A Look at Sepsis

Sepsis Definition

 

In Non-Coronary intensive care units within the United States, sepsis is the leading cause of death Current estimates place the mortality rate between 28 and 50%. Sepsis, however, does not refer to a specific bacteria, but rather to the body’s immune response to an overwhelming infection. Infections, at any point on the body, can lead to sepsis. In hospitals, common sites of the initial infection include IV catheters, surgical sites, and pressure ulcers.

 

Pathophysiology

 

Within normal circumstances, the body’s immune response seeks to increase blood flow and the capabilities of macrophanges to control an infection. .

 

In response to the foreign antigen, the body releases pro-inflammatory mediators such as prostaglandins, tissue necrosis factor, cytokines, and platelet-activating factors. These mediators damage the delicate endothelial lining, leading to capillary leakage. Additionally, they activate neutrophils (which release nitric oxide) and lead to edema. Platelet-activating factors begin to circulate systematically, and coagulation is increased. Together, these effects create symptoms of hypotension, edema, and microthrombi which impair the perfusion of tissues and lead to multi-organ failure.

 

Signs and symptoms

 

Hypothermia, tachycardia, tachypnea, peripheral vasodilation/edema, unexplained shock, and unexplained mental status changes all can indicate sepsis. The CBC will indicate infection and clotting factors will be noted.

 

Prevention

 

The only way to reduce the incidence of sepsis is to prevent infection. Strict adherence to policies regarding IV site care and careful monitoring and treatment of surgical site infections are the best way to prevent healthcare-associated infections leading to sepsis.

 

Surviving Sepsis

 

Sepsis Bundles are evidence-based clinical recommendations for the treatment of sepsis and septic shock. Originally introduced by The Surviving Sepsis Campaign, these bundles have proven to be effective when used together to combat sepsis.

 

The term “bundle” refers to a series of evidence based protocols that are used together. When implemented together, these elements have greater results than any of the interventions used alone. Hospitals are meant to use the bundles as a framework for creating sepsis protocol in their institutions.

 

What’s in the Bundles?

 

Once a patient is triaged in the ED or identification is made of symptoms consistent with severe sepsis, the following steps are to be taken:

 

TO BE COMPLETED WITHIN 3 HOURS:

1) Labs: Lactate levels

2) Obtain blood cultures

3) Administer broad spectrum antibiotics after blood cultures are done

4) Give 30 ml/kg of crystalloid for hypotension or lactate =4 mmol/L

 

TO BE COMPLETED WITHIN 6 HOURS:

5) Give vasopressors (for hypotension not responding to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) =65 mmHg

6) In the event of persistent hypotension after fluid resuscitation (MAP < 65 mm Hg) or if initial lactate was =4 mmol/L, re-assess volume status and tissue perfusion and document findings

7) Re-measure lactate if initial lactate was elevated.

 

DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH

• Repeat focused exam by independent licensed provider (vital signs, assessment of perfusion, fluid status)

OR TWO OF THE FOLLOWING:

• CVP
• ScvO2
• Bedside cardiovascular ultrasound
• Assessment of fluid responsiveness using passive leg raise (does the patient show an increase in stroke volume?)

 

Successful implementation should strive for a twenty five percent reduction in mortality from Sepsis within their organization

 

Interested in learning more about evidenced based nursing care. CNE Explorer is a US based online provider of continuing education for nurses and provides online CE courses to nurses around the world.

Medical Errors

Medical errors are preventable adverse events that result from medical care, and they are the third leading cause deaths in the US!

 

Medical errors include everything from adverse medication events, surgical site infections or wrong-site surgery, blood transfusion errors, falls, pressure ulcers, and other complications. Medical errors with serious consequences are most common in intensive care units, operating rooms, and emergency departments.

 

What Are the Causes of Medical Errors?

 

Most medical errors are not due to one group or the actions of a single individual, but rather from faulty systems and processes that allow people to make mistakes or fail to prevent them.

