Promoting early identification of sepsis in hospitalized patients with nurse-led protocols

Recently, studies focusing on ward-based nurse screenings for sepsis have also demonstrated benefit. A study from Norway targeted early identification of in-hospital sepsis by ward nurses [8]. As part of the Mid-Norway Sepsis Study, the study assessed the impact of a bundle intervention consisting of a flow chart for sepsis identification and physician notification and a clinical tool for triage of patients exhibiting signs of sepsis and organ failure. Additionally, a 4-h training course was provided to all nurses and nursing students working on the wards that included content on pathophysiology, signs of sepsis, and treatment recommendations, including the importance of fluid resuscitation, antibiotic therapy, and monitoring and communication of patient vital signs and condition status changes.

In comparison to a pre-intervention group of 472 patients with confirmed blood stream infection during a 2-year period, 409 patients with confirmed blood stream infection in a 2-year post-intervention period were found to have higher odds of surviving 30 days (odds ratio (OR) 2.7, 95% confidence interval (CI) 1.6–4.6), lower probability of developing severe organ failure (0.7, 95% CI 0.4–0.9), and, on average, 3.7 days (95% CI 1.5–5.9 days) shorter length of stay [8].

Another nurse-based early recognition and response program integrated an early sepsis screening tool into the electronic health record, screening and response protocols, and education and training of nurses with twice-daily screening of hospitalized patients and was found to be associated with reductions of inpatient sepsis-associated death rates [9]. These studies demonstrated significant differences not only in sepsis treatment but also length of stay and survival rates—positive outcomes that have not been consistently demonstrated in other studies of nurse-led screening or protocol use.

A recent multihospital quality improvement program focused on early detection and treatment of sepsis on general medical–surgical wards. Sixty sites engaged in a collaborative implementation process that used a basic screening tool and guidance for routine severe sepsis screening, monitoring, and feedback, and a structured scripted communication framework using the SBAR (situation, background, assessment, and recommendation) technique aimed to improve communication [10]. Key to the success of the initiative was an understanding that the training and experiences of ED, ICU, and ward nurses varies, necessitating that nurse education contain critical assessment skills to determine when to suspect a new or worsening infection.

The role of nurses in quality improvement of sepsis care is significant. As nurses spend the majority of time with patients, their role in the recognition and treatment of patients with sepsis is critical to improving sepsis-related outcomes [11, 12]. Educating all staff about sepsis management and the translation of guidelines into clinical practice can enhance the nurses’ ability to identify sepsis and implement early therapy measures [13]. Additionally, ensuring adequate education for nursing staff is a vital component to establishing highly functional sepsis screening and sepsis management protocols (Table 1).

Targeting early recognition of sepsis with use of multifaceted performance improvement initiatives has been demonstrated to improve compliance with sepsis performance measures with associated reductions in hospital mortality in patients with severe sepsis and septic shock in ICU and ward settings [8, 9, 14]. However, as sepsis remains a leading cause of mortality in critically ill patients worldwide, additional studies are needed to determine the most effective way to achieve sepsis bundle targets, including the incorporation of nurse-led screening and treatment protocols.