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The Nurses Role in the Detection of Sepsis: An Evidence Based Analysis Amber Gall Suzette Ploughman Tamara Putney Ferris State University

The Nurses Role In The Detection Of Sepsis Abstract Nurses have many roles in the course of caring for patients. Promoting safe optimal care is imperative. Sepsis is identified as a true danger and if early identification is the key to saving lives, then what does that mean to the profession of nursing? This evidence based practice

project will present the best evidence from a review of literature to define and support the nurses role in the detection of sepsis. The problem will be explained, and evidence will be described and analyzed. Effects on nursing practice will be discussed then recommendations will be presented. Keywords: sepsis, early detection, nurse role, evidence

The Nurses Role In The Detection Of Sepsis The Nurses Role in the Detection of Sepsis: An Evidence Based Analysis Septic shock is responsible for the death of over 750,000 people each year and is ranked in the top 10 most common causes of death worldwide (Kleinpell, 2012). The number of sepsis diagnoses are not declining, this is due to several factors, some of which are: an increase in chronic illness due to longer life and lack of health promotion and prevention techniques, nosocomial infections on the rise in hospitals, and the increase in cancer diagnoses which is increasing the immunosuppressed patient population of our world (Nelson, LeMaster, Plost & Zahner, 2009). Once the deadly cascade of sepsis starts it is difficult to stop (Nelson, et al., 2009). The

mortality rate of septic shock can be as high as 50% (Kleinpell, 2012). The best way to prevent death from sepsis is to detect it early and intervene (Nelson, et al., 2009). It does not take long for the subtle symptoms of a possible infection to progress to septic shock and result in death. Sepsis basically involves four steps or stages: systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock (2009). SIRS is a response of inflammation in the body resulting from some type of relatively major insult, for example, from such events like cardiac injury, surgery, or trauma (2009). SIRS is considered positive if the patient has two of the following: a white blood cell count greater than 12,000 per microliter or less than 4,000 per microliter, a temperature more than 38 degrees Celsius or less than 36 degrees Celsius, a heart rate more than 90 beats per minutes or a respiratory rate more than 20 breaths per minute (2009). Patients with SIRS can be cared for anywhere in the hospital, but require close observation for worsening symptoms (Kleinpell, 2012). If two SIRS are present and the patient develops an infection of some kind, without antibiotics and other treatments, this possible suspected sepsis condition can rapidly evolve into severe sepsis (2012). Severe sepsis is identifiable when organ

The Nurses Role In The Detection Of Sepsis dysfunction begins in the face of antibiotic therapy or evidence of infection and two or more SIRS criteria are present (2012). At this point, the patient would require intense critical care treatments, and if treatments are not done rapidly, up to half of this patient population dies (2012). In the body, capillaries become leaky and damaged, and vessels dilate due to cytokine production in response to infection, as this progresses organ functions begin to fail from lack of oxygen and low blood pressure; resuscitation is difficult, with a very short window of treatment time (2012). Septic shock treatment requires specially trained critical care nurses and doctors because the hypotension can be severe, vaso-active drugs are needed and often the patient progresses to need ventilator assistance (Nelson, et al., 2009).

Overall, evidenced based patient care has only recently started to be recognized with best practice standards (Schorr, 2012). Schorr (2011) notes that despite best efforts only 60% of patients get true evidenced based care in our hospitals today. It wasnt until the development of the Surviving Sepsis Campaign in 2004 that recommendations and a myriad of evidence-based research began in the area of sepsis (2012). It is this campaign that has started to outline and make evident the important role of the nurse when it comes to sepsis. This campaign also sets out to empower all care providers with knowledge, protocols and standards of care that will drastically improve the outcomes of septic patients, as well as stop sepsis in its tracks before it is too late (Surviving Sepsis, 2012). Not only is the nurse responsible for carrying out the normal day to day standards of nursing care, todays constant and increasing threat of infection makes the job of the nurse even more critical. When it comes to sepsis, the hospital bedside nurse needs to be an expert in the identification of the early warning signs and symptoms of sepsis through assessment and monitoring (McCormick, 2009). Nurses need to be empowered with knowledge to know what

The Nurses Role In The Detection Of Sepsis to assess for, the measures to take to control infection once it is detected, be able to practice proper communication with all team members, and all nurses need to be documentation experts (2009). All of these skills are essential to detect signs of sepsis early in order to prevent the cascade, ensure optimal patient outcomes, and take an active role in the management of sepsis. An overall review of literature has revealed that nurses play an integral role in patient survival when it comes to sepsis. Detecting sepsis early has the potential to save hundreds of thousands of lives each year; this paper will provide support and evidence to prove that the nursing role in the detection of sepsis is critical. Descriptive Summary of Articles Reviewed Article #1 In the article, Nursing Considerations to Complement the Surviving Sepsis Campaign Guidelines, by Aitken et al. (2011), the researchers addressed the essential nursing care that is needed in order to manage patients who have been diagnosed with sepsis, severe sepsis, and septic shock. Sepsis, including severe sepsis and septic shock, continues to be a major

healthcare problem internationally (p.1800). Aitken et al. (2011) performed research to provide suggested recommendations for nursing in the care of patients diagnosed with sepsis. Aitken et al. (2011) state that over the last ten years mortality from sepsis has decreased slightly, but still remain greater than 20%. As part of the response to optimize care for this group of patients, evidence-based clinical practice guidelines have been published by the Surviving Sepsis Campaign (SSC) to facilitate clinicians to improve the outcomes of patients with sepsis and septic shock (Aitken et al., 2011, p. 1800). The SSC guidelines have provided strong practice guidelines for improvement in the outcome of patients diagnosed with sepsis, but they are lacking in the specifics of the nursing care that is needed. Aitken et al. (2011) state that the SCC

The Nurses Role In The Detection Of Sepsis guidelines are comprehensive in the medical management of patients diagnosed with sepsis and septic shock they are frequently silent on the nursing care that is essential for optimal outcome of these patients (p. 1800).

The nursing care and interventions that are recommended in this research article are to be performed by any registered nurse who practices in the acute setting and are related to the adult patient with sepsis (Aitken et al., 2011). It is necessary that the patient who has been diagnosed with sepsis, severe sepsis, or septic shock be monitored both from a medical standpoint and a nursing standpoint. It takes an interdisciplinary team of health care providers to properly manage and intervene when caring for a patient with sepsis. The interventions set forth in this study were designed to provide guidance for all nurses who are involved with the care of a patient with sepsis. The authors also recommendation involvement of other healthcare team members and do address this in this study. With the idea in mind that it takes a multidisciplinary team to successfully manage a patient who has been diagnosed with sepsis, it is constantly stressed that the nurses role at the bedside is one of utmost importance. The aim of this review is to provide a series of recommendations, based on the best available evidence, to guide clinicians providing nursing care to patients with sepsis (2011, p. 1801). The World Federation of Critical Care Nurses formed a team to develop guidelines for the nursing care of patients with sepsis (Aitken et al., 2011, p. 1801). Sepsis experts from different regions of the world were invited and included in the making of these guidelines. The literature that was used for creating the SCC guidelines along with other published literature and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system was used to rate the quality of the evidence (2011). Discussions between the authors were then conducted based on the evidence based sepsis literature found, and no guideline was developed

The Nurses Role In The Detection Of Sepsis without 100% consent and agreement of all participants. Infection prevention, infection management, initial resuscitation, hemodynamic support, other supportive care, and pediatrics are the areas of importance discussed and reviewed by the authors and the recommended guidelines are meant to augment the SCC guidelines (2011).