 

Many hospitals use computerized systems that flag suspicious orders for review as well as flagging drug allergies and drug incompatibilities. These safety mechanisms are meant to make it harder for people make mistakes and seek to reduce errors. Many hospitals are still in the process of moving to electronic MARs and computerized documentation systems, though, and these systems and others are not foolproof.

 

How Can Medical Errors Be Reduced?

 

One way hospital seek to address medical errors is through root cause analysis (RCA).  This method is used to analyze medical errors, accidents, and serious adverse events. Root cause analysis seeks to find the underlying issues that lead to mistakes being made while avoiding blaming individuals. RCA allows the identification of patterns that can reveal where systems may be improved to increase safety. Staff are still held responsible for their actions, but when an error occurs, blaming an individual does little to make the system safer or to prevent the same error from occurring again.

 

Communication failures are commonly cited as the cause of most medical errors, and the Joint Commission has focused efforts on improving hand off communication and preoperative time outs to remedy this. Proving organized and thorough information about your patient in hand off is a great way to ensure that nothing is overlooked.

 

Part of preventing medical errors is building a culture of safety by focusing on root causes instead of blame. This in turn improves morale and communication among staff, one of the best ways to ensure safety and continuity of care for patients.

Interesting in learning more about evidence based nursing? Visit CNE Explorer.com for evidence based online continuing education.

More on Sepsis and Nursing

Sepsis is one of the most serious conditions in health care facilities around the world. As such, it is crucial for nurses to be up to date on the clinical presentations and protocols in order to provide prompt intervention.

 

What Is Sepsis?

Sepsis is best defined as a complication of a bacterial, fungal or viral infection within the body. Severe inflammation in response to the chemicals released in the body to fight infection can cause varying degrees of sepsis. Sepsis can occur anywhere in the body – including, but not limited to the, brain, bloodstream, heart, and lungs.

 

Sepsis Risk Factors:

• Immunosuppressive diseases (HIV and AIDS)
• Patients with chronic illnesses (diabetes and cardiovascular disease)
• Pediatric or Geriatric Patient populations are at higher risk
• Patients who have undergone invasive procedures (intravenous line, surgery)
• Patients with Drug-Resistant bacteria
• Patients with severe wounds
• Patients currently hospitalized in the ICU

 

Sepsis Signs and Symptoms

There are three general categories of Sepsis (Sepsis, Severe Sepsis, and Septic Shock). The earlier the condition is identified, the higher the likelihood of survival.

 

Sepsis

Diagnosis is made when at least two of the following symptoms are present:

Fever above 101F or below 96.8 F

Rapid heartbeat greater than 90beats/ minute

Rapid breathing greater than 20breaths/ minute

Possible or confirmed infection

 

 

Severe Sepsis

Diagnosis of severe sepsis occurs when one of the items listed below is also present – this may begin to indicate organ failure:

Chills

Weakness

Confusion

Significant decrease in urine output

Difficulty breathing

Unconsciousness

 

Septic Shock

Diagnosis is made with any of the signs and symptoms of severe sepsis along with extremely low blood pressure.

 

How Nurses Can Help Prevent Sepsis

Early detection and intervention can improve a patient’s chances of survival. Regular and consistent nursing assessments can identify early signs and symptoms and help to initiate a plan of care.

The following are recommended:

Know signs and symptoms

Regularly monitor at risk patients

Be sure to clean or change IV lines, catheters, or breathing tubes (per hospital policy) in order to prevent the growth of microorganisms

Aseptic technique and hand washing protocols should be followed at all times

Teach patient to recognize complications

 

Interested in learning more evidence based guidelines for nursing care? Visit our sister site at www.cneexplorer.com for more online nursing CE.

