Evolution of Care for the Patient with Sepsis: A Bibliographic Essay
According to the data on the Surviving Sepsis Campaign website it is estimated that over 750,000 people in the United States are diagnosed with severe sepsis and septic shock each year. Despite aggressive medical care 50% of the patients diagnosed with severe sepsis or septic shock will die. Severe sepsis and septic shock are a preventable complication of sepsis. Similar to other disease processes early identification and treatment can reduce long term morbidity and mortality rates. Despite evidence based data and established guidelines for the care of the patient with sepsis, definition and management of sepsis remains variable. Consequently mortality remains high.
Although there are evidence based standard of care models established for the treatment of the patient with sepsis, compliance to the care bundles remains low. To improve the care of the patient with sepsis the Michigan Health and Hospital Association (MHA) has formed a collaborative with participating emergency departments and intensive care units across the state of Michigan. The goal of the MHA collaborative is to improve the quality of care of the patient with sepsis by improving bundle compliance. As a team member in a participating hospital, I am working to improve bundle compliance in our emergency department.
To begin the process of improving bundle compliance in our emergency department the team I am a part of utilized lean methods to identify the barriers to implementing components of care. A significant barrier we identified was education. Therefore, an important part of the improvement plan will be educating the staff. To be an effective educator, I must be informed and up to date with current data. In addition to educational deficits other barriers were identified in our emergency department. It will be interesting to review current literature and note if other emergency departments have encountered similar obstacles.
Standards of care, early goal directed therapy and bundle compliance are defined by the Surviving Sepsis Campaign as a worldwide initiative. However, when evaluating barriers to compliance I will limit my data to research and studies conducted in the United States. This will reduce my data results, but will yield a more comparable study group. Additionally, it is imperative that the data I gather for educational purposes is current. I will limit my search results to the past 5 year with 1 exception. The exception I will identify is the original research study conducted by Rivers, et al. published in 2001. This article is cited in nearly every research article done since that time as Dr. Rivers et al, established the guidelines now referred to as early goal directed therapy (EGDT). I currently have a copy of this article. I am familiar with the study and will refer to the original article when reviewing literature regarding EGDT.
I previously identified the purpose of the research as multifaceted. To improve bundle compliance in our emergency department education will be a strong component of the process improvement project. Also compliance is not simply identified as poor in our department but nationwide. I would like to have an understanding of the identified barriers and knowledge of the reasons they persist. This information will assist me in my endeavor to improve bundle compliance.
Subgroups of my research are:
Definition of terms sepsis, severe sepsis and septic shock
SIRS criteria: Identifying the patient with sepsis
Definition and origination of Early goal directed therapy
To begin my research I need to establish consistent definitions for the terms; sepsis, severe sepsis, septic shock and SIRS. To accomplish this I accessed the Ferris State University’s FLITE Library online encyclopedias, dictionaries, etc. database. I narrowed this to the Health and Medical data base STAT! Ref: Electronic Medical Library. Stedman’s Medical Dictionary is a good place to start to define terms; I searched sepsis, shock and SIRS. To obtain additional definitions and to verify consistency I searched the Stat! Ref Medical Library data base. A search for sepsis yielded 1236 results. I narrowed the results to 945 searching titles by discipline and found relevant material within the first 10 results. I also did a basic search for SIRS using the same database and 50 results were identified, although only 1 was utilized as a reference.
To further my data collection I went to the FLITE Library available on the Ferris State University’s website. Searching by subject, I chose Nursing and was directed to 2 databases, CINAHL and PubMed. Initially I chose PubMed as I am familiar with this database. A search for Surviving Sepsis Campaign yielded 200 results, of these 37 were available in full text. Of the 37 full text articles only 2 fit into my criteria of recent and national study.