Infection prevention is an obvious first step to stop the progression of sepsis. The authors recommend education as the first step of this process because it is considered on the best ways to improve awareness of a problem and is crucial for change (Aitken et al., 2011). The authors, as important recommendations in nursing care, also stress accountability, surveillance of nosocomial infections, and hand hygiene (2011). The authors explain that the rationale behind all of these interventions stems from the fact that at least 20% of nosocomial infections are preventable, proper hand hygiene has proven to reduce infection rates, and the surveillance of nosocomial infections is essential in guiding and evaluating the interventions to reduce infection rates (2011). When nurses are held accountable and personally responsible for their actions in areas such as hand hygiene the risk of spreading disease decreases. Having a system in place for monitoring the effectiveness of the education and the risk for and spread of nosocomial infections can greatly decrease the incidence of infection. Aitkin et al. (2011) report that from the research performed the attitude towards nosocomial infections needs to be one of zero tolerance and every healthcare worker needs to ensure safety to their patients through infection prevention and control (2011). Aitken et al. (2011) also discuss the importance in the prevention of site-specific considerations such as respiratory infections such as ventilator-associated pneumonia (VAP). VAP is often preventable, and application of practices such as education strategies and ventilator bundles have contributed to a reduction in VAP (Aitken et al., 2011, p. 1803). It is

The Nurses Role In The Detection Of Sepsis recommended by the authors in this research article that steps to prevent VAP in patients with sepsis be implemented. Thirty to 45-degree head of bed elevation, use of endotracheal tubes with subglottic secretion drainage, endotracheal cuff pressure of at least 20 cm H20, regular aspiration of secretions, and regular oral care be provided to intubated patients with sepsis in order to reduce the incidence of VAP (2011). It is pertinent that these evidence-based measures

be performed to properly care for intubated patients with sepsis, severe sepsis, or septic shock to prevent further infectious processes. When discussing infection management Aitken et al. (2011) discuss the importance of infection source control issues and transmission-based precautions. The removal of intravascular catheters and culturing of the catheter tip as promptly as possible are key factors in the management patients with sepsis (2011). Aitken et al. state Failure to remove the catheter was demonstrated to be an independent predictor of mortality in an epidemiologic study on CR-BSI (2011, p. 1805). It is also imperative that transmission-based precautions be in place when managing the care of a patient with sepsis. Standard precautions need to be in place when caring for any patient, but the patient diagnosed with sepsis requires additional precautions to prevent any cross-infections that could result (2011). There are multiple routes of transmission including contact, droplet, and airborne; in order to prevent cross infection the appropriate measures and isolation need to be in place and practiced 100% of the time by the nurse and other healthcare members when caring for the patient. One of largest and most pertinent pieces of the picture when caring for a sepsis patient takes place during the initial resuscitation by both the nurse and other members of the interdisciplinary healthcare team members. The SCC guidelines define the initial resuscitation period as the first 6 hours after a patient has been diagnosed with sepsis, severe sepsis, and septic

The Nurses Role In The Detection Of Sepsis shock (Aitken et al., 2011). Interpreting clinical observations, seeking further assistance, and

initiating early resuscitation measures are often the domain of nurses (p. 1805). The nurse plays a key role in the early detection and treatment of sepsis by correctly interpreting the key changes in vital signs and behavior that a patient begins to exhibit when they are experiencing sepsis, severe sepsis, or septic shock. The first step in the initial resuscitation process is the recognition of deterioration of the patients condition and early diagnosis. The authors recommend that any staff that are directly responsible for patient care be educated in recognizing the Systematic Inflammatory Response Syndrome (SIRS) criteria (2011). Aitken et al. (2011) state the importance of educating any staff member who is directly responsible for patient care be educated in the clinical signs that present themselves when a patient starts to deteriorate. The sooner the signs of sepsis are detected the sooner the early resuscitation measures can be implemented to prevent further deterioration of the patient. After the early clinical signs of sepsis are detected, the 6-hour resuscitation bundle can be started. As Aitken et al. (2011) report, when caring for a patient diagnosed with sepsis early recognition and rapid response is the key to improving patient outcomes. The research states and proves through evidence-based practices that the diagnosis of sepsis early is linked to increased survival (2011). The researchers state that after the nurse or other medical staff identifies the clinical signs of sepsis, summoning medical assistance and implementation of the resuscitation bundle is crucial (2011). When initiating early resuscitation measures nurses must be knowledgeable about the components of the 6-hour bundle guidelines created by the SSC, have access to adequate resources for monitoring the patients progress, have adequate staffing, be empowered to activate the 6-hour bundle of orders, and have access to commonly prescribed antibiotics (2011). By implementing all of these steps it is expressed by the authors that the nurse plays a key role in the management of the patient

The Nurses Role In The Detection Of Sepsis 10 with sepsis and is imperative in monitoring the effectiveness of the 6-hour sepsis bundle measures. Aitken et al. (2011) state that after the initial resuscitation period and initiation of the 6hour septic bundle the next recommendations are aimed at improving the patients hemodynamic status through improved tissue oxygenation and improving macro circulation. Complicating the care of patients with sepsis is the hypovolemia and unstable hemodynamic status (2011). Hemodynamic status is a key factor to monitor when a nurse is caring for the patient with sepsis. As stated earlier the findings in this article discuss hypotension as one of the signs of sepsis. Early in the sepsis stages patient status may be adequately maintained by improving blood volume (2011). The authors suggest that in order to improve tissue oxygenation, continuous monitoring and measurement must be in place. Continuous measurement of tissue oxygenation contributes to earlier recognition of changes in patient status and treatment efficacy in relation to periodic central line sampling (p. 1808). Also, the authors recommend monitoring point of care lactate levels instead of using serum lactate levels (2011). The rationale provided for this intervention stems from evidence that shows while standard monitoring parameters may be normal, an elevated lactate can be an earlier indicator of hypoxia (2011). When aiming to improve macro circulation the authors recommend monitoring stroke volume. Aitken et al. (2011) state that improving blood flow is key during the resuscitation period, when blood pressure and central venous pressure have been utilized they have been shown to be inaccurate and slower to change and less precise than the stroke volume (2011). There is additional supportive care to be provided by nurses that can improve the quality and outcomes for patients with sepsis. These recommendations include nutrition therapy, eye care, and pressure ulcer management (Aitken et al., 2011). Aitken et al. (2011) express concerns

