Clinical Care

Adult Sepsis Update

Statistics

Sepsis is a costly and deadly disease with over 350,000 patient deaths annually in the United States.1  Mortality rates are approximately 24% for sepsis and 35% for septic shock with one out of every three patients who die in a hospital having had sepsis sometime during their stay.1,2 Nearly 87% of patients usually develop sepsis from an infection outside the hospital, and it is recognized in the emergency department or first 24 hours.1 However, sepsis recognition for inpatients is vital. These patients who progress to sepsis from an infection acquired in the hospital are sicker, meaning they have even higher morbidity and mortality than patients who develop sepsis in the community.1 Alarmingly, 75% of sepsis survivors may also go on to develop post-sepsis syndrome which includes long-term physical, cognitive, and psychological issues along with an increased risk of readmission, reduced long-term health, and increased mortality.3

Definitions

Sepsis is defined as a life-threatening organ dysfunction which is caused by the patient’s response to an infection.4 Septic shock is a subset of sepsis in which patients have profound hypotension requiring vasopressors despite receiving adequate fluid resuscitation.4 Sepsis always starts with an infection which is typically bacterial although while less common, the cause can be viral including COVID-19, fungal, or parasitic infections.5 The four top locations for bacteria related sepsis are pulmonary, urinary tract, skin, and gastrointestinal.6

Screening tools and clinical tests are important to alert caregivers to suspicion of infection and sepsis so that management and timely evidence-based treatment can begin. Early treatment is known to save lives; however, identification of sepsis continues to be challenging. Research has not shown superiority of any one screening tool and guidelines recommend that hospitals use both a sepsis screening tool and a standard response to positive screening or electronic medical record alerts.,7 There is also currently no standardized test for sepsis with the diagnosis made based on clinical signs and symptoms along with suspicion of infection and new organ dysfunction.7,8 While sepsis-induced organ dysfunction varies between patients, some examples are included below as shown in Table 1.

Table 1: Examples Sepsis-related Organ Dysfunction4,7,8

Vital signs

Fever, tachycardia, tachypnea, hypotension

Neurological

New change in mental status, delirium

Cardiac

New cardiac arrythmia

Pulmonary

New requirement for oxygen

Invasive or non-invasive ventilation

Renal

Low urine output

Hepatic

Coagulopathy

Laboratory values

Increased creatinine

Increased bilirubin

Increased WBC

Decreased platelet count

Increased serum lactate

qSOFA score
  •   Respiratory rate ≥ 22 /minute
  •   Altered mentation
  •   SBP ≤ 100 mm Hg

Used in patients screened positive for sepsis to determine organ dysfunction. A score of ≥2 criteria is considered positive in non-ICU sepsis patients.

SOFA score
  •   PaO2/FiO2 ratio
  •   Glasgow Coma Score
  •   Mean arterial pressure
  •   Vasopressor use
  •   Increased creatinine or low urine output
  •   Decreased platelets

Used in patients screened positive for sepsis to determine organ dysfunction. Scored serially with a score ≥2 considered positive for organ dysfunction for ICU sepsis patients.  

 

Bundles and Management

Sepsis is a medical emergency. The sepsis bundle should be implemented as soon as possible upon recognition or suspicion.7 There are two sepsis management bundles: the Surviving Sepsis Campaign (SSC) Sepsis Bundle and the Severe Sepsis and Septic Shock Management Bundle (SEP-1), which are similar but also have distinct differences. 9,10 See Table 2.

Table 2: Surviving Sepsis Campaign Sepsis Bundle9 and Centers for Medicare & Medicaid SEP-1 Bundle10

 

SSC Sepsis Bundle

CMS SEP-1 Bundle

Timeframe

1-Hour Bundle

3- and 6-hour Bundle

Process measure

Prospective bundle to be implemented at recognition of sepsis.

Retrospective bundle determined on chart review by 3 clinical criteria or documentation by physician/ARPN/PA of severe sepsis/sepsis.

Clinical criteria must be met within 6 hours of each criteria.

1. Presence infection documented

2. 2 or greater SIRS criteria

  • Temperature > 38.3 C or < 36 C
  • Heart rate > 90
  • Respiration > 20
  • White blood cell count > 12,000 or < 4,000 or > 10% bands
3. 1 Organ dysfunction
  • Systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg
  • Systolic blood pressure decrease of > 40 mmHg
  • Acute respiratory failure
  • Creatinine > 2.0 mg/dl
  • Urine output < 0.5 mL/kg for 2 hours
  • Total bilirubin > 2 mg/dl
  • Platelet count < 100,000
  • INR > 1.5 or PTT > 60 sec
  • Lactate > 2 mmol/L

Lactate
  • Measure initial level
  • Remeasure within 6 hours if initial level > 2 mmol/L
  • Measure initial level
  • Remeasure within 6 hours if initial level > 2 mmol/L
  • Remeasure within next 6 hours if repeat level is higher that initial level

Blood cultures

Obtain prior to antibiotics

Obtain prior to antibiotics

Fluids
  • hypotensive, resuscitate with 30 mL/kg crystalloid fluid

OR

  • initial lactate, level ≥ 4 mmol/l

 
  • Within 3 hours of persistent hypotension, resuscitate with 30 mL crystalloid fluids

