SEPSIS PATHWAYSLisa Wong , Clinical Nurse, Cancer Care Services

Royal Brisbane and Women’s Hospital

Image taken from ("SEPSIS TOOLKIT INPATIENT GUIDELINE", 2018)

Introduction

Sepsis is a global issue with rising numbers of

oncology presentations. Current issues when

dealing with sepsis arise with the late detection

of deterioration and sepsis in patients and then

the treatment is delayed. The associated

mortality rates due to severe sepsis and septic

shock range from 25 to 70%. Early detection

and the introduction of a clinical sepsis

pathway is instrumental in improving patient

outcomes.

Sepsis a Global issue

Image taken from ("Toolkits", 2018)

Definition of

Sepsis

Image taken from ("Sepsis

(Septicemia) Treatment", 2018)

Recognising Sepsis

Sepsis occurs as a result of infection, signs suggestive of infection include:

Fever and/or rigors

Hypothermia

Cough, increased sputum production or dyspnoea

Abdominal pain or distension

Dysuria, urinary frequency, odour

New onset confusion or decreased level of consciousness

Recent surgery or invasive procedure with cellulitis or wound infection

Line associated redness/swelling/pain

Painful swollen joint

MeningismImage taken from ("Sepsis Awareness Month Toolkit", 2018)

Stories

about sepsis

Case Study 1.

Coroner’s case: Final report August 2018

Mr Brown was a 64year old man who died at a regional public hospital on

24 May 2016. Mr Brown’s medical history shows he has poorly controlled

type 2 diabetes, right Knee amputation, Chronic obstructive

pulmonary disease and VRE positive.

Events as

follows:

22 May 2016- Patient was noted to be unwell with vomiting and bowel problems. Nursing home notified his doctor of his condition.

At 7.30pm, his observations were recorded BP 105/75. PR 93, Temp 36.8. Ambulance was called and patient transported to reginal private hospital emergency.

8.15pm On arrival patient complained the room was spinning when he sat up, and his eyes were hurting. His observations at 8.20pm were RR 20, Spo2 99% on RA. BP 105/55, HR 95, Temp 35.8.

At 9.00pm Bloods were taken and 1 hour later his observations were taken. RR 19, Spo2 97% on RA, BP 100/60, HR 80, and Temp 36 and patient alert.

Event as

follows:

23 May- Initial urine microscopy results were suggestive of a urinary tract infection. No antibiotics were commenced

despite the consideration of a possible underlying infection.

At 2.00am IDC was inserted and inter-hospital transfer has been organised.

At 11.50pm his observations were RR 20-24, Spo2 95-97% on RA, BP 90/50, HR 100s, no temperature and level of

consciousness were recorded.

At 11.00pm Patient was reviewed, urine microscopy and intravenous fluids were commenced at 11.15pm followed by

chest x-ray at 11.40.

Event as

follows:

The last set of observations were performed at

3.40am and showed significant drop in patient’s

BP 84/42, PR 110, reduced levels of

consciousness. Despite these observations

meeting MET call criteria, the inter hospital

transfer proceeded.

At 5.50am, Blood cultures returned positive for

Staphylococcus epidermis and coagulase

negative Staphylococcus.

Patient arrived at the larger regional hospital

around 11.00 am and was admitted to ICU. His

condition deteriorated and died on May 24. The

pathologist determined the cause of death to

be septic shock.

1. Develop and implement a cognitive assessment

tool/pathway for the emergency department

2. Implementing a sepsis pathway

3. Deliver education to develop critical

reasoning/Critical thinking.

4. Review clinical handover processes (from

residential aged care facility to hospital).

5. Ongoing education, audit and feedback to staff on

clinical documentation standards.

Following this inquest these recommendations were

made:

Case Study

2. July 2018

Mr S, a 65-year male patient presented to outpatients with sepsis and survived. Mr S’s background medical history is MDS undergoing systemic chemotherapy for 8 weeks. Previous perforated peptic ulcer and partial gastrectomy.

Events as follows:

June 5th- At 12.20pm Mr S presented to outpatient clinic complaining of feeling unwell and rigors overnight. Loose bowel motions for 3 days with no GUT pain.

At 12.20pm his observations were recorded Temp 36.9, BP 130/80, HR 80, RR24, Spo2 97% on RA. Resident was notified and patient was assessed. Actions taken by nursing staff were as follows.

12.30pm- Patient cannulated followed by full septic screen. Two sets of blood cultures, FBC, ELFTs collected. MSU and chest x-ray ordered.

Events as

follows

At 12.45pm- Patient’s observations recorded, Temp 38.2, BP 150/80, HR 100, RR 24, Spo2 97 % RA.

At 13. 30pm- IV Piperacillin/Tazobactam 4.5grams was ordered and administered and IV fluids were commenced. Patients FBC showed neutrophil count 0.33.

At 14.20pm- Patient transferred to ward with Temp 37.5 maintaining stable vital signs and chemotherapy deferred.

June 6th- Patient continued IV antibiotics and commenced GCSF for neutropenia and close monitoring.

June 8th- Patient discharged with GCSF injections following count recovery. Blood Cultures negative to date.

Outcome: Patient stabilised and admitted to inpatient ward for further recovery and avoided ICU admission and major organ failure.