The Nurses Role In The Detection Of Sepsis 11 and recommendations in regards to these areas of fundamental nursing care. The need for early nutrition when caring for a patient with sepsis, severe sepsis, or septic shock is often overlooked and malnutrition is not an uncommon result (2011). Enteral nutrition needs to be started within 24 to 48 hours of admission to the ICU in order to prevent intestinal mucosal atrophy and malnutrition (2011). Due to the altered levels of consciousness and limited mobility, patients who are critically ill also need to be monitored for eyelid closure and the presence of pressure ulcers. Critically ill patients, including those diagnosed with sepsis, are more susceptible to these problems because of the seriousness of their condition. The nurse in the acute care setting plays a pertinent role in the observation and interventions suggested to prevent pressure ulcers and eye injuries (2011). Aitken et al. (2011) also took the time to research the evidence-based literature and provide recommendations for nurses and other healthcare members when caring for a pediatric patient who is diagnosed with sepsis. Sepsis in the pediatric population is an important issue and remains one of the most common causes of death (Aitken et al., 2011). As was the same when treating the adult patient with sepsis, fluid resuscitation is one of the first interventions to be implemented. The goal of fluid replacement in children is to restore perfusion and should be monitored using tools such as cardiac output (2011). If adequate volume replacement is not achieved through fluid replacement it is suggested that vasopressors be implemented to achieve adequate perfusion (2011). If the septic shock does not improve and continues to progress towards adrenal insufficiency hydrocortisone therapy can be life saving and is recommended by Aitken et al. (2011). One issue that the authors of this article emphasized when treating pediatric patients that was not mentioned in the adult population is analgesia and sedation (2011). Higher amounts of oxygen and energy are consumed by the body when it experiences pain; by

The Nurses Role In The Detection Of Sepsis 12 addressing these issues with proper sedation and analgesic relief, the patient has more oxygen for the major organs that are necessary for healing during the septic process (2011). Aitken et al. (2011) reviewed the current literature on sepsis and created a number of recommended interventions to be performed by both the nurse and other members of the interdisciplinary healthcare team when caring for a patient with sepsis. These recommendations begin with the early detection and end with the appropriate measures for proper resuscitation. The authors admit that although they used the best evidence based research to guide their recommendations there is an urgent need for more research to be performed on this topic (2011). Article #2 The goal of the article, The Role of Nurses in the Recognition and Treatment of Patients with Sepsis in the Emergency Department: A Prospective Before and After Intervention Study, by Tromp et al. (2010) is to use Emergency Department (ED) nurses to increase the compliance rate for the use of care bundles for the septic patient per the Severe Sepsis Campaign (SSC) guidelines and recommendations. By using care bundles, a group of 3 to 6 care elements related to a disease process, evidence has shown to produce better outcomes for the septic patient (Tromp et al., 2010 p. 1464). Usually the first line of defense starts in the ED. The ED is where almost all patients who have sepsis first present. Evidence has however, shown that compliance with using care bundles by the ED physician is low (Tromp et al., 2010). The evidence has also shown that even after several different strategies to enforce the use of care bundles such as meetings, reminders, audits and feedback the compliance rate remains virtually unchanged (2010). The Surviving Sepsis Campaign (SSC) has tried other ways to look at how to get their recommendations implemented, without much success (Tromp et al., 2010). A research team

The Nurses Role In The Detection Of Sepsis 13 decided to use the ED nurses at a Netherland University Hospital in the early detection of signs and symptoms of sepsis to get the SSC recommendations through (2010). The fact of the matter is that the triage nurse is generally the first person to see and assess a patient with sepsis. The research team put together an evidence-based research program and found that many ED nurses were not aware of the signs of sepsis such as a temperature of less than 36 degrees Celsius, or a low white cell count (Tromp et al., 2010, p. 1466). According to the authors, the first step in the research process was to educate the nurses on signs and symptoms of sepsis and to introduce and teach the nurses about the sepsis care bundle (2010). The ED nurses would then have to look at every patients symptoms and decide if it was right to get the care bundle started, after notifying the ED physician. The team also found that the nurses knowledge on implementing the care bundle was less than desired and they decided to implement a feedback process to see if improvements could be made to the compliance rate of SSC recommendations (Tromp et al., 2010). The research included patients that were 16 years of age or older who presented to the ED with a known or suspected infection and also had 2 or more symptoms of the Systemic Inflammatory Response Syndrome (SIRS). SIRS includes: Temperature greater than 38.3 degrees Celsius, temperature less than 36 degrees, heart rate greater than 90/min, respiratory rate greater than 20/min, cold chills, altered mental status, systolic blood pressure less than 90 mmHg, mean arterial pressure less than 65 mmHg, and hyperglycemia in the absence of diabetes mellitus. (p. 1466) With collaboration from the Netherland Hospital Organization and the ED physicians the ED nurse could implement the SSC recommended sepsis care bundle, after notifying the

The Nurses Role In The Detection Of Sepsis 14 Physician of suspected symptoms (Tromp et al., 2010). According to Tromp et al. (2010) the care bundle for sepsis consists of seven tasks: 1. Measure the serum lactate concentration within 6 hours of arrival 2. Obtain two blood cultures before starting antibiotics 3. Get a chest x-ray 4. Obtain a urine analysis and culture 5. Get antibiotics started within 3 hours of arrival to the ED 6. Volume resuscitation in case the serum lactate is greater than 4mmol/L or hypotension is present 7. Hospitalize or discharge the patient within 3 hours of arrival to the ED Nurses were initiating blood work, cultures, urine and X-rays right away and logging times on a sepsis protocol run sheet they would then give reminders to the ED physician to start antibiotics and to admit or discharge under the 3-hour mark (Tromp et al., 2010). Of the seven care elements only six were measured because volume resuscitation was not always implied (2010). The aim was to see if nurses could play a significant role in producing better outcomes for the SSC guidelines of the use of care bundles (Tromp et al., 2010). The research measured the nurses compliance and use of the required steps of the care bundle and outcomes. The research project was done in 3 phases. The first phase measured the first 3 months before the protocol of care bundles went into effect. The second phase measured 6.5 months of the protocol being in place but without training or feedback given. The last phase measured 3.5 months of protocol after training and feedback were given (Tromp et al., 2010). The results were then analyzed using various methods and instruments and it was found that compliance increased during the second phase from 3.5% to 10.8% (Tromp et al., 2010).

The Nurses Role In The Detection Of Sepsis 15 After training and feedback were given compliance was increased to 12.4% during the last phase (2010). The results showed improvement in early recognition and treatment of the sepsis patient. It also showed a large increase in compliance when training and implementation were added (Tromp et al., 2010). The study also found that nurses did better during the triage process when they had the sepsis screening list available and bundles were implemented sooner than when it was not available (2010). Ultimately, the article proves that the nurses role is a vital tool that needs to be recognized as a factor in fighting sepsis. The article did not require any financial assistance that may have interfered or caused a conflict of interest with the study. The article also notes that the local medical ethics committee waived consent prior to the start of the study. The research also points out limitations such that the study should be repeated in a multicenter controlled trial (Tromp et al., 2010). Article #3 In the article, The Effect of Nurse Champions on Compliance with Keystone Intensive Care Unit Sepsis-Screening Protocol, Jane Campbell (2008) examines the effectiveness of utilizing a nurse champion in intensive care units to promote the use of a screening protocol for early detection of sepsis. The research problem for this study arises from the fact that sepsis has been proven as a key threat to the safety of all hospitalized patients (Campbell, 2008). Patient safety is of the utmost importance and a top priority in this nation. As of 2008, critical care units across the nation are seeing yearly admission rates topping 4 million, of those admissions about 85,000 medical errors will occur with nearly 25,000 of them being life threatening (2008). As Campbell (2008) reports, research has shown that nearly every patient admitted to any intensive care unit will have at least one error in care. In 2003, to start tackling this problem, and better

