Improving the Identification, Delivery of Care, and Outcomes of Hospital-Acquired Sepsis

96 Pages·2016·0.62 MB·English

UUnniivveerrssiittyy ooff KKeennttuucckkyy
UUKKnnoowwlleeddggee
DNP Projects College of Nursing
2016
IImmpprroovviinngg tthhee IIddeennttiifificcaattiioonn,, DDeelliivveerryy ooff CCaarree,, aanndd OOuuttccoommeess ooff
HHoossppiittaall--AAccqquuiirreedd SSeeppssiiss
Nicholas James Welker
University of Kentucky, [email protected]
RRiigghhtt cclliicckk ttoo ooppeenn aa ffeeeeddbbaacckk ffoorrmm iinn aa nneeww ttaabb ttoo lleett uuss kknnooww hhooww tthhiiss ddooccuummeenntt bbeenneefifittss yyoouu..
RReeccoommmmeennddeedd CCiittaattiioonn
Welker, Nicholas James, "Improving the Identification, Delivery of Care, and Outcomes of Hospital-
Acquired Sepsis" (2016). DNP Projects. 85.
https://uknowledge.uky.edu/dnp_etds/85
This Practice Inquiry Project is brought to you for free and open access by the College of Nursing at UKnowledge. It
has been accepted for inclusion in DNP Projects by an authorized administrator of UKnowledge. For more
information, please contact [email protected].
Final DNP Project Report
Improving the Identification, Delivery of Care, and Outcomes of Hospital-Acquired
Sepsis

Nicholas J. Welker, MSN, ACNP-BC

University of Kentucky
College of Nursing
Spring 2016

Committee Chair: Nora Warshawsky, PhD, RN, CNE
Clinical Mentor: Terry Altpeter, PhD, EJD, RN, MSHA, CPHG
Committee Member: Melanie Hardin-Pierce, DNP, RN, ACNP-BC, APRN
Table of Contents
List of Figures…………………………………………………………………………….iv
List of Tables……………………………………………………………………………...v
Capstone Introduction………………………..……………………………………………1
Manuscript One……………………………………………………………………………3
Manuscript Two………………………………………………………………………….37
Manuscript Three………………………………………………………………………...54
Capstone Conclusion…………………………………………………………………….75
Bibliography……………………………………………………………………………..76

iii
List of Figures:
Figure 1 - Venn Diagram of Relationship Between Infection, Sepsis Syndromes, and
SIRS………….....................................................................................................................4
Figure 2 - Bedside Nurse-Driven Sepsis Screening Steps……………………………….12
Figure 3 - Donabedian Quality-of-Care Framework…………………………………….13
Figure 4 - Monthly Number of Cases (n=26) and Location at Point of Sepsis
Identification………………………......…………………………………………………15
Figure 5 - Effectiveness of Bedside Screening at Identifying Hospital Acquired Sepsis
Syndromes………………………………………………………………………………..17
Figure 6 - Laboratory Compliance with Early Goal Directed Therapy (n=26)………….18
Figure 7 - Empiric Antibiotic Compliance (n=26) ……………………………………...19
Figure 8 - Intravenous hydration compliance (n=26)………………...………………….19
Figure 9 - Sepsis Related Mortality……………………………………………………...20
Figure 10 - Intensive Care Unit length of stay (Days)……………………...……………21
Figure 11 - Sepsis/Severe Sepsis/Septic Shock Ratio…………………..………………..22

