First, they must be able to recognize early signs of sepsis and the factors that heighten the risk of dying from the condition. The very young, the very old and people with significant chronic illness are particularly at risk. Early signs are rooted in systemic inflammatory response syndrome (SIRS) criteria, many of which are already programmed for alerts in most electronic health records, but experts would agree that the following symptoms should spur nurses into action:
- Delirium
- Extreme high or low temperatures
- Shortness of breath
- Extreme pain or discomfort
- Elevated heart rate
- Cool and clammy skin
In most cases when they see these conditions, nurses should immediately administer the qSOFA (quick sequential organ failure assessment) test to identify patients with suspected severe sepsis who are at greater risk for poorer outcomes. It uses three criteria, assigning one point for low blood pressure (SBP≤100 mmHg), high respiratory rate (≥22 breaths per min), or altered mentation (Glasgow coma scale ≤13).
A positive score of two or more means that it’s time to call the attending physician, nurse practitioner or physician’s assistant, or initiate the rapid response team to assess the patient and begin administering the sepsis bundles. In some hospitals, the nurses have autonomy to initiate the sepsis bundle based on predetermined criteria because of the Surviving Sepsis Campaign’s recommendation that bundle implementation should occur within the first hour of onset of severe sepsis or septic shock.
For that reason, though most hospitals have the bundles in standard order sets, bedside nurses should know these elements by heart:
- Measure lactate level. Re-measure if initial lactate level > 2 mmol/L.
- Obtain blood cultures before administering antibiotics.
- Administer broad-spectrum antibiotics.
- Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L.
- Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg.
While this is the standard approach for most cases, it’s also where a bedside nurse’s understanding of the patient is essential, because he or she may have information on co-morbidities or vital measures that will help the healthcare provider modify the orders appropriately. And, of course, it is always important to do subsequent evaluations to see how a patient is responding.
Finally, and perhaps most importantly, managing sepsis is true team-based care. Having the right numbers, the right people and the right type of collaborative environment–one where nurses are viewed as equal partners–is the key to reducing the mortality rate for this critical condition.