The Nurses Role In The Detection Of Sepsis 16 ensure patient safety, the Agency for Healthcare Research and Quality (AHRQ) provided a matching grant for the Michigan Health and Hospital Association (MHA) to launch the Keystone: ICU Sepsis Project (2008, p. 251). This initiative brought hospitals and care providers from all over Michigan together in an attempt to lower errors, detect sepsis early, decrease length of hospital stay, and attempt to provide increased quality, more cost effective, safer patient care with better outcomes (2008). The biggest factor to promoting patient safety, when it comes to sepsis, is to detect the condition early and act rapidly to treat it (2008). Much research has gone into the best way to accomplish this; a successful solution includes the application of protocols and care bundles. Protocols and bundles are merely groups of orders that can be used by nurses in response to detected conditions, in order to provide specific care without a direct doctors order. In an attempt to recognize and detect sepsis early on every patient admitted to the hospital, screening tools connected to protocols were implemented. A major gap recognized is the compliance of charting and actually screening the patients for sepsis. This study by Campbell (2008) set out to ask the research question: What is the effect of nurse champions on the ICU nurses compliance with Keystone sepsis screening protocols and patient safety outcomes (p.252)? The purpose of this study was to evaluate whether adding a nurse champions presence and influence in a critical care unit would increase screening compliance therefore promoting better patient outcomes. The author states this study is very significant because sepsis mortality can be as high as 50% if not caught early (2008). Sepsis can usually be prevented and can be treated if resuscitation occurs within the first few hours of onset. The Keystone Sepsis Project utilizes the nurse to screen each patient for specific vital signs, lab values, and therapies on admission and at

The Nurses Role In The Detection Of Sepsis 17 regular intervals throughout the hospital stay (2008). The researcher in this study also wanted to analyze what physiological indicators of early sepsis are most often seen (2008). The framework utilized for this study was Donabedians structure-process-outcome model (p. 252, 2008). As Campbell (2008) describes, this model is frequently used in many health care initiatives that aim to improve quality. Basically, structure refers to the actual institutions physical structure, as well as standards, resources and personnel (2008). In this study, the Donabedian structure component is demonstrated by the use of a nurse champion. The Donabedian process is usually an activity performed by staff; in this case it was the act of the staff nurses doing the screening (2008). Last, the Donabedian element of an outcome is denoted by the outcome of the patient in response to increased screening (2008). It is important to understand what a nurse champion is. A nurse champion is a unit leader and often is revered and enthusiastic (2008). They are defined as a true spirited fellow nurse and patient advocate (2008). As Campbell (2008) notes, these nurses have been found to be visionaries and are extremely effective in many initiates because they are already embedded in the care team, usually already have the confidence of staff, and are very well respected. The researcher recognized the power paradox that might occur with the use of only Donabedians theory (p. 253, 2008). It was for this reason that Campbell (2008) utilized a bridging theory to narrow the scope of the model (p. 253). Using the Rogers Diffusion of Innovations theory the researcher was able to bring greater precision and integrity to the explanation of the effect the nurse champions would have on the actual compliance of the screening (2008). As Campbell (2008) notes, this bridging theory is used to better understand and carry out the implementation and communication of this study. Campbell (2008) describes the Rogers Diffusion of Innovations theory utilizes 5 steps to aid in the implementation of an

The Nurses Role In The Detection Of Sepsis 18 idea, the steps are: knowledge, persuasion, decision, implementation and confirmation (p. 253). Each of these steps or stages is needed to evaluate the effects of adding a nursing champion to change the habits of nurses screening for sepsis. Simply put, the knowledge stage would be informing and educating the staff about the screening, the persuasion stage is showing the staff the value of the screen in an attempt to make them want to use it, the decision step is the decision by the staff nurse to utilize the screen, the implantation is the actual screen and the confirmation stage is the acceptance or rejection of the habit of screening (2008). Campbell (2008) discusses types of adopters and explains how that relates to the chances of this idea being accepted in a timely manner. The review of literature for this study reinforces the fact that sepsis is deadly, not enough screening is done, and if caught early and acted on quickly with standardized treatments, mortality will go down (2008). The review of literature done by Campbell (2008) attempts to provide proof that if bundles and protocols are followed with strict compliance, patient outcomes are better and patient safety is better ensured. The review of literature also demonstrates that the bedside nurse is the best caregiver to be used to accomplish the sepsis screen, although compliance has historically been low (2008). As Campbell (2008) explains, the bedside nurse is with the patient the most and understands all aspects of that patients care plan. Last, the review of literature provides information about other studies that prove nurse champions are the right variable to introduce because other research studies have had successful outcomes with this addition of staff (2008). The research method used in this study was a one group, pretest-posttest, quasiexperimental design, utilizing a nonprobability sample of intensive care unit patients (2008, p. 256). Campbell (2008) explains that after nurse champions were identified and trained, data

The Nurses Role In The Detection Of Sepsis 19 collection over a 7-month period began. Pre implementation data collection was gathered from 60 charts prior to the introduction of the nurse champion to promote the screening process (2008). The nurse champions and criteria for screening were introduced, and the units were given a two-month period to acclimate to the process (2008). After that, post implementation audits of another 60 charts were done. Data analysis was done via a comparative statistics computer program and revealed that over half of the participants were male with an age range between 32 and 93, and over half had an admitting diagnosis of respiratory failure (2008). Two specific aims were developed for this study. One was to isolate the most common early indicators of sepsis; that is, what physiological signs and symptoms are seen prior to a diagnosis of sepsis, severe sepsis or septic shock (2008). The second aim was to determine if adding a nurse champion would improve screening and how that related to the care and safety outcome of the patient (2008). The biggest limitation in this study noted by Campbell (2008) was the staff turnover rates in the institution. In an attempt to control the effects of this limitation, Campbell (2008) ensured all staff had access to education materials pertaining to the study and screening tools. At the conclusion of the 7-month study, data analysis revealed that heart rate was the most common early indicator of sepsis along with increased white blood cell counts, followed by mental status changes; Campbell (2008) remarks that this is consistent with existing sepsis literature. Late indicators were not surprising and were revealed to be various types of renal and organ dysfunction; this is also consistent with existing literature (2008). Campbell (2008) reports the most important result of this study was the increase in early sepsis detected due to a significant increase in the compliance of sepsis screening done by staff nurses in response to a nurse champion present in the care unit. The fact that these champions were actual peers and