My next search engine used was CINAHL. Surviving Sepsis Campaign yielded 85 results. CINAHL is a new database for me. I found it easier to use than PubMed and discovered has many benefits, such as citation in APA format. Of the 85 results, 56 were prior to 2006. I was able to find several which applied to my research criteria. I also searched CINAHL for sepsis bundle compliance and yielded 26 results, 10 of these fit my criteria and were not duplicates of abstracts I had previously reviewed and saved. As I was not satisfied with my previous search results for SIRS I searched SIRS criteria on the CINAHL data base, of the 38 results I was able to identify applicable literature.
An additional search on CINAHL for early goal directed therapy (EGDT) yielded 132 results. Additional criteria of publication date, and linked full text produced 5 results, 2 of which fit my criteria. However, one of the articles was the one which I spoke of in the introduction by Rivers et al., 2001. Fortunately, many of the resources generated in other searches discuss the components of EGDT.
An internet search using Google search engine for surviving sepsis campaign yielded 183,000 results. Of particular interest were scholarly articles available online and the surviving sepsis campaign website surviving sepsis.org. The Institute for Healthcare Improvement at www.ihi.org has several resources available including “how to improve” and “tools”. I changed my search to sepsis bundles and compliance with clinical guidelines and results were 129,000. One of the results was www.sccm.org which is the society of critical care Medicine website. This site discusses the surviving sepsis campaign as this group had in integral part in the process in collaboration with other groups internationally.
Defining Sepsis, Severe Sepsis and Septic Shock
A clear, concise definition facilitates identification of the ill patient, promotes an understanding of the disease process and provides criteria for clinical research. Severe sepsis and septic shock are identified as complications of sepsis therefore a clear understanding of sepsis must exist to understand the disease process. To define sepsis it is recognized different medical professional groups refer to discipline specific references. Consequently two medical dictionaries, a physician and a nursing reference were accessed via the healthcare resource database Stat!Ref. A website designed as a sepsis resource for healthcare professionals and patients was also consulted.
The medical dictionaries define sepsis as a physiological state or response. Stedman’s Medical Dictionary (2006) states sepsis is “the presence of various pathogenic organisms, or their toxins in the blood or tissue”. There is no definition for severe sepsis. Septic shock is defined as “shock associated with infection that has released large enough quantities of toxins or vasoactive substances including cytokines, to be associated with hypotension”. Tabers Cyclopedic Medical Dictionary (2009) defines sepsis as “A systemic inflammatory response to infection, in which there is fever or hypothermia, tachycardia, tachypnea, and evidence of inadequate blood flow to internal organs”. The definition continues to define shock as a complication of sepsis.
The American College of Physicians reference guide, ACP medicine was utilized as a resource which would be consulted by physicians. The ACP medicine (2011) refers to the 2003 revision of the definition of sepsis stating sepsis is “the body’s response to an infection” not necessarily associated with bloodstream invasion. Severe sepsis is defined as “Sepsis accompanied by perfusion abnormalities and organ dysfunction (CNS, renal, pulmonary, hepatobiliary, hematologic, or metabolic)”. Septic shock is “severe sepsis with hypotension not responsive to fluid challenge”. Parameters of vital signs defining hypotension are stated as systolic blood pressure < 90mmHg.
To understand the definition of sepsis instructed to the nursing professional a nursing resource manual was used. Diseases and Disorders: A Nursing Therapeutics Manual (2011) states “The basis of sepsis and septic shock is the presence of infection. Sepsis is a systemic host response to infection with a systemic inflammatory response syndrome (SIRS) plus a documented infection, and severe sepsis is sepsis with hypotension, despite fluid resuscitation and evidence of inadequate tissue perfusion”. Severe sepsis and septic shock are synonymous in this reference as septic shock is defined as “a clinical syndrome associated with severe systemic infection. It is sepsis induced shock with hypotension despite adequate fluid replacement”.
