Learn new ways to treat, monitor septic patients
(Editor’s note: This is the second of a two-part series on care of sepsis patients in the ED. This month, we cover educational strategies for emergency nurses regarding practice changes to comply with new guidelines. Last month, we covered new approaches for assessment and intervention in the ED.)
"I think we’ve got a septic one." Statements like this from triage nurses at Beth Israel Deaconess Medical Center in Boston are now commonplace, due to a complete revamping of treatment for sepsis in the ED.
"These patients are now identified quickly," says Duane A. Young-Kershaw, RN, BSN, ED clinical nurse educator. "Nurses have a sort of sepsis sense’ and have a much higher index of suspicion for sepsis."
EDs are dramatically changing the way they care for sepsis patients to comply with new recommendations for "early goal-directed therapy" from the Surviving Sepsis Campaign, a group formed jointly by the Belgium-based European Society of Intensive Care Medicine, the Des Plaines, IL-based Society of Critical Care Medicine, and the United Kingdom-based International Sepsis Forum. (See resources, below, for more information on the guidelines.) This means that ED nurses need to learn new interventions and monitoring skills, underscores Young-Kershaw.
Previously, treatment in the ED was aimed at addressing symptoms related to sepsis such as hypotension, but current approaches call for early interventions and intensive monitoring, he explains.
When the ED’s "Multiple Urgent Sepsis Therapies" protocol was implemented, ED nurses were very skeptical at first, says Young-Kershaw. "They asked, How are we going to run this protocol in a busy trauma center?’" he recalls. "We answered that early goal-directed therapy has a decreased mortality of 16%, and we’re obligated to do it."1
ED nurses now are well versed in the interventions for each specific parameter of the protocol, reports Young-Kershaw. These include monitoring central venous pressure (CVP) to adequately ensure proper volume repletion, mean arterial pressure (MAP) to assess for perfusion, and saturation of central venous oxygen (ScvO2) and serum lactate to indicate tissue hypoxia, he says.
You can implement a sepsis protocol in your ED by doing the following:
• Give inservices for monitoring.
The No. 1 challenge was teaching ED nurses to set up CVP monitoring equipment, says Mary Stauss, RN, MSN, APN, CEN, advanced practice nurse for the ED at the Cooper Health System in Camden, NJ, where an Early Goal-Directed Therapy Protocol for severe sepsis was implemented. "Invasive hemodynamic monitoring is not a common practice in EDs," she says.
Over a six-week period, Stauss gave one-on-one inservices to ED nurses to explain the algorithm and practice changes. She used the actual equipment to demonstrate set up of CVP and ScvO2 monitors. Seeing the CVP and ScvO2 levels improve gives nurses a sense of accomplishment, since they may not see obvious clinical improvements while the patient is in the ED, she adds.
"Using hemodynamic monitoring such as CVP and ScvO2 provides the nurse with real-time values. The algorithm includes target values," says Stauss. "As the patient improves, the CVP and ScvO2 values move toward the target — providing the nurse and physician with confirmation that the interventions are indeed working."
An ED nurse with intensive care unit experience gave a 30-minute course on setting up and troubleshooting a CVP monitor, says Young-Kershaw. "Nurses were instructed on what the ScvO2 level means for the septic patient," he says. "The algorithm gives treatment guidelines to increase this level in a patient."
While most ED nurses are familiar with basic pathophysiology and mortality of sepsis, nurses needed updating on the most current approaches, adds Young-Kershaw. "Communicating that the mortality of sepsis is nearly that of acute myocardial infarction clarified the importance of rapid identification and intervention for these patients," he says.
• Make documentation easier.
The ED’s trauma and critical care flow sheets were combined into one form containing the sepsis algorithm and pre-printed order sets for physicians to sign. "The nurses like the ease of use and one stop,’ all-inclusive function of the tool," says Young-Kershaw. "Orders, documentation, and guidelines are now all in the same place."
• Give clear criteria to "rule in" patients for the protocol.
If patients present with suspected infection and two of the four systemic inflammatory response syndrome criteria, they are "ruled in" for the sepsis protocol, says Young-Kershaw. (See criteria in box below.) About 15 patients are enrolled in the protocol every month, he reports.
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ED’s criteria rules in’ patients for sepsis protocol ED nurses at Beth Israel Deaconess Medical Center in Boston use the following criteria to "rule in" patients for the Multiple Urgent Sepsis Therapies protocol:
Plus two of the following:
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If nurses are unsure whether a specific patient meets the criteria or have problems calibrating the ScvO2 line prior to insertion, a "code sepsis" is used to page clinical educators available 24 hours a day. "We are also looking into a triage protocol where we will be using a device that gives us a bedside’ lactate level," adds Young-Kershaw.
Reference
1. Rivers E, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1,368-1,377.
Sources/Resources
For more information on educating nurses on sepsis care, contact:
- Mary Stauss, RN, MSN, APN, CEN, Advanced Practice Nurse, Emergency Department, The Cooper Health System, One Cooper Plaza, Suite 901A, Keleman Building, Camden, NJ 08103-1489. Telephone: (856) 968-8678. E-mail: [email protected].
- Duane A. Young-Kershaw, RN, BSN, Clinical Nurse Educator, Emergency Department, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215. Telephone: (617) 754-2310. E-mail: [email protected].
The Institute for Healthcare Improvement’s web site (www.ihi.org) offers tools and resources to implement the guidelines developed by the Surviving Sepsis Campaign. Go to www.ihi.org. Click on "Topics," "Critical Care," and "Sepsis."
This is the second of a two-part series on care of sepsis patients in the ED. This month, we cover educational strategies for emergency nurses regarding practice changes to comply with new guidelines. Last month, we covered new approaches for assessment and intervention in the ED.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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