The Nurses Role In The Detection Of Sepsis 20 well respected was believed to have a major impact on not only the compliance to screening, but actions taken by nurses at the bedside to promote better patient outcomes (2008). It must be noted that this study did not show an increase in the affect of sepsis treatment, nurses can identify sepsis early and if given proper orders to treat, other studies have shown mortality will decrease (2008). The actions carried out by the nurse, after sepsis is identified, were not part of this study. As Campbell (2008) remarks, this study shows that by adding a nurse champion to a critical care unit, compliance to screening will increase, which would mean sepsis can be treated early to promote safer, and possibly, more optimal patient outcomes. More research is needed to further evaluate the effects of certain treatments in response to early sepsis detection (2008). Critical Appraisal Of Evidence Article #1 Purpose and Problem Statement According to Aitken et al. (2011) the purpose of this research article was to create recommendations about the nursing care that should be provided to patients with sepsis, based on the available, current, and reliable evidence. The researchers of this article present a clear and concise purpose to build on previous research, but do not have an easily identified problem statement. There is currently a lack of research on the nurses role when caring for a patient diagnosed with sepsis, severe sepsis, or septic shock and this diagnosis continues to be a significant problem in healthcare associated with high mortality rates (Aitken et al., 2011). The authors do discuss that there is a large evidence base of knowledge and guidelines available about the medical management of a patient with sepsis, but there is a void when it comes to the nursing care necessary both in detecting sepsis and the ongoing management (2011). The nurse in the acute care setting plays a large role in both the early detection of sepsis and the ongoing management that is needed after a diagnosis of sepsis has been made. In order to provide the

The Nurses Role In The Detection Of Sepsis 21 best available and efficient care it is necessary to educate and empower nurses with the proper knowledge and tools. Aitken et al. (2011) have appropriately identified the need for an expansion of the knowledge base of nursing care for the patient with sepsis and provide the recommendations to help guide this process. This research was overseen by the World Federation of Critical Care Nurses (WFCCN), and no sponsorship or funding was received (Aitken et al., 2011, p. 1802). There was also no conflict or interest reported by the authors of this study (2011). Review of Literature The authors of this article do not provide a review of literature within their text, but all of the information can be found and inferred from the reference list. The review of literature for this article cites many sources that support both the nurses role in identifying signs/symptoms of sepsis and when caring for the septic patient. There was a large array of subjects reviewed including care of wounds, health-care associated infections, ventilator associated pneumonia, and the importance of proper staffing of nurses. The majority of the sources used by the authors in this study were primary. This article was comprised from 255 total sources of which 73 of those sources are dated within the past five years. This is just over 25% and seems like a relatively small amount of current knowledge utilized when compared to the large number of sources, some dating back as early as the 1980s. An even mixture of medicine journals and nursing sources seem to make up the information reviewed and studied by the authors. Theoretical Framework Aitken et al. (2011) clearly states that the Surviving Sepsis Guidelines (SSC) was used as a framework for the purpose of this article. The authors discuss that these guidelines provide helpful information when caring for a patient diagnosed with sepsis from a medical management

The Nurses Role In The Detection Of Sepsis 22 standpoint, but seem to lack the importance of the acute care nurse (2011). This gap in knowledge provided the authors with a reason to perform this research. It would have been helpful to the reader if the authors would have discussed the SSC guidelines in more detail, the purpose is unclear and the reader is not informed of where to find additional information. The findings and recommendations in this article are linked back to the SSC guidelines and supplement and improve the knowledge base on caring for a patient with sepsis, severe sepsis, or septic shock. Sample There was no quantitative or qualitative study used in the research for publishing this article, therefore there was no sampling method used for selecting study participants. Aitken et al. (2011) divided themselves into subgroups of two or three and then searched for any and all published literature available on the key role that nursing plays when caring for the patient with sepsis. The authors performed a very comprehensive search and the sample size of all available evidence is one large enough to support the findings. Study Design As stated earlier there are no study participants for the purpose of this article. The authors reviewed already published literature on nursing care of patients with sepsis (Aitken et al, 2011). The authors briefly mention that Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus (Aitken et al, 2011, p. 1800). This is all the further the authors go into discussing the method used for their research. There is no further mention of the design anywhere in the article. Again this section is weak and it would have been helpful in supporting the authors findings if this would have been discussed in more detail for the reader.

The Nurses Role In The Detection Of Sepsis 23 Data Collection Methods and Instruments Aitken et al. (2011) searched for any of the available research on the nursing role when caring for a patient with sepsis. After all of the literature was collected the researchers used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations (Aitken et al., 2011, p. 1800). The literature was then graded with either a 1 or 2, grade 1 being an indicator of benefit and grade 2 having less benefit to the septic patient population (2011). High quality and grade A evidence came from well-conducted randomized control trials and grade D evidence from case studies or expert opinions (2011). Aitken et al. (2011) state that factors like magnitude of treatment of effect, cost related to recommended therapy, and treatment precision affected the strength of the evidence. The methods used by the authors were strong and clearly stated and explained in detail for the reader. Data Analysis Information and data were collected through the reading of already published literature on sepsis and the nurses role when caring for these patients. It is not explained by the authors what amount of time span was spent during the course of this the research. There are no quantitative statistics or outcomes that can be measured from this study, since there was no primary research performed by the authors. Discussion of Findings Aitken et al. (2011) discuss that the recommendations provided in their article are a summary of the available evidence, but that there were several limitations including the time and resources available to them. The authors also express that there is a lack of evidence in multiple areas in the nursing care of the patient with sepsis. Also, although the array of researchers

The Nurses Role In The Detection Of Sepsis 24 spanned the globe, every recommendation was discussed until there was 100% agreement, these discussions were limited to e-mail (2011). The recommendations published in this article conclude and support the idea the nurses play a key role in both the detection of sepsis and ongoing care of the patient, but there is a lack of evidence in many of these areas (2011). It is inferred that further research to support these findings is urgently required (2011). Sepsis is a large problem in the healthcare community and is associated with high rates of mortality; the sooner more research can be performed the better (2011). Conclusions and Implications to Nursing Practice The need for further research on the nurses pivotal role when caring for septic patients is urgently needed. There is a void in the amount of evidence available on this topic currently and is mostly limited to expert opinions (Aitken et al., 2011). The authors state that the findings of their research are based on the best available evidence, but the existing research is still lacking (2011). It is expressed that the nurse in the acute care setting plays a key role not only in the detection of sepsis, but also the ongoing care. More research and studies are needed to support this idea and empower nurses with the knowledge that is needed to properly manage this patient population. Article #2 Purpose and Problem Statement The purpose of this article is very strong and clearly stated: to determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundled based, sepsis protocol followed by training and performance feedback (Tromp et al., 2010, p. 1465). By including the nurses in the screening and SSC protocol, and measuring outcomes over three different phases, researchers were able to measure the compliance rate in this study (2010).