An additional resource used to obtain a definition of sepsis was the Surviving Sepsis Campaign website (2010). The website is designed as a resource for healthcare professionals as well as patients and family members. The language used to provide definitions and explanations is easy to understand. The Surviving Sepsis Campaign defines sepsis as “the body’s response to an infection” (About Sepsis, para.3). This simple definition is the same as the one utilized in the ACP Medicine Manual. Sepsis is further defined to understand the complication of severe sepsis as “a range of clinical conditions caused by the body’s systemic response to an infection, which if it develops into severe sepsis is accompanied by single or multiple organ dysfunction or failure leading to death”. Septic shock is stated as severe sepsis further complicated by low blood pressure which does not respond to fluid.
Defining SIRS Criteria
Sepsis is defined as the body’s response to an infection. Severe sepsis and septic shock is an identified sequel to sepsis with a mortality rate of 30-50% respectively. Evidence based data reveals early treatment can halt the progression of the disease. Therefore to define sepsis clinically it is important to identify the patient who is at risk for or presents with sepsis. To accomplish this objective the term systemic inflammatory response syndrome or SIRS was developed in 1992 by the American College of Chest Physicians and the Society of Critical Care Medicine (Latto, C., 2008).
SIRS is defined by Powers & Burchell (2010) as “a clinical response to an infectious or noninfectious insult” (p.35). SIRS criteria are an assessment tool to further define sepsis from a clinical perspective. SIRS criteria are well documented in literature pertaining to the diagnosis and treatment of sepsis. Powers et al. define SIRS criteria as:
Core temperature below 96.8˚F (36.0˚C) or above 100.0˚F (38.0˚C)
Heart rate greater the 90 beats/min
Respiratory rate greater than 20 or Paco2 less than 32 mmHg
White blood cell (WBC) count less than 4,000 cells/mm² or greater than 12,000 cells/mm²
A patient is diagnosed with SIRS when at least 2 of the 4 defining criteria are present. Sepsis is defined clinically when SIRS and an infection are present. The infection may be identified in a blood culture, a radiologic study or visible upon clinical exam (Powers et al., 2010).
To improve the identification and treatment of patients with sepsis an International Sepsis Definitions Conference was held in 2001 (Dodge, 2010). Although the definition of sepsis changed little, the conference resulted in an expansion of the SIRS criteria. Dodge states the expanded SIRS criteria includes “decreased urine output, decreased skin perfusion, poor capillary refill, skin mottling, decreased platelet count, petechiae, hypoglycemia, chills and unexplained change in mental status” (p. 12). Latto (2008) also discusses the 2001 changes of SIRS criteria stating SIRS criteria … “are separated into 5 categories: (1) general, (2), inflammatory, (3) hemodynamic, (4) organ dysfunction, and (5) tissue perfusion” (p. 196). Powers et al. (2010) identifies the 5 categories as stated by Latto. The categories are alternatively identified by Powers et al. as “systemic manifestations of infection” which “define sepsis” (p. 36). Powers et al. lists SIRS criteria and the 5 categories separately although the general category includes the 4 criteria which define SIRS. Powers et al. references the 2008 Surviving Sepsis updated guidelines.
To determine the current SIRS criteria as updated by the Surviving Sepsis campaign in 2008 additional literature was reviewed. Cronshaw, Daniels, Bleetman, Joynes & Sheils (2011) cite the 2008 Surviving Sepsis Campaign updated guidelines stating current SIRS criteria as:
Hypothermia 96.8˚F (36.0˚C) or Hyperthermia 100.0˚F (38.0˚C)
Tachycardia > 90 beats/min
Tachypnea >20 breaths/min
White blood cell (WBC) count less than 4,000 cells/mm² or greater than 12,000 cells/mm²
Acutely altered mental state
Hyperglycemia in the absence of diabetes
Additional signs and symptoms such as Lactate >2mmol/l and Systolic Blood Pressure (SBP) <90 are stated as “signs of organ dysfunction” (p. 671, table 1).
