______________________________ Infection Control for New York Health Care Professionals ‒ 2024 Update
A 2022 nationwide investigation of Sep-1 by Cimiotti et al. was conducted in hospitals of all sizes in mostly metropolitan areas [39]. Their results, published in the Journal of the Ameri- can Medical Association , reviewed data on nursing components required for Sep-1 early management bundle compliance and their impact on patient mortality. • All bundle components must be implemented within 3 hours in the presence of a systemic inflammatory response (temperature of >101 °F or <96.8 °F, heart rate >90 beats/minute, respirations >20 breaths/minute, and white blood cell count of >12,000 or <4,000/μL, or >10% bandemia) or a diagnosis of suspected severe sepsis or septic shock. • Components include serum lactate levels, blood cultures, antibiotics, and crystalloid fluids. The timely administration of antibiotics and intravenous fluids are associated with improved SEP-1 scores and patient out- comes, and these treatments that are typically delivered by nurses. • Nurse-initiated sepsis treatment and communication protocols in the emergency department and inpatient acute care units have been associated with improve- ments in SEP-1 bundle compliance and a significant decrease in sepsis-related mortality. • The initiation of nurse-led sepsis protocols has been associated with obtaining timely serum lactate levels and blood cultures; however, the timely delivery of antibiotics and fluid administration continues to be suboptimal. • Organizational commitment of leadership, implementa- tion of early sepsis or systemic inflammatory response syndrome screening tools, sepsis screening and response protocols, and education and training of nurses have been associated with a significant decrease in sepsis- related mortality in Medicare beneficiaries. • Nurse–physician communication and collaboration are necessary components to improve sepsis care. • Nurse hours per patient day (HPPD) were compared, and of the 702,140 patients in 1,284 hospitals, findings suggest that if all hospitals were staffed at 6 registered nurse HPPD or higher, there could be 1,266 fewer deaths. This projected trend continues: If all hospitals were staffed at 9 registered nurse HPPD or higher, there could be 6,360 patient deaths avoided. • In a nationwide survey of emergency departments, 58% of physician directors and 48% of nurse managers identified nurse staffing as the primary cause of delays in treating sepsis. • Each additional patient added to a nurse’s workload was associated with a 12% increase in the likelihood of in-hospital death, a 7% increase in 60-day mortality and 60-day readmission, and longer lengths of stay for patients with sepsis.
• An intensivist strengthened the association between registered nurse HPPD and reduced sepsis-related mortality, which could be a result of interprofessional communication. • Findings suggest that nurse workload is an overlooked and underused aspect of the treatment bundle for patients with a diagnosis of sepsis. • Despite the implementation of care bundles, infections continue to affect health care systems, most likely because of nurse workload, which has been identified as a barrier to bundle adherence. New York State Report on Sepsis Care Improvement Initiative: Hospital Quality Performance includes detailed descriptions of pediatric and adult 1-, 3-, and 6-hour bundles, which are found in the Element VII Glossary [33]. Executive Summary: Surviving Sepsis Campaign (SSC): International Guidelines for the Management of Sepsis and Septic Shock 2021 There are many changes in the updated 2021 guidelines that should be reviewed in detail. One area that has not changed is the need for a rapid response. Sepsis and septic shock are medical emergencies, and the SSC recommends that treatment and resuscitation begin immediately [32]. Other 2021 updates include the following recommendations: • Deliver antimicrobials as soon as possible, ideally within 1 hour of sepsis recognition. • For adults with possible sepsis without shock, complete rapid assessment of infectious versus noninfectious causes of acute illness • New to this update, the guidelines recommend against qSOFA* as a sole screening tool and suggest that patients who are determined to need intensive care be admitted to an ICU within 6 hours. • Empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA), empiric double-coverage for gram- negative pathogens, and empiric coverage for fungal pathogens should be determined based on patient and contextual risk factors. • Use crystalloid fluids as a first line for resuscitation, and new in this update, use balanced crystalloids over normal saline. For patients with septic shock, use nor- epinephrine as the first-line vasopressor, which should be started peripherally to avoid delays in administration in the absence of central venous access. • For adults with sepsis or septic shock, remove intravas- cular access devices that are a possible source of sepsis or septic shock after other vascular access has been established. • For adults with suspected sepsis or septic shock but unconfirmed infection, continuously reevaluate, search for alternative diagnoses, and discontinue empiric antimicrobials if an alternative cause of illness is dem- onstrated or strongly suspected.
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