Clinical Problem
Sepsis is a medical emergency that accounts for a majority of intensive care admissions, and it is estimated to be a leading cause of mortality and critical illness worldwide (Samaha, Casserly, & Stevens, 2015). According to the Center of Disease Control, more than 750,000 sepsis cases are reported annually; 13-35% of hospitalized patients develop sepsis, with a mortality rate of one in four. (2014). Due to the high mortality rate associated with sepsis, it is important to treat patients promptly to prevent any further complications and possible mortality.
Current Practice:
The current practice in a Southern California hospital includes the use of Systemic Inflammatory Response Syndrome (SIRS). SIRS is used to detect sepsis in the early stages. However, the identification of sepsis and predicting the mortality rate remains one of the significant problems in the hospital.
PICO Question
A PICO, an acronym for population, intervention, comparison, and outcome question was developed as a helpful approach for summarizing research questions that explore the effect of a therapy (Riva, Malik Burnie, Endicott, & Busse, 2012). The PICO chosen for this problem was “Can the implementation of Quick Sepsis Organ Failure (qSOFA) system predict the mortality rate among the adult population in the emergency department?” The population includes adult emergency room patients. The intervention includes the use of qSOFA to predict the mortality rate. The comparison is the current hospital policy, and the outcome is the perditction of mortality rate.
Search Strategies
In order to obtain the latest research articles for this paper, the Cumulative Index for Nursing and Allied Health Literature (CINAHL) database was accessed via the Point Loma Nazarene University (PLNU) Ryan’s Library. The following keywords were entered using advanced search “Sepsis”, “qSOFA”, “Surviving Sepsis Campaign”, and “SIRS”. Search was further limited by date from January of 2012 to September of 2017. CINAHL yielded 68 articles. Over ten articles were reviewed, and “Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit” by Finkelsztein et al. (2017) was selected for further review.
In addition to CINHAL, ProQuest, a Nursing and Allied Health Database, was accessed through the Ryan Library. A full articles option was selected, as well as scholarly journals search type. The following keywords were entered “Sepsis”, “qSOFA”, “SIRS”, and “ER sepsis”. ProQuest yielded 72 research articles. Five articles were reviewed, and “Assessment of Clinical Criteria for Sepsis for the Third International Consensus Definitions for Sepsis and Septic Shock” by Seymour et al. (2016) was considered for this project.
Finally, Sharp Healthcare Library services were accessed for additional articles. PubMed, a US National Library of Medicine Institute of Health, database was accessed, and full articles option was chosen. The following key concepts were entered “qSOFA”, “Sepsis Bundle”, and “Randomized Control trials for qSOFA”. PubMed yielded 106 articles. Date from January 2013-May 2018 further limited the results. Clinical trials option was chosen, and 21 articles were reviewed. “Time to Treatment and Mortality during Mandated Emergency Care for Sepsis” by Seymour et al. (2017) and “Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients with Suspected Infection Presenting to the Emergency Department” by Freund et al. (2017) were chosen for this project.
QSOFA
Based on the new research and the new definition of sepsis three criteria, patients with suspected infection who are likely to have a prolonged ICU stay or die in the hospital can be promptly identified at the bedside with Quick Sepsis Organ Failure Assessment (qSOFA). qSOFA is a quick tool used to screen patients by assigning one point for alteration in mental status, systolic blood pressure less than 100 mm Hg, and a respiratory rate exceeding 22 breaths /min in addition to suspected infection (Singer et al., 2016). According to Singer et al., 2016, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes if they have at least two or more of the qSOFA clinical criteria. Having a qSOFA of 2 or more with a suspected infection gives the patient a mortality rate greater than 10% (Singer et al., 2016).
Articles Synthesis
According to the sepsis-3 task force, SIRS can be very significant to identify patients with infections by looking at white blood cell count (WBC) and fever. However, increase in WBC is the body’s adaptive response. Therefore, SIRS fails to predict the outcome of septic patients accurately. According to a study by Bellomo et al., 2015, one in eight patients that die of sepsis had zero to one of the SIRS criteria. Also, in the event of SIRS being zero, one, or two, the mortality rate remained the same. Another study by Chupek et al., 2015 shows that 50% of hospital ward patients have SIRS and 100% of intensive care unit patients have SIRS. Therefore, SIRS is not considered a valid tool to predict mortality rate, and qSOFA is the preferred and most straightforward method that can be done at the bedside.
Furthermore, Finkelsztein et al., (2017) and Seymour et al., (2016) studies compare the use of qSOFA and SIRS and predicting mortality rate. Both studies illustrate that qSOFA has a higher accuracy rate in predicting the mortality rate for septic patients outside of the ICU with a p-value of 0.03 for Finkelsztein et al., (2017) study and a p-value of 0.01 in Seymour et al., 2016 study. qSOFA is preferred because of its ability to be user friendly as well as how quick the user can receive results through. Also, qSOFA does not require looking at patients’ labs, and is quicker to calculate at the bedside. Therefore, qSOFA should replace SIRS in predicting sepsis and its mortality rate outside of the ICU environment to facilitate earlier recognition and timely interventions in patients with sepsis.