The Surviving Sepsis Campaign website correlates with SIRS criteria as identified by Cronshaw et al. (2011) and offers an explanation to the inconsistencies identified in the literature search. The Surviving Sepsis Campaign website states “SIRS and MODS are combined in several literatures (Getting Started: Tools for Success). Surviving sepsis SIRS does not include SBP parameters”. MODS is an abbreviation for multiple organ dysfunction syndrome. It is defined by Tabers (2009) as “Progressive failure of two or more organs resulting from acute, severe illness or injuries (i.e., sepsis, systemic inflammatory response, trauma, burns)…”
The statement provided on the Surviving Sepsis Campaign website permits further clarification of the current definitions of sepsis. In conclusion, literature review reveals sepsis is an infection with SIRS criteria. If sepsis is present with MODS it is defined as severe sepsis and septic shock is identified as severe sepsis with hypotension refractory to fluid resuscitation. Conversely, the criteria which define SIRS are not clearly identified in literature.
Early Goal Directed Therapy (EGDT)
Earlygoal directed therapy (EGDT) is defined by Wikipedia as “a systematic approach to resuscitation which is meant to be started in the emergency department and uses a step-wise approach to optimize cardiac preload, afterload and contractility, thus optimizing oxygen deliver to the tissues” (as cited in Marik & Varon, 2010, p. 244). The originator of the term Dr. Emanuel Rivers defines EGDT simply as “early hemodynamic optimization” (Rivers, 2010, p. 476).
Goal directed therapy was first conceived in experimental studies utilizing dogs over 20 years ago. The dog studies revealed a significant improvement in survival of septic shock when treatment therapies were combined rather than applied individually. In 1976, prior to the animal research, Wilson et al. (as cited in Rivers, 2010) wrote a sequence of recommendations for sepsis management. “The recommendations included early identification of high risk patients, appropriate cultures, source control and appropriate antibiotic administration” (p. 476). The recommendations further stated guidelines for optimization of hemodynamic stability utilizing parameters of preload, afterload and oxygen as measurements to verify improving patient status (Rivers, 2010).
Over the next 20 years the recommendations of early identification, combined therapy and end point measurements were applied to the care of patients with severe sepsis and septic shock in the intensive care unit (ICU). Subsequent studies revealed septic shock incidence continued to increase with no remarkable improvements in the associated mortality or morbidity of the patient with sepsis. Responding to statistical data a study was conducted to determine if outcome improvements could be established if therapies were initiated earlier in the course of the disease. The study approached the treatment of sepsis with urgency similar to the initial care of the patient with acute myocardial infarct, stroke or severe trauma. The study modified goal directed therapy to early goal directed therapy (EGDT). The modification defined a standardized treatment plan for the patient with sepsis in the emergency department rather than waiting for admission to the ICU. As sepsis is an evolving disease process, it was theorized treatment standards would be most effective if applied early. The results of the study demonstrated a significant reduction in mortality of patients with sepsis. (Rivers et al., 2001).
The study conducted by Rivers et al. (2001) qualified patients who presented to the emergency department with sepsis syndrome if SIRS criteria and a SBP ≤90 following a 20-30ml/Kg fluid bolus or a serum lactate ≥ 4mmol/L existed. In addition to early identification of the patient with sepsis, standard therapy with source identification and administration of antibiotics is discussed. The study was a blinded, randomized study. All patients in the study received appropriate cultures and antibiotics. Approximately half of the patients who fit the sepsis syndrome criteria received a protocol of care designated as EGDT (Rivers et al., 2001).
The components of the treatment protocol are best summarized by Nguyen et al. (2007). Using a central venous catheter inserted in the emergency department to identify and maintain hemodynamic parameters of “a central venous pressure of 8-12 mm Hg, a mean arterial pressure 65-90 mm Hg and central venous oxygen saturation ≥ 70% by 6 h with the use of fluids, packed red blood cell transfusion, vasopressor and inotrope agents and mechanical ventilation” (Nguyen et al., 2007, p.7, table 2).