 

Nursing Specialties – 5 In Demand Specialties

We are all familiar with the current nursing shortage within the United States and the expectation that nursing needs will continue to grow within the United States. As our profession continues to grow, the demand for various nursing specialties will also grow. Currently there are over 100 nursing specialties in the United States and it can often be difficult to keep up with the ever growing list. We decided to list 5 of the fastest growing nursing specialties here:

Critical Care Nurse

Critical care nurses work within a team of health care providers to make sure critical patients in the hospital (or other facility) get the best care possible. Demand in this specialty is expected to increase by at least 25% through 2020.

Diabetes Nurse

A diabetes nurse works with patients who have diabetes. As our population continues to age, the number of patients with diabetes will increase proportionately. Accordingly the need for diabetes nurses is expected to grow as much as 39%!

Gerontological Nurse Practitioner

A gerontological nurse practitioner is a nurse who has gone through the nurse practitioner certification process and who works with elderly populations. As our population continues to age, the specialty is in high demand. The large need for these specialty nurses is expected to increase by over 25% through 2020.

Informatics Nurse

The informatics nurse’s job is to collect, interpret, and relay necessary medical data coming from and into hospitals, clinics, doctor’s offices, and nursing homes. Informatics nurses also help to design or implement new technology and processes for a variety of nursing interests. At the most basic level, job growth for medical records administrators is projected to be 22%. Advances in technology will affect this both positively and negatively.

Medical-Surgical Nurse

The image of a registered nurse working within a hospital or surgical center is the common image most of the American public entertains. Around 17% of all nurses work within this specialty at any time – making it the largest nursing specialty. Overall demand for medical-surgical nurses is expected to increase by 30% through 2020.

 

Interested in learning more about the growing nursing field and how nursing continuing education can help you get there? Visit CNE Explorer for more information.

Looking Into Infiltration and Extravasation

Infiltration and Extravasation are two commonly overlooked IV complications that are often tough to detect and can cause serious damage. The IV Complication referred to as Extravasation is best defined as the accidental administration of a vesicant fluid or solution into the surrounding tissue area. The term infiltration refers to the accidental administration of a non-vesicant fluid or medication into the surrounding tissues.

 

In both situations, the amount of tissue damage depends on the type of drug or fluid being infused and the amount of time that it remains in the tissue area before being discovered. Tissue damage can range in severity from mild instances to tissue necrosis requiring surgical intervention.

 

There are a variety of reasons why infiltration or extravasation may happen in some patients. These include:

• Selecting an Improper Site (insertion over an area of flexion for example)
• Traumatic insertions that have caused damage to the internal lining of the vessel.
• Inadequate securement of the intravenous device (catheter tip penetrates the catheter wall or the catheter slips out of the vessel)
• Improper device utilization for a specific treatment
• Obstructions to blood flow around or through the catheter

 

Patients with small sclerosed veins (diabetes or atherosclerosis) are at an increased risk of infiltration or extravasation. Children, elderly patients, and patients who are unable to communicate clearly with the staff are at an increased risk of complications. Without a doubt, prevention is the ideal strategy in regards to infiltration and extravasation. Several prevention oriented strategies are:

 

• Accept that these complications can occur and educate staff, patients and family on the early identification of signs and symptoms.
• Quickly respond to complaints of pain or discoloration at the insertion site.
• Monitor patients with IVs regularly – employ a standardized method for visually inspecting an insertion.
• Protect the infusion site form excessive movement.
• Avoid areas of flexion.
• Have a prepared policy and process in place for handling different types of infiltrations and extravasations.

 

Despite our best efforts, infiltration and extravasation can still occur. As health care providers we must be prepared and aware of the most recent evidence based guidelines for handling these sorts of situations. Facilities should actively encourage learning opportunities for providers and hands on learning programs. However, professionals should never be limited by the amount of on-the-job training available. For interested nurses, there is a large amount of content available online that focus on intravenous insertions and complications. Of course, these nursing ceu programs are by no means substitutes for hands on learning, they are options for nurses seeking to learn more about the subjects.

