” (Delaney et al., 2015). Of importance to note, the tests also questioned the nurse’s confidence in identifying signs and symptoms of sepsis, ability to treat septic patients, and confidence to get the team on the same page for early goal-directed therapy (EGDT) (Delaney et al., 2015). After the educational programs were completed, the nurses underwent similar testing to determine effectiveness of the education on the nurse’s knowledge and confidence. It should be noted that the subjects of this study were nurses in a yearlong fellowship for emergency and critical care nursing.

Based on the posttest results from the multimodal educational program, the education was shown to improve the nurse’s knowledge of sepsis, increase abilities to identify sepsis, and, most importantly, increase their confidence in their abilities to perform the above (Delaney et al., 2015). Confidence plays a key role in the nurse’s abilities to care for their patients effectively. Having all of the knowledge without the confidence to speak up and advocate for their patient, is a disservice to the patients that are entrusted into our care.

Use of Early-Goal Directed Therapy to Improve Outcomes

Rivers et al. (2001) was a study done on patients with sepsis that resulted in the largest improvement in mortality outcome based off of early-goal directed therapy (EGDT). These authors discussed that most patients with sepsis would be admitted to the ICU; however, treatment for sepsis should start prior to the ICU, specifically in the ED. The authors state, “The transition to serious illness occurs during the critical “golden hours,” when definitive recognition and treatment provide maximal benefit in terms of outcome” (p. 1368). The purpose of the study was to determine whether EGDT before admission to the ICU would improve mortality rates in patients with severe sepsis or septic shock.

Rivers et al. (2001) found that in-hospital mortality was significantly higher in the standard care group when compared to the EGDT group. The authors found significant benefits in outcomes when therapy was implemented at an earlier stage of disease. It was also stated that earlier identification of sepsis leads to earlier treatment of the illness, thus opening the doors for future researchers to study recognition of the signs and symptoms of sepsis.

Use of a Sepsis Protocol Bundle to Improve Outcomes

The Surviving Sepsis Campaign (SSC) is somewhat of the “gold standard” for what many hospital protocol bundles are based on currently. The 2012 guidelines are the most recent steps for healthcare providers to take in order to properly execute the treatment for patients with sepsis. The campaign uses expert opinion to evaluate research studies and grade the recommendations on their effectiveness for providers to be informed of the most effective care to be given to patients. The guidelines include that the following should be done within 3 hours from the time of presentation to the ED: measure serum lactate level, obtain blood cultures prior to antibiotic infusion, and infuse 30 mL/kg of an intravenous (IV) crystalloid solution in patients with hypotension (SBP <90 mmHg) or hyperlactemia (serum lactate level of 4 mmol/L or greater) (Dellinger et al., 2013).

Wang, Xiong, Schorr, and Dellinger (2013) and MacRedmond et al. (2010) both conducted studies that aimed to compare patients and outcomes before and after the implementation of a sepsis bundle in the ED. The overall results of both studies were that in-hospital mortality significantly decreased in patients after a protocol was implemented. These authors noticed that it seemed both studies had mortality statistics that were mirrored images of compliance with the bundles.

Yealy et al. (2014) was yet another study based on the Rivers et al. study completed in 2001. This study was conducted with the mindset that treatment for sepsis had drastically changed since the Rivers study and thus set out to see if all of the elements of the Rivers protocol were still a necessity. The study concluded that mortality rates of the protocol groups did not differ significantly from the usual care group. These authors believe that these results may have been erroneous due to the fact that the one protocol group allowed the treating physicians to choose which vasopressors and fluid to treat the patients with, which was no different than the usual care group that allowed the providers to direct all care. The results of this study also could have been inaccurate because the authors discuss how the same trained physician-led team implemented both of the protocols. Perhaps using the same team could have influenced the results in a way that did not represent accuracy.