The study by Rivers et al. (as cited by McKenna, 2008) concluded the study participants who received EGDT demonstrated a 16% reduction in mortality when compared to study group participants who received standard sepsis therapy. In response to the data the protocol by Rivers et al. was adapted by the Surviving Sepsis Campaign. The protocol is also currently recommended by the American College of Emergency Physicians, the Society of Critical Care Medicine, and the Institute for Healthcare Improvement (McKenna, 2008).
The Surviving Sepsis Campaign (SSC) was initiated by the European Society of Intensive Care Medicine, the International Sepsis Forum and the Society of Critical Care Medicine in 2002. The purpose of the campaign was to improve the care of the patient with sepsis with the application of evidence based best practice standards to bedside care. The objective of the campaign was to “decrease mortality of patients with severe sepsis and septic shock by 25% by 2009” (Townsend, Schorr, Levy & Dellinger, 2008, p. 721).
Townsend et al. (2008) discusses the development of the SSC, referred to as phase I, as “an ambitious mission not commonly seen in health care initiatives” (p.722). Townsend et al. states literature from the campaign initiative identified several directives including “changing perceptions and behaviors, influencing public policy and defining standard of care in sepsis” (p.722).
The development of the standards of care, or phase II of the campaign was published in 2004. The standardized care guidelines were formulated during a collaborative conference attended by the original founders of the campaign and endorsed by an additional 11 professional societies. The SSC continued to demonstrate a commitment to the care of patients with sepsis. In response to ongoing research data and the foundation of evidence based best care practices the guidelines which define the standard of care for the patient with sepsis were updated again and subsequently published in 2008. The 2008 updates are the current recommendations for patient care and are referred to as phase III of the campaign (Levy et al., 2010). Indicative of a phase IV in progress the SSC website states “the 2008 Guidelines are being revised to incorporate recently published evidence. Revision of the existing treatment bundles will follow in collaboration with the Institute for Healthcare Improvement”.
The Surviving Sepsis Campaign (SSC) website states the campaign is “an initiative of the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum and the Society of Critical Care Medicine (SCCM) was developed to improve the management, diagnosis, and treatment of sepsis”(About the Campaign, para.1). The website further defines the purpose of the campaign. It is stated the campaign aims to reduce the mortality of sepsis with a multifaceted strategy to build awareness, improve diagnosis, educate health care professionals, increase the use of evidence based treatment, develop guidelines of care and collect data.
The website identifies the current contributors of development and updating the website as the SCCM and ESICM. Information on the website is current as evidenced by dated relevant updates and available conference links. In addition to updates and research data the campaign website provides educational and implementation strategy tools for healthcare professionals.
The standardized care guidelines for the management of the patient with sepsis are organized into “bundles”. A bundle is defined by McCarron (2011) as “a set of interventions that, when used together significantly improve patient outcomes” (p. 30). The SSC website defines the sepsis bundle updates published in 2008:
Reducing mortality due to severe sepsis requires an organized process that guarantees early recognition and consistent application of evidence based practices. The "Severe Sepsis Bundles" are a series of therapies that, when implemented together, achieve better outcomes than when implemented individually. The resuscitation bundle is a combined evidence-based goals that must be completed within 6 hours for patients with severe sepsis, septic shock and/or lactate >4 mmol/L (Severe Sepsis Bundles, para. 3).
The SSC website further states “The intention in applying the bundle is to perform all indicated tasks 100 percent of the time within the first 6 hours of identification of severe sepsis”.