The Made Up Bed Time Story – HPV Vaccines and Risky Teen Sex

When the initial HPV (human papillomavirus) vaccine was released in 2006, it was met with a large public outcry in the United States from concerned parents, pediatricians, and politicians. One of their key claims was that vaccination of pre-teen and teen girls would lead to increases in riskier teen sexual behavior.

 

The main thought was that vaccination would provide teens with a false sense of protective security, and therefore encourage engaging in riskier sexual activities. Researchers immediately began to structure studies that would investigate the claim, and several studies began across the nation.

 

The research conclusions were that there was no evidence suggesting a link in riskier teen sexual behaviors among vaccinated teens. Despite the evidence, proposed ideas of mandatory HPV vaccines have stirred up considerable controversy throughout the nation. The predominantly cited reasons for adult opposition were that it was either not necessary for their child or that their child was not sexually active. Physicians have also expressed concern about discussing sexual activity and behavior with pre-teen patients.

 

Over 1/3 of all schools still teach abstinence only sexual education programs in the United States. HPV is spread through sexual contact; thus, encouraging the vaccination of pre-teen girls means acknowledging sexual activity in pre-teens at a legislative level. Accordingly, this caused emotional responses from many parent, politicians, and physicians and has led to requests to defer vaccination to an older age.

 

The concept of mandatory HPV vaccines is not revolutionary – Western European countries, the United Kingdom, Canada, and Australia have all since incorporated HPV vaccines into the required school vaccine schedules. The HPV vaccine is unique in that it is one of the few known drugs to directly reduce the risk of specific cancers.

 

To keep the issue in perspective – cervical cancer was once the leading cause of cancer related death in The United States (during the early twentieth century). The introduction of regular pap smears and a better understanding of the HPV virus led to reduce the prevalence of the cancer to where it affects 12,000 women annually (with 4,000 annual deaths).

 

Internationally, cervical cancer is a very different situation. It is the second most common cause of cancer related death among women and disproportionately affects women during their child bearing years. Over 80% of all cervical cancer cases occur in the developing world (over 300,000 women die each year) and the disease affects women financially, socially, and emotionally.

 

For one of the few times in human history we have a chance to protect our children and young ones from serious illness. As both health care providers and global citizens, it is our duty to minimize the barrier for access to the drugs – regardless of the potential emotional uncomfortableness.

Interested in keeping up to date on evidence based nursing practice? Visit CNE Explorer.com for a variety of online cne, free articles, and more. This guest post was sponsored by CNE Explorer.

The Story and Growth of Evidence Based Medicine

Evidence Based Practice and Medicine as we commonly know it has had an interesting story so far. Today it is viewed as the standards by which patient care should be developed; however, as recently as twenty years ago it was a very controversial topic.

 

Evidence based medicine truly began to gain momentum in the late 19th century thanks to a small group of French Clinicians. French physician Claude Bernard was one of the first to begin to question the clinical efficacy of the common practice of bloodletting for pneumonia patients. Bernard helped to introduce the idea that comparative trials and experiments could have a positive effect on clinical practice. At the time, this idea was protested vigorously by a majority of physicians who believed that medicine was a form of art based solely on a physician’s intuition and experience. Popular physicians of his time believed that there was no tangible value in comparative trials and statistics.

 

From then on the idea advanced dramatically. Experiences during the first and second world wars led many nurses and physicians to search for ways to increase patient safety. Technological advances in the areas of sanitation, anesthesia, etc. helped to spur tremendous advances and innovations in technology and communication helped to communicate these new findings to a now global audience Clinicians around the world began to consult journals and textbooks and gain inspiration from diligently recorded trials and experiments.

 

Throughout the late 80s, 90s, and 2000s the growth of the computer, the internet, and the ability to save and sort through large amounts of data quickly and reliably changed the way that we think about Evidence based concepts. By the mid-2000s the majority of large peer reviewed journals had content online and easily accessible.