iv
List of Tables:
Table 1 - Demographics…………………………………………………………………14

Table 2 - Early Goal Directed Therapy Compliance and Outcomes…………………….17

Table 3 - Summation of Evidence……………………………………………………….47

Table 4 - Communication strategies……………………………………………………..70

v
Capstone Introduction:
This document represents the culmination of my journey towards obtaining a
Doctorate of Nursing Practice. Here are three papers which I feel represent the
enrichment that the doctoral process has provided; an quality improvement program
evaluation, a literature review on an alternate vehicle for delivering therapy, and a paper
addressing issues with end of life care in the critical care setting.
Manuscript one is a retrospective evaluation of a bedside nurse-driven sepsis
screening that was implemented at my place of employment. This study evaluated the
impact that the bedside screening process had on identifying the early development of
sepsis, the initiation of sepsis treatment therapy, and if there was an impact on disease
severity, mortality, and utilization of critical care facilities.
Manuscript two is a review of the literature to address what I feel is a potential
solution to an identified clinical issue that stemmed from manuscript one; that of a
deficiency in the provision of sepsis treatment therapy. In this manuscript I review if
there is evidence in the literature that this specialized care could be better administered by
a rapid response team, as these teams have the training and skillset to provide critical care
in any clinical setting.
Manuscript three is a paper that focuses on the issue of end of life care
administered by nurse practitioners in a critical care setting. This paper delves into the
issues of what constitutes informed decision making on the part of the patient and their
potential surrogates, ethical dilemmas, evidence based recommendations for
1
communication strategies, medication strategies, and the impact that the dying process
can have on staff, patients, and their families.
These three manuscripts highlight what this doctoral journey has provided me; an
ability to assess the evidence and synthesize from it solutions to issues on a systems level,
to evaluate the impact of those solutions, and the ability to speak competently about
issues facing the profession. I have gained a viewpoint that is elevated from the level of
the individual to the level of systems and organizational. This elevated viewpoint is only
made possible by the principles and advanced education that formulate the Doctorate of
Nursing Practice degree. Sir Isaac Newton said “if I have seen further it is by standing on
the shoulders of giants”; I would say that I see farther now, due to the giants that have
come in the profession before me and what I have learned from them. It is my heartfelt
hope that one day, I may be able to raise the awareness of others of our profession.

2
Manuscript One
A Retrospective Quality Improvement Evaluation of the Utilization and Impact of a
Nurse-Driven Bedside Sepsis Screening Tool at Baptist Health Lexington from February
2015 through July 2015.
Nicholas J. Welker, MSN, ACNP-BC

University of Kentucky
College of Nursing
Spring 2016
3
Introduction:
Traditionally, sepsis has been defined as a systematic inflammatory response
syndrome (SIRS) to an infection, either localized or systemic in nature (Bone, 1992).
The concept of sepsis has been imagined as existing on a continuum -- from sepsis, to
severe sepsis, to septic shock -- with a steady progression to greater and greater severity
of illness. Severe sepsis is when sepsis is associated organ dysfunction; septic shock is
when there is organ dysfunction in the presence of hypotension that is refractory to
volume resuscitation. For the purposes of this paper when referring to all forms of sepsis
we will use the term “sepsis syndromes”.
Figure 1 - Venn Diagram of Relationship Between Infection, Sepsis Syndromes, and
SIRS

Copied from Angus, et al., 2001
The initial stages of sepsis can be insidious and difficult to differentiate from
4
other disease processes that also invoke an inflammatory response (Sebat, 2007; Robson,
Beavis, & Spittle, 2007). The inability to detect early sepsis is especially concerning
when you consider that Sebat, et al (2005) found that 24 percent of sepsis syndrome cases
initially developed on the medical-surgical floors where there is less access to critical
care services in the event of a rapid decline in clinical condition.
In 2012, there were over a million in-hospital cases of which sepsis syndromes
were the primary diagnosis (Celeste, 2013), with an annual increase of 6 percent in
hospital cases of sepsis syndromes since 2001 (Elixhauser, 2011). A diagnosis of a
sepsis syndrome is the most expensive condition treated in the United States for all
payers at an aggregate cost of almost $20.3 billion annually (Celeste, 2013). Mortality
can also be highly variable, with higher mortality rates being associated with higher
severity of illness (Guidet, 2005), though the national average is 16 percent (Dellinger,
2013). This mortality rate is approximately eight times higher than the average mortality
rates of in-patient hospital stays for other diagnoses (Elixhauser, 2011). Resource
utilization and length-of-say (LOS) all increase in a “step wise” manner with severity of
illness, with LOS almost doubling as patients moved from the 1st quartile of illness
severity to the 4th (Adrie, 2005). Drieher and associates (2012) found there to be
demographical differences that were directly independently linked with all-sepsis
mortality; male gender, African-American ethnicity, and advancing age.
The Center for Medicare and Medicaid Services (CMS) identified sepsis
syndromes as a major area for quality improvement in inpatient hospital care. CMS
notified hospitals participating in the inpatient quality reporting program that data
collection of the utilization of sepsis management bundles based off of the Surviving
5