McCarron (2011) identifies 2 bundles developed by the SSC for the care of patients with severe sepsis and septic shock. The initial bundle is the resuscitation bundle which must be accomplished in the first 6 hours of diagnosis of severe sepsis or septic shock. The continued care bundle is defined as the sepsis management bundle which outlines interventions that must be performed within 24 hours of diagnosis. McCarron states the resuscitation bundle components as:
Obtaining blood cultures
Administering broad-spectrum antibiotics
Measure serum lactate
Insert urinary catheter
Treat hypotension with fluid and vasopressors if needed (p. 32)
The surviving sepsis campaign website states the resuscitation bundle components are:
Measure serum lactate
Obtain blood cultures prior to antibiotic administration
Broad spectrum antibiotic within 3 hours of ED presentation and within 1 hour of non-ED admission
Treat hypotension and/or elevated lactate with fluids
Deliver an initial minimum of 20ml/kg of crystalloid or equivalent
Administer vasopressors for hypotension unresponsive to fluid
In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate >4 mmol/L maintain adequate central venous pressure and central venous oxygen saturation:
Achieve a central venous pressure (CVP) of >8 mm Hg
Achieve central venous oxygen saturation (ScvO2) > 70% or mixed venous oxygen saturation (SvO2) > 65%
The sepsis management bundle is uniformly stated by McCarron, the SCC website and Levy et al. (2010) as:
Low dose steroids for septic shock in accordance with a standardized hospital policy
Administer recombinant human activated protein C (rhAPC) in accordance with a
standardized ICU policy
Maintain adequate glycemic control
Prevent excessive inspiratory plateau pressures in mechanically vented patients
The SSC is identified as a voluntary international collaborative to improve the care of the patient with sepsis. Hospitals which participated in the collaborative submitted data over a two year period, referenced as the “data analysis period”. Analysis of the data revealed “instituting a practice improvement program grounded in evidence-based guidelines, SSC increased compliance with the change bundles that was associated with better patient outcomes”. Analysis of the data revealed compliance with bundles improved from 10.9% to 31.3% over a two year period. Additionally hospital mortality reduced from 37% to 30.9% when SSC guidelines were implemented. Data analysis further revealed continued measurable improvement in compliance and mortality the longer the hospital site remained active in the SSC (Levy et al., 2010).
Identified Barriers to Bundle Compliance
Despite the evidence of reduced mortality, morbidity and cost, implementation of early goal directed therapy has not been as consistent as the Surviving Sepsis Campaign had aspired. Current literature reveals controversy around the components of the early goal directed therapy, particularly the research done by Dr. Rivers et al. in 2001. Several researchers have successfully duplicated the study results when EGDT was implemented in the emergency department. Although skeptical of the data, Marik & Varon (2010) refer to over 40 studies which support the results of the original research. Similar to Marik & Varon, there are also several studies which challenge the components and the methods used in the original study. Therefore in addition to supporters there remain skeptics. The result has been a resistance to practice change by many physician groups (Marik & Varon, 2010).
Mikkelson et al. (2010) discusses physician practice variability despite an organizational protocol to follow the components of the sepsis bundles. The results of the study reveal early goal directed therapy (EGDT) was completed in less than 10% of the patients identified as eligible by defined criteria despite an organizational policy to follow the components of the sepsis bundles.. In discussing identified barriers Mikkelson et al. discusses the difficulties of changing current practice by physician to protocol driven practice as a mysterious phenomenon. An additional barrier discussed was patient presentation. However, the barrier is not the patient presentation, rather the perception of illness by the physician. Ultimately, the physician did not implement aggressive treatment to identified groups of patients rationalizing the patient did not appear ill. The authors do conclude the barriers identified result from physician knowledge, acceptance and attitude regarding evidence based protocols for the treatment of sepsis. Mikkelson et al. states “The failure to translate evidence into practice has been identified as one of the great challenges of modern medicine” (p.552).
Physician practice change is not the only barrier identified to overcome poor compliance in bundle implementation. A national survey of 30 tertiary care hospitals by Carlborn & Rubenfeld (2007) revealed only 7% were using early goal therapy for severe sepsis. When the survey respondents were questioned regarding noncompliance several themes developed. A high number of respondents cited a shortage of available nursing staff, the inability to monitor central venous pressure in the emergency department and difficulty identifying septic patients.
