Falling Out Over Sepsis

Hello everyone!

I am beginning a several-part series on sepsis awareness. In the emergency department that I work in, we do a really great job at not doing a great job with our sepsis patients. Why? How do we fix it? How do we secure better patient outcomes? Walk with me through this series and maybe we can discover some truths together. Today, I am going to set the scene at my place of employment. The next several posts will be all about the research. 

What happens when hospitals all over the nation keep messing up on a particular patient type? Whatever that fall out is becomes a National Patient Safety Goal. Over time, that NPSG becomes a standard of care. 

One of the NPSG's that I encounter on a daily basis in the emergency department is SEPSIS.

Each and every one of us just LOVE when we get a radio call for a sepsis alert coming in hot. We all know what that typically means. It is typically (but certainly not always) a patient coming from a skilled nursing facility with multiple sources of potential infection that is incredibly febrile and a very difficult stick. 

We grab our cup of ice, our culture bottles, our Foley kit, our IV tray, a few liters of fluid, and go see our new patient. 

How do they typically present: 

- Shallow, rapid respirations 

- Tachycardia

- Hyper- or hypothermia 

- Low urine output 

- Dehydrated 

- and they often have an obvious source of infection

- or are immunocompromised

- or was just released from the hospital for something else 

What is our typical work-up in the ED?

It looks something like this:

- Get them changed into a gown

- Hook them up to the monitor 

- EKG

- 2 lines get put in 

- Sterile urine sample gets collected (via catheter)

- Blood is drawn: CBC, CMP, Lactic Acid, and 2 sets of cultures from 2 different sites 

- Fluids initiated* 

- Doc comes in and puts the sepsis order set in 

- Antibiotics

- Fever management 

- Chest x-rays, CTs, Ultrasounds as needed 

- Admission 

*Some of our docs will hold out on the fluids until the CXR is read due to other pre-existing conditions. Later on, I am going to discuss the most recent research on that practice. 

If all of those tasks are not initiated and COMPLETED in the first hour, it is considered a "fall out." That means, even if we did 9/10 tasks correctly and in the time limit, whatever we missed immediately disregards all of our other hard work. We tend to do better with our truck patients, but are more likely to fall out on a patient that has come in through the waiting room. 

I have been in the emergency department for 6 months now and I have been observing the way other doctors and nurses conduct themselves in a potential septic patient situation. 

Here are some of the things I have noticed about our emergency department: 

-We have people that meet our standard "two SIRS criteria" that we still do not work up as sepsis patients all of the time, and I am not really sure why. 

-I also see a lot of doctors hold off on initiating a sepsis protocol until they have seen the WBC count, and then if they still are not convinced, they will wait for the lactic acid result before initiating sepsis protocols. 

- I see a lot of nurses work slowly through the sepsis protocol, not understanding the urgency of the situation 

- I see culture contaminants or both cultures from the same sample site 

- I see urine samples collected without a catheter (which is not best practice in a sepsis situation)

- I see all the labs sent on patients, but none of the medications given 

- I also see nurses not seeing the potential for sepsis in patients they may not present as obviously as others, leading to a delay in care. 

What I have learned since I started working in the ED:

- Treat everyone as a potential sepsis 

- If those 2 SIRS criteria are met, initiate the protocol yourself (certain labs and diagnostics are in order sets that we are allowed to initiate as nurses) 

- Feel brave enough to educate the doctors as needed on the potential for sepsis 

- Hunt down your potential source of infection

- Work your tail off, even if other nurses aren't. Its better for your patient

- Jump on sepsis alert patients when they come in the door, and work as a group

- Time is Tissue 

If any of y'all are reading this and can relate, please feel free to comment. If you have different ED experiences, please comment. 

My next few posts are going to be about the research that supports sepsis protocols and proves that our docs sometimes are doing the wrong thing. 

As always, its all for the good of our patients! Have a great week!