Education and

Interventions

In the community, sepsis often presents as the

clinical deterioration of common and

preventable infections such as those of the

respiratory, gastrointestinal and urinary tract, or

of wounds and skin. Sepsis is frequently under-

diagnosed at an early stage - when it still is

potentially reversible. Thus, it is important that we

educate our patients on the early signs and

symptoms of sepsis and recognising deterioration

is a key role.Image taken from (Solutions & Solutions,

2018)

The international sepsis guidelines introduced the Sepsis Six in 2oo6. The Sepsis Six care bundle has been shown to reduce the relative risk of death by 46.6 percent when delivered to patients with severe sepsis within one hour. Close monitoring and regular review can identify patients who do not improve with the Sepsis Six, prompting urgent referral to critical care.

The Sepsis Six care bundle comprises:

· Give oxygen to maintain saturations >94%.

· Take blood cultures and consider source control.

· Administer empiric intravenous antibiotics.

· Measure serum lactate and send full blood count.

· Start intravenous fluid resuscitation.

· Commence accurate urine output measurement.

What We Need to do: A Clinical Sepsis Pathway

Facts

Image taken from ("Treat Sepsis", 2018)

Early treatment is known & proven to save lives

In 2017, the Queensland

Department of Health established a

State-wide Sepsis Steering

committee to provide advice and

guidance for a state-wide sepsis

programme aimed at reducing

mortality from sepsis.

As at July 2018, 16 public hospitals have

joined the Adult and Paediatric Sepsis

Breakthrough Collaborative. This initiative

will enable teams from multiple hospitals to

test and share ideas to achieve reliable

recognition and treatment of sepsis

patients presenting to Queensland’s larger

Emergency Departments.

A thorough literature review on sepsis pathways

Figure 1: IV Antibiotics within 1 hr on a sepsis pathway (SP) vs standard care

(SC)

Information taken from Lisa Wong’s

Sepsis protocol 2018,

(Castellanos-Ortega et al., 2010),

(Laguna-Perez et al., 2012), and

(Memon et al., 2012)

Nurses have the potential to help develop evidence base clinical pathways to support patient groups experiencing sepsis.

Currently there is a protocol in process to develop a nursing pathway for sepsis and deterioration in the Cancer Care Services at the RBWH . The International Guidelines for Management of Severe Septic Shock, 2012 have advised that the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence the outcome.

A systematic review was under taken on “Does a Clinical Sepsis Pathway improve outcomes in cancer patients?” and the results were significant.

Septic patients who receive treatment following a Clinical Sepsis Pathway are:

1.5 times more likely to receive IV antibiotics within 60mins

No difference with length of stay

Less likely to die.

Conclusion

Significance

This review contributes to knowledge on

sepsis management in clinical practice,

showing standardised approach is a key

quality indicator. Sepsis is a highly complex

process and clinical sepsis pathways improve

outcomes for patients.

Image taken from ("Potential Causes of

Sepsis and How to Avoid It", 2018)

References

Castellanos-Ortega, Á., Suberviola, B., García-Astudillo, L., Holanda, M., Ortiz, F., Llorca, J., & Delgado-Rodríguez, M. (2010). Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasi-experimental study*. Critical Care Medicine, 38(4), 1036-1043. doi: 10.1097/ccm.0b013e3181d455b6

Laguna-Pérez, A., Chilet-Rosell, E., Delgado Lacosta, M., Alvarez-Dardet, C., Uris Selles, J., & Muñoz-Mendoza, C. (2012). Clinical pathway intervention compliance and effectiveness when used in the treatment of patients with severe sepsis and septic shock at an Intensive Care Unit in Spain. Revista Latino-Americana De Enfermagem, 20(4), 635-643. doi: 10.1590/s0104-11692012000400002

Memon, J., Rehmani, R., Alaithan, A., Al-Gammal, A., Lone, T., Ghorab, K., & Basirat, A. (2012). Impact of 6-Hour Sepsis Resuscitation Bundle Compliance on Hospital Mortality in Severe Sepsis and Septic Shock in a Saudi Hospital. Chest, 142(4), 284A. doi: 10.1378/chest.1384715

Potential Causes of Sepsis and How to Avoid It. (2018). Retrieved from http://www.infusesafety.com/potential-causes-of-sepsis-and-how-to-avoid-it

References

Sepsis Awareness Month Toolkit. (2018). Retrieved from https://cha.com/wp-content/uploads/2017/08/Sepsis-Awareness-Month-Toolkit.pdf

Sepsis (Septicemia) Treatment. (2018). Retrieved from https://www.news-medical.net/health/Sepsis-(Septicemia)-Treatment.aspx

SEPSIS TOOLKIT INPATIENT GUIDELINE. (2018). Retrieved from http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0010/276067/Sepsis_Toolkit_inpatient-full.pdf

Solutions, B., & Solutions, B. (2018). Facebook Open Graph META Tags. Retrieved from http://bottomlinepracticesolutions.com/tag/funny-patients/

Toolkits. (2018). Retrieved from https://www.world-sepsis-day.org/toolkits/

Treat Sepsis. (2018). Retrieved from https://www.world-sepsis-day.org/treatsepsis/

Questions ?