Merritt (2011) identifies barriers as equipment and staffing deficits. The article discusses the barriers to bundle compliance using a cost comparison analysis. It has been stated by the advocates of standardized sepsis treatment that sepsis bundles save lives and reduces health care dollar expenditure. Merritt compares the dollars saved to the dollars which are potentially spent to implement an early goal directed therapy protocol. Although cost should not be a factor in patient care it is cited indirectly in many identified barrier to implementation.
Lack of staffing and specialized equipment is a common barrier stated in literature. Additional barriers identified are knowledge deficit regarding sepsis and clinician disagreement with the recommendations. An additional barrier discussed is lack of time as early goal directed therapy is initiated in emergency departments which are already overcrowded and often understaffed (Stoneking, Denninghoff, Deluca, Keim, & Munger, 2011).
An evaluation of barriers often precedes a process improvement project. Loyola, Wilhelm & Fornos (2011) identified several barriers in a 5 hospital system analysis. The identified barriers were recognition of sepsis in the patient, healthcare providers’ familiarity and knowledge of the guidelines, clinician belief in the evidence, and lack of a clear process. The authors conclude the article with a general theme of identified barriers, which is a good reflection of the barriers discussed in other literature. The authors state to improve the care of patients with sepsis “it is important to change mindset, methods and culture” (p. 198).
This essay provides a review of the current professional publications and websites that I have identified as current and contributory to the pursuit of improving the care of the patient with sepsis. The data is a tool to understand the implications of EGDT and bundle compliance consulting current contributors active in the pursuit to reduce the morbidity and mortality of the patient with sepsis.
The literature review represents the progression of evidence based standards of care for the patient with sepsis. The barriers for bundle compliance are discussed independently in this essay. However the literature review has revealed the evolution of developing evidence based standard care for sepsis has itself contributed to barriers for implementation.
The literature review reveals the definitions for key terms are inconsistent. The definitions for sepsis, severe sepsis and septic shock vary by healthcare discipline. The criteria for SIRS are adaptable depending on the source consulted. It also demonstrates the standards of care are not always clear. Early goal directed therapy is best discussed by the originator as there exists a great deal of controversy in regards to the components. Also, the Surviving Sepsis Campaign has modified the standards of care several times. Although it is justifiable to respond to research, the literature reveals the 2008 modifications have resulted in confusion regarding the components of the resuscitation bundle.
Perhaps a reflection of the identified inconsistencies in the literature, an evaluation of process flow in our emergency department has revealed knowledge deficit as a key contributor to poor bundle compliance. I believe I have acquired adequate knowledge to develop a teaching model for the care of the patient with sepsis. I have identified there are several definition and treatment variables in the literature. It will therefore be essential to survey the staff regarding their current understandings and perceptions. Recollecting the inconsistency identified in the literature, I believe it will be important to ascertain an educational approach which provides clarification and consistency.
About the Campaign, Bundles, Campaign Update, (2010). Surviving Sepsis Campaign. Retrieved from http://www.SurvivingSepsis.org
Carlbom, D., & Rubenfeld, G. (2007). Barriers to implementing protocol-based sepsis resuscitation in the emergency department -- results of a national survey. Critical Care Medicine, 35(11), 2525-2532. Retrieved from http://search.ebscohost.com
Chapter XXX - Sepsis, Section 7, Table 1, the terminology of sepsis, (2011). In Federman &. Nabel (Eds.), ACP Medicine. Decker Publishing Inc. Retrieved from http://0-online.statref.com.libcat.ferris.edu/document.aspx?fxid=48&docid=1341. 10/20/2011 11:12:27 AM CDT (UTC -05:00).