The Nurses Role In The Detection Of Sepsis 25 Review of Literature The review of the literature is weak. Throughout the article it mentions in previous studies however, it never goes into any detail about the other studies. It does state in one short paragraph about what is known but does not specify where the knowledge came from. It does mention that there has been no specific role for the nurse in the Surviving Sepsis Campaign (SSC) guidelines. Perhaps because of this statement there is no other literature out there to review, however a mention of that in the article would have been good to know. Theoretical Framework The framework is weak and does not state any type of framework that was used for the study. The study does imply that nurse-driven, care bundled based, sepsis protocol program along with feedback (independent variable) will improve outcomes in the septic patient (dependent variable). However, this is not explained in a framework and is discussed throughout the article in various areas. Sample The sample population was clearly stated and the sample was taken from patients who arrived in the ED of the Netherland hospital. The patients had to be 16 years of age or older with a known or suspected infection and also had to have 2 or more SIRS symptoms. The ED received 24,412 patients during the research period of those 825 qualified for the sample group. The first phase had 159 patients, 447 during the second phase and 219 during the final phase (Tromp et al., 2010). Study Design The article does clearly state that it used a before-and-after intervention study using 2 interventions: use of a nurse-driven, care bundled based, sepsis protocol (intervention 1) and

The Nurses Role In The Detection Of Sepsis 26 training about sepsis that included feedback about performance before and after the sepsis protocol was introduced (intervention 2) (Tromp et al., 2010, p.1466). This is a correlational design examining the relationship of nurse driven protocols and feedback on the compliance rate to the SSC guidelines. Data Collection Methods and Instruments The selection and how they were obtained is very clearly stated and are appropriate for this study. The research implementation included the ED manager and 3 ED nurses as the contact nurses. They used a sepsis-screening list that met the SIRS criteria to obtain the qualifying patient. The data collection was done over 3 phases and the same method was used every time, compliance with use of bundles. The compliance rate and use of the care bundle was measured by using a generalized linear model with a logarithmic link and Bernoulli distribution function (Tromp et al., 2010, p.1468). The study was not compromised in any way; this section of the study was very detailed and strong. Data Analysis To analyze the information researchers used a generalized linear model with a logarithmic link and a Bernoulli distribution function (Tromp et al., 2010, p.1468). The researchers also had to do a subgroup analysis to factor in the impact of the nurses triages after phase 2 and 3. At times the patient also had multiple nurses and each individual action had to be taken into account, this was done by estimating the intra-class correlation coefficient, based on mixed model analysis of the cases in which the nurse was known, and we used this coefficient to adjust the results of the analysis of variance of all data (Tromp et al., 2010, p.1468). The data analysis section of this study utilized bar graphs and tables and was strong and very detailed. Discussion of Findings

The Nurses Role In The Detection Of Sepsis 27 The discussion of findings section was easy to understand and strong. The data showed that by implementing the nurses in the sepsis protocol and by providing training and feedback that there was a significant increase in compliance to the recommended SSC guidelines. The data also showed that the use of the ED nurse for each individual care element was greatly improved, see Table 1 (see Appendix). Conclusion and Implications to Nursing Practice The research showed that by using nurses in the project compliance rates for the use of SSC guidelines were significantly improved. It also discusses that more attention needs to be given to the role of the nurse and what they are capable of doing. The study also states that further research is needed and recommends doing this study, using a multicenter instead of the single center institution (Tromp et al., 2010). Article #3 Purpose and Problem Statement In this study, Campbell (2008) displays a very strong review of the purpose and problems addressed in this study. A very clear problem is identified, that is, that the occurrences of sepsis is not decreasing and sepsis mortality is high, it is also clear that empirical data can be collected on this topic (Campbell, 2008). The author discusses the sepsis Keystone Initiative, which outlines the need for a nurse role in early sepsis detection and the lack of compliance in nurse screening to not only decrease the incidence of sepsis (2008). The author states that better outcomes are needed for sepsis and probably the best way to do that is to increase the compliance with early screens to prevent sepsis in the first place. The purpose of this study is declarative and 2-fold: to evaluate the effect of introducing nurse champions into an ICU environment on, (1) ICU nurse screening compliance and (2) patient safety outcomes (2008,

The Nurses Role In The Detection Of Sepsis 28 p. 252). Objectives and goals are very clear; the relationship to the intervention and the possible outcomes correlate, this study also displays very significant relationships to the effects of increased screening to a possible change in patient outcomes. The study variables are discussed and include the care unit, the nurse champions, the staff nurses and the actual sepsis screens. Campbell (2008) makes the feasibility of this study evident. The author appears to be affiliated with the hospital in which the study is taking place, and there is nurse and unit agreement, as well as buy in. The problem statement in this study demonstrates a clear significance to nursing; patients are dying from sepsis every day, anything that can be done to promote better outcomes is imperative. Review of Literature Campbell (2208) delivers a concise, thorough and relevant review of literature, exploring all facets of every variable pertinent in this study. The author reviews the definition and cause of sepsis, establishes the importance, as based in the literature, and relates this to the profession of nursing, as well as, the health care system as a whole. The terms compliance and nurse champion are defined, discussed and compared in the review of literature. Points of view from many disciplines is considered and explored as it pertains to the definition of compliance. Campbell (2008) also describes in detail what the literature reveals about the role of a nurse champion. This comprehensive, mostly primary source, review of literature establishes what is known and not known about all the variables and information in this study. It is difficult to distinguish if some of the references are primary or secondary, and one reference relating to theory structure did not appear in the text. The review of literature is not presented directly after the problem and purpose statement. The flow of this study is interrupted by the explanation of the framework, but the reader is still

The Nurses Role In The Detection Of Sepsis 29 able to make sense of all the information presented. Campbell (2008) does not seem to critically appraise the literature presented, it is basically just presented in paraphrased narrative form and most times referred to by numbered in-text citations, rarely are other authors named or quoted. The author does present the review of literature in terms of the evolution of the variable in most circumstances. When describing sepsis, past and present data is touched upon as is the evolution of the thinking of how healthcare views sepsis, and how the economy has been affected. As far as compliance is concerned, the author merely discusses the definition and its inconsistencies and alludes to the fact that literature support is weak. Campbell (2008) does reveal that literature is consistent with the need for sepsis screening, and protocols for nurses to use. However, there is a need for standardization of best practice; it seems there is not enough research to determine what the best way to obtain compliant and appropriate sepsis screening and treatment. Theoretical Framework The very appropriate framework for this study is clearly identified both in the text by name and in the heading of the section named Conceptual Framework (Campbell, 2008). Campbell (2008) utilizes two theories as the framework for this study. The first, is the quality of healthcare related theory called the Donebedians structure-process-outcome model, the other is the multidisciplinary related, Rogers Diffusion of Innovations theory (2008, p. 253). Campbell (2008) needed to utilize two theories because it was evident there would need to be a way to evaluate the effect of the culture change or increase or decrease of compliance on the screening due to introducing a variable such as a nurse champion. The study clearly states why these two theories were selected and explains them thoroughly, in the context and in relation to this study and what will be evaluated. That is, a specific structure and process will be defined and utilized and an outcome will be evaluated with the Rogers Diffusion of Innovations theory

The Nurses Role In The Detection Of Sepsis 30 being used to detail why the nurse champion did or did not make a difference. Campbell (2008) makes it very clear what variable of the study are represented in relation to the theories used, this design adds integrity to the study and guides the proposed aim of the study. Study Aim or Research Question The aim of this study is concise and stated very clearly, is presented directly after the explanation of the purpose and research problem discussion, but is followed by the framework section. According to Burns and Grove (2011) this section usually precedes the method section of a study. There is no predicted hypothesis, this study asks a research question and declares two aims: to determine the most common physiological indicators of sepsis, and evaluate the effects of a nurse champion on compliance with sepsis screening and application of treatment in the intensive care unit (2008). The research question inquires about the effects on sepsis screening compliance when adding a nurse champion to an intensive care unit. It is very evident that the study problem, the lack of sepsis screening compliance, hence delay in detection and treatment of sepsis directly relates to the research question or aim of this study. The aim of this study is related to the study framework used by the author. The Donabedians structure-process-outcome all have an effect and direct relationship to the aim. In other words, each component of the framework has a variable attached to it and will be represented and affected by the outcome being evaluated. The Rogers Diffusion of Innovations theory is used to evaluate or explain the effects of the staff nurses demonstrating increased compliance with only the introduction of the variable of the nurse champion onto the unit. Therefore it can be said, that the aim of the study is not directly related to Rogers theory, but this theory is needed for full evaluation of the outcome. There are two aims of this study, one is to isolate specific physiologic sepsis indicators and their distribution, and the other is to evaluate the effects of the compliance of staff nurses