Stakeholders:
For this project and policy change, the stakeholders addressed are the hospital medical director and chief residents, the emergency department director and nurse manager, and the nurse educator and clinical informatics. The nurse educator and unit manager can further assist with educating the staff and creating educational modules. The medical director and chief residents’ approval of the policy change is crucial in order for the change to be introduced to the rest of the hospital physicians. Finally, clinical informatics to implement the sepsis tool in the the electronic medical records (EMR). Implementing qSOFA assessment and providing timely interventions to reduce mortality rates are the primary interests and well-supported goals for the stakeholders, including, but not limited to clinicians, managers, and patients.
SWOT Analysis
One of the strengths of this policy change is the simplicity of the clinical criteria assessment being proposed. qSOFA contains three variables only, and registered nurses can easily assess it at the bedside without further blood work or equipment. No weaknesses were identified for this project, but it proved to be an excellent opportunity in lowering patients’ mortality rates and the costs associated with them. The opportunity for this project is to predict mortality rate to further improve septic patient management. A potential threat to this policy change may come from older physicians and nurses who do not approve of the change. Another potential threat is the timing of the policy roll out if it coincides with another significant change for the staff.
Cost-Benefit Assessment:
Some of the policy change expenses can include adding qSOFA assessment in EMR, in addition to creating online modules, presentation posters, and the costs associated with nurses’ training. However, Sepsis is a common and expensive condition to treat, costing $25,000 – $50,000 per patient, per episode (Alvaro-Meca et al., 2018). Therefore, timely identification and interventions to decrease the mortality rate can lead to a significant reduction in cost in the long run in addition to attracting more patients and physicians as a result of decrease in mortality rate and improve in the quality of care.
Implementation Plan:
In order to proceed with implementing the new protocol, stakeholders’ approval is obtained first over a one week period, August 15th-August 20th. The second step is working closely with clinical informatics to develop easy access to the qSOFA tool in EMR to ease healthcare providers charting. The expected timeframe to include qSOFA in EMR is from the first to the fifteenth of September. The third step includes working with the ED nurse educator to create online educational modules for staff. The purpose of the online modules is to introduce qSOFA to the staff and prepare the unit for the trial phase. A timeframe of four months will be given to the staff to finish their educational modules and the online assessment. Prior to the trial phase, mortality rate data will be collected with the assistance of the ED manager and the director in order to compare the data post implementation of qSOFA.
ADKAR Change Model:
Since change is inevitable and in order to successfully implement and manage change, the ADKAR change model is chosen for this project. The Prosci ADKAR change model is a goal-oriented change management model used to guide organizations through the process of change (Hiatt, 2006). The ADKAR is an acronym for awareness, desire, knowledge, ability, and reinforcement. ADKAR is implemented by increasing the staff and the stakeholders’ awareness of the high mortality rate associated with sepsis. A decrease in mortality rate is the desired goal of the evidence-based intervention in order to optimize patients and staff recruitment. Knowledge of the newest evidence-based practice regarding qSOFA and its effect on mortality rate is required to successfully convey the change and proceed to the action phase of the model. The action phase includes implementation of qSOFA in the ED over a period of six months. Finally, reinforce the change by collecting and analyzing the post-intervention mortality rate data and sharing it with the stakeholders and the staff.
Measurement/Demonstration of Outcome:
The outcome measure for this project is the mortality rate. Mortality rate data will be collected before implementing qSOFA by asking the manager for mortality rate report related to sepsis. During the trial phase of qSOFA, data will be collected once a month with the help of the ED manager, director, and the unit's nursing educator. Data will be disseminated to the Board of the hospital by the director and the rest of the staff by emails. Process measure will include auditing patients' charts to make sure qSOFA is being calculated and charted by the staff. Audits will be done once a week and the educator as well as the nursing supervisors, will be responsible for auditing. Audit results will be disseminated by email to all staff. The trial phase will last six months and decisions to implement the change permanently will be assessed based on the trial results.
Conclusion
Different research studies concluded that the use of qSOFA has higher accuracy compared to SIRS in predicting patients’ mortality rate and overall improve patient outcome. Implementing qSOFA score will determine the necessity of initiating early treatment and within the recommended time frame, therefore, decreasing mortality rate and hospital stay. In order to maintain the hospital’s Magnet status, the hospital must show improved outcomes and clinical practice based on current evidence. Therefore, there should not be any limitation or restrictions that pose a barrier to adopting this study. As nurses, it is critical to stay up to date and be aware of the new evidence-based practice in order to improve patient outcomes. The use of qSOFA and alone should not replace the use of good clinical judgment for determining the clinical condition and patients’ prognosis. However, qSOFA>2 is an excellent marker of severity of illness and should be used as such to implement the surviving sepsis campaign bundle promptly.