Cronshaw, H., Daniels, R., Bleetman, A., Joynes, E., & Sheils, M. (2011). Impact of the Surviving Sepsis Campaign on the recognition and management of severe sepsis in the emergency department: are we failing?. Emergency Medicine Journal, 28(8), 670-675. Retrieved from http://search.ebscohost.com
Dodge, M. (2010). SIRS: a systematic approach for medical-surgical nurses to stop the progression to sepsis. MEDSURG Nursing, 19(1), 11-15. Retrieved from http://search.ebscohost.com/
Latto, C. (2008). An overview of sepsis. Dimensions of Critical Care Nursing, 27(5), 195-202. . Retrieved from http://search.ebscohost.com/
Loyola, S., Wilhelm, J., & Fornos, J. (2011). An innovative approach to meeting early goal-directed therapy using telemedicine. Critical Care Nursing Quarterly, 34(3), 187-199. . Retrieved from http://search.ebscohost.com/
Levy, M., Dellinger, R., Townsend, S., Linde-Zwirble, W., Marshall, J., Bion, J., & ... Angus, D. (2010). The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine, 38(2), 367-374. doi:10.1097/CCM.0b013e3181cb0cdc
Marik, P., & Varon, J. (2010). Early goal-directed therapy: on terminal life support?. American Journal of Emergency Medicine, 28(2), 243-245. doi:10.1016/j.ajem.2009.11 host.014
Mikkelsen, M., Gaieski, D., Goyal, M., Miltiades, A., Munson, J., Pines, J., & ... Christie, J. (2010). Factors Associated With Nonadherence to Early Goal-Directed Therapy in the ED. CHEST, 138(3), 551-558. doi:10.1378/chest.09-2210
McCarron, K. (2011). Understanding care bundles. Nursing Made Incredibly Easy, 9(2), 30-33. doi:10.1097/01.NME.0000394024.85792.42
McKenna, M. (2008). Controversy swirls around early goal-directed therapy in sepsis: pioneer defends ground- breaking approach to deadly disease. Annals of Emergency Medicine, 52(6), 651-654. Retrieved from http://search.ebscohost.com/
Powers, K., & Burchell, P. (2010). Sepsis alert: avoiding the shock. Nursing, 40(4), 34-39. doi:10.1097/01.NURSE.0000369863.90680.c4
Rivers, E. (2010). Point: adherence to early goal-directed therapy: does it really matter? Yes. After a decade, the scientific proof speaks for itself. CHEST, 138(3), 476-480. doi:10.1378/chest.10-1405
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., & ... Tomlanovich, M. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368-1377. Retrieved from http://search.ebscohost.com
Sepsis, septic shock (2006). In T. Piper (Ed.), STEDMAN'S MEDICAL DICTIONARY - 28th Ed. [STAT!Ref version]. Retrieved from http://online.statref.com
Septic Shock (2011). In Sommers (Ed.), Diseases and Disorders: A Nursing Therapeutics Manual. F. A. Davis Company. [STAT!Ref version]. Retrieved from http://online.statref.com
Retrieved from http://0-online.statref.com.libcat.ferris.edu/document.aspx?fxid=62&docid=217. 10/20/2011 11:22:45 AM CDT (UTC -05:00).
Stoneking, L., Denninghoff, K., DeLuca, L., Keim, S. M., & Munger, B. (2011). Sepsis Bundles and Compliance With Clinical Guidelines. Journal of Intensive Care Medicine (Sage Publications Inc.), 26(3), 172-182. Retrieved from http://search.ebscohost.com
Townsend, S., Schorr, C., Levy, M., & Dellinger, R. (2008). Reducing mortality in severe sepsis: the Surviving Sepsis Campaign. Clinics in Chest Medicine, 29(4), 721-733. Retrieved from http://search.ebscohost.com/
Venes, D (Ed.). (2009). Taber's® Cyclopedic Medical Dictionary(21st ed.). Philadelphia, PA. F. A. Davis Company. [STAT!Ref version]. Retrieved from http://online.statref.com