The Nurses Role In The Detection Of Sepsis 31 completing sepsis screens in the ICU. Both of these aims contain variable and populations. That is, the variables are the patient, the screen, the ICU staff nurses and the nurse champions. It seems the author is alluding to the fact and hoping that by placing a nurse champion in the ICU that staff nurses will be more diligent in screening for sepsis and that by keeping all the data during the study, isolated physiological indicators will be evident. In this sense, the aim could be considered causal, simple and directional in nature (Burns & Grove, 2011). Sample Campbell (2008) lists the sample information under the research methods section and clearly identifies the target population, that is, the ICU patients who are at risk for developing sepsis. The population in this study is stated clearly as accessible during the months of March 2007 through August 2007 at the 16-bed ICU at Regional Michigan Medical Center. A nonprobability convenience sample of patient charts was utilized (2008, p. 257). The patient had to be admitted to the ICU with a stay of more than four hours. The sampling method is sufficiently described, as was the power analysis method. These methods in conjunction determined the patient chart sample size of 60. The demographic characteristics in this study for the sample are not discussed in great detail and no mention of age is made until the results section. The author does not discuss sampling bias and mention is made of patients who dropped out of the study. The pre study review of charts was done, and then the post review was done. The results of the study do review genders and age ranges of patients as well as the main diagnosis but this is after the fact and does not relate to the performance of the study. For this reason, this seems like a very weak section of this study, because too many variables could be present to affect the nurses compliance to screening, even if the champion was present.

The Nurses Role In The Detection Of Sepsis 32 Study Design Data Collection Methods and Instruments Campbell (2008) did a nice job of detailing the design, instrumentation, measurement, and data collection used in this study. The design used was clear, a 1-group, pretest-posttest, quasi-experimental (Campbell, 2008, p. 256). Also, the concept and relationship to the framework was discussed in the design section of this study. A Keystone ICU Sepsis tool was specifically designed for this study by the hospital quality department (p. 257). Additionally, all the criteria used with the tool were set forth by Johns Hopkins Quality and Safety Group and the Michigan Health Association, which seems to increase its reliability (p. 257). However, the author does not discuss validity of the tools used and makes no direct mention of the reliability (this is only assumed by the reader). Measurement was very clear and was described in terms of the conceptual model utilized in the study. The structure-process-outcome model was very specific and at the end measured the absence or presence of a nurse screen for sepsis. The measurement was based on institutional or organizational characteristics, including personnel and their capabilities, the structure, the actual activities performed by the staff (would the users adopt the process or not), the process, and the end result or consequence of the treatment, the outcome (p. 258). Data collection was done pre implementation and again, with the same number of samples, derived in the same way, post implementation. The nurse champions used in this study were educated, and had to pass a test with a 90% or better in order to participate. Data collection occurred over the course of 7 months. Charts were audited in exactly the same method at exactly the same times and days of the week. Campbell (2008) does not report exactly who collected the data, the reader is unable to determine exactly who did the physical data collection. The data collection method was appropriate and very objective for this study.

The Nurses Role In The Detection Of Sepsis 33 Data Analysis The data analysis for this study is strong and right to the point; the author used a Windows program called SPSS 15.0,analysis included descriptive and nonparametric stats (Campbell, 2008, p. 258). Proportional differences between the utilization of champions and screening was done using Chi square statistics (2008). The author could have elaborated more in this section of the study discussed the use of the statistics in more detail. Discussion of findings The results of this study were discussed objectively, in great detail, and related both to each aim of the study and discussed the findings as compare to the review of literature. Campbell (2008) utilized four bar graphs and one distribution table. A few demographics were reviewed and revealed, of the 120 charts audited the age range was wide (32 to 93 years old) but the gender was split nearly in half, with 47% being female and 53% being male (Campbell, 2008). Also, over half of the patients were diagnosed with respiratory failure. The author did a very detailed job of describing the outcome of the study in terms of the aims set forth in the beginning and displayed inferential statistics for each. For example, aim one was looking at sepsis indicators. What the author found was that all the indicators that resulted from the study followed the literature review and past research. That is, increased heart rate was the most common indicator of sepsis, and second, was an increase or decrease in white blood cell count (2008). For severe sepsis the two most common physiologic indicators were an increase in creatinine and lower urine output; this too followed the known literature (2008). For aim two, evaluating compliance to screening and treatment of severe sepsis the author did a great job of using very statistical proof and was able to show a significant increase in sepsis screening due to the presence of a nurse champion in the intensive care unit. The author utilized this section of

The Nurses Role In The Detection Of Sepsis 34 the study to further discuss analysis of data as well as discuss some details of the tools and how the nurses used them and charted post implementation. Overall, the author was able to show severely septic patients, due to increased screening were more apt to get treatment, whether it be antibiotics or other provider driven treatments. Also, although not discussed in the analysis section, the author utilized Spearman rho correlation analysis to demonstrate there was actually no significant difference between increase in compliance of screening and documentation and the physician actually ordering treatments (p. 261). Some very important points noted by the author were that although all the results pointed to an increase in compliance of screening, the most important outcome of this study was the increase of and quality of documentation that occurred by the nurses (2008). Campbell (2008) does a great job pointing out that the increase could be blamed on the Hawthorne Effect, or the being watched makes people do a better job effect (p.262). Besides this, the author remarked that the increase in compliance toward the end of the study could have been from peer to peer involvement as related to the Rogers Diffusion of Innovation theory. Campbell (2008) does explain that a possible limitation in this study was the high turnover rate of nurses in the units, which could have affected the numbers due to educational needs and gaps that probably were not consistent. Overall, this was a strong section of the study; it was very detailed and extremely interesting. Conclusion and Implications to Nursing Practice The author remarks that an important aspect to keep in mind with the results of this study is that there is multiple recommendations in previous research that suggest best evidence based treatments to use with the presence of sepsis, severe sepsis or septic shock (Campbell, 2008). This study did not evaluate the specific treatments in regards to patient outcomes, on the