OR

  • Within 3 hours of initial lactate level ≥ 4 mmol/l

Vasopressors
  • If hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mmHg
  • Within 6 hours of septic shock, if persistent hypotension after fluids or initial lactate ≥ 4 mmol/L

Repeat volume status and tissue perfusion assessment

 
  • Within fluid administration start time and 6 hours after septic shock and Physician/APRN/PA documentation of 1 of the following,

1. Sepsis reassessment

2. Review of 5 of 8 parameters:

  • Oxygen saturation
  • Capillary refill
  • Cardiopulmonary assessment
  • Peripheral pulses
  • Shock index
  • Skin color
  • Urine output
  • Vital signs
3. One of the following measures:
  • Central venous pressure
  • Central venous oxygenation
  • Echocardiogram
  • Fluid challenge or passive leg raise

 

As shown in Table 2, the SSC sepsis bundle consists of steps that should be implemented within one hour of suspicion or recognition.8 The bundle components can be measured prospectively in real time based on when sepsis was identified and can provide quality improvement data.

In contrast, the SEP-1 bundle is a composite measure for discharged patients coded by providers for sepsis and was adopted by the Centers for Medicare & Medicaid (CMS) in 2015.10 The measure is publicly reported and requires that all measures must be met to “pass”. Data is obtained from a comprehensive retrospective chart review approximately 2–3 months after discharge and publicly reported on CMS Hospital Compare under quality of care.11 The SEP-1 bundle is a complex detailed measure with approximately 83 data points and has an additional bundle measure not included in the SSC sepsis bundle, requiring provider documentation of sepsis reassessment in septic shock.9 In 2023, CMS announced that the SEP-1 bundle measure would be included in its value-based incentive program beginning in fiscal year 2026 which will affect hospital reimbursement.12

Take-Home Points

Sepsis remains a deadly diagnosis with high mortality and morbidity for our patients. While recognition can be elusive at times, nurses are crucial in knowing their patients and recognizing those early signs of sepsis to ensure timely treatment for best outcomes. Know your facility’s sepsis alert criteria, guidelines, and treatment policy. If there is any suspicion of an infection with sepsis, start your health system’s sepsis protocol and notify the provider. Sepsis can occur in any patient, anytime, and any hospital unit and early treatment can save lives.

SUSPECT SEPSIS AND SAVE A LIFE!

For additional sepsis resources, visit the AMSN Library and search “sepsis” for on-demand education.

References

  1.  Dantes Raymund B, Kaur Hemjot, Bouwkamp BA, et al. Sepsis program activities in acute care hospital-national healthcare safety network, United States, 2022. MMWR. 2023;72(34):907-911.
  2.  Bauer M, Gerlach H, Voglemann T, Preissing F, Stiefel J, Adam D. Mortality in sepsis and septic shock in Europe, North America and Australia between 2009 and 2019- results from a systematic review and meta-analysis. Crit Care. 2020;24:239. doi:10.1186/s13054-020-02950-2.
  3.  van der Slikke EC, Beumeler LF, Homqvist M, Linder A, Mankowski RT, Bouma HR. Understanding  post-sepsis syndrome: how can clinicians help? Infect Drug Resist. 2023;16:6493-6511.
  4.  Singer M, Deutschman C, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-810.
  5.  World Health Organization. (2024, May 3) Sepsis, key facts. World Health Organization website. Accessed April 30, 2024. https://www.who.int/news-room/fact-sheets/detail/sepsis#:~:text=Common%20signs%20of%20sepsis%20include,as%20viruses%2C%20parasites%20or%20fungi.
  6.  Centers for Disease Control and Prevention. (2024, March 8). About sepsis. Centers for Disease Control and Prevention website. Accessed June 19, 2024. https://www.cdc.gov/sepsis/about/ .
  7.  Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
  8.  Jacobi J. The pathophysiology of sepsis-2021 update: part 2, organ dysfunction and assessment. Am J Health-Syst Pharm. 2022;79:424-436.
  9.  The Society of Critical Care Medicine and the European Society of Intensive Care Medicine. (2019, January 11). Hour 1 bundle, initial resuscitation for sepsis and septic shock. Surviving Sepsis Campaign website. Accessed May 7, 2024. https://www.sccm.org/sccm/media/PDFs/Surviving-Sepsis-Campaign-Hour-1-Bundle.pdf.
  10.   Centers for Medicare and Medicaid Services. Version 5.15a-Specifications manual for discharged 01/01/24-06/30/24. Quality Net Centers for Medicare and Medicaid Services website. Accessed April 29, 2023. https://qualitynet.cms.gov/inpatient
  11.  Centers for Medicare and Medicaid Services. Hospital compare website. Accessed June 29, 2024. https://hospitalcompare.io/
  12.   Centers for Medicare and Medicaid Services. FY 2004 hospital inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS) final rule-CMS-1785-F and CMS-178-F fact sheet. Accessed May 2, 2024. https://www.cms.gov/newsroom/fact-sheets/fy-2024-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0.
  13.   For additional sepsis resources and information, please visit the AACN website.

Content published on the Medical-Surgical Monitor represents the views, thoughts, and opinions of the authors and may not necessarily reflect the views, thoughts, and opinions of the Academy of Medical-Surgical Nurses.

Tags: Clinical Care, Sepsis