Sepsis Screening and Morbidity of Seriously Infected Adult Patients: An Integrative Literature Review

Sepsis Screening and Morbidity of Seriously Infected Adult Patients:

An Integrative Literature Review

Elizabeth Placek

Faculty Sponsor: Elizabeth P. Anderson PhD, RN

Background: Despite the necessary guidelines that require hospitals and healthcare institutions to adopt a sepsis screening and protocol system, institutions are not required to follow a universal protocol for sepsis management. The quandary this presents to evidenced based practice is that the difference of interpretation by healthcare institutions may not be therapeutic or conducive. There may be a variance and difference in how protocols are followed by healthcare institutions that may be ineffective in preventing untoward outcomes and saving lives with the 3 hour bundle (standard up to end 2018).

Objectives: To explore effectiveness of interpretation of the employment of Sepsis Screening for the 3-hour bundle in relationship to patient outcomes by health care institutions.

Method: The process of the integrated literature review (ILR) was based on the guidelines presented by Torraco (2005). This ILR focuses on retrospective analysis of studies that have adopted sepsis protocols and analyzed the results pertaining to patient outcomes. Each study included in this literature review is unique in the way that they designed their protocol for sepsis management. Inclusion criteria: articles reviewed were limited to peer-reviewed articles published between the years of 2012 and 2018. A computerized search of the literature was conducted using Cumulative Index to Nursing and Health Literature (CINAHL), PubMed and Cochrane Library.

Results: A total of six research studies were reviewed and analyzed. This ILR divided studies into two groups: 1) Health Care Institutions That Had Surviving Sepsis Guidelines (4 studies; sample sizes ranged from 118 to 49, 331). All four hospital-based studies utilized the 3-hour bundle protocol; recognition of septic shock, measuring lactic levels, obtaining blood cultures before intravenous administration of broad-spectrum antibiotics, and 30 ml/kg of crystalloids for abnormal lactic levels or hypotension. Results were not uniform per the institutions with only 3 studies providing statistical outcomes. One study found that 28-day mortality decreased from 61% to 33% and also tested for predictors of in-hospital mortality a) interval of time between identification and antibiotic administration >4.5 hours (P<0.002), type of infection- community versus nosocomial (P= 0.006), and vasopressor duration of 1.59 to 1.01 days (P=0.037). Another study found that within 3 to 12 hours of antibiotic administration had 14% higher odds in hospital deaths, found adherence improvement in survival mortality versus patient who did not receive (P=0.035). The last study of the 3 indicated improvement in survival mortality of patients receiving antibiotics within 3 hours than those who did not (P=0.001). 2) Health Care Institutions That Did Not Use the Surviving Sepsis Guidelines (2 studies; samples sizes ranged from 478 to 2524) did not utilize 3 hour bundles focused more on early recognition and impact on outcomes. Early recognition in one study included value of using shock index (SI), vital signs, and systemic and inflammatory response syndromes (SIRS) to predict primary outcomes of hyperlactatemia and secondary outcome of mortality for twenty-eight days. Two hundred and ninety patients presented with hyperlactatemia and 361 patients died with sepsis within 28 days of the total 2524 patients. Subjects with an abnormal SI of 0.7 or greater were three times more likely to present with hyperlactatemia than those with a normal SI. The next study utilized the Until Proven Otherwise (SUPO) protocol which is nursing-based focused on identifying abnormal vital signs. Characteristics related with positive SUPO screening on multivariate logistic regression included the following: presence of cancer (P <0.001 longer operative time (P=0.004), and presence of post-operative infection (p=0.001). Positive SUPO screening tests occurred at a median of 20 hours after operation (all SUPO positive screens had tachycardia; abnormal temperature (78%), tachypnea (31%), and hypotension (3%). Generally, SUPO positive patients were older than SUPO negative patients (P = 0.021), had lower BMI (P = 0.044), longer operations (P = 0.004), and higher rates of cancer (P < 0.001) and post-operative infection (P = 0.001). The hospital length of stay was longer in the SUPO positive patients (P < 0.001). Major limitations:

Conclusion: Major limitation was the lack of theoretical framework and though all studies had the target population (patients with sepsis) 4 out 6 lacked demographics. A return to the literature indicated that there is of 2019 the bundle is now a 1 hour protocol with the same steps of the 3 hour bundle except an additional step of application of vasopressors if hypotensive after fluid resuscitation. Future research recommendations are to conduct studies on the effectiveness and ease of nurses with what technological support system is required in performing the 1 hour bundle.

Examples of technology for increasing time efficiency would be phone application software program with NEWS (national early warning score) of sepsis links to health care providers which has overseas (Hancock, 2015). Analysis should include not only the presence of sepsis but also demographics with larger samples sizes. Conceptual/theoretical framework of the adult learning theory (Knowles, 1984) is recommended. Nurses should be more involved in the interpretation, use, and ongoing development of the 1 hour bundle protocol with a focus on evidence based practice within health care institutions.

Key Words: “sepsis” AND “screening” OR “testing” OR “screen” OR “test” AND “prevention” OR “control”.