Education of Staff on Sepsis and Protocol

A theme in almost all of the research articles evaluated in this literature review involved some sort of education of staff on sepsis and the protocol that was to be used. Much of the education was of the ED nurses and physicians through mandatory online learning or regular meetings about the SSC’s guidelines and the protocol that would be put into place. The issue that this author identifies is the concern of a Hawthorne effect. If training was completed before the protocol was implemented, perhaps the use of it by the staff was influenced by the education. The staff could be on high alert of the damage sepsis can cause and the need for timely treatment of these patients, and thus results may have been skewed. This would be a good thing in the “real-world;” however, this may have influenced the results of the studies evaluated in this review and produced erroneous results. Tromp et al. (2010) did things a bit differently and initiated training six months after initiation of the sepsis protocol, instead of before initiation like many of the other studies discussed in this review. It was discussed that possibly recognition of the signs and symptoms of sepsis could be a barrier to recognition by nurses. Outcomes of the patients in this study significantly improved when nurses were educated and involved in the initiation of the sepsis protocol.

MacRedmond et al. (2010) focused on the education of ED nurses on what sepsis is and how early recognition can help improve outcomes. The researchers also looked at things a bit differently with the education provided. Since most of the patients with sepsis are admitted to the ICU after the ED, the researchers focused on bridging the gap between the ICU and ED nurses and had the ED nurses pair up with an ICU nurse for further practice on monitoring and treating these patients.

Action Plan

Since the beginning of the 21st century, sepsis has become an increasingly more prevalent mass murderer. The Center for Disease Control’s (CDC) National Center for Health Statistics (NCHS) (2014) stated that from 2000 to 2008 there was a near 50% increase in the number of reported sepsis cases in the United States. Dumont and Harding (2013) state that severe sepsis accounts for almost 500,000 ED visits annually in the United States. It is because of these startlingly statistics that these authors planned to evaluate and shed light on this growing and deadly disease.

These authors intended to research if educating emergency room nurses on the signs and symptoms of sepsis as well as using a sepsis protocol will aid in earlier identification of sepsis and improve patient outcomes. This study was performed at Pinnacle’s Harrisburg Hospital ED, where these authors completed their capstones. These researchers utilized their preceptors/team members to gain participation of unit RNs. This study’s results were shared with the unit manager to aid in further investigation and education of the staff.

Twenty emergency department staff nurses completed a pre-quiz to obtain baseline information of sepsis knowledge. The quiz can be found in Appendix A. The quiz was comprised of four sections to evaluate nurses’ knowledge of sepsis, knowledge of hospital protocol for sepsis, and confidence in recognition and treatment of sepsis. Data was compiled from each section and translated into percentages based on participants’ responses.

These researchers intended to develop an educational bulletin board to be posted in the unit break room. The educational board was to be posted for two weeks in order to allow for all participating nurses to review the presented information. However, due to environmental restraints, these researchers formulated an educational flyer to be distributed to the participants. This decision was made to provide participants with handheld information that could be easily referenced and re-obtained if necessary. The information on the flyer reflected the areas of knowledge deficit of the nurses based on the pre-quiz results that are crucial for sepsis identification and protocol utilization. The flyer outlined the following information (see Appendix C):

1)Definition of sepsis and septic shock.

2)SIRS (Systemic Inflammatory Response Syndrome) criteria as per Pinnacle Health’s Protocol. See Appendix B.

3)Sepsis alert protocol used at Pinnacle’s ED

4)Lactate levels

5)Important facts about sepsis.

The educational flyer and post-quiz were hand delivered to the same twenty staff nurses. At that time, nurses were instructed to review the educational material and complete the post-quiz. Nurses were excluded from this study if they were unable or unwilling to participate in the educational phase or the post-quiz. The post-quiz was comprised of the same four sections as the pre-quiz which included evaluating nurses’ knowledge of sepsis, knowledge of hospital protocol for sepsis, and confidence in recognition and treatment of sepsis. The post-quiz results were compiled and translated into percentages to aid in easy comparison to the pre-quiz results. This allowed determination of the efficacy of the implementation of an educational flyer in the unit. The post-quiz can be found in Appendix D.

These authors utilized the same quiz prior to and after providing the educational materials to ensure continuity of results. Participants were not made aware of the correct answers after completing the pre-quiz in order to limit skewed results due to memorization.

In addition, these authors added a post-quiz addendum to evaluate if the educational materials were beneficial in aiding in the nurses’ education about sepsis and the protocol in place at Pinnacle. The addendum was also added to evaluate if the authors’ goals, listed above, were met. This addendum was put in place with the goal of sharing the results with the nurse manager of the unit to aid in possible future staff education.