 

Despite all of the advances, the idea of evidence based medicine still faced considerable opposition. As late as the mid-1990s, US physicians warned that evidence based practices would create cookbook style medicine and doctors who did not personalize the care to the patient. Further, they warned that the movement itself was being driven by ignorant non-doctors who only sought to lower costs and make more money running hospitals.

 

 

It is worth mentioning that the large availability and access of information can be a double-edged sword – there exists a risk of incorrect information being spread widely. This can be exemplified by the false clinical trials that occurred in the British study concerning the link between vaccines and autism in the late 1990s. Although the study was later revealed to be a hoax, and the physician was found to have financial ties to a lawyer suing vaccine manufacturers, the information quickly spread around the world and is still being used as ammunition in the anti-vaccine debates throughout the modern world.

 

Today we define evidence based medicine as the ability to integrate individual clinical experience and the best external evidence. The ultimate goal being to improve patient care and patient safety within the organization. The term “best external evidence” refers to patient centered studies, trials, experiments, and data reviews that are applicable to the specific issue. Presently, the vast majority of nurses and physicians are comfortable with the concept of evidence based medicine and nursing practice as a driver for making appropriate clinical decisions. In order to stay up to date with the best available evidence both physicians and nurses have mandated amounts of continuing education (CE) that is required each licensing cycle. Most continuing education providers seek to create and provide material that is focused on evidence based material for a specific topic. Moving forward, it is crucial that we continue the practice of rigorous introspection – constantly asking, “How can we make this better?” “Is there a safer way to do this?” and “How can I measure that this is working?”

MERS: A Follow-Up

Although MERS (Middle East Respiratory Syndrome) seems to have faded to the back off international consciousness after the troubling Ebola outbreaks in Africa and Measles outbreaks in the United States it has continued to infect and kill individuals in the Middle East.

Beginning in 2012, this mysterious virus emerged in Saudi Arabia and has spread to the neighboring countries in the region. Over 1,000 individuals have had confirmed cases of the illness with over 300 deaths resulting from illness related complications. The virus itself, originating from the family of coronaviruses, is similar in structure to the SARS virus that affected China and Southeast Asia earlier in the decade.

Many elements of the disease are not well understood. Researchers believe that the disease’s natural reservoir is zoonotic in nature, however the exact animal is not known. The exact course of the disease is not fully understood and the median time between onset and death is 12 days. Patients present with a wide range of symptoms related to respiratory illnesses and DNA matching of the virus is often needed to confirm a diagnosis.

The virus is transmitted via person-to-person contact with infected individuals. All cases have been linked in some way to travel or residence to the Middle East and further investigation is needed to better understand how exactly the disease is transmitted from humans-to-animals and from person-to-person.

Of particular concern and risk are individuals who have come into contact with Camels (MERS-CoV virus has been found in camels), who have traveled to the Middle East and have developed symptoms within 14 days of traveling, and health care providers who have treated patients with the MERS virus. Currently, WHO and UN researchers have been unable to trace the origins of disease clusters and are worried about continued transmission in the region and abroad. Currently, there is no cure for the disease and all treatment options work to manage the disease related symptoms.

There are further worries that the number of cases is actually much higher than has been reported. Civil unrest, conflict, and weak health care reporting infrastructure in many areas of the Middle East may have contributed to a significant number of cases going unreported. The actual number of cases and associated deaths may be significantly higher than currently estimated.

It is essential that health care providers seek to prepare their teams for the possibility of handling a MERS patient. To do this, continuing education and forward planning will be absolutely crucial to helping organizations be prepared for a possible encounter for this mysterious virus.

The Centers for Disease Control and Prevention and the World Health Organization have already issued up to date articles and guides for both health care providers and individuals in regards to the virus. Further, there are a variety of online nursing continuing education providers who have prepared material concerning the most current evidence based nursing guidelines for screening and handling a potential MERS patient. The novelty of the virus is not an excuse for unpreparedness – in the current world of global travel and commerce the possibility of several US cases is very real and very timely.