The Nurses Role In The Detection Of Sepsis 35 application of any ordered treatment and the compliance of sepsis screening being done by the nurse at the bedside (2008). One of the reasons many patients may not get appropriate treatment for sepsis could be due to provider buy in for specific cookbook protocols (p. 263). Implications for practice and research as a result of this study is very clearly detailed by the author and supports the fact that placing a nurse champion in an ICU will improve the screening compliance, documentation and application of treatment for sepsis (2008). The author does recognize the barriers for sustainability of such a program exists, in terms of nurse workloads, budgets and staffing issues and recommends further research or development of other frameworks to address this issue (2008). This research is noted by the author as having the ability to positively affect patient outcomes when it comes to detecting and preventing sepsis, severe sepsis and septic shock (2008). Campbell (2008) also identifies a need for more provider input and establishment of official standards of care with these patients. Overall, the conclusion and implication were objective, realistic, and included both statistical finding and clinical, real world finding and possible effects. It would be nice however to see additional research and studies of this nature conducted with larger sample sizes and a variety of patient populations. Nurses, both at the bedside and in leadership roles, play a large part in the detection and treatment when it comes to sepsis. This evidence clearly shows the nurses role at the bedside in the detection of sepsis is imperative; nurses need the knowledge to know how and why to detect sepsis early and they must have the tools to treat or promote optimal care. How the Evidence Can Effect Practice The evidence presented in this project can drastically affect nursing practice by promoting patient safety and optimal patient outcomes. Nurses are constantly at the bedside and

The Nurses Role In The Detection Of Sepsis 36 know the entire treatment plan for the patient. If nurses are aware of what to look for when it comes to the very subtle signs and symptoms of sepsis, then patients detected early will likely not progress to shock, and lives will be saved. It is the hope of this group that the nurses role in the detection of sepsis would become second nature, like assessing vital signs! This project has truly affected every member of our group. We have changed the way we assess patients during our shift. Its amazing that paying attention to a certain combination of assessment characteristics, lab values, vital signs and the presence of antibiotics or infection, can have such a drastic influence on patient outcomes. We are more knowledgeable about sepsis and prior to this project, did not realize it was so common and that the mortality was so high. We fully intend to start sepsis awareness projects at the hospitals where we work and encourage colleagues to be empowered and use with this information. Recommendation The evidence shows that detecting sepsis early, administering fluid and antibiotics, as well as completing diagnostic testing in a timely fashion, can safe lives. The recommendation of this evidence based practice project is for every hospital to utilize the nurse as the front line defender of sepsis. Empower the nurse not only with the knowledge of the pathophysiology of sepsis and its deadly manifestation, but also with the tools, and protocols to autonomously treat patients rapidly when sepsis is detected. Every nurse has a critical role in the detection of sepsis, and the treatment of the patient to ensure an optimal outcome. Nurses can make all the difference. From the charge nurse, to the emergency room nurse to the inpatient nurse, sepsis can usually only be defeated if it is detected early and stopped. Another recommendation from this group is to encourage more research on this topic and on the appropriate combination of treatments to be administered by the care provider. Relatively

The Nurses Role In The Detection Of Sepsis 37 few research studies exist, especially by nurses, on this topic. The review of literature for this project makes it clear, more nursing research needs to be done, both for the advancement for the treatment of sepsis and for the advancement of the profession of nurse researchers. Conclusion It is evident that the role of the nurse in the detection of sepsis in the hospitalized patient is imperative, whether in the emergency room, nursing home, outpatient or inpatient facility, or any other institution where patient care is delivered. Hospital nurses are at the bedside and in the units for a reason: to promote optimal patient outcomes, and provide safe, caring, ethical, efficient patient care. The evidence is clear, the nurses role in detecting sepsis is to be knowledgeable about the signs and symptoms of sepsis and promote early treatment in many settings. Detecting and treating sepsis early will save lives.

The Nurses Role In The Detection Of Sepsis 38 Appendix TABLE 1

Differences between cases included by the ED nurses and cases initially not included by the ED nurses, at the level of performance of the complete sepsis bundle and the sic individual bundle elements (n=589). Variable Cases included by Cases initially not included by ED nurses (n=431) n (%) ED nurses (n=158) n (%) Performance of the complete sepsis bundle (all 6 elements) 56 (13.0) 11 (7.0) Measure lactate within 6 hours 374 (86.8) 75 (47.5) Take 2 blood cultures before starting antibiotics 385 (89.3) 99 (62.7) Take a chest radiograph 375 (87.0) 136 (86.1) Take a urine sample for urinalysis and culture 280 (65.0) 62 (39.2) Start antibiotics within 3 hours 241 (55.9) 56 (35.4) Admit or discharge the patient within 3 hours 207 (48.0) 68 (43.0) Patients with sepsis and complete data set noted after the start of the sepsis protocol. ED=emergency department. (Tromp, M., et al., p.1471, 2010)

The Nurses Role In The Detection Of Sepsis 39 References Aitken, L., Williams, G., Harvey, M., Blot, S., Kleinpell, R., Labeau, S.,Ahrens, T. (2011). Nursing considerations to complement the surviving sepsis campaign guidelines. Critical Care Medicine, 39(7), pp. 1800-1818. Burns, N., & Grove, S.K. (2011). Understanding nursing research: Building and evidenced-based practice (5th ed.). Maryland Heights, MO: Elsevier Saunders. Campbell, J. (2008). The effect of nurse champions on compliance with keystone intensive care unit sepsis-screening protocol. Critical Care Nursing Quarterly, 31(3), pp. 251-269. Kleinpell, R. (2012). Surviving sepsis: Specific strategies exist for preventing infections in older adults. Advance for Nurses. Retrieved from http://nursing.advanceweb.com/continuingeducation/ce-articles/surviving-sepsis.aspx McCormick, M. (2009). Recognizing the signposts of sepsis. Nursing Made Incredibly Easy, 7(3), pp. 40-51. Nelson, D., LeMaster, T., Plost, G., & Zahner, M. (2009). Recognizing sepsis in the adult patient. American Journal of Nursing, 109(3), pp. 40-45. Schorr, C. (2011). Performance improvement in the management of sepsis. Critical Care Nursing Clinics of North America, 23(1), pp. 203-213. Surviving Sepsis Campaign. (2012). Surviving sepsis: Introduction. Retrieved from http://www.survivingsepsis.org/Pages/default.aspx Tromp, M., Hulscher, M., Rovers, C., Peters, L., Berg, D., Borm, G.,Pickkers, P. (2010). The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before and after intervention study. International Journal of Nursing Studies, 47, pp. 1464-1473.

The Nurses Role In The Detection Of Sepsis 40

Paper #1 Evidence-Based Group Project Paper Grading Criteria 15% or 15 points of the grade for this paper can be deducted for APA errors including Spelling and grammar after paper graded.
Headings Possible Points Points Earned Comments

Abstract and Title Page Introduction (What is the problem or question; Provide support for relevance of the question; Clearly describe the aim of the project & paper) A descriptive summary of the most relevant & best evidence to answer the research question (there is not analysis here, just a description of what you found in the literature) An analysis of the evidence (this is a critical appraisal of the evidence and what you feel as a group the evidence suggests and whether there is strong or weak evidence to support the suggested findings)
Describe how the evidence is affected by your experiences as nurses, patient preferences, nursing's or other's values and how these factors would influence your decision to utilize the evidence in practice Make a recommendation as to whether or not to utilize the evidence (support your recommendation with rationale)

10 10

5 10



20 20





APA spelling and Grammar Deductions


Such an awesome paper points taken off for tile page and abstract added back in and 100 given to paper.

The Nurses Role In The Detection Of Sepsis 41 GREAT. Forgot sometimes I was to be grading it!!!
Total 100 possible